HospitalInspections.org

Based on medical record (MR) review, document review and interview, in 3 of 11 medical records reviewed, it was determined that the facility did not provide timely notification to the patient's representative of an occurrence.


Findings include:

1. Review of MR#1 identified the following: This 70 year old was admitted on 8/27/15 for Syncope and was admitted to Telemetry Unit for further monitoring. On 9/27/15 22:15 (10:15 PM), nursing documentation indicated that the patient was found on the corridor floor and was returned to a chair in her room. The physician was notified and the patient was examined; patient complained of left knee pain and an X-ray was done. On 9/28/15 at approximately 6:40 AM, physician documented, patient was complaining of hip pain, and at 9:11 AM, same day, nursing documentation noted patient complaining of pain to left hip area, no redness or swelling noted. X-ray of the left hip on 9/28/15 about 12:15 PM, revealed an Intertrochanteric Fracture.

There was no documented evidence in the medical record that the patient's representative was notified of the patient's incident in a timely manner. Specifically, the family was not immediately notified of the patient's fall of 9/27/15, and of the abnormal x-ray report of 9/28/15, when patient was found to have a left hip fracture.


2. Review of MR #2 identified: a 46 year old, admitted on 10/7/15 with chief complaint of Seizure. The medical record identified that the patient had seizures and was found on the floor on 10/8/15 at 10:20 AM, on 10/9/15 at 2:10 AM and on 10/10/15 at 6:00 PM. There was no documented evidence that the patient's representative was made aware of the patient's incidents by authorized staff.


3. Review of MR #3 identified: an 83 year old admitted on 10/8/15 for chief complaint of Hypertension. On 10/9/15 at 4:00 PM, the patient had a witnessed fall on the 10th floor hallway. There was no documented evidence that the patient's representative was notified by authorized staff.


During interview on 10/27/15 at approximately 3:00 PM, the Vice President of Nursing acknowledged that the facility had no specific written policy on family notification, and that the physician is responsible to notify the family of any changes in the patient's condition.

During interview on 10/27/15 at approximately 3:15 PM, the Chief Medical Officer confirmed that the facility had no written protocol on family notification, and that it is the physician's responsibility to notify the family.

Based on medical record review, and document review, in 1 of 11 medical records reviewed, it was determined that nursing staff did follow the care plan for telemetry monitoring as ordered.


Findings include:

Review of Patient #1's MR identified: this 70 year old was admitted on 8/27/15 for Syncope and was admitted to Telemetry Unit for further monitoring.

The Flow Sheet Record review documented on 9/27/15 from about 1800 (6:00 PM) to 0012 (12:12 AM), that the patient refused telemetry monitoring. There was no documentation to indicate that the physician was made aware of the lack of telemetry monitoring. The physician's order for telemetry monitoring was not followed.

During interview 10/27/15 at approximately 2:00 PM, the Nurse Manager stated "Telemetry monitor is not disconnected, only if ordered or go for test."