HospitalInspections.org

Based on interviews and record review, the facility failed to ensure that physician's order strict intake and output were obtained, for one of three sampled patients. Patient #1.

Findings:

During an interview on 12/17/2019 at 2:30 PM with the Director of Nursing (DON) she stated "The staff did not document the required strict intake and output as ordered by the physician on 08/07/2019 for urine and Eakins drain." The patient's output should have been measured as ordered by the physician. The DON reviewed the missing output documentation for urine and Eakins drainage tube and confirmed there was no documentation of the outputs.

A review of the physician's order dated 08/07/2019 read strict Intake and output. The facility failed to document output on a daily basis as ordered. Output documentation for urine output was not documented on 08/19.09/04/08/24 2019. On 10/13, 10/17 and 10/28/2019.
Eakins drain showed no documentation of output for 08/09 and 08/10/2019. In September 2019 shows 09/08, 09/13 and 09/20. In October 10/10, 10/11, 10/21, 10/26 and 10/27/2019.

A review of the policy and procedure titled "Guidelines and Protocols Clinical" read under nutrition and fluids for intake and output are to be totaled for each shift, and to be totaled for 24 hours by night shift.