HospitalInspections.org

Based on observation, document review and interviews it was revealed facility staff failed to provide patients the right to have confidentiality of his or her clinical records by failing to maintain patient records in a secure manner. Staff failed to safeguard the contents of four (4) patient's medical records from unauthorized disclosure on two (2) out of three (3) intensive care units (ICU). This failure has the potential to adversely place all patients at risk for unauthorized disclosure of patient clinical records.

Findings include:

1. A tour was conducted on the Surgical Intensive Care Unit (SICU) on 5/22/19 at 9:25 a.m. Two (2) clipboards with patient clinical information (patients #31 and #32) was observed lying at an unsecured nursing station. A tour was conducted on the Medical Intensive Care Unit (MICU) on 5/22/19 at 9:33 a.m. Two (2) clipboards with patient clinical information (patients #33 and #34) was observed lying at an unsecured nursing station. A tour was conducted on the Surgical Trauma Intensive Care Unit (STICU) on 5/22/19 at 9:45 a.m. There were no clipboards in use and no unsecured patient information observed.

2. A review of Charleston Area Medical Center's (CAMC) policy Patients Bill of Rights and Responsibilities, publication date February 27, 2017, was conducted on 5/22/19. The policy in section six (6) states in part: "The patient has the right to expect that all communications and records pertaining to the patient's care will be treated as confidential by Hospital, except in cases such as suspected abuse and public health hazards when reporting is permitted or required by law."

Based on document review, clinical record review and interviews the medical staff failed to adopt and enforce bylaws to carry out its responsibilities by failing to render physician services in accordance with the medical staff bylaws/rules, regulation and policies. Medical staff failed to ensure prompt and accurate completion of the portion of the medical record for which he or she is responsible to document accurately. A review of patient #1's medical record revealed physicians and Advanced Practice Registered Nurses (APRNs) failed to accurately document the presence of a pressure ulcer (PU) on daily Critical Care Progress Notes assessments of patient #1 on nine (9) out of nineteen (19) daily assessments (1/7/19, 1/8/19, 1/9/19, 1/10/19, 1/11/19, 1/12/19, 1/13/19, 1/14/19 and 1/15/19) and on the discharge summary dated 1/15/19. This failure has the potential to place all patients at risk for ineffective quality and continuity of patient care.


Findings Include:

An incident report review was conducted on 5/21/19 of the incident report that was completed on 1/8/19 at 9:46 a.m. The incident report revealed the event occurred 1/7/19 affecting patient #1 with a stage two (2) PU located bilaterally on the buttocks with unopened blisters. The incident report shows there are interventions in place to prevent pressure injury of pressure redistribution surface, repositioning, hydration/nutritional support and skin care practices to prevent moisture and shearing.

A document review of the Medical Staff Bylaws, Policies and Rules and Regulations of Charleston Area Medical Center (CAMC), version 002-2018-03-28, was conducted on 5/21/19. The Medical Staff Bylaws, Policies and Rules and Regulations of CAMC on page three (3), section 2.E. Responsibilities of Attending Physician state: "(1) The attending physician will be responsible for the following while in the Hospital: (a) coordinating the medical care and treatment of the patient while in the Hospital, including appropriate communication among the individuals involved in the patient's care (including personal communication with other physicians where possible); (b) the prompt and accurate completion of the portions of the medical record for which he or she is responsible." The Medical Staff Bylaws, Policies and Rules and Regulations on page seven (7), Article III, Medical Records, 3.A. General states in part: "Each practitioner who is involved in the care of a patient will be responsible for the timely, accurate and legible completion of the portions of the medical record that pertain to the care he or she provides."

A document review of CAMC's policy Interdisciplinary Plan of Care (IPOC) published August 27, 2018 was conducted on 5/21/19. The IPOC section III, Procedure, states in part: "A. The attending physician is ultimately responsible for the patient's plan of care and will take the necessary steps during the course of the patient's treatment to see that arrangement for discharge are being made concurrently."

A clinical record review of patient #1 was conducted on 5/21/19. Physician #2 failed to accurately document and include documentation of a PU on the daily Critical Care Progress Note on 1/7/19, 1/8/19 and 1/9/19. Physician #3 failed to accurately document a skin assessment and include documentation of a PU on the daily Critical Care Progress Note on 1/10/19, 1/11/19, 1/12/19 and 1/13/19. APRN #1 failed to accurately document a skin assessment and include documentation of a PU on the daily Critical Care Progress Note on 1/14/19 and 1/15/19 and failed to accurately document a skin assessment and include documentation of a PU on the discharge assessment dated 1/15/19.

