HospitalInspections.org

Based on record review and interview the facility failed to perform a nursing assessment in response to patient care needs and evaluate interventions prior to discharging a patient in 1 of 5 mom/baby records reviewed (Pt #6) in a total sample of 10 records reviewed.

Findings Include:

Review of policy and procedure titled, "Assessment of the Postpartum Vaginal Delivery Patient" last revised 10/2020 stated, "The nurse possesses the knowledge and skills to care for a postpartum patient. The nurse partners with the patient and OB (obstetrics) provider to monitor warning signs and provides timely management of problems when they occur." Per policy assessments, interventions, and communications should be documented in the electronic medical record. Policy stated Vital signs (blood pressure, pulse, respirations) are assessed every 8 hours, frequency is increased based on patient status.

Review of policy and procedure titled, "Pain Management" last reviewed 03/2021 stated that documentation in the electronic medical record includes, as appropriate, the following:
1. Results of pain/comfort screenings, assessments, and reassessments,
2. Plan for managing pain or discomfort
3. Interventions provided, rationale as applicable for interventions, and outcome of interventions
4. Patient education and discharge instructions including plan for managing pain or discomfort and potential side effects of pain/discomfort management treatment.

Review of Medical Doctor (MD) X progress note dated 04/20/21 at 2:58 pm, X stated that Patient (Pt) #6 was having chest pain and Pt #6 "thinks" it is Gastroesphageal Reflux disease (GERD). Per MD X's progress note, Pt #6 "has restarted Famotidine (acid reducer) but hasn't helped yet. Will try tums. If still having symptoms would recommend getting ECG (electrocardiogram)."

Review of Pt #6's Medication Administration Report revealed Pt #6 was given Tums for "Heartburn" on 04/20/21 at 3:19 pm and then given a one time dose of a GI (gastrointestinal) Cocktail at 3:47 pm. Review of Pt #6's nursing assessments and progress notes revealed no documented evidence of a nurse assessment and evaluation of Pt 6's complaint of chest pain/discomfort including but not limited to; type of pain, location, intensity, onset, and pain scale rating. Medication was administered to Pt#6 to address chest pain/discomfort but there was no documented evidence of a reassessment of Pt #6's chest pain/discomfort to evaluate if the interventions were effective or if symptoms were still present. Pt #6 was discharged from the facility at 4:27 pm.

Per review of Pt #6's nursing assessments/interventions revealed the last vital signs were completed on 04/20/21 at 8:09 am. This was more then 8 hours from when Pt #6 was discharged at 4:27 pm. Per policy vital signs should be completed every 8 hours and increased based on patient status.

Review of obstetrics and gynecology progress notes dated 04/21/21 at 9:20 am (day after discharge), revealed Pt #6 spoke with a registered nurse via telephone. Pt #6 complained of "...experiencing a pain/chest tightness and discomfort, along with shortness of breath...this started yesterday." Per the nurses progress notes, Pt #6 was advised to go to the emergency department for further evaluation.

Per interview with Manager G on 06/02/21 at 12:35 pm, G stated if a patient is experiencing pain this should be documented in the nursing assessments. G confirmed there was no pain assessment/reassessment documented for Pt #6's complaint of chest pain/discomfort prior to discharge. When asked if vital signs should be checked if a patient is complaining of chest pain, G responded "Yes" vital signs should be assessed by the nurse if a patient is complaining of chest/pain discomfort. G confirmed there were no vital signs documented in the nursing assessments after Pt #6 complained of chest pain/discomfort and prior to patient being discharged.

Based on record review and interview the facility failed to ensure all consultants document patient evaluation and plan in the medical record in 1 of 5 records reviewed with a consultation (Pt #7) in a total sample of 10 records reviewed.

Findings Include:

Review of Medical Staff Bylaws last revised 01/2021 revealed, "A written or dictated opinion signed by the consultant must be included in the Medical Record." "In addition to the consult note, the consultant will verbally contact the requesting provider with patient management recommendations." Per review of the Medical Staff Bylaws, routine consults should be completed within 24 hours of the request.

Review of Medical Doctor (MD) O's progress notes dated 04/20/21 at 3:35 pm revealed due to Patient (Pt) #7's increased Bilirubin, Pt #7 needed intensive phototherapy and a double volume exchange transfusion. MD O's progress notes dated 04/20/21 at 3:35 pm stated, "Discuss with hematology for any further recommendations or insights." MD O's progress notes dated 04/21/21 at 2:20 pm stated, "Awaiting results of G6PD (enzyme in blood that help red blood cells function normally) evaluation." MD O's progress notes dated 04/22/21 at 12:14 pm stated, "We will discuss with hematology timing of the repeat G6PD testing." MD O's progress notes dated 04/23/21 at 12:25 pm stated, "We have discussed further evaluation and work-up with hematology. They would anticipate following up with her in a month as an outpatient."

