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Based on record review and interview, the hospital failed to ensure the patient or their representative had the right to make informed decisions regarding their care. This deficient practice is evidenced by the hospital's failure to notify a patient's representative of a change in the patient's condition for 1(#2) of 5 total sampled patient records reviewed.

Findings:

Review of Patient #2's medical record revealed the patient was admitted on 8/5/16 with an admission diagnosis of UTI (urinary tract infection) with secondary sepsis due to E. (Escherichia) coli.


Review of Patient #2's medical record revealed a nurses' note entry dated 8/14/16 at 4:00 p.m. indicating the patient had spiked a temperature of 100.7 degrees Fahrenheit, and the following vital signs were documented: blood pressure: 145/68, Oxygen saturation: 93% on room air, respiratory rate: 28, heartrate: 97. The note indicated S5MD had been notified of the patient's condition change and new orders were initiated. Further review revealed a chest x-ray, blood cultures times 2, and a urinalysis with culture and sensitivity had been obtained. Additional review revealed vancomycin (antibiotic) and gentamicin (antibiotic) were also initiated on 8/14/16 at 6:30 p.m.

Review of Patient #2's physician progress note, dated 8/14/16 at 6:30 p.m., revealed the following: patient seen and examined at bedside earlier today. Patient with shortness of breath, wheezing; chest x-ray, blood cultures, urine cultures, breathing treatments and antibiotics added.

Review of Patient #2's entire medical record revealed no documented evidence that the patient's responsible party had been notified of the change in the patient's condition.

In an interview on 10/11/16 at 12:53 p.m. with S2CNO (chief nursing officer) she indicated it is her expectation that staff would notify a patient's responsible party in charge of a significant change in patient status. She further indicated the notification should have been documented in the patient's record.

Based on record review and interview, the hospital failed to ensure that the RN supervised and evaluated the nursing care of each patient as evidenced by:
1) failure of the nursing staff to document an indication for use when documenting insertion of a Foley catheter in a patient's record (#2) for 1(#2) of 5 patient records reviewed; and
2) failure of the nursing staff to document a daily assessment indicating continued need for an indwelling Foley catheter for 4 (#2, #3, #4, #5 ) of 5 patient records reviewed.


Findings:


Review of the hospital policy titled, Urinary Catheter Criteria, reviewed/revised: 9/2014; 1/2/15, revealed in part: Policy: The goal is to limit the use of catheters in selected patients, thereby reducing the risk of developing a catheter associated urinary tract infection. The criteria for use are developed using CDC and APIC Guidelines.
Procedure: A. Upon admission the nurse to determine if patient has criteria for indwelling urinary catheter. Use the following resources: 1) Pre-Assessment form, 2) Discharge summary, 3) Transfer report from discharging hospital, 4) Verbal report from RN/LPN/LVN from transferring hospital, 5) Physical assessment of patient.
B. If patient meets criteria for an indwelling catheter, document order and criteria in medical record. Catheter should be removed once criteria no longer met. Notify physician. C. If no medical reason can be obtained, remove catheter and monitor patient to ensure ability to void.

1) Failure of the nursing staff to document an indication for use when documenting insertion of a Foley catheter in a patient's record.

Review of Patient #2's medical record revealed a nurses note dated 8/5/16 at 5:00 p.m. documenting insertion of a 16 French indwelling Foley catheter. Further review of the note revealed no documented evidence of an indication for use of the Foley catheter.

In an interview on 10/11/16 at 12:35 p.m. with S2CNO, she confirmed, after review of Patient #2's medical record, that there was no documented indication for use of the indwelling Foley catheter in the narrative nurses note (dated 8/5/16 at 5:00 p.m.) that detailed insertion of the catheter.


2) Failure of the nursing staff to document a daily assessment indicating continued need for an indwelling Foley catheter.


Patient #2

Review of Patient #2's medical record revealed an indwelling Foley catheter had been inserted on 8/5/16 (day of admission) and had been removed on 8/19/16 (prior to discharge). Further review revealed no documented evidence of a daily assessment of continued need for use of an indwelling Foley catheter for Patient #2 on the daily nurses' note flowsheets. Patient #2's medical record did not have the flowsheets with the preprinted area to document the indication for continued use of an indwelling Foley catheter. There was also no documentation in the narrative nurses' notes for the continued need of the indwelling catheter.

In an interview on 10/11/16 at 12:25 p.m. with S4RNMgr (Nurse Manager), she confirmed there was no documented daily assessment of continued need for use of an indwelling Foley catheter in Patient #2's medical record. S4RNMgr indicated the hospital had initiated new nurses' notes that included a section addressing assessment for determining continued urinary catheter usage. S4RNMgr said nursing staff was not utilizing the form correctly and further staff education was needed.

Patient #3
Review of the medical record for Patient #3 revealed she was admitted on 7/16/16 with an indwelling Foley catheter.

Review of Patient #3's nursing notes dated 10/7/16, 10/8/16, 10/10/16 and 10/19/16 revealed the preprinted area to document the indication for an indwelling Foley catheter was left blank. Further review revealed on the nurse's note dated 10/9/16 the indication for the Foley was listed as "indwelling". There was also no documentation in the narrative nurse's notes for the continued need of the indwelling catheter.

Patient #4
Review of the medical record for Patient #4 revealed she was admitted on 10/7/16 with an indwelling Foley catheter.

