HospitalInspections.org

Based on interview and record review, the hospital failed to ensure the RN (Registered Nurse) assessed/evaluated and/or provided medical intervention for 1 of 10 patients (Patient #1). (Patient #1) had some reported GI (gastrointestinal) bleeding on the 7 PM-7 AM shift for 01/20/13 through 01/21/13. The 7 PM-7 AM RN failed to evaluate and/or document (Patient #1's) GI bleeding. (Patient #1) was sent to the ED (emergency department) for further medical treatment on the morning of 01/21/13 and was admitted.

Findings included:

(Patient #1's) Psychiatric Assessment dated 01/16/13 reflected, "Reports here for alcohol detox...some days he drinks vodka and other days he drinks beer...has been drinking daily for the last week...last drink this morning...reports he has been throwing up blood recently..."

The nursing note dated 01/16/13 timed at 17:00 PM reflected, "Coughing...verbalized cough is chronic...patient currently has a diagnosis of hematesis and gastrointestinal reflux disease...observed coughing up some blood...doctor notified..."

The internal medicine consultation dated 01/18/13 reflected, "States yesterday after dinner he threw up with some blood intermixed with the food and liquid...denies any recurrent hematemesis, blood or melena in his stool...states in the past he has been told at other hospitals he had a gastrointestinal lining tear..."

The 01/20/13 7 PM to 7 AM nursing note timed at 20:40 PM reflected, "No acute distress...on 01/21/13 at 04:00 AM...resting quietly will continue to monitor..."

The 01/21/13 7 AM to 7 PM nursing note timed at 09:00 AM reflected, "Writer received report about patient having some GI (gastrointestinal) bleeding ...writer immediately notified the physician...patient verbalized coughing up blood...blood stains were seen on pillow during nursing assessment...10:00 AM...patient transferred to ER (emergency department)...at 15:15 PM...patient admitted to (medical hospital)...patient discharged at this time..."

The internal medicine consultation dated 01/21/13 reflected, "Patient was seen on Friday for hematemesis and diagnosed with a Mallory-Weiss tear...states he was doing well until yesterday when he again vomited after eating dinner and found scant blood in his vomit...I believe it will be prudent to transfer him to the emergency room for further evaluation .. "

On 03/08/13 at 01:10 PM Personnel #1 was interviewed. Personnel #1 stated the night shift should have documented regarding (Patient #1's) coughing up blood and/or having gastrointestinal bleeding.

The hospital policy entitled, "Assessment and Reassessment of Patients" with an issue date of 11/15/2010: reflected, "Reassessments are documented when there is a significant change in patient status...RN (Registered Nurse) will reassess the patient based on the patient needs..."

Based on interview and record review, the hospital failed to ensure 1 of 10 patients (Patient #1's) comprehensive treatment plan included and/or addressed (Patient #1's) medical needs. (Patient #1) had recurrent episodes of coughing up blood and/or gastrointestinal problems during his hospital stay. (Patient #1) was sent to the ED (emergency department) for further medical treatment on 01/21/13 and was admitted.

Findings included:

(Patient #1's) Psychiatric Assessment dated 01/16/13 reflected, "Reports here for alcohol detox...some days he drinks vodka and other days he drinks beer...has been drinking daily for the last week...last drink this morning...reports he has been throwing up blood recently..."

The nursing note dated 01/16/13 timed at 17:00 PM reflected, "Coughing...verbalized cough is chronic...patient currently has a diagnosis of hematesis and gastrointestinal reflux disease...observed coughing up some blood...doctor notified..."

The internal medicine consultation dated 01/18/13 reflected, "States yesterday after dinner he threw up with some blood intermixed with the food and liquid...denies any recurrent hematemesis, blood or melena in his stool...states in the past he has been told at other hospitals he had a gastrointestinal lining tear..."

The 01/21/13 7 AM to 7 PM nursing note timed at 09:00 AM reflected, "Writer received report about patient having some GI (gastrointestinal) bleeding ...writer immediately notified the physician...patient verbalized coughing up blood...blood stains were seen on pillow during nursing assessment...10:00 AM...patient transferred to ER (emergency department)...at 15:15 PM...patient admitted to (medical hospital)...patient discharged at this time..."

On 03/08/13 at 10:00 AM Personnel #3 was interviewed. Personnel #3 was asked to review (Patient #1's) treatment plan. Personnel #3 stated no problem was identified for (Patient #1) which addressed coughing up blood and/or gastrointestinal problems. Personnel #3 verified the treatment plan should include medical problems.

The hospital policy entitled, "Treatment Plan Interdisciplinary Treatment Planning/Master Treatment Plan" with an issue date of 11/15/2010 reflected, "The treatment plan shall be appropriate to the interests of the patient and directed toward restoring and maintaining optimal levels of physical and psychological functioning...the treatment plan shall be reviewed and its effectiveness evaluated when there is a significant change in the patient's condition or diagnosis..."