HospitalInspections.org

Based on review of the medical records, policies and procedures and interviews, it was determined the facility failed to ensure the nursing staff :

1. Performed observational monitoring and vital signs according to the facility's policy.

2. Reported changes in the patient condition.

3. Performed daily weights per the admission care plan.

This affected MR # 8 and MR # 10, 2 of 10 medical records (MR) reviewed, and had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Assessment of Patients, 2.01.132

Policy:

"Patient's who receive care at Providence Hospital are assessed and reassessed by qualified individuals to determine the patient's initial needs, continuing needs, and the outcomes of care and interventions...

Assessment is the systematic collection and review of patient data. This data is utilized to determine and prioritize the care needs of the patient. The plan of care is based upon physiological, psychological, spiritual and social/cultural data...

Reassessment across disciplines is ongoing and:

Occurs at designated intervals during the patient's treatment to determine the outcomes of the care and interventions and when significant changes occur in the patient's condition or diagnosis...

Procedure:

A. Acute Care Nursing Division

Vital Signs: Q (every) 4 hours and prn (as needed)
Temperature (T)
Pulse (P)
Respirations (R)
B/P (Blood Pressure)

I&O (Intake and Output): Q 8 and prn

Daily Weights: Admit weight - weigh on admission...On all renal, dialysis, and CHF (Congestive Heart Failure) patients...If ordered daily by MD (Medical Doctor)..."

Policy: Nursing Division
Section: Nursing
Subject: Charting

Policy:

"A. The patient's medical record is a legal document in which pertinent and accurate data about the patient is recorded and communicated to members of the health care team.

B. Nursing personnel are responsible for documenting in patients' medical records information pertaining to assessments, nursing care, response and outcome to care, and patient's discharge needs...
Procedure:

C. Focus Notes:

1. Method - Focus notes should be written whenever a significant change in the patient's condition occurs, a problem is identified, the patient is transferred or discharged, or the assessment needs to be explained further...

5. Crisis results and other pertinent physician communication are documented:

b. Other pertinent MD (physician) communication is documented under the "MD Communications" tab in HED (Horizons Electronic Record).

IV Graphic Flow Sheet:

The Graphic Flow Sheet in HED or written is used to record vital signs, intake and output, number of stools, and weight.

b. Frequency - Information is recorded every shift as indicated and should be entered into the electronic documentation system at the point of care (or when collected)...

c. Responsibility - The RN (Registered Nurse) may delegate the completion of this form to the NA (nursing assistant), who is responsible for reporting observations to the RN."

1. MR # 8 was admitted to the facility on 7/20/14 with a Lower Gastrointestinal (GI) Bleed and Coumadin Toxicity.

Review of the MR revealed no vital signs were documented between the hours of 8:22 PM on 8/10/14 and 6:17 AM on 8/11/14.

Further review of the MR revealed the patient had a bronchoscopy on 8/11/14 and returned to the floor at 12:13 PM with documentation on Focus Note 12:13 for vital signs q. 15 minutes x (times) 4 and q. 30 minutes x 2. Review of the "VSIO (Vital Signs/Input and Output)" flowsheet for 8/11/14 revealed BP (blood pressure), T, P, R and Oxygen (O2) saturation were documented at 12:14. At 12:28 PM, 12:43 PM, 12:57 PM, 13:21 (1:21 PM), 13:43 (1:43 PM), and 14:03 (2:03 PM), P and BP only were documented. A complete physical assessment was not documented postoperatively until 21:15 (9:15 PM) after shift change.

Review of the Nursing Care Plan dated 7/25/14 at 20:29 (8:29 PM) revealed documentation to obtain daily weights. Review of the VSIO flowsheets dated 7/20/14 to 8/15/14 revealed the following documentation for daily weights:

7/20/14: 93.6 kg (kilograms)
7/25/14: 98.6 kg
7/26/14: 99.6 kg
7/28/14: 101.6 kg
8/2/14: 100.5 kg
8/4/14: 105.5 kg
8/5/14: 105.0 kg
8/6/14: 104.0 kg
8/8/14: 104.0 kg
8/9/14: 101.8 kg
8/10/14: 105.9 kg
8/11/14: 106.7 kg
8/12/14: 109.1 kg
8/13/14: 11.8 kg (per flow sheet)
8/14/14: 113.5 kg
8/15/14: 112.6 kg

Review of the Nursing focus notes dated 7/20/14 to 8/15/14 revealed no documentation the physician was notified of the weight gain of 30 kg (41.8 pounds) throughout the hospital stay.

An interview was conducted on 3/18/15 at 10:00 AM with Employee Identifier (EI) # 1, Chief Nursing Officer, and EI # 2, 10 North Unit Manager, who verified the aforementioned findings.



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2. MR # 10 was admitted to the facility on 7/16/14 with the diagnosis of Congestive Heart Failure.

Review of the Nursing Flow Sheet Shift Goals for Fluid/ Volume (plus / minus) Section dated 7/16/14, 7/18/14, 7/22/14, 7/23/14, 7/25/14 and 7/29/14 revealed the following,

Problem (actual) - volume access,
Goal- Maintain appropriate fluid volume,
Planned Intervention - Monitor Intake and Output, Daily Weights with dialysis order,

Review of the Vital Signs, Intake and Output Record dated 7/17/14, 7/18/14, 7/19/14, 7/20/14, 7/21/14, 7/22/14, 7/23/14, 7/24/14, 7/26/14, 7/27/14, 7/28/14, 7/29/14 revealed there was no documentation output was monitored.

An interview was conducted on 3/18/15 at 12:15 PM with Employee Identifier (EI) # 3, Joint Commission Manager verified the above mentioned findings.