HospitalInspections.org

Based on medical record review, policy review and interviews, the facility failed to ensure that all medical record entries were complete for 1 of 1 Patient reviewed (Patient #1) for a complaint that alleged the patient was not being repositioned regularly.

Specifically, nursing staff failed to consistently document the repositioning of Patient #1 every 2 hours as ordered by the physician.

As a result of this deficient practice, it could not be determined whether the patient was repositioned every 2 hours as ordered.

Findings Include:

Review of the Intake Notes for complaint TX00377999 alleged a complaint on behalf of Patient #1 that indicated Patient #1 was not being repositioned regularly.

1. Medical Record Review

Review of the medical record in part for Patient #1 on 04/07/21 at 7:00 a.m. revealed the following in part:

Admission orders given by a physician on 02/09/21 at 1905 included an order to "Turn and reposition every 2 hours."

Review of page 3 of the Daily Nursing Notes, specifically the section entitled, "Reposition" in the daily nursing notes revealed that the position was left blank and not recorded every 2 hours on the following dates and times. In addition, repositioning was not documented as having been done in the daily nursing notes on page 4 on the following dates and times: [times presented are in military times 00 to 24]

02/10/21 from 07 until 10 (3 hours), from 16 until 19 (3 hours) and from 19 on 02/10/21 thru 06 on 02/11/21 (11 hours)
02/12/21 from 16 until 19
02/13/21 from 06 until 19
02/14/21 from 05 until 19
02/16/21 from 06 thru 19
02/17/21 from 07 until 19 (12 hours) and from 22 until 19 on 02/18/21 (21 hours)
02/20/21 from 07 until 19
02/21/21 from 07 until 20
02/22/21 from 16 until 19
02/23/21 from 16 until 19
02/24/21 from 08 until 11, from 11 until 16 (5 hours) and from 16 until 19
02/25/21 from 12 until 16 and from 16 until 19
02/26/21 from 16 until 19
02/28/21 from 16 until 19
03/02/21 from 02 until 07 (5 hours) and from 17 until 08 on 03/03/21 (15 hours)
03/03/21 from 19 until 08 on 03/04/21 (13 hours)
03/04/21 from 18 until 08 on 03/05/21 (14 hours)
03/05/21 from 18 until 08 on 03/06/21 (14 hours)
03/06/21 from 18 until 08 on 03/07/21 (14 hours)
03/07/21 from 18 until 08 on 03/08/21 (14 hours)
03/08/21 from 18 until 08 on 03/09/21 (14 hours)
03/09/21 from 08 until 11, from 11 until 16 and from 16 until 07 on 03/10/21 (15 hours)
03/10/21 from 07 until 11 (4 hours), from 12 until 16 (4 hours), and from 18 until 08 on 03/11/21 (14 hours)
03/11/21 from 08 until 12 (4 hours), 12 until 16 (4 hours), 16 until 08 on 03/12/21 (16 hours)
03/12/21 from 16 until 19
03/13/21 from 03 until 08 (5 hours)
03/14/21 from 16 until 19
03/15/21 from 05 until 08
03/16/21 from 04 until 08 (4 hours)
03/17/21 from 05 until 08
03/19/21 from 24 until 1200 (12 hours), 1545 until 1200 on 03/20/21 (20 hours)
03/20/21 from 1200 until 1630 (over 4 hours), from 1630 until 1100 on 03/21/21 (over 18 hours)
03/21/21 from 1100 until 1615 (over 5 hours), from 1615 until 08 on 03/22/21 (over 14 hours)
03/22/21 from 16 until 19, from 19 until 2400 (5 hours)
03/23/21 from 2400 until 0400 (4 hours), from 0400 to 08 (4 hours) and 16 until 19
03/27/21 from 0400 until 07
03/28/21 from 13 until 18 (5 hours)
03/29/21 from 12 until 15
03/31/21 from 07 until 11 (4 hours)
04/01/21 from 06 until 19 (13 hours)
04/02/21 from 07 until 11 (4 hours), from 11 until 14, from14 until 17
04/03/21 from 07 until 07 on 04/04/21 (24 hours)
04/04/21 from 07 until 11 (4 hours), from 11 until 15 (4 hours), from 15 on 04/04/21 until 07 on 04/05/21 (16 hours)
04/05/21 from 07 until 11 (4 hours), from 11 until 15 (4 hours) and from 15 on 04/05/21 thru 06 on 04/06/21 (15 hours)

