HospitalInspections.org

Based on documentation review, policy review, and staff interview, the hospital failed to ensure their staff documented interventions and vital signs for one of 15 sampled records for review (Patient #1). This deficient practice had the potential for all staff to provide inadequate care to patients.

Findings Include:

- Medical record documentation review on 3/13/2017 revealed Patient #1 was admitted on 11/22/2016 following a fall with a subsequent traumatic subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) and loss of consciousness for more than 30 minutes. On 1/25/2017 at 4:30pm, the patient had an episode of vomiting that "appeared to be tube feeding with large grape size clots". It was noted at that time that the patient's abdomen was distended (swelling of the abdomen may be caused by a number of different diseases and conditions (e.g. irritable bowel syndrome, constipation or bowel blockage, gastro-intestinal bleeding, etc.). Later in the evening the patient had some respiratory distress with increased heart rate, increased respiratory rate and decreased oxygen saturations (measures the percentage of hemoglobin binding sites in the bloodstream occupied by oxygen; normal 90-100%) which led to the patient being transferred to an acute care hospital.

Registered Nurse (RN) Staff G's interview on 3/14/2016 at 3:10pm indicated as they read their nurses' notes from 1/25/2017 regarding Patient #1 that they had missed some documentation. Staff G stated they called Physician Staff C twice that evening and she did not find that documentation in the patient's medical record. "I am really feeling strongly that I missed (documenting) another phone call to Physician Staff C about the patient's status, it was after the oxycodone (narcotic pain medication), I am pretty sure Physician Staff C felt like monitoring was the step to take. Additionally, RN Staff G indicated she checked on Patient #1 every 15 minutes from 6:50pm to the time patient transferred to the acute care hospital at 11:00pm. However, RN Staff G failed to document the every 15 minute checks regarding the patient's oxygen saturation, otherVital Signs (heart rate, respiratory rate, blood pressure), behavior, assessment of patient's spasticity, color, etc. from 7:00 -7:30pm, 8:00pm, 8:45pm, 9:00pm, and 9:30-10:00pm.


- Policy reviewed on 3/15/2017 revealed the hospital failed to have a policy to ensure their nursing staff follow standards of nursing documentation.