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Based on policy and procedure review, medical record review, and staff interviews, the nursing staff failed to document chest tube assessments per hospital policy in 2 of 3 patients with chest tubes (#6, and #9); failed to document routine care of a chest tube following insertion as per hospital policy in 1 of 3 patients (#9); and failed to document a complete patient assessment upon admission as per hospital policy in 1 of 3 patients (#9).

Findings include:

A. Review of the hospital's policy and procedure titled "Chest Tubes: Insertion and Care of the Patient", with "Last Revised/Reviewed Effective Date: Jun 14", revealed "...For all drainage systems Repeatedly note the character, consistency, and amount of drainage in the drainage collection chamber...Observe the integrity of the drainage tubing and chest tube (a hollow tube inserted into the chest cavity to release trapped air or drain fluid) every 2 to 4 hours and with a change in the patient's condition...Documentation...At the end of every shift, record the frequency of system inspection; amount, color, and consistency of drainage; presence or absence of bubbling or fluctuation in the water-seal or air-leak monitor chamber (if applicable); the patient's respiratory status...".

1. Closed medical record review revealed Patient #6, a 68 year old female patient admitted to the hospital on 09/04/2015 at 1459 with a diagnosis of Hepatic Encephalopathy (the occurrence of confusion as a result of liver failure). Review revealed Patient #6 developed a pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest) which necessitated insertion of a chest tube. Review revealed a chest tube was inserted by a physician on 09/06/2015 at 1435. Review of a chest tube assessment written on 09/06/2015 at 1915 by Registered Nurse (RN) #2 revealed, "Site assessment: Drainage Sersosanguinous (containing or relating to both blood and the liquid part of blood). Suction Function: 20 cm (centimeters). No Air Leak. Patient Interventions: Tip/Tilt Leg (an extension device built into the drainage collection system that prevents the system from tipping over). Dressing: New. Dressing Type: Vaseline Gauze. Output: 950 mL (milliliters)." Review of a chest tube assessment written on 09/07/2015 at 0300 (7 hours and 45 minutes later) by RN #2 revealed, "Output: 950 mL." Review revealed Patient #6 was transferred to another facility on 09/07/2015 at 0430. Record review revealed no other nursing documentation for a nursing assessment of chest tube system inspection, drainage, or water-seal integrity.

Staff interview, conducted on 10/22/2015 at 0900 with Administrative Staff (AS) #1, revealed a gap of 7 hours and 45 minutes in the documentation of chest tube assessments does not follow hospital policy.



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2. Closed medical record review of Patient #9's "History and Physical", dated 05/16/2015 at 0001, revealed a 86 year old male admitted with a diagnosis of pneumothorax (a collapsed lung), and left, lower lobe pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid). Review of Patient #9's Emergency Department (ED) records revealed the patient had a chest tube (a hollow, flexible tube placed into the chest to drain blood, fluid, or air from around the lungs) placed on 05/15/2015 at 1807 in the ED. Review of ED Nursing documentation revealed, "Chest Tube 1...Placement date: 05/15/15...Placement Time: 1807...Chest tube Orientation: Left, Anterior (front)...Collection Chamber: Atruim (brand of chest tube drainage system)...hooked on low continuous wall suction Patient Tolerance: Tolerated well...". Further review of the ED Nursing documentation revealed a category in the "Chest Tube 1" documentation titled "Site Assessment" in which there was no entry by the ED nurse. Further review of Patient #9's ED record revealed the patient's chest tube was clamped for transport and Patient #9 was transferred/admitted to a medical/surgical unit on 05/15/2015 at 2210. Further record review revealed the next documented chest tube site assessment for Patient #9 occurred on 05/16/2015 at 1647 (21 hours, 53 minutes after the initial chest tube note) which reported, "Date First Assessed: 05/16/15 Time First Assessed: 1600 Location: Left, Anterior Wound Description...chest tube...Site Assessment Clean;Dry;Intact...Dressing gauze and tegaderm (a waterproof, transparent dressing). Record review revealed no documentation of chest tube site assessment, drainage, chest tube system inspection, presence or absence of an air leak from the time Patient #9's chest tube was inserted in the ED, on 05/15/2015 at 1807, until 05/16/2015 at 1647.

Interview with RN #6 and AS #3 on 10/22/2015 at 1115 revealed, after review of Patient #9's record, no documentation of chest tube site assessment or drainage was present in the nurse's notes from 05/15/2015 at 1807 until 05/16/2015 at 1647.

B. Review of the hospital's policy and procedure titled "Chest Tubes: Insertion and Care of the Patient", with "Last Revised/Reviewed Effective Date: Jun 14", revealed "Record the date and time thoracic drainage began, type of system used, the amount of suction applied to the pleural cavity, presence or absence of bubbling or fluctuation in the water-seal or air-leak monitor chamber (if applicable), initial amount and type of drainage, and the patient's respiratory status...".

