HospitalInspections.org

Based on review of medical record (MR), facility policy and interview with staff (EMP), it was determined the facility failed to maintain high professional standards and provide good quality care to execute physician order in a timely manner for one of 25 medical record reviewed (MR1).

Findings include:

Review on September 28, 2016, of facility policy, "Patient Rights and Responsibilities," last revised, revealed "... Patient Rights ... You have the right to expect emergency procedures to be implemented without unnecessary delay. ... You have the right to expect good management techniques to be implemented within the hospital, the avoidance of unnecessary delays ...".

A request was made to EMP1 on September 29, 2016, at 11:30 AM, for facility's policy on stat [urgent] orders and procedures. No policy on stat [urgent] orders and procedures was provided.

A request was made to EMP4 on September 29, 2016, at 12:00 PM, for facility's policy on performing stat [urgent] diagnostic tests. No policy on stat [urgent] diagnostic tests was provided.

A review of MR1's physicians orders dated November 3, 2015 at 18:51 [6:51 PM] revealed, "...CTACHEST [computed tomography angiography] ... STAT [urgent] ... Reason for Exam: R/o [rule out] PE [pulmonary embolism]". Further review of MR1's physicians orders dated November 3, 2015 at 18:51 [6:51 PM] revealed, "...2126 [9:26 PM] ... order's status changed from LOGGED to TAKEN ...".

A review of MR1's physicians orders dated November 3, 2015 at 18:55 [6:55 PM] revealed, "...CTABDPELVIS [computed tomography abdomen pelvis] ... STAT [urgent] ... Reason for Exam: VOMITING/INCREASED WBC [white blood cells]". Further review of MR1's physicians orders dated November 3, 2015 at 18:55 [6:55 PM] revealed, "...2126 [9:26 PM] ... order's status changed from LOGGED to TAKEN ...".

A review on September 28, 2016, of Event Note for MR1, dated November 3, 2015 at 22:39 [10:39 PM], revealed " ...2100: After returning from CT [computed tomography] scan, pt [patient] had worsening hemodynamic instability ...".

An interview conducted on September 28, 2016, at 11:30 AM, with EMP1 revealed there was no policy to address implementation of stat [urgent] orders and procedures.

An interview conducted on September 28, 2016, at 1:30 PM, with EMP4 revealed there was no policy to address implementation of stat [urgent] diagnostic tests. Further interview with EMP4 revealed there was no documentation explaining the time that was lapsed [2 hours and 35 minutes] between ordering and performing the STAT [urgent] diagnostic test for MR1.

Based on review of facility policy and procedures, review of facility document, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to provide Medicare beneficiaries with "An Important Message from Medicare (IMM)" within two days of admission or within two days prior to discharge for six of six medical records reviewed for IMM (MR20, MR21, MR22, MR23, MR24, MR25).

Findings include:

Review on September 29, 2016, of facility policy "Important Message from Medicare and Detailed Notice of Discharge," effective August 1, 2014, revealed " ... The Important Message from Medicare (IMM) will be provided to patients within two calendar days of admission and again within two days of discharge."

1) Review on September 30, 2016, of MR25 revealed no documentation that an IMM was provided within two days of admission for this Medicare patient.

2) Review on September 30, 2016, of MR20, MR21, MR22, MR23 and MR24 revealed there was no documentation that an IMM was provided prior to or at the time of discharge for each of these Medicare patients.

Interview with EMP1 on September 30, 2016, at 11:30 AM confirmed there was no documentation that an IMM was provided within two days of admission for the Medicare patient in MR25 and there was no documentation that an IMM was provided prior to or at discharge for each of the Medicare patients in MR20, MR21, MR22, MR23 and MR24.

Based on review of facility policy, medical records (MR), and interview with staff (EMP), it was determined that the facility failed to ensure the provision of accurate and concise nursing records and reports which reflect the progress of the patient and contribute to the continuity of patient care for one of 25 medical record reviewed (MR1).
Findings include:
A review on September 28, 2016, of facility policy "Enteral Tube Feedings" last revised November 24, 2014, revealed "Policy: Patients receiving enteral feedings are to receive nutritional formulas prescribed by a physician and monitored by nursing personnel. ... 9. Continuous Feeding: Check for residual volume every 4 hours - hold for signs of intolerance; increasing abdominal distention, ... nausea or emesis. 11. Discontinue feeding if patient regurgitates [sic] chokes or complains of nausea. ...".
A review on September 28, 2016, of MR1 physician order, dated October 31, 2015, revealed "... If patient shows signs of intolerance ( ... nausea, emesis) ... Hold enteral feeding for 1 hour ...".
A review on September 28, 2016, of nursing documentation for MR1, dated November 3, 2015 at 4:34 PM, revealed "1415 [2:15 PM] pt [patient projectile vomited, zofran [an antiemetic drug] IV [intravenous] given". A review of MR1 revealed two shift assessments dated November 3, 2015, at 08:00 AM and 12:00 PM indicating "...Gastric Tube Assessment Label ... no residual ...". Further review of MR1 revealed no additional documentation of the patient's gastric tube residual nor documentation regarding holding the tube feeding in accordance with physician order and facility policy.
An interview on September 28, 2016, at 2:00 PM with EMP1 confirmed there was no documentation in MR1 of patient's gastric tube residual with an exception of two instances on November 3, 2015, as per facility policy. Further interview with EMP1 confirmed no documentation in MR1 of holding the tube feeding as per physician order and facility policy.