2. Policy Review

The hospital policy #CL - 1.00 entitled, "Plan for the Provision of Patient Care," with a last revised date of 6/2020 was reviewed on 04/12/21 at 4:00 p.m. and stated the following in part:

...Admission and Medical Management of Patients ...
B. All patient care is provided by or in accordance with the orders of a practitioner who meets the medical staff criteria and procedures for the privileges granted ...
...
Patient Focused Functions ...
B. Assessment of Patients
1. d. The activities of the patient assessment function are defined in writing and structures are in place for supporting the assessment of patients. The scope of assessment for each discipline involved in patient assessment as defined in writing.

The hospital's Job Description for the position entitled, "LTAC - LVN/LPN," with a last revision date of "09/13," was reviewed on 04/21/21 at 12:12 p.m. and stated the following in part:

Essential Functions and Responsibilities
Job Function ...Documents the delivery of health care in accordance with specific unit standards and hospital nursing policy.

Additional Responsibilities ... Performs or supervises complete, timely and accurate documentation of patient care.

Information Management ...Enters or records data timely and accurately ...

The hospital's Job Description for the position entitled, "LTAC - RN," with a last revision date of "September 2017," was reviewed on 04/21/21 at 12:28 p.m. and stated the following in part:

Essential Functions and Responsibilities
Job Function ...Documents the delivery of health care in accordance with specific unit standards and hospital nursing policy.

Additional Responsibilities ...Performs or supervises complete, timely and accurate documentation of patient care.

Information Management ...Enters or records data timely and accurately ...

3. Interviews

In a telephone interview of Staff #9 on 04/20/21 at 9:26 a.m., she confirmed that she works 7 p.m. to 7 a.m. and was asked to refer to page 3 of the Daily Nursing Notes, specifically the section entitled, "Comfort, Activity & Hygiene Flowsheet" on 02/10/21, 02/17/21, 03/19/21 and 03/20/21. After her own review of the Daily Nursing Notes, she confirmed the following:

02/10/21 There was no documentation of the patient's position or that the patient was repositioned after "19" thru "06" on 02/11/21 (11 hours).

02/17/21 There was no documentation of the patient's position or that the patient was repositioned after "22" thru "06" (8 hours).

03/19/21 There was no documentation of the patient's position or that the patient was repositioned during either the 7 a.m. to 7 p.m. or her entire shift of 7 p.m. to 7 a.m. (24 hours).

03/20/21 There was no documentation of the patient's position or that the patient was repositioned during either the 7 a.m. to 7 p.m. or her entire shift of 7 p.m. to 7 a.m. (12 hours).

03/21/21 There was no documentation of the patient's position or that the patient was repositioned during either the 7 a.m. to 7 p.m. or her entire shift of 7 p.m. to 7 a.m. (12 hours).

Nurse #9 was asked about the lack of documentation and stated, "It does not mean he was not repositioned. That would mean that I did not put it down. I don't recall why it was not documented. I have to do perineal care, he is on Nepro and he has accidents. It is impossible to change him without repositioning him. I have to do wound care for him and I have to reposition him to do that. If his position is off when he is feeding, I have to reposition him. Sometimes the leads for telemonitoring, the leads are not picking up and I have to move him."

In a telephone interview of Staff #10 on 04/20/21 at 10:00 a.m., he was asked to refer to page 3 of the Daily Nursing Notes, specifically the section entitled, "Comfort, Activity & Hygiene Flowsheet" on 02/21/21. After his review of the Daily Nursing Notes, he confirmed that he worked the 7 p.m. to 7 a.m. shift. He also confirmed that on the shift prior to his or the 7 a.m. to 7 p.m. shift there was no documentation of the patient's position or that the patient was repositioned.