An interview with the Director of Nursing Practice Quality and Education was conducted on 5/22/19 at 1:42 p.m. When asked about physician's responsibility for skin assessment and documentation, the Director of Nursing Practice Quality and Education stated, "There are only certain things a Registered Nurse (RN) or a wound ostomy care (WOC) nurse can institute for interventions not needing orders" and further verbalized a RN might not need to tell a physician if there is a stage one (1) but if it is a stage two (2) or higher then a physician should be responsible for skin assessments and documentation.

An interview with physician #1 was conducted on 5/22/19 at 2:35 p.m. When asked about skin assessments physician #1 stated, "We usually don't document on wounds from the get-go, that's part of the nursing assessment." When asked when physicians are notified of pressure wounds, physician #1 stated, "When we round daily we have a checklist for quality metrics. Every morning between 10:00 a.m. and 11:00 a.m. we round daily with RN Coordinator, Dietary, Respiratory, Social Worker, Pharmacy and primary RN. The checklist is completed by the patient's RN to address patient concerns including skin breakdown for reporting." When discussing documenting PUs on daily progress assessments and discharge summarys, physician #1 verbalized physicians should be noting pressure ulcers on assessments and the expectation is physicians would have documented stage three (3) PU at discharge assessments.

Based on document review, clinical record review and interviews nursing staff failed to supervise the nursing care of patient #1 on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy. Nursing staff failed to notify the attending physician of a change in patient #1's skin condition of a developing pressure ulcer (PU). This failure has the potential to place all patients at risk for ineffective quality and continuity of patient care.

1. A document review of the Lippincott Procedures-Pressure Injury Prevention, last reviewed February 15, 2019, utilized by Charleston Area Medical Center (CAMC) was conducted on 5/22/19. The Lippincott Procedures-Pressure Injury Prevention in section Documentation states in part: "If a pressure injury develops, note changes in the condition or size of the pressure injury and elevations of skin temperature. Document when the practitioner was notified of pertinent observations of abnormalities, interventions performed and the patient response to interventions."

2. A document review of CAMC's policy Interdisciplinary Plan of Care (IPOC) published August 27, 2018 was conducted on 5/21/19. The IPOC section III, Procedure, states in part: "B. The Registered Nurse in the in-patient setting coordinates the IPOC activities," and "C. 2. Needs Assessment. Appropriate members of the health care team will evaluate the patient needs as warranted by the patient's diagnosis and condition during Multi-Disciplinary Team Rounding (MDTR)/discharge planning activities/meetings in all settings. Discipline specific detail notes will be documented in designated sections of the medical records."

3. A clinical record review of patient #1 was conducted on 5/21/19. Nursing notes were reviewed. There is lack of documentation of when the physician was notified patient #1 developed a PU. Registered Nurse wound skin assessments document a stage two (2) pressure wound on 1/7/19, 1/8/19, 1/9/19 and 1/10/19, a pressure wound stage three (3) on 1/11/19, 1/12/19, 1/13/19 and 1/14/19 and a pressure wound deep tissue injury (DTI) on 1/15/19.

4. An interview with RN #1 was conducted on 5/21/19 at 1:07 p.m. When asked if the physician was notified, RN #1 verbalized she was not sure how the physician gets notified.

5. An interview with the Corporate Director of Patient Safety and Risk was conducted on 5/22/19 at 9:55 a.m. When asked how physicians are notified of patient's pressure wounds the Corporate Director of Patient Safety and Risk stated, "I would think basic nursing practice that the nurse would inform the physician."

6. An interview with the Nursing Practice Director of Innovation and Informatics was conducted on 5/22/19 at 1:15 p.m. When asked how physicians are notified of patient's pressure wounds the Nursing Practice Director of Innovation and Informatics verbalized there isn't an automatic notification to physicians and nurses aren't notifying physicians in rounding. The Nursing Practice Director of Innovation and Informatics further stated, "RN should notify physicians that a patient has a wound. We recognize it doesn't occur. The hope is that it will be automated."