HospitalInspections.org

Based on document review and staff interview, although hospital staff had identified a problem with documentation of the nursing assessment of patients in the electronic medical record, namely, the practice of copying a prior nursing assessment of a patient into the current nursing assessment of the patient, the facility staff failed to address this practice which did not ensure safe and effective nursing services.

1. Failure to comprehensively assess the patient to accurately reflect the patient's current medical condition. (Refer to A-395)

2. Failure to identify and create a care plan that accurately addressed all the patient's issues. (Refer to A-396)

The cumulative effect of these systemic failures and deficient practices resulted in the facility not meeting the requirements of the Condition of Participation for Nursing Services.

Based on document review and staff interview, the hospital staff failed to ensure nursing staff performed and accurately documented a comprehensive assessment of each patient's medical condition in 2 of 20 medical records selected for review, but has the potential to affect all patients treated at the hospital. The hospital administrative staff identified an average of 72 inpatients per day.

Failure to comprehensively perform and accurately document the nursing assessment of each patient resulted in nursing staff missing early changes in a patient's medical condition, and failing to take action to prevent further decline in that patient's medical condition. For Patient #1, this potentially resulted in the loss of a left foot and lower leg.

Findings include:

1. Review of the policy "Assessment/Reassessment of Patients", revised 9/10, revealed in part, "All patients who receive care at [Great River Medical Center] are assessed by qualified individuals to determine the patient's initial needs, changing needs and effectiveness of care/intervention.... Reassessment across disciplines is ongoing and occurs at designated intervals during the patient's treatment to determine the response to and effectiveness of the care and interventions."

2. Review of the policy "Electronic Health Record: Copy, Paste or Clone Functions", created 7/11, revealed in part, "Authorized individuals who document in the [Great River Health Systems] electronic health record(s) are responsible for assuring the accuracy, completeness and timeliness of all patient-specific clinical documentation, for which they are liable.... One authorized individual's text documentation should never be copied/pasted/cloned as another's."

3. During an interview on 9/26/11 at 3:30 PM, Nursing Information Registered Nurse (RN) M stated the electronic medical record allowed the nursing staff to transfer all the documentation from a prior nursing assessment of a patient and easily insert it into the current nursing assessment. The electronic medical record did not require the nursing staff to verify the accuracy of the information, and allowed the nurse to record the prior assessment as their own information.

4. Review of Patient #1's medical record revealed:

a. On 8/11/11 at 4:55 PM, Podiatrist L documented Patient #1 had seen Podiatrist L for chronic wounds on both feet with treatment that included Podiatrist L wrapping both feet in bandages. On 8/11/11, Patient #1failed to show up for a scheduled appointment with Podiatrist L so Podiatrist L called and spoke with the patient. When Patient #1 did not respond appropriately to the Podiatrist's questions, Podiatrist L spoke with the patient's family and instructed them to take Patient #1 to the Emergency Department at Great River Medical Center, for emergency care.

b. On 8/11/11 (the first day of hospitalization), at 9:00 PM RN A documented in the Physical Assessment that Patient #1's skin assessment was "warm and dry - free of any abnormalities", and Patient #1's "sensation is intact with no complaint of numbness or tingling". However, at 10:44 PM on 8/11/11, Physician B documented in the History and Physical assessment that Patient #1 had diabetes with chronic numbness in both feet, and Patient #1 had poorly kept feet in addition to poor circulation in both feet. Neither RN A nor Physician B documented the bandages on Patient #1's feet, or the support braces Patient #1 wore while walking. At 10:19 PM, RN C documented in the Past Medical History that Patient #1 had 3 toes removed in 2009 and had wounds on both feet.

c. On 8/12/11 (the second day of hospitalization):
- At 12:00 AM, RN A documented in the Physical Assessment, the identical information and language as RN A documented on 8/11/11 at 9:00 AM.
- At 4:00 AM, RN A documented the identical information and language as RN A documented on 8/11/11 at 9:00 PM, and added that Patient #1 required supportive boots to walk.
- At 8:10 AM, RN D documented the identical information and language as RN A documented on 8/11/11 at 9:00 PM, and added that Patient #1 had wounds on both feet, and numbness in both feet.
- At 8:13 AM, Physician B documented in the Progress Note that Patient #1's left foot was warm to the touch (potentially an early sign of infection).
- At 12:55 PM, RN D documented in the Physical Assessment the identical information and language as RN D used at 8:10 AM, and RN D also documented Patient #1 had bruises on the legs from the boots worn while Patient #1 walked. RN D did not document Patient #1's left foot was warm to the touch.
- At 5:07 PM, RN E documented the identical information and identical language, as RN D documented on 8/12/11 at 12:55 PM. RN E did not document Patient #1's left foot was warn to the touch.
- At 8:14 PM, RN F documented in the Physical Assessment for Patient #1, "Old dressing to right [big] toe, left foot/ankle swollen, red, and warm. [Blood tinged] drainage noted from between toes on left. Bruise/blood blister noted on top of left foot with another bruise on inside of left ankle." RN F also documented the same information in the Wound Assessment. RN F did not document Patient #1's left foot was warm to the touch.

