HospitalInspections.org

Based on medical record review, policy review and staff and family interviews, it was determined that for 1 of 3 patients (33%) in the sample (Patient #1) that required plan of care representation, staff failed to include a designated family member in the development and implementation of the plan of care. Findings include:

The hospital policy entitled "Standards of Nursing Practice" stated, "...The development of a written, individualized, plan of care, based on problem identification...collaboratively developed with patient/family..."

Patient #1 (1/25 - 2/1/10 hospitalization)

A. Patient #1's Admission H & P (history & physical) revealed a history of traumatic brain injury resulting in the inability to communicate verbally.

B. During a phone call to the State Agency on 1/29/10 at 11:13 AM, Patient #1's mother reported that due to Patient #1's inability to communicate, it was important that she (mother) be included in Patient #1's plan of care. Patient #1's mother reported that she specifically asked to be contacted for any change in the plan of care.

C. During an interview with registered nurse (RN) #2 on 3/10/10 at 11:55 AM, RN #2 reported that while Patient #1's mother was visiting, she specifically asked to be called by RN #2 or any other staff member, even if it was in the middle of the night, if Patient #1 ran a fever, if test results came in, or if there was any updated information regarding Patient #1. RN #2 reported that she worked the 7:00 AM - 7:00 PM shift (1/27/10) and passed this information on to the oncoming nurse, RN #6.

D. Review of the "Plan of Care and Education Record" for the 1/25 - 2/1/10 hospitalization revealed staff failed to revise the plan of care, when Patient #1's mother requested inclusion in Patient #1's plan of care, including specific notification requirements.

E. Review of the "Interdisciplinary Patient Progress Record" revealed no documented communication between nursing staff and the complainant, after it was known on 1/27/10 that the complainant requested inclusion in Patient #1's plan of care.

F. Interview with the Corporate Director Patient Safety and Accreditation on 3/8/10 at 12:45 PM, confirmed that staff should have included the 1/27/10 communication input relayed to the nurse (RN #2) by Patient #1's mother, into the plan of care.

Based on observation, policy review and staff interview, it was determined that staff failed to ensure confidentiality of patient records for 6 of 104 (6%) medical records (MR#'s 1, 2, 3, 4, 5 and 6) in the record observation sample. Findings include:

The hospital policy entitled "Patient Rights and Responsibilities" stated, "...You have the right...To confidentiality, regarding your medical care and information related to that care...To have your medical record read only by staff directly involved in your treatment..."

The following issues related to patient confidentiality were identified during record storage observations on 3/10/10:

A. 2:35 PM: Unit 3D - Census 31

The spines of three charts (MR #'s 1, 2 and 3) had the patients' first and last names. The chart spines were facing the hallway/walkway at the center nurses' station and were visible to all staff and visitors in the area.

Accreditation Coordinator A, present at the time of the observation, confirmed this finding. Accreditation Coordinator A explained to the Unit Clerk that this was a confidentiality issue and requested that the records be secured.

B. 2:40 PM: Unit 5D - Census 33
The spine of one chart (MR #4) had the patient's first and last name. The chart spine was facing the hallway/walkway at the nurses' station outside of the patient room and was visible to all staff and visitors in the area.

Accreditation Coordinator A, present at the time of the observation, confirmed this finding. Accreditation Coordinator A stored the record at the time of discovery.

C. 3:10 PM: Unit 5C - Census 40
The spines of two charts (MR #'s 5 and 6) had the patients' first and last names. The chart spines were facing the hallway/walkway at the nurses' station outside of the patient room and were visible to all staff and visitors in the area.

Accreditation Coordinator A and Nurse Manager C, present at the time of the observation, confirmed this finding. Nurse Manager C stored the records at the time of discovery.

