HospitalInspections.org

Please refer to 482.23(b)(3) RN Supervision of Nursing Care, and 482.24(c) Content of Record, elsewhere in this report.

Based on interview and record review it was determined the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care of 1 of 5 sampled patients (Patient 5). Findings include:

According to hospital records, on 5/14/10 Patient 5 presented in the hospital Emergency Department with symptoms of "pain in the right forearm" and "abrasion of the right lower quadrant." The patient was diagnosed with a "right radial head" fracture. According to the record a splint was applied, and the patient was discharged home for follow-up care with the primary physician.

When the splint was removed in the physician office on 5/20/10, concerns were raised that the splint had not been properly applied. There was evidence from Witness D, and later from Witness G that "the arm had been splinted without the wound being dressed." An investigation survey was initiated on 7/26/10.

Record review during the survey revealed that it could not be determined who had completed Patient 5's arm splint. The record was not clear who had completed the treatment, and what procedures had been followed. There was no evidence of the presence or absence of abrasions on the patients' arm. It was not clear what wound treatment, if any, had occurred. From the record it could not be determined if "the arm had been splinted without the wound being dressed," as alleged.

In interview on 6/26/10 Witness B indicated that the procedure had been completed by an Emergency Room Technician. Although it was not reflected in the record, Witness B indicated that "the nurse assigned an ED tech to complete the procedure."

Record review revealed no evidence that the registered nurse had assigned a technician to splint the arm. There was also no evidence that the registered nurse supervised or evaluated the ED Tech who completed the procedure. Since it is not known who completed the procedure, it is not clear that they were trained and competent to do so.

The hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for Patient 5, as required.

Based on interview and record review it was determined the hospital failed to ensure that the medical record of 1 of 5 sampled patients (Patient 5) contained information that supported the diagnosis and described the patient's condition, treatments and response to service. Findings include:

According to hospital records, on 5/14/10 Patient 5 presented in the hospital Emergency Department with symptoms of "pain in the right forearm" and "abrasion of the right lower quadrant." The patient was diagnosed with a "right radial head" fracture, a splint was applied, and the patient was discharged home for follow-up care with the primary physician.

According to evidence from Witness G, when Patient 5's splint was removed on 5/20/10 there were open wounds under the splint, with infection. A 6/16/10 note by Witness D indicated that the arm had been splinted without the wound being dressed, and that the wound bed had dried to the "webroll." On 6/26/10 a survey was initiated to determine if proper treatment procedures had been followed.

Policy review revealed that the hospital had a specific policy regarding medical record documentation. That policy "Patient Care Record Documentation" provided specific detail of the information that was to be documented in each patient's medical record.

According to that policy the record was to include information regarding "procedures performed on patient, time performed and patient response." Review of the record for Patient 5 revealed that policy had not been implemented as planned.

Although there was evidence of splint application, it could not be determined who had applied the splint, or the procedures that had been followed. There was no documentation of the procedure performed, who performed it, the time performed, or patient response.

There was also no record of treatment, if any, to the patient's abrasions. It could not be determined exactly where the abrasions were located. There was no documentation or evidence regarding the presence or absence of abrasions to the patients right forearm, or of wound cleansing or treatment before splinting.

From the medical record it could not be determined if the arm had been "splinted without the wound being dressed" as alleged by Witness D. There was no record of any procedure or treatment of abrasions, or the patient's response.

The hospital failed to ensure that policy "Patient Care Record Documentation" had been followed. Patient 5's medical record did not contain information to describe the patient's condition, treatments, progress or response to services as required.