HospitalInspections.org

Based on document review, policy and procedure review, medical record review and personnel interview, nursing staff failed to supervise and evaluate the nursing care for each patient related to documentation of intake and output for 1 of 5 (N1A) closed patient medical records reviewed and of reporting patient status to nursing staff prior to transport for 1 of 5 (N1) closed patient medical records reviewed.

Findings:

1. Policy titled "Nursing and Secretary/Monitor Tech Responsibilities to set up on Outside Procedure and Transportation", revised/reapproved 4/2012, was reviewed on 5/5/14 at approximately 3:42 PM, and indicated on pg. 1 under Nurse Responsibilities section, point 7., "Call report to hospital/department."

2. Review of closed patient medical records on 5/5/14 at approximately 12:22 PM, indicated Patient:
A. N1 was a 41-year-old who presented to the Inpatient Unit on 1/27/14 for tracheostomy weaning and management, PEG (percutaneous endoscopic gastrostomy) management, seizure disorder, and anoxic encephalopathy.
a. per Nursing Progress Notes dated 3/11/14 at 1645, "[ambulance service] here to pick up patient to transfer to vent facility F2...was walked off unit with sister and mother and [ambulance] staff."
b. lacked documentation of report called by nursing staff from F1 to F2 prior to transport.

3. Ambulance Service Run Report dated 3/11/14 was reviewed on 5/5/14 at approximately 3:30 PM and indicated, patient N1was transported to F2 on 3/11/14 at 17:24 and nurses stated that F1 had not given a report to them on this patient prior to their arrival.

4. Facility documentation for December, 2013 through May, 2014 was reviewed on 5/5/14 at 1:50 PM and indicated a complaint was filed regarding an event that occurred on 3/11/14 and nurse did not call report to F2 prior to transport of patient N1.

5. Personnel P1, RN, was interviewed on 5/5/14 at approximately 1:02 PM and confirmed no report was called by nursing staff to F2 prior to this patient being transported and this is required per facility policy and procedure.

6. Policy titled "2012 Plan for the Provision of Patient Services", revised/reapproved 3/3/12, was reviewed on 5/5/14 at approximately 3:42 PM, and indicated the following:
A. 2, under Philosophy of Patient Care Services section, bulleted points, "All professions and disciplines must work together as an interdisciplinary team to assure that the needs of patients and families are met, and patient care is supported."
B. 5, under Nursing section, "Nursing provides patient care on a continuous basis, 24 hours a day, seven days a week, following the philosophy of patient care services...Effective communication channels exist between nursing and all other clinical and non-clinical disciplines in an inter-disciplinary format for clinical decision-making."

7. N1A was a 79-year-old who presented to the Inpatient Unit on 12/27/13 for weakness, dysphagia, and wound care.
a. per Physician Progress Notes dated 12/28/13, "strict I's and O's (intakes and outputs)."
b. documentation of Output was lacking for 12/31/13 to 1/1/14, 1/5/14 to 1/6/14, 1/12/14 to 1/14/14 and 1/17/14 to 1/21/14 for a total of eight 24 hour periods.