HospitalInspections.org

Based on a review facility documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure that the medical record contained information to describe the patient's progress and response to services for one of 16 medical records reviewed (MR1).

Findings included:

Review of facility policy "Guidelines For Charting" last reviewed August 2011 revealed "...Sunrise Documentation Standards 1. S total systems assessments is required at the beginning or each shift and with any major alteration in patient condition...2. Individual systems documentation will occur throughout the shift as changes occur or indications are present... ."

Review of facility policy "Guidelines For Sunrise Charting" last reviewed August 2012 revealed "...D. 1. Assessments are completed by the Registered...Assessments must be completed every shift. Assessments should be updated as the patients condition changes..."

Review of facility policy "Draining Fistulas" last reviewed August 2011 revealed "...observe intact collection system/dressing and character of fistula drainage q shift..."

1) Review of CR1 physician progress note dated May14 th (no year) at 11:36 AM by revealed "...non-healing Stamm gastrostomy site now (with) "stoma" formation...16 fr(ench) Foley placed into stoma to divert stomach content to allow excoriated skin to heal better. Will follow."

2) Review of EMP16 progress note dated 5/14/12 at 11:45 AM revealed "Called for pouching of Stamm gastrostomy site stoma now present via skin and rest @ or just above skin level...CR1 placed 16 fr(ench Foley filled balloon into stoma "gastrostomy track" to divert secretions into pouch...placed Foley into pouch and applied ...pouch to drainage bag... ."

3) Review of Medical Record -Flowsheets Nursing documentation by EMP12 dated 5/14/12 at 12:00 revealed "Incision wound care collection bag applied by ACS and ET RN Foley inserted by ACS into wound..."

4) A subsequent review of all Medical Record-Flowsheet nursing documentation up through May 23, 2012, at 1600 revealed no documentation that indicated a Foley drainage tube was observed extending from the MR1's stoma site.

5) Review of facility email correspondence from EMP11 forwarded to this Department dated June 20, 2012, at 3:03 PM revealed "After a thorough review of the patient's medical record (MR1) and interviews with staff members, including...The last nursing documentation of the tube's presence was during 11pm-7am shift on May 15, 2012... ."

During interview on June 25, 2012, at approximately 10:30 AM EMP9 confirmed the above findings and revealed "...EMP12 is the only nurse that documented observing the drainage tube... ."