HospitalInspections.org

Based on interview, review of medical records and other documents, it was determined that the nursing staff failed to implement facility's policy and procedures to ensure safe delivery of care. This finding was noted in 1 of 10 applicable records reviewed (Patient #3).

Findings include:

Patient #3 is a 42 year old male admitted to the facility on 12/02/14. On 12/04/14 at 3:44 PM, physician ordered one fleet enema to be administrated to the patient if no flatus after Ducolax suppository or lactulose.

On 12/04/14 at 5:12 PM RN Progress Notes indicated the patient was given suppository as ordered with no bowel movement result and then received Fleet enema as ordered. The nurse noted small watery bowel movement and drops of blood were noticed on toilet. On 12/04/14 at 5:15 PM physician ordered Occult Blood Specimen which was negative.

The facility's policy titled Management of the Patient with Alteration in Bowel Function, last reviewed February 2015, notes, in section 4b, that if Fleet Enema is to be administered, "place patient to left side lying or knee chest position".

The Nursing staff failed to administer the enema in accordance with facility's policy and procedure. The Facility investigative report notes the patient was neither in a side lying nor in a knee chest position when the enema was administered.

At interview on 04/21/15 at approximately 11.30 AM, Staff #1 stated that the enema was administered incorrectly, while the patient was in a standing position in the bathroom.

Based on medical record and policy review, it is determined the facility failed to implement its post-operative re-assessment policy to ensure that patients experiencing urinary retention are treated in a timely and safe manner.

Findings include:

Review of medical record #1 on 4/28/15 determined a 75 year old male with a history of Benign Prostatic Hypertrophy underwent a right Total Hip Replacement and Makoplasty on 9/5/14. The Foley catheter which was placed during surgery, was removed prior to the patient being sent to the medical floor.

Nursing staff did not follow the hospital's policies for re-assessment after removal of indwelling catheters. Review of policy on 4/28/15 titled: "Management of the Adult Patient Requiring an Indwelling Urinary Catheter, Indwelling catheter, Indwelling Catheter Removal, Bladder Scan and Intermittent Urethral Catheterization", found that "Nursing assessment determines adequacy of bladder emptying after urinary catheter removal. A nurse driven algorithm can be used to identify and address potential urinary retention".

Per hospital policy, staff are required to assess the patient for voiding of urine after six hours. A"nurse driven" algorithm designed to guide nursing actions was not followed.

Nursing staff did not document their assessments in the medical record. Staff did not consistently document the patient's input and output from 9/5/14 to 9/8/14.