HospitalInspections.org

Based on record review and interview, the facility failed to ensure the registered nurse followed the nursing process for each patient by failing to follow physician's orders including securing an order for discharge for 1 (Patient #3) of 3 closed records reviewed.

The findings include:

Review of records for Patient #3 reveals an admission date of 9/28/09. Patient #3 had surgery on 9/29/09 for a left total hip replacement. The patient improved and on 9/30/09 the physician ordered the patient to be discharged to rehab on 10/1/09. Patient #3 developed an elevated temperature and also required a blood transfusion. Discharge was postponed. On 10/2/09, a physician's order was received to discharge to rehab but again abnormal labs required a transfusion and further testing. The discharge was again postponed. On 10/3/09, a third transfusion was required and the patient was not able to be discharged. There are no further physician's orders available for review. Patient #3 was discharged from the facility on 10/4/09. There is no physician's order for discharge on 10/4/09 in the medical record.

Interview with the quality manager on 7/21/09 at 11:00 a.m. reveals medical records prior to 2010 are maintained in an off-site facility in another city. Records received for review were received at various times throughout the survey via fax. Part of the record is maintained electronically in the facility and was easily obtained. The hand written documentation is not maintained locally. Physician's orders for Patient #3 were requested 3 times from the storage facility and the same documentation was received each time. A specific request was made for physician's orders for 10/4/09 and again the same orders were received which stopped on 10/3/09. There were no physician's orders for discharge from the facility on 10/4/09. The quality manager confirmed there was no physician's order to discharging the patient from the facility.