HospitalInspections.org

Based on document review and interview, it was determined that the facility staff failed to follow it's policy to access and document output for one (1) of two (2) Patients, (Patient (P) # 1).

The findings include:

On May 31, 2023 at 9:45 a.m., a Clinical Record review for P # 1 revealed the following:

On March 20, 2023 at 8:50 p.m. "Patient arrived in ED."

At 8:59 p.m., an ED (Emergency Department) triage note reads in part "Pt arrived EMS (Emergency Medical Services) with c/o (complaint of) lightheadedness since 4:30 a.m. this morning. Pt states it is getting better since this am. Pt alert and oriented X 4, able to move all extremities equally, and answer triage questions in full."

At 11:33 p.m. "purewick placed."

On March 21, 2023 at 9:40 a.m., "discharged."
ED disposition "transferred to another facility."

There was no documentation of urine output after placement of the purawick.
There was no documentation of any complaints of discomfort by P # 1.

On May 31, 2023 at 10:15 a.m. when questioned about documentation, Staff Members (SMs) # 3 and # 4 confirmed "there was no documentation of output or discomfort by P # 1."

On May 31, 2023 at 10:10 a.m., a review of the facility policy titled "External Urinary Management" reads in part "The RN/LPN maintains responsibility for the implementation and maintenance of the urinary incontinence system. No provider order is required. Indications for use include, but are not limited to: Patient with urinary incontinence. Provide perineal care with the barrier cream wipe before placing a new wick and when replacing the wick.
Documentation. Record urine output."

On May 31, 2023, the findings were discussed with SMs # 1, # 2, # 3 and # 4 during the exit interview.