HospitalInspections.org

Based on document review and interview, facility nursing staff failed to obtain and document daily patient weights, failed to obtain and document orthostatic blood pressure readings, and failed to document urine output every 8 hours as ordered by provider in 1 of 10 patient medical records reviewed. (P1)

The cumulative effects of these systemic problems resulted in the facility's inability to provide nursing care in a safe manner.

Based on document review and interview, facility nursing staff failed to document and/or resolve patient complaints in a timely manner and failed to notify patient advocacy of a patient complaint and/or grievance as policy indicates in 1 of 10 patients. (P1)

Findings include :

1. Facility policy titled,"Patient/Parent Rights and Responsibilities, Complaints and Grievances", no policy number, last revised 06/22/2023, indicated under VI: PROCEDURES: B. Patient Complaint Process. 1. When a patient voices a complaint, the team members immediately present should solve the complaint promptly. Issues such as unanswered questions, change in bedding, housekeeping, immediate care issues such as pain control, and food services are examples of complaints that may be addressed and resolved quickly. 3. If the complaint cannot be solved by team members immediately present, the team members should contact their immediate supervisor, their delegate, or clinical leadership to address the patient/family concern and reach resolution. If the leader is unable to resolve the issue, he/she can refer the complaint to the Patient Relations for assistance. Unresolved complaints may become grievances, and the following procedures may apply if resolution is not achieved.

2. Review of facility complaint and/or grievance log indicated P1 was listed once on 9/23/24. P1 called patient advocacy to report his/her complaints related to lack of nursing care ordered by physician. Patient advocacy relayed the information to A4 (Manager of Clinical Operations) who then rounded on the patient addressing his/her concerns. This complaint was documented as closed on 9/23/24. This log lacked documentation of P1's initial complaints without complaint resolution from 9/19/24. This log lacked P1 concerns being escalated to a grievance.

3. In an interview on 2/7/25 at approximately 3:50 pm with A4 (Manger Clinical Operations) confirmed A5 (Clinical Manager of Operations Bone Marrow Transplant) contacted him/her on 9/19/24 to relay P1's complaints of lack of nursing care. These concerns were unable to be resolved and were not escalated to patient advocacy but should have been. A4 confirmed he/she received an email from Patient Advocacy on 9/23/24 after the patient called to complain about lack of nursing care. A4 then rounded on the patient and listened his/her concerns at the bedside.

Based on document review and interview, facility nursing staff failed to obtain and document daily patient weights, failed to obtain and document orthostatic blood pressure readings, and failed to document urine output every 8 hours as ordered by physician or provider in 1 of 10 medical records reviewed. (P1)

Findings include:

1. Facility policy titled," Documentation Standards", no policy number, last revised 08/05/2024, indicated under V. POLICY STATEMENTS: A. GENERAL DOCUMENTATION STANDARDS. 1. Registered Nurses are accountable for the patient assessment and documentation process.

2. Review of P1's MR (Medical Record) indicated physicians orders for the following: On 9/16/24 at 11:37 am indicated physician orders for strict intake and output to be documented every 8 hours. On 9/17/24 at 8:00 am orders for Blood Pressure and Pulse Lying and Standing every 24 hours (orthostatic blood pressure),and a daily weight every 24 hours. MR for P1 lacked the following documentation for physician orders.

Oral Intake:
I&O documented on 9/16/24 at 9:00 pm. No further I&O documented until 9/17/24 at 6:00 am
I&O documented on 9/17/24 at 7:00 pm. No further I&O documented until 9/18/24 at 5:00 am.
I&O documented on 9/18/24 at 6:00 pm. No further I&O documented until 9/19/24 at 3:00 am.
I&O documented on 9/19/24 at 7:00 pm. No further I&O documented until 9/20/24 at 5:00 am.
I&O documented on 9/20/24 at 10:00 pm. No further I&O documented until 9/21/24 at 6:00 am.
I&O documented on 9/21/24 at 3:00 pm. No further I&O documented until 9/22/24 at 10:00 am.
I&O documented on 9/28/24 at 6:00 pm. No further I&O documented until 9/24/24 at 5:00 am.
I&O documented on 9/30/24 at 7:00 pm. No further I&O documented until 10/1/24 at 4:00 am.
I&O documented on 10/1/24 at 9:00 pm. No further I&O documented until 10/2/24 at 5:00 am.
I&O documented on 10/2/24 at 8:00 pm. No further I&O documented until 10/3/24 at 5:00 am.
I&O documented on 10/5/24 at 9:00 pm. No further I&O documented until 10/6/24 at 5:00 am.
I&O documented on 10/6/24 at 4:00 pm. No further I&O documented until 10/7/24 at 7:00 am.

Urine Output:
I&O documented on 9/21/24 at 4:00 pm. No further I&O documented until 9/22/24 at 4:00 pm.
I&O documented on 10/2/24 at 9:00 pm. No further I&O documented until 10/3/24 at 4:00 am.

Documentation of ordered daily weights for dates 9/19/24, 9/21/24, 9/22/24, 9/23/24, and 10/1/24.

Documentation of completed blood pressures laying and standing (orthostatic blood pressure) every 24 hours for dates 9/19/24, 9/20/24, 9/22/24, and 10/1/24.


3. In interview on 2/7/25 at approximately 11:00 am with A5 (Clinical Manager of Operations Bone Marrow Transplant) confirmed daily weights, strict intake and output, and orthostatic blood pressures lying and standing for P1 were not completed by facility nursing staff for dates including but not limited to 9/19/24, 9/21/24, 9/22/24, 9/23/24, and 10/1/24 but should have been.