HospitalInspections.org

Based on medical record reviews, review of hospital policies and interviews for one of two patients who required urinary catheterization (Patient #2), the hospital failed to ensure bladder scans were performed per the physician's order. The finding includes:

Patient #2 was admitted to the hospital on 5/12/23 with vascular dementia with behaviors and hallucinations. Progress notes by APRN #2 dated 5/24/23 identified patient was assessed with urinary retention and constipation.
Orders by APRN #2 dated 5/24/23 at 11:54 directed bladder scan every shift and straight catheterization as needed for residual > 400mls, discontinue on 5/27/23.

Review of bladder scan nursing documentation dated 5/24/23 to 5/27/23 and interview with the Senior Director of Behavioral Health on 5/30/23 at 11:53 AM noted bladder scans were not performed by nursing staff on the night shift for 5/25/23, 5/26/23, and 5/27/23, on the evening shift for 5/25/23 and on the day shift on 5/26/23. Review of the record and interview with the Director of Behavioral Health on 5/30/23 at 11:53 AM identified Patient #2 was incontinent once or twice on the days and shifts the bladder scans were not performed.

The hospital policy entitled Bladder Scan, identified a bladder scan will be performed for each newly admitted patient and with orders from the provider.

Based on clinical record review, review of hospital policy and staff interview for one of three patients (Patient #6) reviewed for incomplete medical records, the hospital failed to ensure a telephone order to discharge the patient was documented in the Physicians orders. The finding includes:

Patient #6 was admitted to the hospital on with a diagnosis of dementia with aggression. On the Day of Admission Patient #6 was sent to an emergency room at 6:50 PM for a low oxygen reading.

A review of a Nurses notes by LPN #2 dated 3/27/23 at 11:50 PM identified that while at dinner, Patient #6 appeared to have bluish hands and fingers which were cold to the touch. The documentation further identified an attempt to measure Patient #6's oxygen level via a pulse oximeter showed a result of 58% with a reassessment of 38%.

A late entry Nurses note dated 3/28/23 at 3:30 PM by RN #2 identified a higher oxygen level could not be obtained and noted Patient #6 was assessed to have wheezing when breathing. Additionally, the note indicated LPN #2 was instructed to contact the provider who gave an order to place the patient on oxygen 1 liter per minute via a nasal cannula and to send Patient #6 to the Emergency Room for further evaluation.

During an interview and review of the medical record with RN #1 on 5/30/23 at 1:00pm, the telephone order for Patient #6 could not be located and did not appear to have been entered into the patients record. Additionally, RN #1 indicated it is the responsibility of the nurse taking the telephone order to enter it into the electronic medical record.

A review of Behavioral Health Hospital and Verbal Orders policy dated 2/28/23 directed that the telephone order will be entered into the electronic health record. Additionally, the hospital policy identified that all telephone orders will then be signed off by the practitioner within 48 hours.