HospitalInspections.org

Based on record review and interview the hospital failed to follow their policy and procedure for informed consent as evidenced by the failure of the physicians to document communication with the family/POA (Power of Attorney) concerning DNR (Do Not Resuscitate) orders for 3 of 4 patients with DNR orders. (#7, #8, #9). Findings:

Review of the medical records of patient's #7, #8, and #9 revealed all three had a form titled "Resuscitation Orders" in the medical record. Further review revealed the physician had checked the "Do Not Resuscitate" area on the form.

Review of the instructions under "Do Not Resuscitate" (DNR) reads as follows: "documentation and confirmation of communication with patient and/or family/responsible party must be written in the Physicians' Progress notes."

Review of the Physicians' Progress notes for patients #7, #8, and #9 revealed no documented evidence of who the Physician spoke to prior to making the patient "DNR."

In a face to face interview on 05/04/10 S1 DON (Director of Nursing) confirmed the physicians' progress notes had no documented evidence of communication with the patient and/or family/responsible party at 11:15 a.m.(#7), 11:50 a.m.(#8), and 12:45 p.m. (#9).

Based on record review and interview the hospital failed to ensure RN supervision of care as evidenced by 1) failing to obtain a stat portable chest x-ray to confirm PICC (Peripherally Inserted Central Catheter) placement for 1 of 4 patients with a PICC line; 2) failing to ensure weekly weights had been performed as ordered #4, #6, R1; and 3) failing to ensure accurate weights had been performed and documented in the medical record for. 10 medical records reviewed. Findings:

1) failing to obtain a stat portable chest x-ray to confirm PICC placement
Review of the medical record for patient #8 revealed she had been admitted to the hospital on 04/28/10 and a PICC line was ordered by MD S10. Further review of the documentation revealed the PICC line was inserted at 1900 (7:00 p.m.) on 04/28/10. Review of the physician's pre-printed order sheet, titled "PICC Line Placement Orders", read under #1 "Stat portable CXR (chest x-ray) for central line placement."

Review of the Radiology reports revealed the first CXR was performed on patient #8 on 04/09/10 at 10:14 a.m. This was 15 hours and 14 minutes after the PICC line was placed.

In a face to face interview on 05/04/10 at 11:15am S1 DON (Director of Nursing) confirmed that the x-ray was not done within the stat time frame. S1 further indicated he would expect the CXR to be done within 4 hours.


2) failing to ensure weekly weights had been performed as ordered
Patient #4
Review of the medical record for Patient #4 revealed he had been admitted to the hospital for antibiotic treatment for MRSA (Methicillin Resistant Staph Aureus) of the left ankle and hand. Review of the Physicians' Admit Order dated/timed 03/03/10 at 10:15(AM or PM not documented) revealed an order to weigh upon admit and weekly.

Review of the Vital Signs and Intake & Output Record revealed Patient #4 had been weighed on 03/13/10. Further review revealed no documented evidence he had been weighed again before his discharge from the hospital on 03/21/10.

Patient #6
Review of the medical record for Patient #6 revealed she had been admitted to the hospital on 12/11/09 (no time documented) for treatment of multiple decubiti. Review of the Physicians' Admit Order dated/timed 12/11/09 (no time documented) revealed an order to weigh upon admit and weekly.

Review of the Vital Signs and Intake & Output Record revealed no documented evidence Patient #6 had been weighed from 01/05/10 until discharge on 01/22/10.

Patient R1
Review of the medical record for Patient R1 revealed she had been admitted to the hospital on 09 /29/09 at 1600 (4:00pm) for treatment of multiple decubiti. Review of the Physicians' Admit Order dated/timed 09/29/10 at 1600 (4:00pm) revealed an order to weigh upon admit and weekly.

Review of the Vital Signs and Intake & Output Record revealed no documented evidence Patient R1 had been weighed from 02/15/10 until 02/28/10 when he was placed in a Clinitron bed and the physician discontinued the weekly weights.



2) failing to ensure accurate weights had been performed and documented in the medical record
Patient #10
Review of the LTAC Pre-screen (no date/timed documented) revealed Patient #10 had not been assessed for weight as evidenced by a blank in the section titled " weight " .

Review of the medical record for Patient #10 revealed she had been admitted to the hospital on 04/26/10 for antibiotic therapy for right heel osteomyelitis. Review of the Physician ' s Admit Orders dated 04/26/10 revealed, " weigh patient on admit and weekly " .

Review of the Initial Nursing Assessment dated 04/26/10 revealed Patient #10 ' s weight documented as 238.5 and performed via the use of the bed scale.

Review of the Nutritional Assessment for Patient #10 dated 04/27/10 revealed a documented weight of 238.5 which was utilized by the S3 Dietitian to make dietary recommendations to the physician.

Review of the Vital Signs and Intake &Output Records dated 05/02/10 revealed a weight of 259.7 for Patient #10 which represented a weight gain of 21.2 pounds in a 7 day period.

The survey team requested the Director of Nursing to supervise Patient #10 being re-weighed which resulted in Patient #10 having a weight of 222.0 which represented a weight loss of 37.7 pounds in a 2 day period.

In a face to face interview on 05/05/10 at 8:30am LPN S10 (assigned to the care of Patient #10) indicated she was aware of the weight gain and attributed it to the patients congestive heart failure. When asked how she weighs a patient using the bed scale she responded that she does not zero the scale before performing the weight.


Patient R2
Review of the medical record for Patient R2 revealed she had been admitted to the hospital on 04/21/10 (no time documented) for Necrotizing Fascitis of the left thigh and buttock. Review of the physicians' Admit Orders dated/timed 04/21/10 (no time documented) revealed an order to weigh upon admit and weekly.

Review of the Initial Nurse Assessment dated 04/21/10 at 1915 (7:15pm) revealed Patient R2's admit weight was documented as 275.5 pounds.

Review of the Vital Signs and Intake & Output Record for Patient R2 revealed the following weights: 04/25/10 - 285 pounds and 05/02/10 - 147.8 pounds indicating a weight loss of 137.2 pounds in 1 week. After being re-weighed at the request of the survey, the DON indicated the bed had been zeroed and the patient weighed 247.7 pounds.

Review of the job description titled "Charge Nurse" submitted by the hospital as the one currently in use revealed.... "Position Responsibilities: e. Has up to date knowledge of health status, treatment, care and progress of patients, recognizing changes in condition that require administrative intervention to support the plan of care".

In a face to face interview on 05/04/10 at 3:00pm the DON indicated there had been no consistency in the performance of the weights. Further he indicated it was the responsibility of the charge nurse to review this information and if the weights are more than 4 pounds off, the patient should be re-weighed. In addition the DON indicated with a significant weight loss or gain it is the responsibility of the charge nurse to notify the attending physician.

Based on record review and interview the hospital failed to ensure the H&P (history and physical) was on the patients medical record within 24 hours of admission for 1 of 10 sampled patients (#9). Findings:

Review of the medical record of patient #9 revealed the patient had been admitted to the hospital on 04/27/10 (no time indicated) and the orders were noted by the nurse at 1815 (6:15 p.m.).

Review of the H&P, handwritten by Physician S9, revealed a date/time of 04/29/10 at 0720 (7:20 a.m.).

In a face to face interview on 05/04/10 at 12:45pm S1 DON (Director of Nursing) confirmed the H&P could not have been on the chart within 24 hours.