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ERIE, PA 16550

CARE OF PATIENTS - RESPONSIBILITY FOR CARE

Tag No.: A0068

Based on review of facility documentation, medical record review (MR), and staff interview (EMP), it has been determined that the facility failed to ensure that the attending physician failed to monitor the care of patient(s) in one of one medical record reviewed. (MR1)
Findings Include:
On October 18, 2013, review of UPMC Hamot Medical Staff Handbook, issued February 2012, states, "... Section 2.04 Quality of Service. 1. Provide appropriate, timely and continuous care of patients to include at least daily visits by the attending Staff Member or the covering Staff Member..."
1. Review of MR1 revealed that EMP5 was the patient's attending physician. MR1 revealed that the patient was not seen by the physician or by a member of the physician's group on October 8, 2013.
2. EMP2 confirmed the above findings on October 18, 2013, at 1:00 PM.

FORM AND RETENTION OF RECORDS

Tag No.: A0438

Based on review of facility documents, the medical record (MR), and staff interview (EMP), it was determined facility staff failed to maintain a medical record that was accurately written for one of one medical records (MR1).

Findings include:

Review of "Documentation by Nursing Personnel" policy reviewed September 1, 2013, revealed, "It is the policy of UPMC Hamot that there is an official record of patient care, nursing assessment, interventions, plan of care, and teaching ... 4. Documentation process follows the schema [sic] of charting by exception. For any body system assessed to be within defined limits, the nurse may chart as such without further detail. When an abnormality is found, the nurse will document all pertinent info as it applies to that body system. The nurse will also chart all details of the nursing process related to that exception to include nursing interventions and outcomes of those interventions. Details of the content of 'within defined limits' for each body system can be found in appendix A..."

1. Further review of the policy failed to reveal the necessity of documentation being accurate and needing to provide a clear picture of what was happening with the patient and treatments.

2. Review of MR1 revealed the patient was admitted via the Emergency Department with a diagnosis of small bowel obstruction. Additional diagnostic testing was performed on October 1-2, 2013. On Thursday, October 3, 2013, EMP17 documented, "I would recommend no further delays to surgery ... " More testing was performed on Friday, October 4, 2013 ((EGD). A physician/extender note on October 5, 2013, revealed that bowel surgery was being planned for Tuesday, October 8, 2013, for a laparoscopic assisted removal of part of the colon. The record did not include documentation of why there was a 5 day delay for surgery.
3. Further review of MR1 revealed the patient was ordered Norco for chronic arthritic pain. Documentation of pain assessments following administration of medications was inconsistent throughout the patient's stay. On October 8, 2013, the patient developed abdominal pain and was administered Norco. The pain assessment documentation following the administration of Norco revealed the pain as 0 on a scale of 1-10, with 0 being the least severe. Further documentation revealed an order was obtained for Dilaudid injectable 22 minutes following the administration of the Norco, even though the assessment indicated pain on the scale as 0 and "improved." It was unable to be determined from nursing documentation why the patient required the Dilaudid if the pain was improved from the Norco. Eight minutes later the nurse documented that the patient was still having pain but it was "improved." Another, later pain assessment revealed Dilaudid was given for an "ache" without description of where the pain was, with a note added, "Pain, Severe (7-10)." That reassessment noted the pain was less on the numeric scale than previously noted and per the patient it was "worse."
4. Continued review of MR1 revealed nursing staff contacted surgery on October 9, 2013, to find out what time the patient was on the surgery schedule. They learned the patient "was not on the list for today." A physician note three hours later cleared the patient for surgery on October 9, 2013. A rapid response was called due to the patient being in respiratory distress later on October 9, 2013. The patient was taken to surgery on October 10, 2013. There was no documentation explaining the additional delay in surgery by the physician or nursing staff.
5. Interview on October 18, 2013, at 11:40 AM with EMP3 confirmed the documentation in the medical record was unclear.
6. Interview on October 18, 2013, at 1:25 PM with EMP19 revealed the employee had assessed the patient twice during the night of October 9, 2013. EMP confirmed there were no progress notes written for either time EMP19 assessed the patient.



Findings include:

Review of "Documentation by Nursing Personnel" reviewed September 1, 2013, revealed, "It is the policy of UPMC Hamot that there is an official record of patient care, nursing assessment, interventions, plan of care, and teaching ... 4. Documentation process follows the schema [sic] of charting by exception. For any body system assessed to be within defined limits, the nurse may chart as such without further detail. When an abnormality is found, the nurse will document all pertinent info as it applies to that body system. The nurse will also chart all details of the nursing process related to that exception to include nursing interventions and outcomes of those interventions. Details of the content of 'within defined limits' for each body system can be found in appendix A..."


1. Further review of the policy failed to reveal the necessity of documentation being accurate and needing to provide a clear picture of what what happening with the patient and treatments.

2. Review of MR1 revealed the patient was admitted via the Emergency Department with a diagnosis of small bowel obstruction. Additional diagnostic testing was performed on October 1-2, 2013. On Thursday, October 3, 2013, EMP17 documented, "I would recommend no further delays to surgery ... " More testing was performed on Friday, October 4, 2013 ((EGD). A physician/extender note on October 5, 2013, revealed that bowel surgery was being planned for Tuesday, October 8, 2013, for a laparoscopic assisted removal of part of the colon. The record did not include documentation of why there was a 5 day delay for surgery. Although the patient was on Norco, a narcotic oral medication for chronic arthritic pain, documentation of pain and relief of pain was inconsistent throughout the patient's stay. The patient developed abdominal pain on October 8, 2013, that was listed under the assessment of pain for the Norco, then was given another injectable narcotic, Dilaudid, 22 minutes later for abdominal pain listed as a 0 (on a scale of 0-10 with 0 being the least severe and 10 being the most severe) and the pain being documented as "improved." It was unable to be determined from nursing documentation why the patient required the Dilaudid if the pain was improved from the Norco. Eight minutes later the nurse documented that the patient was still having pain but it was "improved." Another, later pain assessment revealed Dilaudid was given for an "ache" without description of where the pain was, with a note added, "Pain, Severe (7-10)." That reassessment noted the pain was less on the numeric scale than previously noted and per the patient it was "worse." The patient's condition continued to deteriorate. Nursing documented that nursing staff contacted surgery on October 9, 2013 to find out what time the patient was on the surgery schedule to be told the patient "was not on the list for today." A physician note three hours later cleared the patient for surgery on October 9, 2013. A rapid response was called due to the patient being in respiratory distress later on October 9, 2013. The patient was taken to surgery on October 10, 2013. There was no documentation about the additional delay in surgery by the physician or nursing staff.
3. Interview on October 18, 2013, at 11:40 AM with EMP3 confirmed the documentation in the medical record was unclear.
4. Interview on October 18, 2013 at 1:25 PM with EMP19 revealed the employee had assessed the patient twice during the night of October 9, 2013. EMP19 confirmed [he/she]did not record progress notes in the medical record for either time EMP19 assessed the patient.