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Based on record review, policy review and staff interview it was determined the registered nurse failed to ensure nursing assessment and interventions related to monitoring of urine output, pain management and pressure ulcer prevention was implemented for 3 (#1, #2, #9 ) of 11 sampled patients.

Findings include:

1. Patient #9 was admitted to the facility on [DATE] for repair of an aortic aneurysm. The post-operative orders included an order to monitor intake and output and to notify the physician of urine output less than 30 milliliters (ml)for 2 consecutive hours.

Review of documentation of urine output revealed the following:
3/9/13-No documentation of urine output from 7 a.m. until 7 p.m.
3/22/13-Urinary catheter removed at 5:00 p.m.
3/23/13-no documentation of urine output from 6 a.m. until 4 p.m., which indicated the patient had voided twice, however, the amount was not noted. At 6:00 p.m. a bladder scan revealed there was 850 mls of urine in the bladder. A urinary catheter was inserted at 7:00 p.m. and 1200 mls of urine was obtained.

Review of the policy"Pressure Ulcer/Wound Prevention and Treatment", #10-8-016, revised 9/13, indicates that patients whose Braden Assessment scores are 18 or less are considered to be at risk for skin breakdown. The pressure ulcer prevention protocol is to be implemented. The protocols calls for repositioning of the patient at least every 2 hours while in bed and every 30 minutes to 1 hour while in a chair.

Review of the Braden assessments for patient #9 revealed he was at risk for skin breakdown. Review of skin assessments revealed that a stage II pressure ulcer was noted on 3/21/13 at 8 p.m.

Review of documentation of repositioning revealed the following:
3/19/13-To chair at 8 a.m. In chair from 8 a.m. until midnight-no documentation of repositioning
3/20/13-No documentation of repositioning from 2 a.m. until 6 a.m. Transferred to chair at 6 a.m. The patient was in the chair until 4 p.m. There was no documentation of repositioning during that time.
3/21/13-No documentation of repositioning from midnight until noon. The patient was transferred from the bed to the chair. No documentation of repositioning from noon until midnight, while in the chair.
3/22/13-No documentation of repositioning from midnight until 9 a.m. This was after the stage II wound had been identified.

Review of the policy " Care of the Patient with Pain" #6-018, revised 2/12 requires that pain is to be assessed utilizing a 0-10 pain score. It also requires that response to pain medication is to be reassessed within 1 hour and requires that the physician be notified if the pain medication is not effective in controlling the patient's pain. Review of the pain assessment and Medication Administration Record (MAR) revealed the following:
3/9/13: 2 p.m. - documentation of pain, but no score, no medication
3: p.m.-documented pain 7-no pain medication
4 p.m.-documentation of pain-no score-no medication
5 p.m. - MAR indicates percocet administered-no pain assessment
6 p.m.-pain assessment 10-no medication
7 p.m. pain assessment 10-Dilaudid administered per MAR
8:00 p.m. documentation of pain, but no score-Nurse's note indicated dilaudid had been administered at 6:00 p.m. which is in conflict with the MAR documentation. There was no indication the physician was notified regarding patient's lack of response to the pain medication.

The Lead Clinical Informatics Systems Liaison was present during the review of the medical record for patient #9 on 9/26/13 from approximately 11:00 a.m. until 3 p.m. and substantiated the above findings.

2. Patient #1 presented to the Emergency Department (ED) on 5/6/13 at 3:56 p.m. with a chief complaint of fever. The patient stated he had left knee ACL surgery on 5/1/13. The ED physician physical exam noted the patient had mild swelling below the left knee, sutures were intact, no redness, and no drainage. The plan was to admit the patient. The initial nursing assessment dated [DATE] at 10:11 p.m. revealed no dressing was presence, the wound was healing, sutures intact, no drainage, uses crutches to ambulate and a brace was checked. Review of the nursing assessment dated [DATE] at 8:00 a.m. revealed no evidence of the knee wound being assessed and no mention of a dressing or brace. Nursing documentation dated 5/7/13 at 7:00 p.m. noted the patient used crutches, no dressing and no mention of a brace. Review of nursing notes dated 5/8/13 at 8:00 a.m. revealed no wound assessment and no mention of a brace or dressing. Documentation at 7:55 p.m. noted crutches, no dressing and no mention of a brace. Nursing documentation dated 5/9/13 at 8:00 a.m. revealed no evidence of a wound assessment or mention of a dressing or a brace. At 7:46 p.m. documentation noted no dressing, the use of crutches and no mention of a brace. Nursing documentation dated 5/10/13 at 8:00 a.m. revealed the use of crutches. There was no evidence of the knee wound assessment. There was no documentation of a dressing or a brace. Nursing notes a 7:00 p.m. on 5/10/13 revealed a dry gauze dressing with an ace wrap and Don Joy brace was applied. Nursing documentation dated 5/10/13 at 7:07 p.m. revealed the patient was discharge. Review of orthopedic physician progress notes dated 5/6/13 -5/9/13 revealed no evidence of the presence of a dressing or brace. Orthopedic Advanced Registered Nurse Practitioner dated 5/10/13 at 5:30 p.m. indicated will allow out of bed non wait bearing with locked brace. Review of admission physician orders dated 5/6/13 revealed no orders for crutches, a brace, or a dressing. The activity order was as tolerated. Review of subsequent orders until the time of discharge revealed no orders for the above. Review of discharge instruction dated 5/10/13 revealed generic information related to an ACL injury. There was no mention of being discharged with a brace, crutches or what to do about the dressing and wrap that was applied to the left knee or the surgical site. Interview and record review with the Manager of 5 Main and the Clinical Informatics Liaison on 9/26/13 at approximately 2:27 p.m. confirmed there were no orders for the dressing, wrap or brace found. They confirmed there were no assessments on day shift assessment for 5/7-5/9/13 for the wound. They confirmed the activity order and the conflicting information from the ARNP. They confirmed the discharge instruction were not specific to the patient's needs for dressings, the brace, or crutches.
3. Patient #2 (MDS) dated [DATE] at 8:28 a.m. with a chief complaint of weakness, anxious, and increased blood pressure. The triage blood pressure was 215/95. ED nursing assessment at 8:50 a.m. revealed positive shortness of breath.

ED physician orders at 8:53 a.m. included 1000 milliliters (ml) Normal Saline (NS) at 200 ml per hour intravenously (IV) for five hours.

ED nurse documentation revealed the IV was started at 8:50 a.m. and the NS was started at 9:11 a.m. ED nursing documentation revealed the patient was transferred to the progressive care unit (PCU) at 1:31 p.m. Review of the ED documentation failed to reveal how much IV fluid was received by the patient in the ED.

Review of admission orders dated 6/20/13 at 12:39 p.m. revealed there was no IV fluid ordered. The patient was transferred to the Intensive Care Unit (ICU) at 3:00 p.m. Review of the PCU documentation did not reveal what time the IV fluid was stopped or how much IV fluid was received by the patient in PCU.

Interview and record review with the Physician Liaison confirmed the lack of documentation for intake in the ED and PCU.