HospitalInspections.org

Based on observation, interview and record review the hospital failed to ensure IV (Intravenous) solutions were maintained for 1 of 2 crash carts. The adult crash cart in the ED (Emergency Department) did not contain IV solutions which were available for use in the event of an emergency.

Findings included:

On 12/06/11 at approximately 10:30 AM the adult crash cart was inspected with Personnel #7. The lower shelf of the adult crash cart was empty. No IV fluids were found on the crash cart. Personnel #7 verified the above observation. Personnel #7 said the crash cart should have IV fluids on the lower shelf.

On 12/06/11 at approximately 10:45 AM Personnel #5 was interviewed. Personnel #5 was asked by the surveyor why IV fluids were not on the crash cart. Personnel #5 stated the nursing staff obtain the IV fluids from the storage closet. Personnel #5 said the IV fluids should have been on the adult crash cart.

On 12/06/11 at 10:50 AM Personnel #7 provided the surveyor a list of what items were supposed to be on the adult crash cart. Personnel #7 said IV fluids were on the list.

The adult emergency equipment inventory record with a revision date of 06/03/08 reflected under the section entitled, "Lower Shelf" the following IV fluids: 1) N/S (Normal Saline) 1000 ml (milliliters)-2. 2) L/R (Lactated Ringers) 1000 ml-2. 3) N/S 100 ml-2. 4) D5W (Dextrose 5% in water) 250 ml-2.

The adult crash cart check off sheet dated 08/29/11 to 12/06/11 reflected unit staff were checking the crash cart.

The policy and procedure entitled, "Emergency Crash Cart" with a reviewed/revised date of 07/11 reflected, "Emergency drugs and supplies, for use in medical emergencies only, shall be immediately available for the patient floor and the Emergency Department...the cart will be restocked on the unit by the unit personnel...crash carts are to be inventoried, cleaned, and outdated stock removed monthly..."

Based on interview and record review, the hospital failed to ensure the nursing plan of care addressed a Stage I Pressure Ulcer to the coccyx for 1 of 22 patients (Patient #17).

Findings included:

The attestation statement dated 06/23/11 reflected Patient #17 was admitted 06/11/11 with a Urinary Tract Infection, Dementia, Altered Mental Status, Cardiac Dysrhythmias and Hypotension..."

The Patient Assessment dated 06/11/11 timed at 16:50 PM reflected, "STG (Stage) 1 (one) pressure ulcer noted to buttocks..."

The Patient Assessment dated 06/12/11 timed at 07:15 AM reflected, "WDI (Wound Dry Intact), Stage I to coccyx..."

The Patient Assessment dated 06/15/11 timed at 07:20 AM reflected, "Redness noted on coccyx..."

Patient #17's Plan of Care was reviewed by the surveyor and Personnel #7 on 12/08/11 at approximately 11:30 AM. Personnel #7 validated the plan of care did not address the stage I pressure ulcer found on Patient #7's coccyx upon admission and thoughout the course of Patient #17's hospital stay.

The policy entitled, "Planning Care, Treatment and Services with a reviewed/revised date of 07/11 reflected, "It is the policy of the Nursing Department to provide an individualized, interdisciplinary plan of care for all patients that is appropriate to the patient's need, strengths, and limitations and goal...the plan of care will be individualized to the needs of the patient.

Based on interview and record review, the hospital failed to ensure 3 of 22 medical records (Patient #1, #2 and #3's) were accurate and complete.

Findings included:

1) Patient #1"s face sheet reflected Patient #1 presented to the ED (Emergency Department) on 11/04 at 03:09 AM.

The emergency physician record for chest pain timed at 03:15 AM reflected no date seen.

The physician order sheet reflected no date and/or time on the orders.

The emergency nursing record timed at 03:05 AM reflected no date seen.

2) Patient #2's face sheet reflected, Patient #2 presented to the ED on 11/03/11 at 14:10 PM.

The emergency physician record for abdominal pain timed at 14:25 PM reflected no date seen.

The physician order sheet reflected no date on the orders.

3) Patient #3's face sheet reflected, Patient #3 presented to the ED on 10/30/11 at 13:50 PM.

The emergency physician record for upper respiratory symptoms timed at 14:00 PM reflected no date seen.

On 12/08/11 at approximatley 10:30 AM Personnel #7 stated the hospital policy did not include, all medical record entries had to be timed.

The hospital policy entitled, "Medical Records Core Documentation Guidelines with a reviewed date of 07/11 reflected, "Orders for treatment should be dated and timed..."