HospitalInspections.org

Based on document review and staff interview, nursing staff failed to supervise and evaluate the nursing care for each patient related to lack of documentation in the EMR (electronic medical record) by nursing staff every shift and/or daily of how patient toilets, I&O (intake & output), peri-care, underpad/linen change, and/or bath completed for 1 of 10 (patient 1) medical records reviewed.

Findings:

1. Policy #NADM 1.30 AP, Documentation Standards: Inpatient, revised/reapproved 4/12/16, indicated the expectation for documentation of the patient assessment process or reviewing the documentation and validating this review with nursing staff signature is a minimum of once per the RN's (Registered Nurse's) shift. This policy states to refer to the Daily Assessment and Care Standards, which indicates what should be documented by the RN under the: Physical Assessment section, frequency is per unit standard for all systems including gastrointestinal and genitourinary; Routine Care section, linen changes and personal hygiene as it occurs; Nutrition/All Intake and Output (I&O) section, I&O that occurs episodically (i.e. intermittent feedings, incontinence, voiding or intravenous boluses) in real time; and Plan of Care section, completed nursing interventions on each shift.

2. Review of patient 1's medical record on 8/11/16 at approximately 1152 hours indicated there was no documentation of whether or not nursing staff assisted the patient with toileting. Documentation was lacking for toileting method on 6/2/16 through 6/10/16, 6/14/16 and 6/16/16. The patient was incontinent of urine and I&O documentation was lacking on 6/8/16 and 6/9/16. Patient did not have a Foley catheter. Documentation of peri-care was lacking on 6/5/16 and 6/7/16. Documentation of underpad and/or linen change was lacking on 6/5/16, 6/7/16 and 6/9/16. Documentation of bath (including CHG wipes) was lacking on 6/2/16, 6/7/16, 6/13/16 and 6/15/16.

3. Staff 7 (Shift Coordinator) was interviewed on 8/11/16 at approximately 1440 hours and confirmed the expectation for documentation in the patient EMR, as far as peri-care and baths (including CHG wipes), is for nursing staff to document the completion of these tasks daily. Patients who are incontinent may have peri-care, baths, I&O, or underpad/linen changes documented several times a day. Toileting is documented either when it is done or every shift. Diapers are not used and patients have an underpad on their bed that is changed when it becomes soiled or as needed. The above-mentioned patient EMR lacked documentation by nursing staff every shift and/or daily of how the patient toileted, I&O, peri-care, underpad/linen change, and/or bath completed as required per facility policy and procedure.