Observations:
Based on review of facility documents, medical record review (MR) and staff interviews (EMP), it was determined that the facility failed to ensure that all significant clinical information pertaining to a patient be incorporated in the medical record for one of one medical records reviewed (MR1).
Findings Include:
On June 7, 2024, review of hospital policy "Guidelines for Patient Deaths" (last revised 1/29/2024) revealed, ... "Documentation: Patient care areas will complete automated Expired Note using the Patient Death Record...".
On June 7, 2024, a review of MR1 revealed that the patient was a 22 year old who arrived to the emergency department, on April 16, 2024, following a sudden cardiac arrest. The patient was admitted to the intensive care unit unit and following another cardiac arrest, died on April 17, 2024, at 03:03. There is no evidence of completion of the Patient Death Record, as per policy.
During an interview on June 7, 2024, at approximately 10:30 AM, EMP3 confirmed the above.
| | Plan of Correction - To be completed: 07/01/2024
POC 0933
To ensure that all significant clinical information pertaining to a patient is incorporated in the medical record:
1.Responsible Leader: Director Critical Care Unit
2.All patients who expire in the Critical Care Unit (CCU) have a completed Expiration Note (as named in the Clinical Documentation System) or "Death Record" (per PA DOH Surveyor).
3.All patients who expire in the CCU have documentation of the date and time the body is transported to the morgue.
4.Nurses in the CCU will be educated regarding completion of the Expiration Note to include all pertinent clinical information, including the date and time the body is transported to the morgue.
5.An educational page explaining the necessary components of an Expiration Note will be completed by all CCU RNs via Symplr (the organization's online learning program).
Monitoring:
1.Chart reviews will be completed on all patients who expire in CCU to ensure complete documentation of the Expiration Note, including the date and time the body is transported to the morgue.
2.Monitoring will be ongoing for 3 months with a goal of 100% or greater.
3.Monitoring will begin on July 1, 2024 and continue for 3 months. If 100% is not achieved for 3 consecutive months, monitoring will continue for an additional 3 months or until 100% compliance is achieved for 3 consecutive months.
4.Results of monitoring will be reported to the Director of Critical Care and the Patient Safety Committee.
Corrective action will be completed by: July 1, 2024
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