HospitalInspections.org

Based on review of facility policy, medical record review (MR) and staff interview (EMP), it was determined the facility failed to ensure pertinent documentation related to care and services, patient's progress and response to services provided was included in the medical record for three of nine patients (MR1, MR8 and MR9).

Findings include:

Review of facility policy "Documentation of Food and Fluid Intake" reviewed September 29, 2010, revealed "Policy: It is Kindred's policy to document food and fluid intake for all patients to screen for inadequate nutrition intake. Procedure: 1. Each meal and supplement is observed and the percentage eaten is recorded for each patient."

Review of facility policy "Placement of a Foley Catheter" reviewed September 29, 2010, revealed "Procedure: Female Patient: ...14. Document in medical record foley size, description of urine, and patient's tolerance to procedure."

Review of facility policy "Assessment/Reassessment - Interdisciplinary Patient" revised November 2010 revealed "Purpose: ...3. To establish a comprehensive information base for decision making about each patient's care. ...Procedure...Nursing Department 1. An assessment is performed by a Registered Nurse and is recorded in the patient medical record, within 12 hours of admission. This assessment is based upon actual observation, patient/family interview, and records accompanying the patient from the referral facility. 2. ...The initial assessment of the patient's nursing care needs will include: Biophysical..."

1. Review of MR1, on June 22, 2011, at approximately 3:00 PM revealed that there was no documentation of meal consumption for lunch or dinner on June 11, 2011, and there was no fluid intake documented for June 11, 2011.

2. Review of MR9, on June 24, 2011, at approximately 3:15 PM revealed that there was no documentation of meal consumption for lunch or dinner on June 17, 2011.

Interview with EMP2 on June 22, 2011, at approximately 3:30 PM, indicated, "No that would be it, that is all there is [regarding food consumption documentation for MR1 for June 11, 2011]."

3. On June 22, 2011, between 2:00 PM and 4:00 PM, a review of MR8 revealed that from May 22, 2011, through May 29, 2011, there was no documentation of meal consumption for 17 of 24 meals.

4. Continued review of MR8 revealed a physician's order to begin tracking intake and output (I&O) every eight hours starting May 24, 2011. I&O documentation was incomplete on this record for May 24, 25, 26, 27, 28 and 29, 2011.

During an interview on June 23, 2011, at 11:00 AM, EMP2 confirmed the above findings related to meal consumption and record of I&O for MR8 and stated "The nursing assistants are responsible for entering the meal consumption into the system. ...there are multiple dates where there is just no documentation for meal consumption. They have the ability to also indicate if the patient refused a meal, but there is no documentation either way in this record."

5. On June 22, 2011, at approximately 2:00 PM a review of MR8 revealed the patient had a urine specimen drawn from a foley catheter for a urinalysis and urine culture and sent to the lab on May 28, 2011, at 18:43 PM. There was no documentation regarding insertion of a foley catheter.

Interview of EMP2 on June 23, 2011, at 11:00 AM confirmed there was no documentation as to when the indwelling catheter was placed, what size catheter was used or the patient's tolerance to the procedure. EMP2 stated, "Only nurses insert catheters and I would expect to see a nurse's note as indicated in our policy."

6. On June 22, 2011, at 3:00 PM review of MR8 revealed the patient was admitted to the facility on May 21, 2011. A nursing note dated May 24, 2011, 14:22 revealed "Pt has vascular discoloration of BLE [bilateral lower extremities]. No open areas. Pt denies pain. BUE [bilateral upper extremities] with multiple ecchymotic areas all purple/dark blue. Pt has no complaints except tenderness when areas are touched."

During an interview on June 24, 2011, at 8:50 AM, EMP2 related that on May 24, 2011, photos were taken of the ecchymotic areas on the arms of MR8 which the wound care nurse identified as "Not new bruises. They were in different stages of healing and looked more like venipuncture and IV sites than from another type of injury. There were marks in her antecubital areas."

EMP2 also confirmed that the ecchymotic areas on the arms of MR8 should have been documented during the admission assessment and stated "No they weren't ...yes I would expect to see notation of them in the nursing [admission] assessment."

7. On June 22, 2011, at approximately 3:45 PM a review of MR8 revealed there was no documentation of bathing or linen change on May 22 and May 28, 2011.

During an interview on June 22, 2011, at 4:00 PM, EMP2 stated "We don't have a policy regarding documentation of baths and linen change. Our expectation is that all patients get bathed and fresh linens every day and additionally as needed. The nursing assistants are responsible for this and they would document in [computer].

During an interview on June 23, 2011, at 11:00 AM EMP2 confirmed there was no documentation related to bathing or linen change for MR8 on the above identified days.