HospitalInspections.org

Based on interview, documentation in 4 of 4 medical records reviewed of patients (Patients 1, 2, 3 and 4) who required nursing services, and review of policies and procedures, it was determined the hospital failed to ensure that the registered nurse supervised and evaluated the patient's nursing care needs in accordance with physician's orders and policies and procedures in the following areas:
* I&O monitoring;
* Fluid restrictions;
* Weight monitoring;
* Vital signs; and
* Labwork.

Findings included:

1. The medical record for Patient 1 was reviewed and reflected the patient was admitted to the hospital on 05/05/2014 at 1450 with a diagnosis of bipolar disorder and a traumatic brain injury.

Physician orders dated 01/12/2015 reflected an order for I&O charting and a fluid restriction of 2500cc/day.

There was no documentation reflecting that the patient's fluid intake was recorded for the following dates:
* 01/12/2015 through 01/16/2015; and
* 01/19/2015 through 02/01/2015.

There was no documentation reflecting the patient's fluid output was recorded.

There was no documentation reflecting the RN monitored and evaluated the patient's fluid restriction in accordance with the physician's order.

RN progress notes dated 02/01/2015 reflected "At 0215...found pt having a seizure...Pt convulsed for approximately 1-2 minutes, then stopped, but was still not responding to staff...After about 10 minutes, pt began having another apparent seizure...911 was called...pt began second seizure...Emergency transport arrived and took pt to [Salem Hospital] ED. Per report from staff with pt, Labs showed low [sodium] at 109..."

These findings were verified with the RN on 05/21/2015 at 1505.

2. The medical record for Patient 2 (the same patient who was transferred to Salem Hospital on 02/01/2015 above) was reviewed. The record reflected the patient was re-admitted to the hospital on 02/07/2015 with a diagnosis of hyponatremia-induced seizure.

The physician's orders dated 02/07/2015 at 1430 reflected orders for I&O charting and a fluid restriction of 3 Liters/day.

The record lacked documentation reflecting the physician's orders for I&O charting and fluid restriction were carried out. Examples included but were not limited to the following:
There was no documentation reflecting that the RN recorded the patient's I&O, or that the RN monitored and evaluated the patient's fluid intake with respect to the physician's order for a fluid restriction, from 02/23/2015 through 05/20/2015.

Physician orders dated 02/09/2015 at 1555 reflected "weigh twice a day X 7 days. Record in [medical record]."

Review of the record reflected no weights were recorded on 02/09/2015, 02/10/2015 and 02/11/2015; and only one weight was recorded on 02/17/2015.

These findings were confirmed with the RN on 05/21/2015 at 1300.

During an interview on 05/21/2015 at 1500 the Interim RN Supervisor stated that Patient 1 was on a fluid restriction in order to manage his/her sodium level. He/she stated that when the patient's sodium level dropped, the patient became more agitated and experienced seizures.

During an interview on 05/26/2015 at 1630 the Interim CNO acknowledged the medical record lacked documentation of I&O monitoring. He/she stated that staff were not recording patient I&Os as they should be.

3. The medical record for Patient 3 was reviewed. the patient was admitted to the hospital on 06/09/2014 with a diagnosis of hypertension and diabetes mellitus.

Physician's orders dated 03/20/2015 at 1410 reflected "...Track po fluid intake [for] 1 week - goal is 1500-2000cc/24 [hours]."

There was no documentation that the RN tracked and evaluated the patient's fluid intake with respect to the fluid goal in accordance with the physician's orders.

A physician's order dated 03/30/2015 at 0915 reflected that the patient's vital signs were to be taken every 4 hours during the day.

The record lacked documentation reflecting vital signs were taken in accordance with the physician's order. Examples included but were not limited to the following:
* On 04/01/2015, the only vital signs recorded were at 0700 and 2000;
* On 04/03/2015, the only vital signs recorded were at 2000; and
* On 04/04/2015, the only vital signs recorded were at 0700.

These findings were confirmed with the Clinical Informaticist on 05/26/2015 at 1320.

4. The medical record for Patient 4 was reviewed. The patient was admitted to the hospital on 05/07/2013 with a diagnosis of polysubstance abuse and schizophrenia.

Physician orders dated 05/12/2014 at 1301 reflected that a lipid panel was to be completed every 3 months.

Physician progress notes dated 08/14/2014 at 0807 reflected "...triglycerides are quite high at 422. [His/her] prior was high in the high 200's...the elevating triglyceride level is certainly concerning..."

The record reflected a lipid panel was completed on 08/14/2014.
The record reflected the next lipid panel was not completed until 01/06/2015 at 0730. This was confirmed with the Clinical Informaticist on 05/26/2015 at 1340.

There was no RN documentation to reflect why the lipid panels were not completed in accordance with physician's orders, and there was no documentation to reflect that the physician was notified.

5. An interview was conducted with the Interim CNO on 05/26/2015 at 1345. He/she stated that nursing staff were responsible for ensuring labwork was collected in accordance with physician's orders. He/she stated that if a lab was not collected as ordered, then nursing staff were responsible for notifying the patient's physician and documenting in the medical record that the lab was not completed and that the physician had been notified. He/she confirmed there was no documentation in the record reflecting this had been done.

6. The policy and procedure titled "Plan for the Provision of Nursing Care" dated 02/20/2015 reflected the following: "The RN collects information with which to assess the patient's mental and physical health status through observations...Observations will include...Collecting data with which to assess the patient's health status utilizing a comprehensive system review methodology on admission, at organizationally determined intervals and upon any significant change in the patient's status...Recording assessment data in order to establish a functional baseline and to facilitate the sharing of relevant information...Analyzing data to identify and prioritize problems...Documenting assessment findings and analysis...The RN continually assesses/re-assesses the patient's health status, evaluating responses to nursing interventions and progress toward achievement of identified goals...Re-assessing the patient's health status on an ongoing basis to determine whether existing problems have resolved and/or new problems have developed..."

The policy and procedure titled "Intake/Output Monitoring" dated 02/26/2014 reflected the following: "Nursing personnel will monitor and document patient intake and/or output as ordered or when there is a reason to believe that an issue exists or is developing." The procedure section of the policy reflected "Obtain Intake/Output Flowsheet...Measure and record all intake and output values, including intermittent catheterizations and tube feedings...All entries must be dated and timed...Input and output must be totaled in milliliters and recorded on the Flowsheet at the end of each shift...24-hour totals must be recorded where indicated, at the end of night shift...Record any comments in the corresponding box. Fluid restrictions...should be noted here...Sign after each completed entry..."

The policy and procedure titled "Clinical Documentation" dated 02/23/2015 reflected the following: "A patient's medical record is...maintained for purposes of communication, accountability, and coordination of care and services provided to a patient...Clinical documentation contained in the medical record references...staff interventions and observations regarding patient response to interventions, and records progress related to individual patient treatment care plan (TCP) goals...Clinical findings and observations must be recorded clearly, concisely, and in a timely manner...Clinicians in each discipline must complete and document required assessments and progress notes...Each clinician is responsible for accuracy and necessity of documentation in the medical record..."