HospitalInspections.org

Based on medical record review, document review, and staff interview, the hospital failed to ensure that nursing adhered to the Bladder Program Policy for three (3) of three (3) patients (#1, #5, and #9) with documented episodes of incontinence. This failure has the potential to affect all patients receiving services at the hospital.

Findings are as follows:

A review was completed of the medical records for Patient #1. Patient #1 was admitted from 10/17/23 to 11/04/23, with a diagnosis of cerebrovascular accident (CVA). During the stay, Patient #1 had no roommates; and consults were made for Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), Neuropsychology, and Case Management (CM).

A Family Conference Meeting was held on 10/27/23, with Patient #1, adult child with their spouse, live-in significant other and their parent in attendance. Updates were given to progress, including: "Having trouble with incontinence - does not always feel sensation or gets it too late, has trouble verbalizing ... Continue toileting schedule and if need to, will increase frequency with nursing ..."

There were no physician orders for Bladder Training. A review of the Bladder Management Flow Sheet revealed that with a few exceptions, Patient #1 was incontinent of urine. The Bladder Management Flow Sheet documentation included, but was not limited to:

10/18/23: five (5) hours three (3) minutes between checks
10/19/23: fifteen (15) hours forty-four (44) minutes between checks
10/20/23: sixteen (16) hours thirty (30) minutes between checks
10/21/23: seven (7) hours five (5) minutes between checks
10/22/23: five (5) hours eight (8) minutes between checks
10/23/23: ten (10) hours fifty-four (54) minutes between checks
10/24/23: twenty-six (26) hours twenty-three (23) minutes between checks
10/25/23: fourteen (14) hours one (1) minute between checks
10/26/23: ten (10) hours one (1) minute between checks
10/27/23: twelve (12) hours thirty-nine (39) minutes between checks
10/28/23: four (4) hours fifty (50) minutes between checks
10/29/23: nine (9) hours twenty-seven (27) minutes between checks
10/30/23: six (6) hours twenty-seven (27) minutes between checks
10/31/23: thirteen (13) hours nineteen (19) minutes between checks
11/01/23: eight (8) hours fifteen (15) minutes between checks
11/02/23: two (2) hours thirty-five (35) minutes between checks
11/03/23: nineteen (19) hours fifty-two (52) minutes between checks
11/04/23: seven (7) hours twenty-one (21) minutes between checks

A review was completed of the medical records for Patient #5. Patient #5 was admitted 11/08/23 to present with a diagnosis of rib fractures status post (S/P) all-terrain vehicle (ATV) accident.

There were no physician orders for Bladder Training. A review of the Bladder Management Flow Sheet revealed the following, including, but not limited to:

11/10/23: an episode of incontinence with the previous documentation fifteen (15) hours and
fifty (50) minutes prior.
11/13/23: an episode of incontinence with the previous documentation twenty-one (21) hours
and forty (40) minutes prior.

A review was completed of the medical records for Patient #9. Patient #9 was admitted 07/27/23 to 08/02/23 with a diagnosis of CVA with Ataxia.

There was a physician order for Bladder Training every two (2) hours. A review of the Bladder Management Flow Sheet revealed the following, including, but not limited to:

07/27/23: an episode of incontinence with the previous documentation six (6)
hours and forty (40) minutes prior.
07/30/23: an episode of incontinence with the previous documentation seven (7)
hours and forty-eight (48) minutes prior.
07/31/23: an episode of incontinence with the previous documentation five (5)
hours and thirty-one (31) minutes prior.
08/07/23: an episode of incontinence with the previous documentation nine (9)
hours and thirty-nine (39) minutes prior.

A review of the policy, titled "Bladder Program" reviewed: 08/24/23; stated in pertinent part, "... It is the responsibility of the licensed staff to set up a bladder program for each patient with impaired bladder elimination ..."

A review of the complaints and grievances over the past three (3) months revealed that at least twenty (20) involved slow response to call lights and/or issues with elimination. Two (2) were filed on behalf of Patient #1:

An interview was conducted on 10/13/23 at 12:10 p.m. with the Director Quality Risk (DQR) regarding Patient #1. The DQR confirmed that they were currently investigating two complaints placed on behalf of Patient #1 - on 10/30/23 and 11/03/23; and that they had observed negative postings on social media.

An interview was conducted on 11/15/23 at 9:50 a.m. with the Director Quality Risk (DQR) regarding bladder management. The DQR confirmed that the bladder management policy listed specific bladder training for spinal cord injury patients; but all other patients would have individualized bladder management ordered by the physician after being assessed to need and discussed in the weekly team conference meetings. The DQR confirmed that Patient #1 had no bladder management ordered by the physician; and that while there was no standard, elimination needs should be addressed at every hourly check. The DQR confirmed after reviewing the documentation for Patient #1, #5, and #9, that the incontinence and time frames for checking and documenting were unacceptable.