Based on medical record review, policy review and staff and family interview, it was determined that for 2 of 6 patients (33%) in the sample (Patient #'s 1 and 5) with documented sensory losses, staff failed to develop a communication plan of care. In addition, staff failed to revise the plan of care when one responsible party (Patient #1's mother) voiced the desire to be included in the plan of care. Findings include:

The hospital policy entitled "Communication with Patients Having Vision, Hearing, Speech or Language Barriers" stated, "It is the policy of Christiana Care to respect the right of all patients to have their communication needs met as an integral part of the care and service they receive from the system...goal is to clearly communicate with the patient in a method understandable to him or her...Preferred Method of Communication...Language of choice through language interpreter...the printed word, sign language through sign language interpreter, lip reading or special assistive devices...Document preferred method of communication and intervention for ongoing plan of care or service..."

The hospital policy entitled "Standards of Nursing Practice" stated, "...Care is planned in an interdisciplinary manner in response to identified patient/family problems...plan provides continuity of care...The development of a written, individualized, plan of care, based on problem identification...collaboratively developed with patient/family and other health care providers...The RN (registered nurse) reviews & documents the appropriateness and completeness of the plan at least once each 24 hours..."

I. Patient #1 (1/25 - 2/1/10 hospitalization)

A. Patient #1's Admission H & P (history & physical) revealed a history of traumatic brain injury resulting in the inability to communicate verbally.

Review of the 1/25/10 "Interdisciplinary Patient Progress Record" entered at 3:55 AM revealed, "...non verbal, blink [sic] her eyes for communication..."

Phone interview with RN #3 on 3/10/10 at 2:55 PM, revealed RN #3 performed Patient #1's admission physical assessment on 1/25/10. RN #3 reported that she contacted the long term care facility and also spoke with Patient #1's mother by phone, to obtain information about Patient #1's specific needs including her preferred method of communication. RN #3 reported that Patient #1 communicated by blinking her eyes in response to yes and no questions.

Interview with RN #5 on 3/10/10 at 1:35 PM, revealed Patient #1 communicated by blinking her eyes - a long blink for "No" and a short blink for "Yes" question responses.

Review of the "Plan of Care and Education Record" for the 1/25 - 2/1/10 hospitalization revealed staff failed to develop a plan of care to address Patient #1's communication deficit and preferred method of communication.

On 3/10/10 at 2:24 PM, Surveyor A and Nurse Manager A reviewed Patient #1's plan of care and confirmed that the plan of care did not include Patient #1's communication needs. Nurse Manager A reported that the expectation would be that staff should have developed an individualized communication plan of care for Patient #1.

B. During a phone call to the State Agency on 1/29/10 at 11:13 AM, Patient #1's mother reported that due to Patient #1's inability to communicate, it was important that she (mother) be included in Patient #1's plan of care. Patient #1's mother reported that she specifically asked to be contacted for any change in the patient's condition, ordered diagnostic testing and reported test results.

During an interview with RN #2 on 3/10/10 at 11:55 AM, RN #2 reported that while Patient #1's mother was visiting, she specifically asked to be called by RN #2 or any other staff member, even if it was in the middle of the night, if Patient #1 ran a fever, if test results came in, or if there was any updated information regarding Patient #1. RN #2 reported that she worked the 7:00 AM - 7:00 PM shift (1/27/10) and passed this information on to the oncoming nurse, RN #6.

Interview with RN #1 on 3/10/10 at 11:45 AM, revealed RN #1 provided care to Patient #1 on two days (1/28 and 1/29/10). RN #1 reported that she was unaware of the 1/27/10 request by Patient #1's mother to be called with specific information related to Patient #1's care.

Interview with RN #4 at 12:05 PM, revealed RN #4 provided care to Patient #1 on a few days (1/30, 1/31 and 2/1/10). RN #4 reported that she was unaware of the 1/27/10 request by Patient #1's mother to be called with specific information related to Patient #1's care.

