HospitalInspections.org

Based on a review of facility documents and medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure nursing staff followed physician orders in the provision of care for eight of nine medical records reviewed (MR1, MR2, MR7, MR8, MR11, MR14, MR15, and MR17).

Findings include:

Review of the job description provided by the facility for a Patient Care Tech revealed, "Responsibilities Effective Date 05/25/2012...Care Delivery: Performs the UPMC nursing core nursing assistant responsibilities (blood glucose, weights, vital signs, I&O, specimen collection and foley care)...Provides patient care including assisting with patient procedures and activities of daily living. ...Provides feedback to the RN regarding patient care and reports changes in patient status."

Review of the job description provided by the facility for a Professional Staff Nurse revealed, "Job Purpose Effective Date 05/11/2010...The Professional Staff Nurse is responsible to set the standards for the level and quality of care. The Professional Staff Nurse has responsibility, authority and accountability for the provision of nursing care. ...provides patient care activities for a group of patients and their families through the application of independent judgment, communication and collaboration with all team members. ...Patient documentation is comprehensive and promotes communication between caregivers."

Review of facility policy "Patient Related Orders and Safe Medication Practices" dated June 10, 2015, revealed "II Patient Related Orders A. All orders for medications and treatment for inpatients and outpatients shall be recorded either in the medical record electronically via computerized order entry or written in the paper record by a health care professional authorized or privileged to do so."

1. On October 19, 2015, at approximately 9:15 AM a request was made for a policy related to I&O (Intake and Output). None was provided.

2. On October 20, 2015, at approximately 8:15 AM EMP1 stated the facility does not have a policy related to I&O. When asked how staff know what the expectation is when a physician writes an order for I&O, EMP1 stated "They should be doing I&O. It's self explanatory."

3. On October 19, 2015, between 9:30 AM and 1:30 PM a review of MR1 was conducted. This review revealed the patient was admitted to the facility from September 4 -24, 2015. At the time of admission there was a physician order for I&O every eight hours.

Continued review of MR1 revealed that documentation of I&O was incomplete on 9/4, 9/9, 9/10, 9/11, 9/12, 9/13, 9/14, 9/15, 9/20, 9/22 and 9/24.

On October 20, 2015, at approximately 11:55 AM EMP2 confirmed the above findings.

4. On October 20, 2015, review of MR15 revealed the patient was admitted to the facility on October 14. At the time of admission there was an order for daily weights.

Continued review of this record revealed there was no daily weight documented on October 17, 2015.

EMP2 confirmed the above findings at the time of discovery.

5. On October 19, 2015, review of MR17 revealed the patient was admitted to the facility on September 28, 2015. At the time of admission there was an order for daily weights.
Further review revealed documentation of a weight on five days from September 28, 2015, thru October 18, 2015.

Interview with EMP1 on October 20, 2015, at approximately 1:30 PM confirmed the above findings and revealed "That's right"

6. Interview with EMP3 on October 20, 2015, at approximately 9:10 AM revealed "It(intake and output) is not a task it is a physician order. It is ultimately the nurses responsibility to document it"

7. Review of MR2 on October 20, 2015, at approximately 10:00 AM revealed that the patient was admitted on October 18, 2015, and ordered intake and output on October 18, 2015, at 7:03 PM. There was no documentation of any intakes and outputs for MR2 as of October 20, 2015.

8. Review of MR7 on October 20, 2015, at approximately 11:30 AM reveal that the patient was admitted on October 11, 2015, and was ordered daily weights on admission. There was no weight recorded for MR7 on October 13, 2015.

9. Review of MR8 on October 20, 2015, at approximately 10:15 AM revealed that the patient was admitted on October 10, 2015, and was ordered daily weights on October 10, 2015. There was no weight recorded for October 12, 2105, for MR8.

10. Review of MR11 on October 20, 2015, at approximately 10:20 AM revealed that the patient was admitted on October 17, 2015, with an order for daily weights. The patient did nto have a weight recorded on October 17, 2015.

11. Review of MR14 on October 20, 2015, at approximately 10:30 AM revealed that the patient was admitted on October 4, 2015, and was ordered daily weights on October 5, 2015, at 1400. There was no weight recorded for MR14 on October 7, 2015.

During an interview on October 20, 2015, at approximately 11:45 AM, EMP2 confirmed the missing intake and output for MR2 and the missing weights for MR7, MR8, MR11 and MR14.