d. On 8/13/11 (the third day of hospitalization):
- At 3:30 AM RN G documented in the Physical Assessment the identical information and language RN F documented on 8/12/11 at 8:14 PM.
- At 8:25 AM, Physician B documented Patient #1's legs were swollen. Physician B did not document any of the problems RN F noted with Patient #1's legs and feet.
- At 8:50 AM, RN H documented the identical information and identical language RN F documented on 8/12/11 at 8:14 PM.
- At 12:23 PM, RN H documented the identical information and identical language, RN F documented on 8/12/11 at 8:14 PM.
- At 3:08 PM, RN H documented the identical information and identical language RN F documented on 8/12/11 at 8:14 PM.
- At 8:48 PM, RN F documented the identical information and identical language RN F documented on 8/12/11 at 8:14 PM.
- At 11:55 PM, RN G documented the identical information and identical language RN F documented on 8/12/11 at 8:14 PM.

e. On 8/14/11 (the fourth day of hospitalization):
- At 4:50 AM, RN G documented the identical information and identical language RN F documented on 8/12/11 at 8:14 PM.
- At 8:44 AM, RN H documented the identical information and identical language RN F documented on 8/12/11 at 8:14 PM.
- At 9:21 AM, Physician B documented in the Progress Notes that Patient #1's right ankle was warm, swollen, and had broken blood blisters. (If the ankle was warm and swollen, that could indicate an infection was present in Patient #1's ankle)
- At 1:11 PM, RN H documented the identical information and identical language RN F documented on 8/12/11 at 8:14 PM. RN H's documentation did not include any of the information Physician B documented about Patient #1's ankle.
- At 5:02 PM, RN H documented in the identical information and identical language RN F documented on 8/12/11 at 8:14 PM.
- At 9:00 PM, RN I documented the identical information and identical language RN F documented on 8/12/11 at 8:14 PM. Additionally, RN I documented Patient #1 did not walk because of Patient #1's medical condition. RN I documented Patient #1 had previously had the right big toe and another toe on the right foot surgically removed.

f. On 8/15/11 (the fifth day of hospitalization):
- At 12:00 AM, RN I documented the identical information and identical language RN I documented on 8/14/11 at 9:00 PM. At 4:00 AM, RN I documented the identical information and identical language RN I documented on 8/14/11 at 9:00 PM.
- At 7:30 AM, Physician B documented in the Progress Notes, Patient #1's left foot had increased in warmth and noted wounds on Patient #1's left foot with discoloration of the skin and increased pain (both potential signs of infection in the foot).
- At 8:36 AM, Wound Medicine Physician J documented in the Wound and Hyperbaric Consultation Note that Patient #1 had a wound on the top of Patient #1's left foot, and an open would on the inside of Patient #1's left foot. Physician J removed the dead tissue from the wound on the top of Patient #1's left foot, and removed a large quantity of foul smelling pus from the wound on the inside of Patient #1's left ankle. (The foul smelling pus indicated a severe infection in Patient #1's leg.)
- At 6:50 PM, Surgeon K surgically removed Patient #1's left foot and lower leg, because of an infection of the bones in Patient #1's left leg.

5. Review of Patient #2's medical record revealed nursing staff admitted Patient #2 to the hospital on 8/25/11. RN N initially documented bruises on Patient #2's body, and included several spelling errors in the documentation. During the course of the hospitalization, the nursing staff repeatedly copied the prior nurse's assessment, including spelling errors, and documented the copied assessment of Patient #2's bruises as their own.

6. During an interview on 9/23/11 at 8:40 AM, the Vice President (VP) of Nursing acknowledged Nursing Staff members had copied the exact documentation from prior nursing assessments, and pasted it into their assessments. The VP of Nursing stated the hospital administrative staff had identified the "cut and paste" use in nursing assessments as a problem, had created a policy prohibiting the use of "cut and paste" in nursing documentation, but had not educated the nursing staff about the new policy. The VP of Nursing acknowledged when nursing staff copied the documentation of another nurse, the nurse's actions appeared as if the nurse did not perform a thorough assessment of the patient, and instead relied on the documentation of another nurse.