Review of the "Plan of Care and Education Record" for the 1/25 - 2/1/10 hospitalization revealed staff failed to revise the plan of care, when Patient #1's mother requested inclusion in Patient #1's plan of care, including specific notification requirements.

Interview with the Corporate Director Patient Safety and Accreditation on 3/8/10 at 12:45 PM, confirmed that staff should have included the 1/27/10 communication input relayed to the nurse by Patient #1's mother, into the plan of care.

During an interview on 3/15/10 at 9:50 AM, Patient Safety and Accreditation Coordinator A reviewed Patient #1's plan of care and reported that the expectation of staff would be that the communication hand-off should have been on Patient #1's plan of care. The Coordinator reported that the original nurse (RN #2) should have updated the care plan to reflect the mother's request and if not, the second nurse (RN #6) should have updated the plan of care. The Coordinator reported that the documented problem would be part of the education provided and the documentation would be used as a follow-up.

II. Patient #1 (2/18 - 2/26/10 hospitalization)

A. Review of "Interdisciplinary Patient Progress Record" documentation revealed the following:

2/19/10 at 3:30 AM - "...opens eyes & (and) focuses. Does not follow commands. Pt. (patient) is non-verbal..."

2/19/10 at 1:05 PM - "...blinks for Y/N? (Yes/No questions)..."

2/20/10 at 1:32 AM - "...She did answer yes/no questions with long and short blinks..."

Review of the "Plan of Care and Education Record" for the 2/18 - 2/26/10 hospitalization revealed staff failed to develop a plan of care to address Patient #1's communication deficit and preferred method of communication.

On 3/11/10 at 1:30 PM, Surveyor A and Nurse Manager A reviewed Patient #1's plan of care and confirmed that the plan of care failed to include Patient #1's identified communication needs.

III. Patient #5 (2/5 - 2/9/10 hospitalization)

Review of Patient #5's H & P revealed diagnoses including mental retardation, schizoaffective disorder, OCD (obsessive compulsive disorder), intermittent explosive disorder, ADHD (attention deficit hyperactivity disorder) and deafness.

A. Review of the 2/6/10 "Interdisciplinary Patient Progress Record" entered at 11:00 AM revealed, "...Pt unable to speak or hear, reads lips & mouths words, but primary communication is by sign language..."

Interview with Nurse Manager B on 3/12/10 at 3:37 PM revealed Patient #5's preferred method of communication was sign language, however, Patient #5 could "text" on his cell phone and "read lips very well". Nurse Manager B reported that Patient #5 accessed the hospital's teaching web network for educational information. The Manager reported that a friend provided sign language interpretation and that the hospital had interpreters on call seven days a week, 24 hours a day.

Interview with RN #7 on 3/12/10 at 3:55 PM revealed Patient #5 communicated by mouthing words, "texting" back and forth with the physician and writing on paper. RN #7 reported that Patient #5 could read and had an understanding of what he was told.

Review of the "Plan of Care and Education Record" for the 2/5 - 2/9/10 hospitalization revealed staff failed to develop a plan of care to address Patient #5's communication deficit and preferred method of communication.

Interview with Nurse Manager B on 3/12/10 at 3:37 PM, confirmed that the plan of care failed to include Patient #5's identified communication needs.

B. Review of the "Admission Referral Process" documentation dated 2/6/10 at 9:46 AM, revealed Patient #5's behavior was observed to be "aggressive".

Review of the "Doctor's Order Sheet" dated 2/6/10 at 9:10 PM, revealed an order for "1:1 sitter for safety".

Review of the "Safety Companion Observation Record" revealed Patient #5 had a 1:1 sitter from 11:00 AM on 2/6/10 through 11:00 AM on 2/9/10. Entries on the sitter record revealed the following behavior observations:

2/8/10
- 10:00 AM: 2 episodes of agitation leading to elopement attempts
- 6:00 PM: Agitated - Pulled heart monitor off

2/9/10
- 10:00 AM: Agitated - Punched on walls
- 11:00 AM - Agitated

Review of the 2/9/10 "Interdisciplinary Patient Progress Record" entered at 11:30 AM revealed staff arrived in Patient #5's room in response to hearing a call for help. Patient #5 was observed to be choking his 1:1 sitter. Patient #5 attempted to leave his room and became combative with the two intervening RNs.

