HospitalInspections.org

Based on review of documentation and interview it was determined that the hospital failed to ensure that Certified Nursing Assistants (CNAs) documented care provided to the patient as required by the care plan.

Findings were:
CNAs did not document care provided to the patient as required by the care plan. Review of the "Care Plan" for patient #1 revealed that the frequency for "Tech Charting Flowsheet" was "Q12H". The current status of this was listed as "Active". Review of the "Tech Charting Flowsheet" revealed various areas of care that involved tech charting, these areas included: "Hygiene, Mobility, Feeding, Tolieting, Was routine perineal care performed?" and "Additional Care". For the date of 01/24/2019 there was an entry for 20:40 hours but no entry was found for the day shift. Continued review of the "Tech Charting Flowsheet" revealed no entries for the date of 01/25/2019.

Review of hospital policy entitled: "Clinical Documentation for Acute Inpatient Nursing" with an effective date of 12/15/07 stated on page two: "4. Interventions will be charted when performed in the HMS Patient Care Worklist by the staff with assigned permissions Entries will be electronically signed, dated and timed when performed."

In an interview with staff members #1 and #2 on the afternoon of 3/4/2019 it was confirmed that there was no documentation available for review that indicated that the CNAs had charted on the "Tech Charting Flowsheet" for the above dates. In an separate interview with staff members #1 and #2 on the morning of 3/5/2019 the above was reconfirmed.

Based on review of documentation and interview it was determined that the hospital failed to ensure that nursing assessments were accurate.

Findings were:
Nursing assessments for January 30, 2019 were not accurate. Patient #1 was a paraplegic. Review of Admission - Adult Interview and History dated 01/22/2019 at 18:21 documented: "Musculoskeletal History Deformity Foot Drop Weakness Other-See Comment Comment: parapalegic, mva 2009". "Orthopedic Devices Wheelchair Comment: Heel Protectors".

Review of the physician history and physical for patient #1 revealed: "The patient is is a 49-year-old female, with past medical history of T10 level paraplegia status post motor vehicle accident." Review of the physician discharge summary revealed: "The patient is a 49-year old female with past medical history of T10 paraplegia, status post motor vehicle accident..."

Review of the Nursing: Med/Shift Assessment, dated Jan-30-2019 at 0915 and electronically signed by a Registered Nurse on Jan-30-2019 at 1641 stated in the Neurological Assessment section that: "Foot Pushes are Equal and Strong." The Musculoskeletal Nursing Assessment stated: "Musculoskeletal test normal: Able to move all extremities, full flexion and extension, no involuntary movements, no spontaneous, no deformities or fractures."

Review of the Nursing: Med/Shift Assessment, dated Jan-30-2019 at 2108 and electronically signed by a Registered Nurse on Jan-31-2019 at 0412 stated in the Neurological Assessment section that: "Foot Pushes are Equal and Strong." The Musculoskeletal Nursing Assessment stated: "Musculoskeletal test normal: Able to move all extremities, full flexion and extension, no involuntary movements, no spontaneous, no deformities or fractures."

In an interview with staff members #1 and #2 on the morning of 3/5/2019 in the hospital conference room it was confirmed that the above referenced nursing assessments from January 30, 2019 were not accurate.