HospitalInspections.org

Based on policy review, medical record review, and interview, nursing services failed to provide appropriate interventions and assessments, follow physician orders and adhere to policies and procedures for documenting in the medical record for 1 of 3 (Patient #1) medical records reviewed.

The findings included:

Review of Hospital #1's Medical Surgical Admission Guidelines policy dated 11/18/2020 revealed, "...The patient's admission history and assessment creates the foundation for the planning, implementation, and evaluation of nursing care...A comprehensive physical assessment will occur at the beginning of each shift...The focus assessment will be based off of an individualized plan of care and documentation will reflect appropriate nursing diagnosis or problems...A licensed RN [Registered Nurse] will perform and document a physical assessment once every 12 hours...Intake and Output will be recorded every eight (8) hours or based on the physician's order.

Review of Hospital #1's Physician Orders policy dated 01/2019 revealed, "...All transcribed orders must be checked, dated, times and signed off by an RN [Registered Nurse]..."

Medical record review revealed Patient #1 was admitted to Hospital #1's Medical/Surgical/Telemetry floor on 4/28/2021 at 4:04 PM with diagnoses of Acute Congestive Heart Failure (CHF), Acute Kidney Injury (AKI), Hyperkalemia, Edema and Shortness of Breath.

Patient #1's medical history included Cardiomyopathy, Heart surgery, Type 2 Diabetes, Alcoholism (5-6 hard drinks every day), Hypertension and Prostate Hypertrophy.

Review of Physician #1's order dated 4/28/2021 at 2:04 PM for Patient #1 revealed orders for Daily Weights and Strict Intake and Output (I&O) related to diagnosis of CHF. (Intake and Output is the measurement of fluids that enter the body (intake) and the fluids that leave the body (output)).

Review of Patient #1's Body Measurement flowsheet revealed on the day of the patient's admission (4/28/2021) the patient weighed 125.9 kilograms (kgs) or 276.98 pounds (lbs).

On 4/29/2021 at 10:14 AM, Patient #1's weight was recorded as 126 kgs or 277.8 lbs on a Transthoracic Echocardiography (TTE) report.

There was no documentation of Patient #1's weight on 4/30/2021 in the medical record.

Review of the Patient #1's I&O flowsheet revealed there was no documentation of Patient #1's I&O on the following dates/times:
On 4/29/2021 from 7:00 AM - 7:00 PM.
On 4/30/2021 from 7:00 AM - 7:00 PM.

Review of the Genitourinary Assessments for Patient #1 revealed the following:
On 4/28/2021 at 7:58 PM, the nurse documented the patient's bladder was non-distended with a foley catheter (indwelling urinary catheter) in place and clear yellow urine.

On 4/29/2021 at 9:00 AM, the nurse documented the patient's bladder was non-distended, non-tender, voiding without difficulty, foley. There was no documentation of the urine color or description.

On 4/29/2021 at 7:48 PM, the nurse documented the patient's bladder was non-distended, non-tender, foley, urine description as clear, urine color was pink.

There was no documentation of Patient #1's Genitourinary Assessment/foley assessment on 4/30/2021.

Review of Physician #1's orders dated 4/30/2021 at 7:40 AM revealed, "...Discharge patient...keep foley catheter in and follow up with urology by 2 weeks..." The order was electronically signed by RN #1 on 4/30/2021 at 7:48 AM.

Review of the Drains/Ostomy/Tubes flowsheet revealed RN #1 documented the urinary catheter was removed on 4/30/2021 at 3:54 PM.

Patient #1 was discharged on 4/30/2021. There is no documentation on the discharge summary or in the medical record of the time the patient was discharged.

On 5/25/2021 at 2:20 PM, the Director of Clinical Quality sent an email to this surveyor of a form titled Custom Information. The form revealed the date and time of discharge for Patient #1 was documented as 4/30/2021 at 4:47 PM. The form was not part of the medical record received by this surveyor.

In an interview on 5/20/2021 at 11:55 AM, the Director of Clinical Quality and Chief Nursing Officer reviewed the medical record and verified assessments that included Daily Weights and Strict Intake and Output were not completed.

In a telephone interview on 5/24/2021 at 5:40 PM, Physician #1 stated Patient #1 was stable for discharge. Physician #1 stated, "...[Patient #1] had been assessed through consults with Urology, Gastroenterology, and Cardiology. Orders were to follow up with Urology and his Primary Care Physician (PCP). He has a cardiologist who sees for heart..."
When asked if he recalled if the urine in the foley was bloody at the time of discharge Physician #1 stated, "... it (urine) was blood tinged, much better, urology saw him on the 4/30 and cleared him, to keep foley in until he sees the Urologist..."
When asked if the wife or the patient had expressed any concerns related to care or information they received while the patient was hospitalized Physician #1 stated, "... no, no complaints, I don't know if patient is very compliant in medications treatments. I discussed with wife and patient diagnosis and the need to keep foley in for now, also medications I discussed with patient and wife..."
When asked if in his opinion Patient #1 was stable to be discharged Physician #1 stated, "... yes, I wrote that, stable in discharge summary, no problems, if he follow up I do not know with Urology and PCP, if he was compliant with discharge orders..."

In a telephone interview on 5/25/2021 at 12:00 PM. Patient #1's wife stated, "...when we were getting ready for discharge the nurse came in and said she was going to remove the Foley catheter. I told her that the doctor said [Patient #1] had to wear it [foley] for three weeks. The nurse said she needed to remove it before he was discharged and she removed it anyway. We left the hospital around 5:00 - 5:30 PM on 4/30..."

