HospitalInspections.org

Based on review of a medical record of a 61 year old female patient, and interview of staff. This requirement is not met as follows:

Findings:

a. In review of medical record of 61 year old female patient who was admitted to the facility for Physical paraplegia hypotension and respiratory failure that on 10/17/16, 10/18/16, 10/22/16, 10/23/16, and 10/26/16 on the night shift the assigned respiratory technicians on duty did not document respiratory assessments as required per facility policy. Additionally the assigned nurses on 10/19/16 night shift, and day shift, 10/20/16 day shift, and night shift, 10/21/16, day shift, and night shift, 10/22/16 day shift and night shift, and on 10/23/16 day shift, did not document required PIC line flushes as required per facility policy.



b. On March 15, 2017 at 12:30pm in the facility conference room staff # 1, RN Director of Nursing reviewed the medical record for documentation in the record. She explained the assigned nurses on 10/19/16 day shift, and night shift, 10/20/16 day shift, and night shift, 10/21/16, day shift, and night shift, 10/22/16 day shift and night shift, and on 10/23/16 days shift, did not document required PIC line flushes as required per facility policy.

c. On March 15, 2017 at 3:30pm in the facility conference room staff # 2 LVN, floor nurse reviewed the medical for her documentation pertaining to PIC lines flushes in the record. She explained that she did not document the PIC line flush in the patient record on the 19th, and 20th for the day shift on October 2016.

d. On March 15, 2017 at 3:45pm in the facility conference room staff member #3, Respiratory Manager reviewed the medical record for documentation in the record. He explained on 10/17/16, 10/18/16, 10/22/16, 10/23/16, and 10/26/16 on the night shift, the assigned respiratory technicians on duty did not document respiratory assessments as required per facility policy.

e. In review of the Texas Nurse Practice Act 217.11 Standards of Nursing Practice, it states in part:

"(1) Standards Applicable to all Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: ...
(D) Accurately and completely report and document:
(i) the client's status including signs and symptoms;
(ii) nursing care rendered; ...
(v) client responses; and
(vi) contacts with other health care team members concerning significant events regarding clients status"


f. In review of Facility Policy titled, Respiratory Care Routine Responsibilities, revised January 2016 revealed in part, Oxygen rounds must be performed every shift. Maintain all documentation as it applies to the patient chart, departmental records, billing office, and patient assessments per policy.

g. In review of Facility Policy titled, Central Venous Catheters, revised October 2015, revealed in part, If the catheter is not being used for IV fluids/medications, it is to be flushed with 10ml Normal Saline and Heparin 100 units every 12 hrs. If Heparin is indicated. Flush using a pulsating motion. Never apply force. Mediports will be flushed with 10ml of Normal Saline followed by 1000 units Heparin in 2ml Normal Saline.