In progress notes dated 4/20/2021-4/23/2021, MD O documented that there would be discussions with Hematology for further recommendations, evaluations, and work up. Pt 7's medical records showed no documented evidence of a Hematology assessment, evaluation, and/or plan documented from 04/20/21 to 04/26/21. There was no documentation of a Hematology consult order placed until 4/26/2021 (6 days after birth) when MD W assumed Pt #7's care.

Per interview with Chief of Medical Informatics T (covering for Chief Medical Officer) on 06/3/21 at 2:30 pm, T stated that he/she would expect consults to assess and/or evaluate patient within 24 hours of a request for consult and to document a consult note in the patient's medical record.

Per interview with Nurse Manager F on 06/02/21 at 3:19 pm during medical record review, F stated that he/she was unable to find documentation of a Hematology consult note from 04/20/21 to 04/26/21.

Based on record review and interview the facility failed to ensure that the parent and/or legally authorized patient representative sign an informed consent for procedures in 1 of 2 records with consents for procedures (Pt 7) in a sample of 10 records reviewed.

Findings include:

Review of policy and procedure titled, "Consents, Agreements, and Refusals: Minors" last reviewed 03/2021 revealed, "In all cases where a patient's agreement or refusal is being sought, the patient or his/her legally authorized representative must be provided with sufficient information to make an informed decision. Certain treatments, procedures, agreements, and refusals require consent/refusal to be completed and documented on the appropriate approved (facility) form." This policy stated, "All informed consent discussions and their content must be documented and placed in the patient's medical record."

Review of the Medical Staff Bylaws last revised 1/2021 revealed, "Informed consent must be obtained from the patient or legally authorized representative before performing invasive procedures that involve anesthesia or procedures and treatments with risk of harm, except in emergencies." The bylaws stated, "Informed consent means the practitioner has provided the patient with an explanation of the procedure, what the procedure is expected to accomplish, the major risks and benefits, the possibility of complications and reasonable alternatives available. Proof of such consent shall be documented by a dated and signed consent form."

Review of the policy and procedure titled, "Exchange Transfusion--Neonatal" last reviewed 03/2019 stated the "Provider responsibility" is to "Obtain informed consent for procedure".

Review of Patient (Pt) 7's Discharge Summary dated 05/05/21 at 11:39 am revealed Pt 7 was born on 04/17/2021 at 1:01pm at 34 weeks and 2 days gestation to mother (Pt 6) and was admitted to the neonatal intensive care unit for prematurity. Pt #7's Discharge Summary revealed, "Serial bilirubin levels were trended and (Pt 7) developed a rapid elevation of indirect bilirubin of unclear etiology that required escalation of interventions including intensive phototherapy, albumin, and two double volume exchange transfusions (4/20/21 and 4/21/21)."

Review of Pt #7's "Consent for Surgery and Invasive Procedures" dated 04/20/21 at 7:30 am revealed the "Statement of Consent" reads, "I, (Pt #7) authorize the following physicians...to perform the following proposed procedure: umbilical venous catheter, umbilical arterial catheter". Per review of the consent form, the "Signature of Patient or Representative" is signed by the Medical Doctor (MD) V. The section stating, "Reason Patient not able to sign" was blank. Informed consent form was not signed by Pt #6 who is the mother/legal representative of Pt #7.

Review of Pt #7's medical records showed there is no documented signature obtained from Pt #6 (mother/legal representative) acknowledging an informed consent for the "Exchange Transfusion" procedure performed on Pt #7 on 04/20/21 and 04/21/21.

Review of Pt #7's "Consent for Blood Transfusion Product" revealed Medical Doctor V signed on 04/20/21 at 07:30 am as the "physician/surgeon obtaining consent". On this consent form, there is no documented signature obtained from Pt #6 (mother/ legal representative) consenting to Pt #7's blood transfusion.

Per interview with Nurse Manager F on 06/02/21 beginning at 2:30 pm, F stated consent forms should have been signed by Pt #6 and that MD V should not have signed as the patient's representative. F confirmed the informed consent did not specifically list the "Exchange Transfusion" on the consent form. Per F the staff obtain consent for the blood transfusion and the placement of the umbilical catheters but do not usually list the "Exchange Transfusion" on the informed consent. F confirmed the policy stated an informed consent should be obtained for the "Exchange Transfusion".