HospitalInspections.org

Based on medical record review, interview, and policy review, nursing staff are not documenting intake and output per provider order for per facility policy for one of twenty three patients (Patient #1).

Findings Include:

Review on 08/289/23 of the medical record for Patient #1 revealed the following:
- On 12/30/21 at 05:37 PM, Provider Order revealed strict intake and output every shift.
- On 01/13/22 at 01:26 PM, Provider Order revealed nutritional supplement two times a day at breakfast and lunch.
- From 12/30/21 to 01/21/22, Nursing Flowsheets revealed no evidence strict oral intake/output was documented on 12/30/21, 01/01/22, 01/08/22, 01/14/22, and 01/17/22.
- From 01/14/22 to 01/15/22 and 01/17/22 to 01/22/22, Nursing Flowsheets revealed no evidence that nutritional supplement intake was documented twice daily per provider order and facility policy.

Interview on 08/29/23 at 08:40 AM with Staff (S), Registered Dietitian revealed "I would absolutely expect to see nutritional supplement intake documented in the flow sheet."

Review of policy "Crisis: Documentation Requirements" dated 12/2020 revealed the policy requirements go into effect when there is substantial change in usual healthcare operations. There may be times of unusually high demand on nursing resources, which require flexible medical record documentation to enable staff to prioritize direct patient care. Performance and outcome of ordered interventions are to be documented by the end of shift. The attachment titled "COVID 19 Crisis Documentation Requirements" with a table of documentation requirements for all areas, indicates there is "no change" to documentation requirements for vitals, weights, intake, and output.

Interview on 10/13/23 at 01:30 PM with Staff (GG), Senior Director of Quality, stated the policy in effect "No Change" in the Crisis: Documentation Requirements," means staff are to follow the physician order. In this case, the intake/output should be documented by staff every shift.

Based on policy review, medical record review, and interview, nursing staff do not assess and/or reassess pain when providing pain medication for one of twenty three patients (Patient #1).

Findings Include:

Review of policy "Pain Management Policy" last revised 01/2022 indicates assessments, re-assessments, and treatments for pain will be documented in the patient 's medical record, including date and time.

Review of policy "Pain Management Procedure" last revised 01/2022 indicates staff are to evaluate the effectiveness and side effects of the pain treatment through a focused pain reassessment. Complete reassessments within sixty minutes of administering as needed pain medications. Document the following information: Pain reassessment- answer yes or no; pain scale; intensity; and acceptable to patient.

Review on 08/28/23 of the medical record for Patient #1 revealed the following:
- On 12/30/21 at 05:37 PM, Provider Order revealed Tylenol 650 mg was ordered every six hours as needed for mild pain (pain of 1-4).
- On 01/12/22 at 08:35 AM, Provider Order revealed Dilaudid 0.5 mg injection was ordered as a onetime occurrence and Oxycodone 5 mg tablet was ordered every 6 hours as needed. Oxycodone 5 mg tablet ordered every six hours as needed for mild pain (pain of 5-7) and Oxycodone 7.5 mg tablet ordered every six hours as needed for severe pain (pain of 8-10).
- From 01/10/22 to 01/22/22, the Medication Administration Record revealed Tylenol 650mg was signed out as administered on 01/11/22 at 11:30 PM; 01/12/22 at 06:48 AM, and 06:42 PM; 01/21/22 at 08:54 AM; and 01/22/22 at 08:25 AM. Dilaudid 0.5mg was signed out as administered on 01/12/22 at 09:07 AM. Oxycodone 5mg was signed out as administered on 01/12/22 at 05:07 PM and 01/13/22 at 07:58 AM.
- From 12/30/21 to 01/22/22, there was no pain assessment documentation completed on 1/11/22 at 11:30 PM or 01/12/22 at 06:48 AM. Additionally, there was no pain reassessment documented within sixty minutes of pain medication administration on 01/11/22 at 11:30 PM; 01/12/22 at 06:48 AM; 01/12/22 at 09:07 AM; 01/13/22 at 07:58 AM; 01/21/22 at 08:54 AM; and 01/22/22 at 08:25 AM.

Interview on 8/28/23 at 04:00 PM with Staff (E), RN Director of Clinical Practice, verified these findings.