HospitalInspections.org

Based on closed medical record review and staff interview, the facility staff failed to maintain medical records that are complete and accurately documented for 6 of 11 patients (#7, #6, #8, #1, #2, and #3).
1. Closed medical record review for patient #7 revealed admission to the facility's Emergency Department on 8/30/15 at 0555 with chief complaint of SOB (shortness of breath) and unresponsiveness. Review revealed the patient was a resident of a local nursing home, and was admitted via EMS (Emergency Medical Services), and had a documented history of hypertension (high blood pressure), diabetes, and CVA (stroke), and paraplegia (paralyzed from the waist down). Review revealed a nurse's note documented by RN #1 at 0555 stated "...skin diaphoretic (sweaty). Responds to verbal stimuli ...O2 sats (oxygen content in the blood) 98%..." Admission vital signs at 0555 were: BP (blood pressure) - 145/99, T (temperature) - 98.3, P (pulse) - 108, R (respirations)- 28. Review revealed MD (physician) #1 examined the patient at 0600, and ordered a CT (cat) scan and labwork. MD #1 documented "no respiratory distress." Review revealed additional nurse's note at 0600 by RN #1 "increased responsiveness. O2 sats 98%. 100% non-rebreather (a type of oxygen mask)." Review revealed the patient was transported to radiology for the CT scan and the nurses's note at 0700 by RN #1 stated "Returned from CT and responds to name." Review revealed at 0727 a BP 220/123 and the patient was given Lopressor (for BP) 50 milligrams and Lisinopril (for BP) 10 milligrams by mouth at 0730 as ordered by FNP (family nurse practitioner) #1.
Review of remaining nursing documentation between 0731 and 1120 revealed the following: "0755 - Humalog R (insulin) given SC (subcutaneous), 6 units as ordered; 0830 - FSBS (finger stick blood sugar) 187; 1000 - no changes in patient status; 1015 - IV started in R (right) jugular (large vein in the neck) by FNP. Site patent; 1120 - Air transported to Greenville to V (Vidant) Greenville. Report given."
Review of FNP #1 documentation revealed orders as follows: "0850 - ABG (arterial blood gas); 0903 - hydralazine 20 mg IV, EKG (electrocardiogram), foley (urinary catheter), U/A (urinalysis); 0905 - Lasix (for fluid) 60mg; 0920 - versed (for sedation) 4mg IV, succinate (for sedation) 20 mg/ml 100mg IV; 0945 - Lasix 60 mg IV." Review further revealed FNP #1 documentation as follows: "Diagnosis: respiratory failure, pulmonary edema and "1010 - progress 'improved' "
Review of Respiratory Therapist #1 notes revealed only one note, documented at 1010 on the ventilation flow sheet, and listed ventilator settings, vital signs, and ABGs. Review further revealed staff initials that were illegible, and no corresponding signature.
Interview conducted with MD #1 on 10/08/15 at 1050 revealed "our (ED providers) shift ends at 0800. I worked the night shift and signed off to the day shift provider at 0800 that morning."
Interview with RN #2 10/07/15 at 1415 revealed "there should be some documentation in a progress note by the FNP about the patient's condition change and procedures that were performed." RN #2 confirmed that the FNP did not document the patient's change in condition, insertion of the jugular IV, or intubation. FNP #1 was unavailable for interview.
Interview conducted with Respiratory Therapist (RT) #1 on 10/08/15 at 1040 revealed "we (respiratory therapy) are supposed to document on the green respiratory therapy sheet in the patient's chart. If we perform interventions, we are supposed to document interventions (such as intubation) on the progress notes in the patient's chart." RT #1 reviewed patient #7's medical record and confirmed there was no respiratory therapy documentation in the record, except for the note at 1010 on the ventilation flow sheet.
Interview conducted with RN #1 on 10/08/15 at 1300 revealed "...when the patient came in, he was steadily talking and joking around and his O2 sats were good ...We did make several attempts to start the patient's IV, but were unable to due to swelling. I normally do document that but didn't this time ...I took the patient's BS at 0830 and he was still talking ...the patient's sister came in sometime after that and called for assistance ...FNP started a jugular IV and I charted the wrong time...the patient was intubated and I did not chart that ...I inserted a foley and I did not chart that...I should have documented more in the nurse's notes."
