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Based on interview and medical record review, the facility failed to ensure a registered nurse or physician assistant evaluated the nursing care for one of ten patients reviewed (Patient #1). This could affect all patients receiving services from the facility. The census was six.

Findings include:

The medical record review for Patient #1 was completed on 09/09/21. The patient came to the facility for an outpatient full left hip replacement on 06/07/21. The medical record review revealed an operative note dated 06/07/21 at 12:42 PM that stated the patient was diagnosed with severe symptomatic arthritis of the left hip, and the operative procedure was a left total hip arthroplasty.

Review of the anesthesia record dated 06/07/21 completed on 09/09/21 revealed the patient entered the operating room at 12:42 PM and left the operating room at 2:41 PM. The patient received one liter of lactated ringers during the procedure and a second bag of lactated ringers was begun at 2:50 PM and infused at a rate of 100 milliliters/hour.

The medical record review revealed the patient arrived on the acute care unit on 06/07/21 at 3:33 PM. The review revealed a nursing assessment at that time found the patient in no pain.

On 06/07/21 at 4:28 PM lactated ringers was stopped and at 4:42 PM an intravenous infusion of normal saline at 75 milliliters/hour was begun. The medical record review did not reveal when the normal saline infusion was stopped, but did reveal the patient's intravenous access was pulled on 06/08/21 at 9:05 AM.

It was not clear how much of the normal saline had been infused

On 09/09/21 at 2:47 PM in an interview, Staff A was unable to locate in the medical record when the normal saline infusion stopped.

The medical record review revealed on 06/07/21 at 4:28 PM the patient was toileted and voided 50 milliliters (ml) plus an unmeasured amount.

The medical record review did not reveal that the toileting had occurred. Therefore the length of time the patient spent on the commode was not known. The clinical record did not record any urine output on or about 6:00 PM.

The medical record review revealed at 8:26 PM the patient's pain was recorded at seven out of 10, with 10 being the worst pain. The clinical record did not reveal where that pain was, but did reveal the patient was medicated with two pain pills.

The medical record review revealed a physician's order dated 06/07/21 at 10:29 PM that directed staff to "straight cath as need for distended bladder, inability to void." The medical record review revealed at midnight a bladder scan revealed the bladder was holding 996 ml of fluid, and the patient was catheterized for one liter.

On 09/09/21 at 8:41 AM in an interview, Staff B said she was the nurse with the patient at around 6:00 PM. She said she assisted the patient to a bedside commode on or about 6:00 PM. She said she found the patient pleasant and conversational and the patient was alert, oriented, and completely cognitively intact. Therefore, not wanting to stand over patient while they were trying to void, she left the patient with a call light with instructions to call when done. She said at shift change (6:30 PM) she notified the relieving nurse about the patient being on the bedside commode trying to void.

On 09/09/21 at 9:00 AM, in an interview, Staff A confirmed the clinical record did not contain an entry pertaining to the attempted void at around 6:00 PM.

On 09/09/21 at 11:55 AM the nurse for the patient on 06/07/21 at 7:00 PM, Staff C, was interviewed. The nurse said he remembered being told by the nurse he was relieving at change of shift that the patient had recently left post op, and had voided little since coming to the unit. He said he could not remember where the patient was having pain. He confirmed the clinical record revealed that at 7:18 PM on 06/07/21 the patient's abdomen was assessed as normal. Further interview with Staff C revealed the clinical record was incorrect and that he actually catheterized the patient shortly after the order was written. He said prior to performing the bladder scan, he palpated the lower abdomen and found it to be obtunded.

The medical record documentation indicated the patient voided 50 ml plus an unmeasured amount between 4:28 PM and midnight after the patient received over 1000 ml of fluid and before the patient was straight catheterized for 1000 ml of urine.

This substantiates Substantial Allegation OH00125074.