HospitalInspections.org

Based on interview and record review, it was determined that the nursing staff failed to provide nursing care and services to meet the needs of one of ten sampled patients (#10).

Findings include:
1)On 10/17/11 at 1:45 pm, an interview was conducted with the primary physician of patient #10. She stated that she has seen the patient on numerous occasions, and that she continues to have to have a Foley catheter. She stated that the patient is actually seeing a specialist this week.

2)On 10/18/11 at 10:00 am, an interview conducted with the attending physician related to the urinary output status of the patient. He stated that he is aware now and that he had ordered Intake and Output to be done on the patient when she was admitted.

3)On 10/18/11 at 11:05 am, an interview was conducted with the nurse who was assigned to the patient on 9/17/11. She was asked if she remembered how much urine the patient put out during her shift, and she stated, "no, but I know she voided, and if it's who I think it is, she only complained about her diverticulitis, not her bladder".

4)Review of the record was conducted. On admission on 9/16/11, the physician ordered patient #10 to be placed on Intake and Output every 24 hours. Documentation on the nurses notes indicates that the patient's intake was recorded but the output was documented as x2, or x3, not as is indicated in accurate output total.

5)Record review indicates that the patient left the facility Against Medical Advice at around 10:00 pm, and presented to another facilities Emergency room. Review of the record from the ER indicated that the ER physician assessed her abdomen, and noted that the bladder area was significant fullness in the supra-pubic, area, with tenderness. The ER record also indicates that a Foley catheter was inserted in the patient and there was a return of 2300ml. of urine.

6)On 10/19/11 at 12:40 pm, a telephone interview with the ER physician at the facility the patient went to after leaving AMA, was conducted. He stated that he remembered a patient coming in from another hospital, and stated, "I have never seen a bladder with that much urine before, and the patient actually had to go home with a catheter".

The standard is not met as evidenced by:

Based on interview and record review, it was determined that the facility failed to follow the physician ordered plan of care for one of ten sampled patients (#10).

Findings include:

1) A review of the record indicated that on the date of admission, 9/16/11, a CPM machine was ordered to be used a minimum of two hours per day. The nursing staff placed a CPM machine on patient #10 that did not work. The nurse documented in the nurses notes, "Attempted to place patient on CPM. Unfortunately, machine stopped working. There is no documentation that the machine was replaced with a new one in order to complete the treatment.

2)A review of the record on 9/17/11 indicated that the CPM machine was placed on the patient at 7:15 pm and at 7:30 pm was again noted not to be working. Once again, there the nurse documented in the notes at 7:30 pm, "attempted to use CPM machine on Rt. knee, machine not functioning, error "7". No replacement CPM available at this time.

3)On 10/18/11, an interview was conducted with the Physical Therapy Director. When asked about the availability of CPM machines, he stated, "the hospital has a lot of machines, and when one goes down, there is always another one available". He was asked if he was aware of a patient with bilateral knee replacements having a machine that did not work, and was just left in the room and not replaced, and he stated that no, no one had said anything to him, and the staff always lets him know if they have to get a replacement so he can have the one that did not work correctly, looked at and sent off if needed. He again reitterated that if one does not work, there are plenty more to replace it with. The maintenance supervisor was asked about this and verified that the hospital has more than enough to meet the needs, even if some are being fixed.