HospitalInspections.org

Based on facility policy review, clinical record review and interview, the facility failed to ensure nursing notes, reports of treatment and other information necessary to monitor the patient's condition were documented.

Findings included:

Facility Policy titled, "Small Bore Feeding Tube Insertion, Maintenance, and Care" with effective day 04/2012 stated in part, "Purpose: To provides [sic] guidelines for the safe administration of Enteral Nutrient Solutions (ENS) directly into the gastrointestinal tract of adults ...
Procedure:
II. Administration of feedings and medications
C. Special instructions
1. Weigh patient daily ...
D. Documentation
6. Document weight daily at 6am."

Review of clinical record for patient #1 revealed patient #1 was admitted on 1/29/16 and discharged on 2/26/16. Physician orders read "daily weight" ordered on 1/31/16 through time of discharge on 2/26/16. Tube feeding was ordered on 1/31/16 through time of discharge on 2/26/16. The following weights were documented:
· 1/29/16 at 10:05 am: 238 lbs [pounds]
· 1/29/16 at 1:30 pm: 241.4 lbs
· 1/30/16 at 9:00 am: 242.2 lbs
· 1/31/16 at 7:10 am: 258 lbs
· 2/7/16 at 6:00 am: 241.4 lbs
· 2/8/16 at 6:00 am 107.4 lbs
· 2/10/16 at 1:37 pm: 236.7 lbs
· 2/10/16 at 4:00 pm: 237.8 lbs
· 2/12/16 at 6:00 am: 237.8 lbs
· 2/12/16 at 7:00 pm: 237.8 lbs
· 2/13/16 at 7:00 am: 109 lbs
· 2/15/16 at 6:00 am: 110.3 lbs
· 2/20/16 at 3:57 am: 239.2 lbs
· 2/21/16 at 8:00 am: 243.1 lbs
Only 11 out of 27 inpatient days had weights recorded.

Review of clinical record for patient #4 revealed patient #4 was admitted on 5/20/16. Physician orders dated 5/22/16 read "weight daily" and continuous tube feeds were ordered. The following weights were documented:
· 5/22/16 - no weight documented
· 5/23/16 - no weight documented
· 5/24/16 - no weight documented
· 5/25/16 - 175.2 lbs

Review of clinical record for patient #9 revealed patient #9 was admitted on 5/18/16 and discharged on 5/24/16. Physician orders dated 5/18/16 read, "neuro [neurological] assessments Q [every] 3 hours until stable." Documentation revealed neurological assessments were only done once per shift and the "neuro assessment ordered frequency" were charted as "per shift" by the nursing staff.

Review of clinical record for patient #10 revealed patient #10 was admitted on 5/23/16. Physician orders dated 5/23/16 read, "Vital signs Q 15 min [minutes] times four, then Q 30 mins times two, then Q 1H [hour] times four, routine." Documentation revealed vital signs were not completed per orders by the nursing staff.

Four out of ten patient charts reviewed lacked documented information necessary to monitor the patient's condition.

The above was verified in an interview with the chief nursing officer on the afternoon of 5/26/16.