1. Closed medical record review of Patient #9's "History and Physical", dated 05/16/2015 at 0001, revealed a 86 year old male admitted with a diagnosis of pneumothorax and left, lower lobe pneumonia. Review of Patient #9's ED records revealed the patient had a chest tube placed on 05/15/2015 at 1807 in the ED. Review of a General Surgery "Consultation" note electronically signed by the physician on 05/16/2015 at 1613 revealed, "...Apparently a chest tube was placed last night, the patient invert the remove the tube (inadvertently removed the tube). He currently is slightly symptomatic complaining of some left lower chest pain...". Further review of the "Consultation" note revealed, "Recommendations Chest tube placement Catheter was placed at the bedside...The catheter was then secured to the chest wall...and connected to the Pleur-evac (chest drainage system) ...". "Nursing Notes" dated 05/16/2015 at 1904 revealed, "Patient pulled chest tube out this AM. I heard bed alarm going off and began walking to patients room. PT (patient) was standing in doorway...Chest tube was dislocated. Patient asymptomatic. potraleum jelly gauze applied. Dr. notified. New tube placed...". Record review revealed no documentation indicating time thoracic drainage began, type of system used, the amount of suction applied to the pleural cavity, presence or absence of bubbling or fluctuation in the water-seal or air-leak monitor chamber, initial amount and type of drainage, and the patient's respiratory status.

Interview with AS #2 on 10/22/2015 at 1330 revealed AS #2 had reviewed Patient #9's record and confirmed, no focused assessment was present after Patient #9 pulled out his chest tube and no procedure note was present for the new chest tube placement as per policy.

C. Review of the hospital's policy and procedure titled "Assessment/Re-assessment Dimensions" with a "Last Revised/Reviewed Effective Date: October 13, 2015" revealed, "Patients will receive a full/complete assessment by an RN (Registered Nurse): 1. On admission...3. When patient is transferred from one level of care to another level of care...Patients will receive a focused re-assessment: 1. At least every shift and as warranted by the patient's clinical condition...3. When there is a change in primary caregiver...".

1. Closed medical record review of Patient #9's "History and Physical", dated 05/16/2015 at 0001, revealed a 86 year old male admitted with a diagnosis of pneumothorax and left, lower lobe pneumonia. Review of Patient #9's ED records revealed the patient had a chest tube placed on 05/15/2015 at 1807 in the ED. Further review of Patient #9's ED record revealed the patient's chest tube was clamped for transport and Patient #9 was transferred/admitted to a medical/surgical unit on 05/15/2015 at 2210. Record review revealed no physical assessment was documented for Patient #9 upon his arrival/admission to the medical/surgical unit. Nursing documentation on 05/16/2015 at 0739 indicated RN #4 had received report from RN #5. Further review of the Nursing documentation revealed a complete assessment by RN #4 recorded on 05/16/2015 at 1647 for Patient #9.

RN #5 was unavailable for interview.

Interview with AS #2 on 10/22/2015 at 1330 revealed AS #2 had reviewed Patient #9's record and confirmed, "No nursing assessment was present for the night of 05/15/2015 (for Patient #9)...that should be there per policy."

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Based on review of hospital policy, medical record review, and staff interview, hospital staff failed to document blood transfusion stop times on 2 of 3 patients (Patient #2, #6) per hospital policy.

The findings include:

Review of hospital policy titled, "Blood and Blood Product Administration", Last Revised/Reviewed Date 08/11/2015, revealed, "...Competency Assessment Tool Blood Product Administration... 16. Document Transfusion stop time in (named documentation system)...".

1. Closed medical record review revealed Patient #2 to be a 73 year old male admitted on 09/21/2015 at 2004, with an admission diagnosis of Iron Deficiency Anemia (too few healthy red blood cells due to low iron in the body). Review revealed a transfusion of 1 unit of PRBC (Packed Red Blood Cells) was initiated on 09/27/2015 at 1509. No stop time for the unit of PRBC was documented.

Staff interview conducted on 10/22/2015 at 0900, with Administrative Staff #1, revealed if blood transfusion stop times are not documented, hospital policy was not followed.

2. Closed medical record review revealed Patient #6 to be a 68 year old female admitted on 09/04/2015 at 1459 with an admission diagnosis of Hepatic Encephalopathy (the occurrence of confusion as a result of liver failure). Review revealed a transfusion of 1 unit of PRBC (Packed Red Blood Cells) was initiated on 09/08/2015 at 1915. No stop time for the unit of PRBC was documented.

Staff interview conducted on 10/22/2015 at 0900, with Administrative Staff #1, revealed if blood transfusion stop times are not documented, hospital policy was not followed.

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