HospitalInspections.org

Based on interviews and record reviews, it was determined the facility staff failed to ensure documentation was completed in a timely manner and failed to ensure the integrity of the documentation for 1 of 10 sampled patients (Patient #5).

The findings include:

Patient #5's 'ED Provider Notes' for the 10/14/13 emergency department (ED) visit was not signed/filed until 10/21/13 and the 'ED Provider Notes' were maintained in a manner that made changes to the document difficult to identify.

The following information was found in the facility's 'MEDICAL STAFF POLICIES': "All entries in the medical record shall be legible, contain pertinent, meaningful observations, and information dated, timed and authenticated by the person making the entry. Documentation should be done as soon as possible after each occurrence."

Patient #5's clinical record included 'ED Provider Notes' which were documented with a 'note time' of 10/14/13 at 7:13 PM and a 'filed'/'signed' date of 10/21/13 at 4:32 PM. During an interview with the eCare Physician Liaison (eCPL) on 6/11/14 at 11:30 AM, the eCPL reported the aforementioned note could have been started on 10/14/13 and not filed until 10/21/13. The eCPL was asked about possible changes to the documentation prior to it being filed on 10/21/13; the eCPL reported that an audit trail does not start until the documentation is filed therefore changes, if occurred, would not be captured.

This same 'ED Provider Notes' indicated the documentation had been revised twice in just minutes after being filed on 10/21/13 at 4:32 PM. Review of the 'ED Provider Notes' failed to reveal what changes were made. The eCPL reported that to identify what changes were made each revision of the documentation would have to be printed and compared 'word for word' to find the changes. The eCPL stated that an upgrade was planned for March of 2015 to allow for the changes in documentation to be captured in the document instead of having the new/revised information replace the previous/changed information in the document.

Based on interviews and record reviews, it was determined the facility staff failed to document information about care provided to 1 of 10 sampled patients (Patient #5).

The findings include:

Patient #5's oral intake was not documented until the patient's family questioned the care the patient was receiving; Patient #5's discharge documentation did not include what information was reported to staff at the assisted living facility where the patient lived.

1. Review of Patient #5's clinical record indicated the patient arrived at the emergency department on 10/15/13 at 10:56 AM. Patient #5 was in the emergency department (ED) until he/she was placed in an observation bed in another department on 10/16/13 at 2:55 AM.

The following nursing documentation was found in Patient #5's clinical record: 10/15/13 at 8:33 PM - "(Adult child and adult child's spouse) at bedside, upset with care pt has been given. This author reassured family that patient has been watched and rounded on all day, been provided with water as needed. Care Coordination has been making arrangements for patient [sic] to have personal assistant at (assisted living facility). Pt placed on hospital bed, given meal. Positioned for comfort. Family is in possession of call bell at this time."

During an interview on 6/11/14 at 10:20 AM, Staff Member #16 (ED Director of Critical Care) questioned if oral intake was restricted due to the patient's condition. The absence of a physician order, during this emergency department stay, for Patient #5 to not be given oral intake was discussed; an order for Patient #5 to not be given anything by mouth was not found by nor provided to the survey team. The aforementioned nursing note (dated 10/15/13 at 8:33 PM) indicated Patient #5 was able to have oral intake during his/her stay in the ED.

During an interview on 6/11/14 at 11:20 AM, Staff Member #5 stated this was the only documentation found during the emergency department stay related to providing the patient food or liquids.

During a survey team meeting with facility staff members, that included the Nurse Administrator, Patient Safety/Accreditation Coordinator, Vice-President of Medical Affairs, President, and Nursing Director, the absence of documentation of Patient #5's oral intake until questioned by the patient family was discussed for a final time; no additional information was provided to the survey team.

2. A nursing note signed on 10/14/13 at 11:10 PM provided the following information: "Spoke with (staff member name/initials at the assisted living facility) at (assisted living facility's name omitted) and made aware that resident is returning [sic]." No documentation was found to detail what information the hospital staff provided the assisted living facility staff.

A nursing note, signed on 10/15/13 at 1:44 AM, provided the following information: "... Condition stable ... Patient discharged to nursing home ... Patient education was completed: N/a [sic] (not applicable): Severe dementia ... Education taught to: n/a ... Teaching method used was n/a ... Understanding of teaching was n/a ..."

Discharge instructions were found in Patient #5's clinical record. These instructions included information/guidance related to "stroke". This instruction form had areas to be signed by the 'patient' and 'provider'; no signatures were found in these areas. During an interview on 6/11/14 at 9:45 a.m. with Staff Member (SM) #5, SM #5 reported that a signed copy of the discharge instructions was not found.