Interview with RN #2 10/08/15 at 1400 revealed "this chart is incomplete ...the FNP should have documented more ...the RT should have documented more ...the RN should have documented more." RN #2 confirmed that the medical record for patient #7 is neither complete nor accurate.
2. Closed medical record review for patient #6 revealed a 75 year old male admitted to the facility ED with abdominal pain. Review of the facility medical screening exam sheet, page 1, revealed an assessment documented by PA#1. Review further revealed the form was neither dated nor timed.
Interview conducted with PA #1 10/07/15 at 1600 revealed "I can't tell the date or time I saw the patient by looking at the form." Interview with RN #2 10/08/15 at 1400 confirmed that the medical record is incomplete.
3. Closed medical record review for patient #8 revealed a 76 year old patient with diabetes who was admitted to the ED on 09/30/15 at 1355 from the physician's office with low blood sugar. RN #1 documented: "1355 - patient received via ER. Skin W/D (warm and dry), Resp. (respirations) even and unlabored. FSBS (finger stick blood sugar) 69. Gave ice tea; 1510 - patient discharged. NAD (no acute distress)." Review of the Medication Reconciliation form revealed RN #1 signature and date, and the form contained no medication information (it was blank). Review further revealed a provider order to "feed patient and check FSBS 30 min after eating." Review of the nurse's notes failed to reveal documentation of feeding the patient or the FSBS 30 min after eating.
Interview with RN #1 on 10/8/15 at 1330 revealed "I did not chart feeding the patient, rechecking her blood sugar, and completing the medication reconciliation form, and I should have."
Interview with RN #2 10/8/15 at 1400 confirmed that the medical record is incomplete and inaccurate.
4. Closed medical record review on 10/08/2015 of patient #1 revealed a 67 year old male admitted on 08/17/2015 with a diagnosis of new onset A-fib (atrial fibrillation; an irregular, often rapid heart rate that can cause poor blood flow) with CHF (Congestive heart failure occurs when the heart can not pump enough blood to provide what the body demands, resulting in a reduction in blood flow to the body and a backup (congestion) of blood into the lungs). Further record review revealed a "Physician's Order Form" signed by PA #2 in the designated "Provider Signature/Date:" space on the form. The order sheet was not dated by PA #2.
Interview with RN #2 10/8/15 at 1400 confirmed that the medical record is incomplete and inaccurate.
5. Closed medical record review on 10/08/2015 of patient #2 revealed a 74 year old female admitted on 08/26/2015 with a diagnosis of Dyspnea (difficult or labored breathing); COPD (Chronic Obstructive Pulmonary Disease - a lung disease that gets worse over time and makes it hard to breathe) acute exacerbation (worsening in the signs and symptoms of a disease). Further record review revealed an "...EMERGENCY PHYSICIAN RECORD (EPR) Dyspnea (COPD, CHF & Other)" form, with patient #2's barcoded label present in the lower right hand corner of the form, which included patient #2's history of present illness, review of systems, past history, social and family history, physical exam, labs and x-rays, progress and clinical impression. The EPR does not provide a location for the date the patient assessment was performed. Further record review revealed a "Physician's Order Form" signed by PA #2 in the designated "Provider Signature/Date:" space on the form. The order sheet was not dated by PA #2.
Interview with RN #2 10/8/15 at 1400 confirmed that the medical record is incomplete and inaccurate.
6. Closed medical record review on 10/08/2015 of patient #3 revealed a 71 year old female admitted on 08/28/2015 with a diagnosis of Shortness of Breath and COPD exacerbation. Further record review revealed an EPR with patient #3's barcoded label present in the lower right hand corner of the form. The EPR does not provide a location for the date the patient assessment was performed. Review of "Physician's Order Form" signed by PA #1 in the designated "Provider Signature/Date:" space on the form revealed the order sheet was not dated by PA #1.
Interview with RN #2 10/8/15 at 1400 confirmed that the medical record is incomplete and inaccurate.