Review of Patient #4's nursing notes dated 10/8/16 and 10/10/16 revealed the preprinted area to document the indication for an indwelling Foley catheter was left blank. There was also no documentation in the narrative nurse's notes for the continued need of the indwelling catheter.

Patient #5
Review of Patient #5's medical record revealed she was admitted on 10/1/16 with a Foley catheter.

Review of Patient #5's nursing notes dated 10/6/16, 10/8/16 and 10/9/16 revealed the preprinted area to document the indication for an indwelling Foley catheter was left blank. There was also no documentation in the narrative nurse's notes for the continued need of the indwelling catheter.

In an interview on 10/11/16 at 1:00 p.m. with S3Quality, she said the nurses should be documenting the need for continuing catheter usage every day on the nurse's note. S3Quality verified there was a preprinted area on the nurse's note for an explanation for the indication of a Foley catheter but the staff was not documenting consistently or correctly.











30364

Based on record reviews and interviews, the hospital failed to ensure all verbal orders had been authenticated within 10 days as required by the Medical Staff Rules and Regulations for 2 (#2, #3 ) of 5 total patient medical records reviewed for authentication of verbal orders.

Findings:

Review of the Hospital's Medical Staff Rules and Regulations revealed in part: 6. All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated.
C.General Conduct of Care: 1. All verbal orders shall be transcribed in the medical record and shall be countersigned by the practitioner per state regulations.

Patient #2
Review of the medical record for Patient #2 revealed a verbal order dated 8/11/16, 9:00 p.m. that had not been authenticated within 10 days by the ordering physician/licensed independent practitioner. The order had been authenticated by the ordering physician on 9/7/16 at 12:00 p.m.

Patient #3
Review of Patient #3's medical record on 10/11/16 revealed verbal orders written on 9/26/16 at 11:30 a.m. and 9/21/16 at 3:43 p.m. that had not been authenticated by the physician.

In an interview on 10/11/16 at 10:00 a.m. with S3Quality, she indicated the hospital required authentication of verbal orders by the practitioner within 10 days of being ordered as set forth by state licensing requirement.














30364

Based on record review and interview, the hospital failed to ensure all information necessary to monitor the patient's condition and other necessary information was included in the patient's medical record. This deficient practice was evidenced by failure of the ordering physician to provide an indication for insertion of a Foley catheter for a patient (#2) for 1(#2) of 5 patient records reviewed.


Findings:


Review of the hospital policy titled, Urinary Catheter Criteria, reviewed/revised: 9/2014; 1/2/15, revealed in part: Policy: The goal is to limit the use of catheters in selected patients, thereby reducing the risk of developing a catheter associated urinary tract infection. The criteria for use are developed using CDC and APIC Guidelines.

Procedure: The following criteria are used to determine necessity. ...Note: even though a patient may meet the criteria for catheterization, it is not required to be in place. This guideline is to prevent unnecessary utilization. Criteria: Urological Related: Acute urinary retention and complete inability to void, Recent urological procedure or catheter placement by a urologist, Chronic uretheral obstruction or urinary retention and surgical interventions, and/or Use of intermittent catheterization has failed or is not feasible.;
Treatment Related: 24 hour urine collection and patient is incontinent, hemodynamically unstable ICU patient needing accurate intake/output monitoring, Continuous bladder irrigation for hematuria or Anti-infective irrigation-remove once treatment completed.;
Condition Related: End of life care, Presence of Stage III or IV pressure ulcers that are not healing because of continual urine leakage in female patient, Presence of Stage III or IV pressure ulcers that are not healing because of continual urine leakage in a male patient in whom condom catheter is not feasible, Pelvic or Hip fracture, and Traction.
A. Upon admission the nurse to determine if patient has criteria for indwelling urinary catheter. Use the following resources: 1) Pre-Assessment form, 2) Discharge summary, 3) Transfer report form discharging hospital, 4) Verbal report from RN/LPN/LVN from transferring hospital, 5) Physical assessment of patient.
B. If patient meets criteria for an indwelling catheter, document order and criteria in medical record. Catheter should be removed once criteria no longer met. Notify physician. C. If no medical reason can be obtained, remove catheter and monitor patient to ensure ability to void.

Review of Patient #2's medical record revealed an admission date of 8/5/16 with an admission diagnosis of UTI (urinary tract infection) with secondary sepsis due to Escherichia coli.

Review of Patient #2's hospital admission orders revealed an order for insertion of a 16 French Foley catheter (indwelling urinary catheter). The order for the urinary catheter had no documented indication for use. Further review of the patient's entire medical record revealed no documented indication for use of the Foley catheter.

In an interview on 10/11/16 at 12:35 p.m. with S2CNO, she said it is best practice to indicate the reason for use of an indwelling Foley catheter. S2CNO reviewed Patient #2's admission orders and medical record and confirmed there was no documentation of indication for use of the Foley catheter for Patient #2.

In an interview on 10/11/16 at 1:07 p.m. with S5MD (Patient #2's admitting and treating physician), he indicated Patient #2 had recurrent UTI's and had been admitted for treatment of sepsis. He reviewed Patient #2's medical record and indicated he could not find a documented indication for the Foley catheter. S5MD speculated that maybe the catheter had been used because the patient couldn't move, because of altered mental status, or to monitor urinary output because the patient was on vancomycin and gentamicin (Foley inserted on 8/5/16, on admission, and these antibiotics were not started until 8/14/16). S5MD indicated he really couldn't recall the reason, but anybody at 89 years old receiving fluids would need a Foley catheter.