HospitalInspections.org

Complaint #074

Based on a review of documents and staff interview it was revealed the facility failed to ensure the medical record had accurately written documentation. This failure was identified in one (1) of thirty (30) medical records reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed on 3/8/21 Physician Assistant (PA) #2 documented personal protective equipment (PPE) being worn in the patient's room as a surgical mask and shield. On 3/10/21 Hospitalist #4's documentation stated in part: "PPE: Patient seen this day while wearing face shield and surgical mask. Patient wearing a surgical mask." On 3/12/21 Hospitalist #4's documentation stated in part: "PPE: Patient seen this day while wearing face shield and surgical mask. Patient wearing a surgical mask." On 3/23/21 Hospitalist #4's documentation stated in part: "PPE: Patient seen this day while wearing face shield and surgical mask. Patient wearing a surgical mask." On 3/24/21 Hospitalist #4's documentation stated in part: "PPE: Patient seen this day while wearing face shield and surgical mask. Patient wearing a surgical mask." On 3/25/21 Hospitalist #4's documentation stated in part: "PPE: Patient seen this day while wearing face shield and surgical mask. Patient wearing a surgical mask." On 3/27/21 Hospitalist #3's documentation stated in part: "PPE: Patient seen this day while wearing face shield and surgical mask. Patient wearing a surgical mask." On 3/28/21 Hospitalist #3's documentation stated in part: "PPE: Patient seen this day while wearing face shield and surgical mask. Patient wearing a surgical mask."

2. A review of the policy titled "Infection Prevention and Control, Transmission Based Precautions and the Prevention of Multidrug Resistant Organisms (MDROs), revision date August 2019, stated in part: "II. PROTECTIVE PRECAUTIONS C. Gloves and Handwashing, Perform hand hygiene prior to gloving to go into the Protective Precaution environment. Gloves are to be worn (clean non-sterile gloves are adequate) when entering the room. While providing care for a patient, change gloves after having contact with infective material that may have high concentrations of microorganisms (fecal material, excretions or wound drainage). Remove gloves before leaving the patient's environment and wash hands immediately with an antimicrobial agent or waterless antiseptic agent."

3. An interview was conducted with the Chief Quality Officer on 4/6/21 at 1:03 p.m. When asked about the medical staff not documenting wearing of gloves, he stated all physician's wear gloves when they see any patient. He stated the physician's documenting PPE were just going above and beyond documentation of what they were donning along with the standard PPE. I explained if staff are documenting PPE then all PPE has to be documented.