HospitalInspections.org

Based on a review of facility documentation, medical records (MR) and staff interviews (EMP), it was determined that the facility failed to meet weekly to re-evaluate and document progress toward goals and barriers to discharge for their Infection Transdisciplinary Plan of Care for four of five medical records reviewed (MR1, MR2, MR3, and MR4).


Findings include:


Review of facility policy "Transdisciplinary Care Planning" last revised January 2014 revealed "...Patient care needs are identified and prioritized and a plan of care, which appropriately addresses priority need, is initiated within 24 hours of admission. following the evaluations by other disciplines, the Transdisciplinary Care Team will meet formally (within 72 hours of admission) to further develop the plan. At least every business week thereafter, the Transdisciplinary team will meet to revise and update the established care plan and to discuss discharge options and needs. The Case Manager is responsible for overseeing the development, appropriateness, and follow through of the Transdisciplinary Plan of Care...During the team meetings, the, the team members will document progress toward goals and barriers to discharge and each team members present will sign the Transdisciplinary Team Conference Summary form to note collaboration and attendance at the meeting..."

1) Review of MR1's Transdisciplinary Plan of Care dated March 3, 2016 revealed Infection as one of seven significant problems and barriers to discharge.

2) Further review of MR1's Transdisciplinary Plan of Care revealed that a plan of care for Infection was initiated on March 3, 2016, and was not re-valuated again prior to the patient's discharge on March 21, 2016.

3) Review of MR1's Transdisciplinary Team Conference Summary documentation revealed that Infection Control staff documented progress toward goals and barriers to discharge related to infection on March 3, 2016, but no further documentation was made by Infection Control staff on March 9, 2016, or March 16, 2016, to re-evaluate the Infection plan of care or document progress toward goals or barriers to discharge.

During interview on April 8, 2016, at approximately 1:30PM EMP2 confirmed the above findings and revealed "...I was not present at those meetings..."

4) Review of MR2 revealed "Transdisciplinary Plan Of Care ... Problem 3: INFECTION Date Initiated 3/19/16 ... Isolation Status:" Further review revealed no documentation the patient isolation status was droplet as per physician order.

5) Review of MR3 revealed "Transdisciplinary Plan Of Care ... Problem 3: INFECTION Date Initiated 2/24/16 , 3/2, 3/9, 3/16/16, 3/23/16... Isolation Status:" Further review revealed no documentation the patient isolation status was contact as per physician order.

6) Review of MR4 revealed "Transdisciplinary Plan Of Care ... Problem 3: INFECTION Date Initiated 3/19/16." Further review of MR3 revealed no documentation was made by Infection Control staff on March 19, 2016, March 25, 2016, or March 30, 2016 to re-evaluate the Infection plan of care or document progress toward goals or barriers to discharge.

During review of the medical records EMP3 confirmed the above findings and revealed "It's[isolation status] not there".

Based on a review of facility documentation, medical records (MR), and staff interviews (EMP), it was determined that the facility failed to use appropriate abbreviations and document legibly for one of 10 medical records reviewed (MR1).

Findings include:

Review of facility policy "Basic Clinical Documentation" last reviewed January 2016 revealed " ...write legibly ...Use only hospital approved abbreviation and symbols ... "
Review of facility policy "Abbreviations and Symbols" last reviewed January 2016 revealed " ...Policy: Only symbols and abbreviations/symbols in the Abbreviations List and approved by the Medical Staff will be used in the Medical Record documentation ... "
1) Review of MR1 Respiratory Care Flowsheet dated March 21, 2016 at 10:00 revealed " ...NT (Nasotracheal) SX for sputum C&S (Culture and Sensitivity) ...2150 ...NT SX for Thick Dark Bloody Secretions ... "
Review of Facility policy "Abbreviations and Symbols" revealed that the documentation letters SX is the facility approved abbreviation for "Symptoms."
2) Further review of MR1 for the period of March 2, 2016 through March 21, 2016 revealed multiple entries by Respiratory, Nursing, and Physicians that were not legibly written and required extensive scrutiny by EMP1 to ascertain exactly what was written by staff.
During interview on April 8, 2016, at approximately 1:00PM EMP1 confirmed the above findings and revealed " ...Respiratory was using the abbreviation SX for suctioned and that is not what it means ...I would not say all the documentation by staff is not legible but some of it I definitely cannot read... "

Review of facility documentation, medical records (MR), and employee interview interviews, it was determined that the facility failed to ensure documentation of pertinent informatuon to contribute to the continuity of patient care for four of four medical records reviewed (MR2, MR3, MR4, and MR5).

Findings include:

Review of facility policy and procedure "Precautions for Resistant Organisms" dated January 26, 2016, revealed "Infection Control Precautions A. Contact precautions will be routinely implemented for all patients with MDRO's[multi drug resistant organisms], whether colonized or infected."

1. Review of MR2 revealed "General Admission Orders dated 03/16/16... Isolation" with a check box marked "Droplet Isolation" further review revealed no documentation droplet precautions was implemented or maintained.

2. Review of MR3 revealed "General Admission Orders date 2/22/16 ... Isolation" with a check box marked "Contact Isolation" further review revealed no documentation contact isolation was implemented or maintained.

3. Review of MR4 "General Admission Orders" dated April 2, 2016, revealed a check box marked "Contact Isolation" further review revealed no documentation contact isolation was implemented or maintained.

4. Review of MR5 revealed "General Admission Orders Date 4/01/16 ... Isolation" with a check box marked "Droplet Isolation" further review revealed no documentation droplet isolation was implemented.

During an interview on April 8, 2016 at 11:00AM, EMP2 confirmed the above findings and revealed, "these are new forms there use to be a place to document isolation, it's not there anymore."