Review of the "Plan of Care and Education Record" for the 2/5 - 2/9/10 hospitalization revealed staff failed to develop a plan of care to address Patient #5's aggressive behaviors.

Interview with Nurse Manager B on 3/12/10 at 3:37 PM and 4:03 PM, revealed Patient #5 was easily frustrated and had anger management issues. Nurse Manager B reported that Patient #5 threw the keyboard to the computer because he wanted a "mouse" instead of the keyboard. The Manager also provided pictures of the sitter's neck following the 2/9/10 choking incident. Nurse Manager B reported that Patient #5's friend and interpreter from the group home had shared information with staff on how to de-escalate some of Patient #5's known behaviors, however, the manager reported that the posted interventions were not included in the written plan of care.

Based on medical record review, policy review and staff interview, it was determined that the medical record for 1 of 6 (17%) patients in the sample (Patient #1) failed to contain accurate information. Findings include:

The hospital policy entitled "Documentation in the Medical Record" stated, "...Guidelines for Documentation...Make entries that are...consistent and avoid contradictions..."

A. Review of "Patient Care Flowsheet..." documentation for Patient #1 revealed the following observations:

- 2/25 at 12:00 AM - 2/26/10 at 4:00 PM
Right lower extremity (leg) edema: 5 entries by nursing staff documenting observable edema of the right lower extremity

- 2/26/10 at 8:00 AM
Nursing documented a problem with peripheral edema in the right leg (exact location of edema was not identified).

B. Interview on 3/10/10 at 2:11 PM with registered nurse (RN) #8 revealed the following:

RN #8 provided care to Patient #1 on 2/22, 2/23 and 2/24/10 and reported that she observed Patient #1's edema was "getting progressively worse". A call was placed to Physician A on one of the days identified above to report the observation because she was concerned about the possibility of a blood clot formation in the leg.

C. Review of the "Interdisciplinary Patient Progress Record" documentation revealed Physician A assessed Patient #1 on 2/22 at 11:34 AM, 2/23 at 8:27 AM, 2/24 at 9:15 AM and 2/25/10 at 9:35 AM. There was no documentation regarding the presence of peripheral edema in the right leg.

D. Review of the "Interdisciplinary Patient Progress Record" documentation dated 2/26/10 at 6:30 PM revealed that Patient #1 was discharged from the hospital to a long term care facility.

E. Review of the "Discharge Summary" completed by Physician A on 2/26/10 at 11:05 PM, revealed Patient #1 had no edema of the extremities on the day of discharge.

F. Review of the "Interdisciplinary Patient Progress Record" documentation dated 2/26/10 at 8:00 PM revealed that nursing received a call from the long term care facility reporting that Patient #1 was observed to have a swollen right knee.

G. Review of the long term care facility Nurse's Notes dated 2/26/10 at 9:00 PM revealed, "...(right) knee very swollen, red & hot & tender to the touch...back to hospital to R/O (rule out) septic knee, fracture or cellulitis..."

H. Patient #1 returned to the hospital and an x-ray of the right leg was performed. The radiology report dated 2/26/10 revealed a right distal femur (knee area) fracture. During an interview with Radiologist A on 3/10/10 at 9:55 AM, Radiologist A reported that he had reviewed the 2/26/10 film (x-ray) and confirmed the presence of an "acute fracture" that had occurred "within the last 48 hours" and was no older than a week.

On 3/8/10 at 2:25 PM, Surveyor A and Peer Case Review Specialist A reviewed the medical record and confirmed that the nurse and Physician A's documentation was contradictory.