Based on document review, the hospital failed to ensure the nursing staff identified and implemented all appropriate care planning needs for 1 of 20 patient's (Patient #1) selected for review. The hospital administrative staff identified an average of 72 inpatients per day.

Failure to identify and implement appropriate care plan interventions, specific to Patient #1's condition, resulted in the nursing staff failing to provide adequate and/or appropriate care for Patient #1's nursing and medical needs. Potentially this resulted in the Patient's loss of a left foot and lower leg.

Findings include:

1. Review of the policy "COMPUTERIZED CLINICAL DOCUMENTATION MEDITECH PATIENT CARESYSTEM (PCS) EMERGENCY DEPARTMENT MANAGEMENT (EDM), OPERATING ROOM MANAGEMENT (ORM) AND ENTERPRISE MEDICAL RECORD (EMR)", revised 1/11, revealed in part, "The Plan of Care is to be individualized for each patient ... as appropriate to the patient's condition."

2. Review of Patient #1's medical record revealed Registered Nurse (RN) A admitted Patient #1 to the hospital on 8/11/11 at 9:00 PM. RN A failed to document the chronic wounds Patient #1 had on both feet. Physician B did document the wounds on Patient #1's feet during the initial History and Physical examination. During the first 5 days of the hospitalization, members of the nursing staff identified the chronic wounds on Patient #1's feet, and eventually on 8/15/11, Patient #1 required an amputation below the left knee for an infection in Patient #1's left foot.

However, review of the nursing Care Plans in Patient #1's medical record revealed nursing staff did not identify the chronic wounds on Patient #1's feet in the care plan until 8/15/11, the same day Surgeon K amputated Patient #1's left foot and lower leg.

See A395.

Based on document review and staff interview, the hospital failed to ensure nursing staff performed and accurately documented the nursing assessments in 2 of 20 medical records selected for review from 7/1/11 to 9/20/11 (Patients #1 and 2). The hospital administrative staff identified an average of 72 inpatients per day.

Failure to perform and accurately document the nursing assessments resulted in nursing staff missing early changes in a patient's medical condition, and failing to take action to prevent further decline in that patient's medical condition.

Findings include:

1. Review of the policy "Assessment/Reassessment of Patients", revised 9/10, revealed in part, "All patients who receive care at [Great River Medical Center] are assessed by qualified individuals to determine the patient's initial needs, changing needs and effectiveness of care/intervention.... Reassessment across disciplines is ongoing and occurs at designated intervals during the patient's treatment to determine the response to and effectiveness of the care and interventions."

2. Review of the policy "Electronic Health Record: Copy, Paste or Clone Functions", created 7/11, revealed in part, "Authorized individuals who document in the [Great River Health Systems] electronic health record(s) are responsible for assuring the accuracy, completeness and timeliness of all patient-specific clinical documentation, for which they are liable.... One authorized individual's text documentation should never be copied/pasted/cloned as another's."

3. During an interview on 9/26/11 at 3:30 PM, Nursing Information Registered Nurse (RN) M stated the electronic medical record allowed the nursing staff to transfer all the documentation from a prior nursing assessment of a patient to easily insert it into the current nursing assessment. The electronic medical record did not require the nursing staff to verify the accuracy of the information, and allowed the nurse to record the prior assessment as their own information.

4. Review of Patient #1's medical record revealed nursing staff admitted Patient #1 to the hospital on 8/11/11. Registered Nurse (RN) A initially failed to document the chronic wounds on Patient #1's feet. The next day, the nursing staff identified the wounds. However, during the course of the hospitalization, the nursing staff repeatedly copied the prior nurse's assessment, including spelling errors, and documented the copied assessment of Patient #1's wounds as their own.

5. Review of Patient #2's medical record revealed nursing staff admitted Patient #2 to the hospital on 8/25/11. RN N initially documented bruises on Patient #2's body, and included several spelling errors in the documentation. During the course of the hospitalization, the nursing staff repeatedly copied the prior nurse's assessment, including spelling errors, and documented the copied assessment of Patient #2's bruises as their own.

6. During an interview on 9/23/11 at 8:40 AM, the Vice President (VP) of Nursing acknowledged Nursing Staff members had copied the exact documentation from prior nursing assessments and, then, pasted it in their assessments. The VP of Nursing stated the hospital administrative staff had identified the "cut and paste" use in nursing assessments as a problem, had created a policy prohibiting the use of "cut and paste" in nursing documentation, but had not educated the nursing staff about the new policy. The VP of Nursing acknowledged when nursing staff copied the documentation of another nurse, the nurse's actions could appear the nurse did not perform a thorough assessment of the patient, and instead relied on the documentation of another nurse.