HospitalInspections.org

Based on interview and record review, the facility staff failed to follow their policy regarding documentation and response to interventions for 1 out 10 Patients (Patient #1) in a sample of 10 records reviewed.

Findings:

The facility policy, titled "Patient Assessment", last revised 12/18/2018, revealed: "Procedure: A. Nursing Assessments: 1. Inpatients a. A registered nurse completes a comprehensive assessment incorporating all the interdisciplinary standards of care within 8 hours of admission. b. Further assessments and reassessments are based on patient needs and conditions, and patient's response to interventions ....G. Re-Assessment 1. Patient need and condition will determine the frequency and type of re-assessment. Exceptions are with regard to physical assessments: b. Focus assessment-more detailed assessment based on information gathered in basic assessment when not within normal limits. 2. Re-assessment is designed to evaluate the patient's response to care."

The facility policy, titled "Interdisciplinary Documentation", last approved 8/1/2020, revealed: "Policy: Charting by Exception: The basic philosophy used for documentation is charting by exception. The Interdisciplinary Standards of Practice utilizes (WDL) with defined limits for charting. Findings outside the defined limits are entered as so. Procedure: A. Charting parameters-Inpatient 3. Reassessment: a. The reassessment is designed to evaluate the patient's response to care and interventions and to determine if a change in the plan of care is warranted ...c. Additional reassessments are done when the patient's diagnosis/condition warrants and/or there is a significant change in the patient's diagnosis/condition."

The facility policy, titled "Medical Record Documentation", last revised 6/28/2018, revealed: "Record Content: 1. The content of the medical record must be sufficient to identify the patient, support the diagnosis, justify the treatment, document the course and results accurately, facilitate consistency and continuity of care among health care providers ....f. Documentation and findings of assessments; r. All reassessments and plan of care revisions, when indicated. Timeliness, Authentication and approved documenters 2. Entries in the medical record should be made electronically as close to the delivery of care time as possible."

Patient #1's History and Physical, completed on 10/17/2021 at 6:22 PM, revealed: "Patient is a 40-year-old [gender] with history of hypertension (high blood pressure) presenting for shortness of breath. [Gender] had a complex hospital stay in 7/2021 at [name] with the following events. Extended hospitalization from 7/6/2021-7/29/2021 after being hospitalized in June for pneumonia. During [gender] hospitalization [gender] require (sic) ventilator support (breath tube) in the ICU (Intensive Care Unit) from 7/6/2021 to 7/13/2021 for acute respiratory failure ....Assessment/Plan: Principal problem: Acute respiratory distress. #Acute on chronic respiratory failure. Hx (history) of organizing pneumonia with fibrosis (scarring), Hx of organizing diffuse alveolar (small air sacs) damage. Consult pulmonology (lung specialists), Maintain oxygen saturations greater than 92%."

A review of Patient #1's Flow sheets on 10/18/2021 revealed:
3:00 AM Resp (respirations) 22; respiratory pattern regular; SpO2 (oxygen saturation) 92%; 02 (oxygen) devise: simple mask; O2 flow rate (L/min) 3 L/min (minute)
10:07 AM Resp (respirations) 26; respiratory pattern: accessory muscle use; SpO2 (oxygen saturation) 89%; 02 (oxygen) devise: nasal cannula; O2 flow rate (L/min): not documented.
3:15 PM Resp (respirations) 26; respiratory pattern: accessory muscle use; SpO2 (oxygen saturation) 82%; 02 (oxygen) devise: nasal cannula; O2 flow rate (L/min): not documented.
3:55 PM Resp (respirations) not documented; respiratory pattern: accessory muscle use; SpO2 (oxygen saturation) 86%; 02 (oxygen) devise: nasal cannula; O2 flow rate (L/min): not documented.
5:00 PM Resp (respirations) not documented; respiratory pattern: accessory muscle use; SpO2 (oxygen saturation) not documented; 02 (oxygen) devise: not documented; O2 flow rate (L/min): not documented.
7:00 PM Resp (respirations) not documented; respiratory pattern: not documented; SpO2 (oxygen saturation) 85%; 02 (oxygen) devise: not documented; O2 flow rate (L/min): 4 L/min
7:30 PM Resp (respirations) 22; respiratory pattern: accessory muscle use; SpO2 (oxygen saturation) 88%; 02 (oxygen) devise: nasal cannula; O2 flow rate (L/min): not documented.
8:30 PM Resp (respirations) 24; respiratory pattern: Tachypneic (abnormal rapid breathing); SpO2 (oxygen saturation) 92%; 02 (oxygen) devise: OxyMask; O2 flow rate (L/min): 12 L/min

During an interview on 11/16/2021 at 3:30 PM, Patient Care Supervisor B stated, "We chart by exception but I am trying to move my staff to do a shift summary note, but we aren't there yet." When asked about Patient #1's respiratory status on 10/18/2021-would you expect to see a note documenting the low oxygen saturation levels and what was done? Supervisor B stated, "Yes." Supervisor B confirmed the medical record did not include a complete respiratory assessment, reassessment or response to interventions on 10/18/2021.