HospitalInspections.org

Based on record review and interview staff failed to document nursing assessments and interventions, Intake and Output, and daily weights to ensure staff are monitoring patient care needs in 5 of 10 records reviewed (Pt #1, 2, 7, 8, and 10) in a total sample of 10.

Findings Include:

Review of policy and procedure titled, "Documentation Guidelines" (No review date) revealed that documentation "Provides information about the patient's current condition, treatment response, and progress." Per policy the essential elements of documentation include:
1. Assessment of the patient's condition
2. Plan of care and interventions based on assessment
3. The patient's response to interventions
4. Changes in the patient's condition
5. Communication to other team members regarding the patient's status
The Documentation Guidelines policy and procedure also revealed the following;
-Documentation is to be accurate, legible, concise, continuous, and complete.
-Care is to be documented as close to possible to the time it was provided.

Review of the policy and procedure titled, "Nursing Standards of Care" (No review date) revealed, the "Daily Routine" includes but is not limited to; daily weights on all inpatients and Intake and output will be recorded in real time and be assessed prior to the end of every shift.

Review of policy and procedure titled, "Urinary Management" (no review date) revealed, for the "Removal of Indwelling Catheter (Foley)" the first step of the procedure is to "Verify MD (medical doctor) order to remove catheter" after removal of the indwelling catheter "Record output and document discontinuation date".

Review of Pt #1's medical record revealed Pt #1 was admitted on 05/29/21 at 6:13 pm with admitting diagnosis of Decubitus Ulcer of Coccyx and discharged to Hospice on 06/02/21 at 12:46 pm. Review of Pt #1's "ED (Emergency Department) Provider Note" dated 05/29/21 at 2:01 pm revealed Pt #1 presented to the ED with concerns from home health nurse about worsening wound to buttocks. Per ED Provider Note, Pt #1 had an "Indwelling Foley catheter". Review of the results for Pt #1's CT (Computed Tomography) scan on 05/29/21 at 2:26 pm during ED visit, revealed Pt #1 had an "Indwelling Foley catheter with circumferential wall thickening involving the bladder and minor stranding inflammation surrounding." Review of ED MD (medical doctor) orders dated 05/29/21 revealed there were no orders documented to remove Pt #1's indwelling Foley catheter. Review of Pt #1's inpatient MD orders dated 05/29/21 and 05/30/21 revealed there were no orders to remove Pt #1's indwelling Foley catheter. Review of ED nursing notes dated 05/29/21 revealed no documentation of removal of Pt #1's indwelling Foley catheter. Review of Pt #1's inpatient nursing assessment of "Lines/Drains/Airways" dated 05/29/21 beginning at 6:39 pm, revealed no documentation of a indwelling Foley present on admission to the inpatient unit. Pt #1 had an indwelling Foley catheter on admission to the ED but there was no documentation of a MD order to remove Pt #1's indwelling Foley catheter or nursing notes documenting the removal of this Foley catheter. Per review of Pt #1's inpatient nursing assessment, Pt #1 had a new "Female External Urinary Catheter" placed on 05/30/21 at 2:00 pm and removed on 06/02/21 at 12:40 pm prior to discharge.

DON A confirmed during interview on 07/08/21 at 8:34 am that there was no documentation in Pt #1's medical record of a physician order to remove Pt #1's indwelling Foley catheter and no nursing documentation of the Foley removal. Per DON A, there should be a MD order to remove an indwelling Foley catheter and nursing staff should document Foley removal under the nursing assessment for "Lines/Drains/Airways".

Review of Pt #1's medical records revealed Pt #1's weight increased from 38.4 kg (84 pounds) on 05/30/21 to 43.4 kg (95 pounds) on 06/1/21 (weight increase of 11 pounds in 2 days). There was no documentation of a daily weight on 05/31/21 (per Nursing Standards of Care policy weights should be documented daily on all inpatients). Review of nursing assessments dated 06/01/21 revealed there was no documentation of nursing assessment related to Pt #1's 11 pound weight increase in 2 days, communication with the physician in regards to Pt #1's change in weight, and/or interventions provided in response to Pt #1's weight increase.

Per interview with DON A on 07/08/21 at 9:00 am, DON A stated that there was no documentation in the nursing flow sheets including an assessment, interventions, or provider notification related to Pt #1's 11 pound weight increase in 2 days. DON A stated, "I think we have a gap here, there should be documentation."

