HospitalInspections.org

Based on medical record review, interview and review of facility policies, the hosptial staff failed to provide accurate and complete medical records including evaluations for pain, treatment for hyperglycemia and results of bladder scan diagnostic ultrasound for 1 out of 30 patients (Patient #1)

Findings include

Review of Patient #1's medical record on 11/13/24 at 9:00 AM showed that staff failed to document results from straight catheterizations following bladder scans.
On 10/29/24 at 12:15 PM, the Registered Nurse (RN) documented a bladder scan performed with 600 ml (milliliters) urine documented in the bladder but no documentation how much urine was removed with straight catheterization. On 10/30/24 at 00:01 AM, the RN documented straight catheterization performed with 650 ml urine removed from the bladder, but failed to document the bladder scan results prior to the catheterization. During an interview on 11/15/24 at 1:30 PM in the third-floor multipurpose room, Regional Cheif Nursing Officer verifies the findings.

Review of Patient #1's medical record on 11/13/24 at 9:00 AM showed that staff failed to document sliding scale insulin lispro injections having been performed.
Documentation dated 10/29/24 at 00:01 reports blood glucose level of 250; per physician orders, 4 units of lispro insulin should have been administered but there is no documentation to show it was completed.
Documentation dated 10/30/24 at 00:01 AM reports blood glucose level of 335; per physician orders, 8 units of lispro insulin should have been administered but there is no documentation to show it was completed.
Documentation dated 10/30/24 at 01:15 reports blood glucose level of 487; per physician orders, 12 units of lispro insulin should have been administered and the physician notified but there is no documentation to show it was completed.
Documentation dated 10/30/24 at 5:29 AM reports blood glucose level of 331; per physician orders, 8 units of lispro insulin should have been administered but there is no documentation to show it was completed.
Documentation dated 10/31/24 at 11:27 PM reports blood glucose level of 177; per physician orders, 2 units of lispro insulin should have been administered but there is no documentation to show it was completed.
Documentation dated 11/01/24 at 6:12 AM reports blood glucose level of 412; per physician orders, 12 units of lispro insulin should have been administered and the physician notified but there is no documentation to show it was completed.
Documentation dated 11/01/24 at 8:57 AM reports blood glucose level of 254; per physician orders, 6 units of lispro insulin should have been administered but there is no documentation to show it was completed.

During an interview on 11/15/24 at 1:30 PM in the third-floor multipurpose room, Regional Cheif Nursing Officer verifies the findings.

(Physician orders dated 10/28/24:
insulin lispro injection SQ every 6 hours sliding scale as needed for hyperglycemia: less than 70 initiate hypoglycemia treatment, 70-150 No insulin, 151-200 2 units, 201-250 4 units, 251-300 6 units, 301-350 8 units, 351-400 10 units, greater than 400 12 units and call medical provider.)

Review of Patient #1's medical record on 11/13/24 at 9:00 AM showed that although Patient #1 was administered topical and intravenous (IV) medication for moderate sedation during catheter insertion, there is no documentation of pain assessments or levels. Medical chart documents on 11/02/24 at 8:36 PM pain level of 0 and on 11/02/24 at 11:42 PM pain level of 0. On 11/03/24 there is no documentation for pain levels during catheter re-insertion attempts.
During an interview on 11/15/24 at 1:30 PM in the third-floor multipurpose room, Surveyor asked RCNO if documented pain levels for Patient #1 should be part of the medical record as he was given sedation during indwelling urinary catheter insertion procedure on 11/03/24 and RCNO stated "should have been documented, but was not."

Review of Patient #1's medical record on 11/13/24 at 9:00 AM showed that there are no orders for transfer or discharge on 11/03/24 from hospital #1 to hospital #2 and no transfer paperwork to demonstrate that Patient #1 or spouse agreed to the transfer in the best interest of the patient. During an interview on 11/15/24 at 1:30 PM in the third-floor multipurpose room, RCNO states that if patients have Medicaid for insurance, there would be no orders for transfers out of Hospital #1, no transfer paperwork would be required and no discharge orders necessary.