HospitalInspections.org

Based on document review and interview, it was determined for 3 of 3 (Pt. #s 1, 2 and 6) patients with Epidural catheters, the hospital failed to ensure the insertion site dressing was assessed and documentation of findings occurred every shift.

Findings include:

1. Hospital policy titled, "Care of the Patient with an Indwelling Epidural Catheter for Pain Control (revised January 2010)" required, "Documentation: ... B. Assess occlusive dressing over insertion site and document findings at least once a shift."

2. The clinical record of Pt. #1 was reviewed on 9/2/14. Pt. #1 was a 72 year old female admitted on 5/2/14 after surgery (splenectomy). Pt. #1 had an Epidural catheter inserted during surgery. An anesthesia note dated 5/5/14 at 1:30 PM included, "Epidural catheter self-migrated out." The nurses notes from 5/2/14 through 5/5/14 lacked documentation of an assessment of the Epidural dressing site.

3. The clinical record of Pt. #2 was reviewed on 9/3/14. Pt. #2 was a 74 year old male admitted on 9/2/14 after surgery (sigmoidectomy). Pt. #1 had an Epidural catheter inserted during surgery. The catheter remains in place. The nurses notes from 9/2/14 through 9/3/14 lacked documentation of an assessment of the Epidural dressing site.

4. The clinical record of Pt. #6 was reviewed on 9/3/14. Pt. #6 was a 34 year old female admitted on 8/29/14 after surgery (ileostomy). Pt. #6 had an Epidural catheter inserted during surgery. The catheter was removed on 8/31/14. The nurses notes from 8/29/14 through 8/31/14 lacked documentation of an assessment of the Epidural dressing site.

5. During an interview on 9/3/14 at approximately 10:30 AM, the Practice Manager of 12 East stated, "There is no specific place to document Epidural sites, only the medication administered."