HospitalInspections.org

Intakes: TN00029461

Based on medical record review and interview, it was determined the facility failed to follow physician's orders for physical therapy for 2 of 5 (Patient's #4 and #5) sampled patients, and failed to follow physician's orders for documentation of Hemovac drainage for 1 of 1 (Patient #4) sampled patients with a Hemovac.

The findings included:

1. Medical record review for Patient #4 documented an admission on 3/6/12 for a left hip fracture. On 3/9/12 the patient had surgery to repair the fractured hip. Following surgery on 3/9/12 the physician wrote an order, "...PT [Physical Therapy] TDWB [touch down weight bearing] BID [twice a day] & [and] OOB [out of bed] in chair BID" There was no documentation the PT had implemented the orders. On 3/12/12 the physician wrote the PT order a second time, "PT BID as per orders post op & OOB BID" There was no documentation PT evaluated and began treatment until 3/12/12, 3 days after the patient's surgery and the original post-op order.

2. Medical record review for Patient #5 documented an admission on 3/4/12 for an intertrochanteric fracture of the right hip. Post-operative on 3/5/12 the physician wrote an order, "PT- 25% [percent] PWB [partial weight bearing] R [right] gait training" There was no documentation the PT had implemented the therapy. A physician's progress note dated 3/7/12 documented, "No PT done - order on chart [to begin] on 3/5/12 ...Re enter PT orders in chart from 3/5 & OOB"

During an interview in the conference room on 4/18/12 at 11:45 AM, the Director of Quality stated, "Order was noted but not put in the computer...it's an order entry issue"

4. Review of the Policy and Procedure "Intake & Output, Vital Signs, and Weight" documented, "...RN's [Registered Nurses] or LPNs [Licensed Practical Nurses] will be responsible for assessing and documenting various drainage apparatus (i.e., chest tubes, Jackson Pratts) output at least every eight hours or more often as indicated"

Medical record review for Patient #4 documented on 3/9/12, "Received pt [patient] from OR dpt [Operating Room Department] nurse ...dressing to L [left] hip area with Hemovac in place ..." At 6:00 AM the nurse documented on the Nursing/Shift Intervention form that the patient had 200 cubic centimeters (ccs) output from his Hemovac.

On 3/10/12 at 7:40 AM, the physician documented an order, "Please record JP [Jackson Pratt] drain output on progress notes q [every] shift"

The Nursing/Shift Intervention Form dated 3/10/12 documented at 1600 there was 40 cc of drainage. A nurse's note with no date documented, "No drainage noted from Hemovac or from site area" There was no other documentation of the drain output.

The facility failed to follow the physician's order to document the amount of drainage on the progress notes every shift and failed to follow the facility policy and procedure to document drainage every 8 hours.