Based on medical record review, policy review and staff interview, it was determined that the hospital failed to ensure that the medical record entries for 6 of 6 (100%) patients in the sample (Patient #'s 1, 2, 3, 4, 5 and 6), were dated, timed and signed. Findings include:

The hospital policy entitled "Documentation in the Medical Record" stated, "...Guidelines for Documentation...Date, time and sign entries as you make them..."

I. Patient #1 - Review of the "Interdisciplinary Patient Progress Record" revealed the following:

a. The year of medical record entry was not documented on the following dates: 1/25 at 3:55 AM, 1/30 at 6:20 PM, 1/31 at 10:22 AM, 2/1 at 2:40 PM, 2/23 at 6:35 AM, 2/25 at 2:45 PM and 2/26/10 at 2:15 PM

b. The time of medical record entry was not documented on the following dates: 1/26, 1/27, 1/28, 1/29 (3), 1/30, 1/31, 2/1, 2/24, 2/25 and 2/26/10 (2)

c. The year and time of medical record entries were not documented on the following dates: 1/27, 2/24 and 2/25/10

d. The date and time of medical record entry was not documented on: Continuation of an assessment note started on a new page (Physician B 1/31/10 progress note)

Surveyor A and the Corporate Director Patient Safety and Accreditation reviewed the 1/25/10 - 2/1/10 medical record on 3/10/10 at 10:45 AM and confirmed these findings.

Surveyor A and Patient Safety and Accreditation Coordinator A reviewed the 2/18 - 2/26/10 medical record on 3/15/10 at 9:50 AM and confirmed these findings.

II. Patient #2 - Review of the "Interdisciplinary Patient Progress Record" revealed the following:

a. The year of medical record entry was not documented on the following dates: 3/8 at 1:30 AM, 2:20 AM, 4:20 AM, 6:20 AM, 5:20 PM and 3/9 at 12:30 PM

b. The time of medical record entry was not documented on the following dates: 3/7 (2) and 3/8/10

c. The year and time of medical record entry was not documented on the following date: 3/8

d. The date and time of medical record entry was not documented on: Communication note to the physician

Surveyor A and Nurse Manager C reviewed the medical record on 3/11/10 at 11:00 AM and confirmed these findings.

III. Patient #3 - Review of the "Interdisciplinary Patient Progress Record" revealed the following:

a. The year of medical record entry was not documented on the following dates: 3/8 at 6:30 PM and 8:45 PM, 3/9 at 6:00 PM

b. The time of medical record entry was not documented on the following dates: 3/8, 3/9, 3/10 (2) and 3/11/10

Surveyor A and Nurse Manager C reviewed the medical record on 3/11/10 at 12:15 PM and confirmed these findings.

IV. Patient #4 - Review of the "Interdisciplinary Patient Progress Record" revealed the following:

a. The year of medical record entry was not documented on the following dates: 3/1 at 4:28 PM, 3/2 at 2:45 PM, 3/3 at 10:00 AM, 1:00 PM, 3/8 at 4:00 PM, 3/9 at 9:00 AM, 3/9 at 9:30 AM, 2:40 PM and 4:40 PM, 3/10 at 3:50 PM and 3/11 at 1:45 PM

b. The time of medical record entry was not documented on the following dates: 3/1, 3/2 (2), 3/5, 3/6 (3), 3/7 (3), 3/10 and 3/11/10

c. The year and time of medical record entry was not documented on the following date: 3/6

d. Review of "Discharge Planning Note" documentation revealed no timed entries by Oncology Social Worker A on the following dates: 12/17, 12/29/09, 1/12, 1/14, 1/18, 1/20, 1/26, 2/5, 2/9, 2/24, 2/26, 3/2, 3/3, 3/5, 3/9, 3/10 and 3/11/10

Surveyor A and Nurse Manager A reviewed the medical record on 3/11/10 at 2:10 PM and 3:00 PM and confirmed these findings.