Review of Pt #2's medical record revealed Pt #2 was admitted on 05/30/21 at 3:27 pm for hyponatremia (low sodium) and discharged home on 05/31/21 at 11:49 am. Review of Pt #2's MD orders dated 05/30/21 at 4:49 pm revealed orders for a Neurological assessment every 4 hours. Review of the nursing Neurological assessments on 05/30/21 revealed the nurse documented a neurological assessment at 6:15 pm, 11:49 pm (5 hours and 34 minutes later), and at 8:48 am (9 hours later). Neurological assessments were not documented as completed every 4 hours.

Review of Pt #2's MD orders dated 05/30/21 at 6:02 pm revealed orders for Orthostatic vital signs (series of vital signs taken supine then standing) every 8 hours. Per review of Pt #2's "Orthostatic Blood Pressure" assessments flowsheet there was no documentation of Orthostatic vital signs.

Per interview with DON A on 07/07/21 at 3:30 pm, DON A stated that the orthostatic vital signs should be documented under "Orthostatic Blood Pressure" assessments in the nursing flowsheets. Per DON A Orthostatic vital signs were not documented in Pt #2's nursing Flowsheets.

Review of Pt #2's MD orders revealed an order dated 05/30/21 at 4:49 pm to track Pt #2's Input and Output. Review of Pt #2's "Nutrition" assessment on the nursing flowsheet revealed documentation that Pt #2 consumed 100% of his/her meal on 05/30/21 at 7:10 pm and 100% of his/her meal on 5/31/21 at 8:48 am. Review of Pt #2's "Intake" assessment flowsheet revealed there was no documentation of the amount of fluid Pt #2 consumed during these meals to ensure fluid "Intake" is documented accurately and recorded in real time as per the Nursing Standards of Care policy.

Per interview with DON A on 07/07/21 at 3:45 pm, DON A stated that Pt #2 consumed 100% of his/her food "so they should have drank something, but it is not documented".

Review of Pt #7's medical record revealed Pt #7 was admitted to the hospital on 05/30/21 at 7:31 am with complaints of abdominal pain and discharged home on 06/02/21 at 10:57 am. Review of Pt #7's MD order dated 05/30/21 at 12:40 pm revealed an order to track Pt #7's Input and Output. Review of Pt #7's "Nutrition" assessment on the nursing flowsheet revealed Pt #7 consumed 100% of his/her meal on 06/01/21 at 9:41 am and at 12:29 pm. Review of Pt #7's "Intake" assessment flowsheet revealed there was no documentation of the fluid consumed during these meals to ensure fluid "Intake" is documented accurately and recorded in real time as per the Nursing Standards of Care policy.

Review of Pt #7's daily weights revealed Pt #7 did not have a daily weight documented on 05/31/21 as per Nursing Standards of Care policy.

Review of Pt #8's medical records revealed Pt #8 was admitted on 07/02/21 at 5:52 am with complaints of diarrhea and discharged home on 07/07/21 at 1:30 pm. Review of Pt #8's MD order dated 07/02/21 at 3:57 pm revealed an order to track Pt #8's Input and Output. Review of Pt #8's "Nutrition" assessment on the nursing flowsheet revealed Pt #8 consumed 100% of his/her meal on 07/03/21 at 8:46 pm and 100% of his/her meal on 07/05/21 at 09:03 am. Review of Pt #8's "Intake" assessment flowsheet revealed there was no documentation of the fluid consumed during these meals to ensure fluid "Intake" is documented accurately and recorded in real time as per the Nursing Standards of Care policy.

Review of Pt #10's medical records revealed Pt #10 was admitted on 07/02/21 at 11:27 am with a Urinary Tract Infection and was currently an inpatient at the time of record review on 07/08/21. Review of Pt #10's MD order dated 07/02/21 at 11:45 am revealed an order to track Pt #10's Input and Output. Review of Pt #10's "Intake" assessment flowsheet revealed PO (by mouth) Intake was not documented for breakfast and lunch on 7/03/21, 7/4/21, and 7/6/21.

Review of Pt 10's daily weights revealed Pt #10 did not have a daily weight documented for 07/03/21, 07/04/21, 07/05/21, and 07/06/21 as per Nursing Standards of Care policy.

Per interview with DON A on 07/08/21 at 10:50 am, DON A stated staff should be documenting in real time on the nursing flowsheet when patients have Intake and Output. DON A stated that staff should be documenting Intake for breakfast, lunch, and dinner.