HospitalInspections.org

Based on document review and interview, facility nursing staff failed to notify the patient's primary care physician of a change in patient condition for 1 of 10 medical records reviewed. (P1)

Findings include:

1. The Facility policy titled, CORE: Interdisciplinary Assessment and Re-Assessment, policy number H-PC 02-001, released date 06/2023, indicates under 15. Notification Responsibilities When an Assessment Reveals a Change or Suspected Change in Condition: a. The nurse assigned to the patient or supervising the care of the patient is responsible for notification and communication to the patient's primary physician or designee using appropriate channels and chain of command for assuring that there is physician response.

2. Medical record review for patient (P1) indicated on 9/12/24 at 4:44 am the clinical impression of the patient indicated he/she was short of breath, had a Pulse Ox reading of 88 %, and displayed the use of accessory muscles to breathe. P1 was placed on supplemental oxygen. Medical record lacked documentation of provider notification of patient change in condition.

3. In telephone interview on 10/2/24 at approximately 10:00 am with MD1 (Medical Doctor) confirmed that he/she was not notified by facility nursing staff of P1's change in condition related to a decrease in respiratory function requiring supplemental oxygenation on 9/12/24 and should have been.

Based on document review and interview, the facility failed to maintain documentation of incontinence management education or documented competencies for 7 of 7 nursing personnel files reviewed. (N1, N2, N3, N4, N5, N6, and N7)

Findings include:

1. The Facility policy titled, CORE: Incontinence Diarrhea Management, policy number H-PC 03-002, released date 06/2022, indicates under POLICY: The policy of Kindred Hospital is to ensure the following: 4. Intra-anal management system. c. Clinicians should have competencies on file for the maintenance and insertion of the system.

2. MR review for patient (P1) indicated a Physician Order documentation of rectal tube placement by MD1 (Medical Doctor) on 9/8/24 at 12:42 pm, this order was acknowledged by N4 (Registered Nurse) on 9/8/24 at 12:51 pm, the rectal tube was placed by N1 (Registered Nurse, Day Shift Nursing Supervisor) at approximately 1:57 pm. The rectal tube was removed on 9/9/24 at 8:08 am by N7 (Registered Nurse) citing a lack of effectiveness even after flushing, there was notable leaking around the rectal tube.

3. Personnel file(s) were reviewed for N1 (Registered Nurse), N2 (Registered Nurse), N3 (Registered Nurse), N4 (Registered Nurse), N5 (Registered Nurse), N6 (Registered Nurse), and N7 (Registered Nurse) indicated lack of completed education and/or competencies for Incontinence Diarrhea Management including Intra-anal management systems currently used for patients.

4. In interview on 9/26/24 at approximately 11:45 am with A5 (Registered Nurse, Day Shift Supervisor) confirmed the nursing staff placing rectal tubes, did not, but should have had documentation of device specific education or completed competencies related to placing or removing rectal tubes.