HospitalInspections.org

Based on staff interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure the Emergency Room's (ER) Registered Nurse (RN) adequately supervised and evaluated the care provided to one patient (#1), in the selected sample of ten patients.

Findings include:

Review of the facility's policy,"Documentation in the Medical Record," revealed the purpose of documentation in the medical record was "to provide a complete and accurate record that reflects observations regarding patient status, nursing care provided to the patient, the effectiveness of nursing interventions, medical treatment ordered, and discharge preparation activities. The licensed nurse is responsible for maintaining accurate nursing documentation in the medical record."

Review of Patient #1's ER record, dated 04/26/12, revealed the patient was transferred to the ER by ambulance, from a rehabilitation facility, after the patient complained of "chest pain." Patient #1 presented to the ER on 04/26/12 at 9:14 AM. The ER physician ordered a "cath urine" for Patient #1 on 04/26/12 at 9:37 AM. The ER record contained no documentation of the "cath urine" procedure being performed on Patient #1 in the ER. However, there was a physician's order for the "cath" urine (9:37 AM), and there was documented evidence that ER Technician (ER Tech) #1 signed out and removed an in-out "cath" from the pyxis. Additionally, there was urinalysis test results (10:24 AM) in Patient #1's record. ER Tech #1 was the only ER Tech working in the ER at the time Patient #1 presented to the ER. (The second ER Tech began work at 11:00 AM). The nurse responsible for Patient #1's care and treatment in the ER was RN #1.

On 05/07/12 at 3:30 PM, RN #1 was interviewed at the facility. She stated that she reviewed Patient #1's ER record prior to the interview to help to jog her memory. She stated, "I just can't remember her/him." RN #1 confirmed that she was Patient #1's nurse on 04/26/12. She revealed that ER Techs were trained to catheterize patient's in the ER to assist the nurses. She confirmed that she did not see any documented evidence Patient #1 was catheterized other than the physician's order (9:37 AM) and the urinalysis results (10:24 AM). She stated the ER Tech catheterizing the patient should document the procedure in the patient's record. RN #1 reviewed the photographs of the bruising to Patient #1 and stated, the "bruising looked older." She stated that she would have expected to be made aware of any type of bruising on a patient, old or new, by the ER Tech who catheterized the patient. She revealed she would have assessed the patient and brought it to the attention of the ER physician.

On 05/07/12 at 3:45 PM, ER Tech #1 was interviewed at the facility. ER Tech #1 stated she did not recall performing an in-out catheterization on Patient #1. She stated that she's worked in the ER for 6 years and she performs a lot of in-out catheterizations on patients on a daily basis. She revealed it was her responsibility to document a procedure, such as an in-out catheterization, in the patient's medical record. She stated that she would immediately report any bruising to a patient's genital area to the nurse. ER Tech #1 reviewed the photographs of the bruising to Patient #1. She stated "I would have definitely reported the bruising. I honestly don't remember seeing it. I would have been surprised and reported it immediately."

On 05/08/12 at 10:00 AM, a telephone interview was conducted with Patient #1's ER physician. He revealed he did not recall Patient #1 and stated he would not have assessed his/her "genital region" if his/her presenting complaint was "chest pain." He confirmed he ordered a "cath" urinalysis on Patient #1. He stated he was not made aware of any bruising to Patient #1's genital region.

It was determined the bruising to Patient #1's genital area and bilateral thighs was not documented or reported while the patient received care in the ER (in-out catheterization for a urinalysis). The patient was admitted and upon arrival to the nursing floor, the bruising to the patient's genital area and thighs was discovered during incontinent care provided by CNA (Certified Nursing Assistant) #1. CNA #1 immediately reported the bruising to RN #2. The bruising was documented, the physician was notified, the family was made aware, and the bruising was reported to the appropriate authorities for further investigation.