V. Patient #5 - Review of the "Interdisciplinary Patient Progress Record" revealed the following:

a. The year of medical record entry was not documented on the following date: 2/9 at 11:30 AM

b. The time of medical record entry was not documented on the following dates: 2/6, 2/8 and 2/9/10

c. The date and time of medical record entry was not documented on: Continuation of a nursing note started on a new page (2/8/10 at 10:35 AM)

d. Review of the "Safety Companion Observation Record" revealed no documented year of entry into the medical record on the following dates and times:

2/6: 11:00 AM - 10:00 PM
2/8: 12:00 AM - 7:00 AM
2/9: 12:00 AM - 11:00 AM

e. Review of a written psychiatric "Consultation" revealed that the document was not dated, timed or signed.

Surveyor A and Peer Case Review Specialist A reviewed the medical record on 3/12/10 at 11:02 AM and confirmed these findings.

VI. Patient #6 - Review of the "Interdisciplinary Patient Progress Record" revealed the following:

a. The year of medical record entry was not documented on the following dates: 3/5, 3/6, 3/7, 3/8, 3/10 (4), 3/11 and 3/12

b. The time of medical record entry was not documented on the following dates: 3/4, 3/7 (2), 3/8/10 (2)

c. The year and time of medical record entry was not documented on the following dates: 3/9, 3/10, 3/11

d. Review of the "Center for Heart & Vascular Health Progress Record - Procedure Note" revealed no documented time of medical record entry for the 3/4/10 arteriogram.

Surveyor A and Nurse Manager A reviewed the medical record on 3/12/10 at 1:40 PM and confirmed these findings.

Based on medical record review, review of Medical-Dental Staff Rules and staff interview, it was determined that for 4 of 6 (67%) patients (Patient #'s 1, 2, 5 and 6) in the sample, verbal physicians' orders were not authenticated within 48 hours of receipt. Findings included:

The hospital document entitled "Medical-Dental Staff Rules" stated, "...Verbal orders shall be signed dated and timed by the originator...no later than 48 hours after the transmission of the verbal order...Telephone orders shall be signed, dated and timed by the originator within 48 hours of transmission of the telephone order and authenticated...within forty-eight (48) hours of transmission of the order..."

A. Patient #1

Review of "Doctor's Order Sheet" documents revealed:
- 4 entries (1/29, 2/19, 2/23 and 2/24/10) - Failed to include telephone order authentication

Review of the "Pharmacy Order Clarification for Nursing" documents revealed:
- 2 entries (1/31 and 2/19/10) - Failed to include telephone order authentication

On 3/10/10 at 10:45 AM, Surveyor A and the Corporate Director Patient Safety and Accreditation reviewed the electronic medical record information against the paper medical record and confirmed these findings.

B. Patient #2
Review of "Doctor's Order Sheet" documents revealed:
- 4 entries (3/6 and 3/8/10) - Failed to include telephone and/or verbal order authentication

On 3/11/10 at 11:00 AM, Surveyor A and Nurse Manager C reviewed the electronic medical record information against the paper medical record and confirmed these findings.

C. Patient #5
Review of "Doctor's Order Sheet" documents revealed:
- 1 entry (2/6/10) - Failed to include telephone order authentication

On 3/12/10 at 11:02 AM, Surveyor A and Peer Case Review Specialist A reviewed the electronic medical record information against the paper medical record and confirmed this finding.

D. Patient #6
Review of "Doctor's Order Sheet" documents revealed:
- 3 entries (3/6/10) - Failed to include telephone order authentication

Review of the "Medication Reconciliation Order Sheet..." revealed:
- 1 entry (3/9/10) - Failed to include telephone order authentication

On 3/12/10 at 1:30 PM, Surveyor A and Nurse Manager A reviewed the electronic medical record information against the paper medical record and confirmed these findings.