HospitalInspections.org

Based on record review, review of facility documentation and interview, the facility failed to ensure that it followed the interdisciplinary care plan for monitoring and documenting a patient's ordered Input & Output in one of five sampled patients. (#1)

Findings:

A review of the medical record of patient #1 was performed.

A physician note of 10/27/22 at 1:44 PM read: "Patient is a ...year-old male with a history of a T6/T7 (thoracic) vertebral fracture as well as COPD (chronic obstructive pulmonary disease), HTN (hypertension) and OSA (obstructive sleep apnea) complaining of back pain and shortness of breath. . . . Patient states he is unable to sit due to the pain but standing causes him to have increased shortness of breath with his oxygen saturation sitting around 93%.

Advanced Practice Registered Nurse orders of 10/26/22 at 6:47 PM were entered for the performance of "Input and Output" (I/O). A review of Input and Output measurements (I&O) revealed the absence of any output measurements as follows: 10/27/22: no volume indicated; 10/29/22: no volume indicated; 10/30/22: no volume indicated; 10/31/22: no volume indicated; 11/1/22: no volume indicated; 11/2/22: no volume indicated; 11/3/22: no volume indicated.

A review of facility policy "Input and Output Measurement" revealed the following: "Process / procedure: Monitor intake and Output (I&O) routinely on all patients unless otherwise ordered. Monitor intake and output at least every four (4) hours. Record intake and output in the electronic medical record at least every 12 hours with 24 hour totals." Since there was no output documentation at all on the previously listed days, the facility was not in compliance with this policy.

During an interview of the Risk Manager on 12//22/22 at 1:35 PM she confirmed the facility failed to ensure that it followed the interdisciplinary care plan for monitoring and documenting a patient's ordered Input & Output.