HospitalInspections.org

Based on medical record review, policy and procedure review, and staff interview, the governing body failed to ensure that the medical staff was accountable for care provided to patients.

Findings:
1. On May 18, 2015 at 5:00 p.m. surveyors observed multiple entries in patient #9's medical record that Staff W documented, "...still eating well...AM glucose 218..." [The hospital lab range for normal blood glucose ranges from 70 mg/dl (milligrams per deciliter) to 110 mg/dl.] There was no documented evidence that the physician addressed the abnormal blood glucose. This was verified by Staff W.
2. On May 18, 2015 at 5:00 p.m. surveyors reviewed multiple entries in patient #9's medical record that Staff R documented, "...skin on gross exam, skin is warm and dry. No erythema. See nursing notes regarding wound/lesion..." Surveyors were unable to find the documented evidence of the physician assessment of the wound(s)/lesion(s).
3. On May 18, 2015 at 5:30 p.m., Staff W was unable to find the physician's assessments of the wound(s)/lesion(s) in patient #9's medical record.
4. On May 18, 2015 at 1:50 p.m. Staff W told surveyors that all physicians document using standardized templates in the electronic health record. Staff W told surveyors, "Physicians documentation can be found in a progress note, a history and physical (H&P), and or on the medication administration record (MAR).

Based on medical record review, policy and procedure review, and staff interviews, the hospital failed to ensure that the registered nurse evaluated the nursing care provided to each patient. The registered nurse failed to evaluate nursing care on an ongoing basis.

Findings:
1. On May 13, 2015 at 12:15 p.m. surveyors reviewed three hospital investigative reports. One of three hospital investigative reports documented a patient fall however; the medical record did not contain documented evidence of the fall by nursing staff and/or medical staff.

2. On May 13, 2015 at 12:15 p.m. Staff E and Staff M told surveyors that patient #9 had a fall. There was no documented evidence of the fall. Staff E and Staff M could not find documentation in patient #9's medical record of the fall. Staff E and Staff M could not find documentation in patient #9's medical record where the physician was notified of the fall.

3. On May 18, 2015 at 5:00 p.m. surveyors reviewed 12 medical records. One (#9) of twelve medical records reviewed did not contain documented evidence of changes in the patient condition regarding the fall.

4. On May 18, 2015 at 5:00 p.m. surveyors reviewed multiple entries in patient #9's medical record that documented patient's finger stick blood sugars were abnormal. There was no documented evidence in the medical record that the physician was notified.

5. On May 18, 2015 at 5:00 p.m. surveyors reviewed multiple entries in patient #9's medical record that nursing staff documented patient's wounds. There was no documented evidence that the physician was notified of patient #9's wounds.

6. On May 18, 2015 at 4:22 p.m. Staff M told surveyors that any change in a patient's condition must be charted in the electronic health record and the physician must be notified.

7. On May 18, 2015 at 5:00 p.m. Staff E told surveyors that physicians were notified when patient's have a change of condition. Staff E told surveyors the documentation would be in the patient's electronic health record.

Based on medical record review and staff interview, the hospital failed to ensure medical records were accurately written. This occurred in one (#9) of twelve medical records reviewed.

Findings:
1. Patient #9's medical record did not contain documented evidence of notification to the physician when patient medical condition changed. This was confirmed by the Medical Director and Director of Nursing (DON).

2. Patient #9's medical record did not contain clear documentation by medical staff and nursing staff.

3. Patient #9's medical record documented inconsistent findings by the medical staff and nursing staff. There was no documentation of a wound upon admission in patient #9's medical record by the medical staff. Nursing staff documented that patient #9 had a wound upon admission. This was confirmed by the Medical Director and DON.

4. On May 18, 2015 at 1:50 p.m., the Medical Director and the DON told surveyors that any change in a patient's medical condition must be reported to the physician and be documented in the patient's medical record.