In a telephone interview of Staff #11 on 04/20/21 at 10:14 a.m., she confirmed she works 7 a.m. to 7 p.m. and was asked to refer to page 3 of the Daily Nursing Notes, specifically the section entitled, "Comfort, Activity & Hygiene Flowsheet" on 03/19/21, 03/20/21, and 03/21/21. After her own review of page 3 of the Daily Nursing Notes, she confirmed the following:

03/19/21 There was no documentation of the patient's position during her entire shift of 7:00 a.m. to 7 p.m. shift and no documentation of the patient's position or that the patient was repositioned during the entire 7 p.m. to 7:00 a.m. shift (12 hours).

03/20/21 There was no documentation of the patient's position during her entire shift of 7:00 a.m. to 7 p.m. shift and no documentation of the patient's position or that the patient was repositioned during the entire 7 p.m. to 7:00 a.m. shift (12 hours).

03/21/21 There was no documentation of the patient's position during her entire shift of 7:00 a.m. to 7 p.m. shift and no documentation of the patient's position or that the patient was repositioned during the entire 7 p.m. to 7:00 a.m. shift (12 hours).

Nurse #11 was asked about the lack of documentation and did not remember why she did not fill out the section on repositioning. She stated, "It is a daily routine that they reposition the patient - sometimes before the 2 hours. I did reposition. I did wound care and put the time I did the wound care. I would have needed assistance from my CNA because the patient is bedbound and needs extensive wound care."

In a telephone interview of Staff #12 on 04/02/21 at 11:35 a.m., she confirmed she works 7 a.m. to 7 p.m. and was asked to refer to page 3 of the Daily Nursing Notes, specifically the section entitled, "Comfort, Activity & Hygiene Flowsheet" on 02/24/21, 02/25/21, 03/09/21, 03/10/21, and 03/11/21. After her own review of page 3 of the Daily Nursing Notes on these dates, she confirmed the following:

02/24/21 There was no documentation of the patient's position or that the patient was repositioned after "08" until "11" (3 hours), after "11" until "16" (5 hours) and after "16" until "19" (3 hours).

02/25/21 There was no documentation of the patient's position or that the patient was repositioned from "12" until "16" (4 hours) and from "16" until "19" (3 hours).

03/09/21 There was no documentation of the patient's position or that the patient was repositioned from "08" until "11" (3 hours), from "11" until "16" (5 hours).

03/10/21 There was no documentation of the patient's position or that the patient was repositioned from "07" until "11" (4 hours), from "12" until "16" (4 hours).

03/11/21 There was no documentation of the patient's position or that the patient was repositioned from "08" until "12" (4 hours), from "12" until "16" (4 hours) and from "16" until "08" (16 hours) on 03/12/21.

Nurse #12 stated, "I didn't document it but it doesn't mean it didn't happen. The CNA's go in and change the patient constantly. They change and reposition. He is total care. They change linen. They give bed baths. They would reposition during these times."

In a telephone interview of the Director of Quality Management on 04/20/21 at 2:16 p.m., she was asked about a policy on documentation and according to her the hospital does not have a policy on documentation but stated she "would expect the nurses to document something every 4 hours. The nurses follow the daily nursing notes. The nursing staff are expected to reposition the patient every 2 hours and are expected to document the patient's position at least every 2 hours on page 3 of the daily nursing notes."

In a telephone interview of the Director of Quality Management on 04/20/21 at 2:49 p.m. she was asked to refer to page 3 of the Daily Nursing Notes, specifically the section entitled, "Comfort, Activity & Hygiene Flowsheet." After her own review of page 3 of the Daily Nursing Notes, the Director of Quality Management confirmed the following:

There was no documentation of the patient's position or that the patient was repositioned during the entire 7 a.m. to 7 p.m. shift on 02/14/21, 02/16/21, 02/20/21 and 02/21/21.

There was no documentation of the patient's position or that the patient was repositioned during the entire 7 p.m. to 7 a.m. shift on 03/02/21, 03/03/21, 03/04/21, 03/05/21, 03/06/21, 03/07/21, 03/08/21, 03/09/21, 03/10/21, and on 03/11/21.

There was no documentation of the patient's position or that the patient was repositioned on 04/03/21 after 07 thru 06 on 04/04/21.

There was no documentation of the patient's position or that the patient was repositioned during the entire 7 p.m. to 7 a.m. shift on 04/04/21 and 04/05/21.