In a telephone interview on 5/25/2021 at 12:09 PM, Physician #1 stated he was not aware the nurse had not followed the discharge orders to leave the foley catheter in at discharge. Physician #1 stated he had written the order to leave it [foley] in and it should have been left in. Physician #1 stated, "...I can't tell you why the nurse removed it..."

A telephone call was placed by this surveyor on 5/25/2021 and 5/26/2021 to RN #1. There was no answer and a message was left for the RN to return the call. The RN is no longer employed at Hospital #1 as of 5/19/2021.

On 5/26/2021 at 12:52 PM, RN #1 returned this surveyor's telephone call and stated she recalled having a patient that was being discharged with a foley in place. RN #1 stated she thought the name was (named Patient #1) and remembered the patient's wife being concerned about the Foley having blood in the bag. RN #1 stated she had called the urologist to ask why the foley was in place and spoke to the nurse, but does not remember the name of the nurse she spoke with. RN #1 stated the urologist called her back and asked her why the foley was still in. RN #1 stated she received an order from the urologist to remove the foley before the patient was discharged. RN #1 stated she did not remember the name of the urologist, but he was in the urology group. RN #1 stated she might not have written the verbal order. RN #1 stated she thought she charted when she talked to the urologist and received orders but might not have hit the save button on the computer, so it might not have been saved in the medical record. When asked if she completed the discharge documents, RN #1 stated she thought she completed everything but couldn't be sure.

Based on policy review, medical record review and interview the hospital failed to ensure nursing documented disposition of patient discharge on the Discharge Summary and failed to document patient education related to patient diagnosis and discharge medications for 1 of 3 (Patient #1) medical records reviewed.

Review of Hospital #1's Discharge Planning Process policy revealed, "...the purpose of this policy is to ensure discharge plans are coordinated and individualized ...assessment findings will be documented in the EMR [Electronic Medical Record] ...the name of the participants, date, and time will be documented in the EMR...Documentation must address follow-up-concerns and the patient/family member's understanding of information given...Upon discharge each patient/ family members/significant other will receive written discharge instructions based upon physician orders and patient's learning needs as identified by patient care providers. The patient care provider reviews these instructions completed in the Discharge Summary form and potential Food/Drug interaction form. Patient/family members/significant others are requested to sign acknowledgement of these instructions...Document discharge time, mode of exit, escort and destination in the EMR..."

Medical record review revealed Patient #1 was admitted to Hospital #1's Medical/Surgical/Telemetry floor on 4/28/2021 at 4:04 PM with diagnoses of Acute Congestive Heart Failure (CHF), Acute Kidney Injury (AKI), Hyperkalemia, Edema and Shortness of Breath.
Patient #1 has a medical history of Cardiomyopathy, Heart surgery, Type 2 Diabetes, Alcoholism (5-6 hard drinks every day), Hypertension and Prostate Hypertrophy.

Review of the Discharge Summary revealed there was no documentation in Patient #1's medical record to indicate the date and time of discharge, mode of discharge, who accompanied the patient, where the patient was discharged to or mode of transportation.

On 5/25/2021 at 2:20 PM, the Director of Clinical Quality sent an email to this surveyor of a form titled Custom Information. The form revealed the date and time of discharge for Patient #1 was documented as 4/30/2021 at 4:47 PM. The form was not provided to the surveyor at the time of the survey and was not part of the medical record.

Patient #1's vital signs were documented on 4/30/2021 at 4:04 PM. There were no other nursing assessments documented after that time for Patient #1. There was no documentation the following Patient Assessment-flowsheets were completed on 4/30/2021 by an RN: Gastrointestinal, Genitourinary, Integumentary, Musculoskeletal, Neurological, Neurovascular, and Respiratory.

Review of Physician #1's discharge summary revealed Patient #1 was discharged home with the following medications: Eliquis 5 milligrams one (1) tablet oral two (2) times a day, Diazepam 10 mg one (1) tablet oral 2 times a day as needed, Furosemide 40 mg one (1) tablet oral 2 times a day, Magnesium Oxide 400 mg oral daily, Hydrocodone 10 mg one (1) capsule oral three times a day as needed, Metformin 1000 mg oral 2 times a day, Metoprolol 50 mg one (1) tablet oral 2 times a day, Tamsulosin 0.4 mg (no dose was documented), Aspirin 81 mg one (1) tablet oral daily, and Thiamine 100 mg one (1) tablet oral daily for 30 days.

There was no documentation Patient #1 received discharge medication instructions.

There was no documentation in Patient #1's medical record the patient had received patient education/information related to his diagnosis of Congestive Heart Failure prior to discharge.

In an interview on 5/20/2021 at 12:25 PM, the Chief Nursing Officer after reviewing Patient #1's medical record verified the Discharge Summary was incomplete.

In a telephone interview on 5/25/2021 at 12:00 PM. Patient #1's wife stated she and Patient #1 left the hospital between 5:00 PM - 5:30 PM on 4/30/2021. Patient #1's wife verified she nor the patient had received any information related to the patients diagnosis of Congestive Heart Failure.

In an telephone interview on 5/26/2021 at 12:52 PM, Nurse #2 stated she recalled having a patient that was being discharged with a foley in place. RN #1 stated she thought the name was (named Patient #1) and remembered the patient's wife being concerned about the foley having blood in the bag. When asked if she completed the discharge documents, RN #1 stated she thought she completed everything but couldn't be sure. When asked if she provided education and instructions to the patient and/or patient's wife RN #1 stated she thought she had and if she did it would be in the discharge documentation.