HospitalInspections.org

Based on medical record review, policy review, and interview, the facility failed to ensure a registered nurse evaluated the nursing care for one of 10 patients reviewed (Patient #5). The census was 296.

Findings include:

Review of the facility policy titled, Nursing Documentation Requirements, (Revision 6, Effective Date 02/06/24), revealed documentation in the clinical record should be timely, detailed, accurate, and reflect the care or services provided.

Review of Patient #5's medical record revealed she arrived to the emergency department (ED) on 01/14/24 at 1:40 PM and was transferred to an inpatient room on 01/15/24 at 4:13 PM.

The medical record of Patient #5 did not contain documentation of incontinence care while the patient was in the emergency department.

Staff D was interviewed on 02/20/24 at 8:53 AM. Staff D reported Patient #5 was moved from the hall bed to room 22 because of frequent toileting.

Staff W was interviewed on 02/20/24 at 9:51 AM. Staff W reported he assisted an orientee with changing Patient #5 in the ED. Staff W reported the orientee took the Patient #5 to a trauma bay to clean the patient up. Patient #5 had three loose stools for Staff W. Staff W reported having the facility patient satisfaction staff member and Staff Y cleaning up Patient #5, too. Staff W confirmed that incontinence care was not frequently documented in the ED.

Staff Y was interviewed on 02/20/24 at 9:57 AM. Staff Y reported Patient #5 had been incontinent and Staff Y put a PureWick on Patient #5, and then the patient had another accident. Staff W and Staff Z went in and cleaned Patient #5. "We were on her frequently throughout the day". She started having diarrhea and two float nurses cleaned her up. Staff P reported to Staff Y that Patient #5 only asked once to be cleaned up and that Staff P cleaned her up. Staff Y reported "we are to document any interventions that we do."

Staff N was interviewed on 02/20/24 at 12:16 PM. Staff N was unable to recall Patient #5. Staff N reported the ED was not floor nursing and that he/she probably would not document in the medical record each time he/she provided incontinence care for emergency department patients.