HospitalInspections.org

Based on record review, staff interview and review of the facility's standards of care protocol it was determined the registered nurse failed to inform the physician of a change in condition for one (#1) of eight patients sampled. This does not ensure the patient's change in condition is managed in a timely manner.

Findings include:

Review of patient #1's medical record revealed the patient was admitted to the facility on 1/23/2012 with sepsis and renal failure. Review of the physician orders revealed an order on 1/23/12 at 9:00 p.m. for CVVHD (Continuous Veno-Venous Hemodialysis). Documentation revealed the treatment was initiated on 1/23/12 at 9:13 p.m.

On 1/26/12 at 9:00 a.m. documentation revealed the patient's continuous hemodialysis was stopped due to the catheter clotting. Review of the physician orders on 1/26/12 at 12:35 p.m. revealed an order by the primary care physician to consult Interventional Radiology to replace the catheter at bedside as soon as possible. Documentation revealed the catheter was replaced and the continuous hemodialysis was restarted on 1/26/12 at 3:45 p.m.

Review of the record revealed the patient's nephrologist was not notified of the patient's change in condition or the interruption, approximately 7 hours, in the continuous hemodialysis.

Review of the facility's clinical standard, "Care of the Adult Hospitalized Patient", issued 8/2009, stated to notify the physician of any deterioration in patient condition and/or critical and/or significantly abnormal tests or results.

The facility failed to notify the nephrologist of the interruption in the prescribed continuous hemodialysis treatment and change in the patient's condition.