109.36 Nursing notes
Nursing records and reports which
reflect the progress of each patient
and the nursing care planned shall be
maintained. They shall be pertinent,
accurate, and concise so that they
contribute to the continuity of
patient care. Nursing records and
reports shall become part of each
patient's medical record.
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Observations:
Based on review of facility policies, medical records (MR), and staff interviews (EMP), it was determined that the facility failed to provide accurate and concise nursing records, which reflect the progress of the patient and contribute to the continuity of patient care for one (1) of one (1) medical record reviewed. (MR1).
Review on February 28, 2024, of facility policy "Patients Leaving Hospital Against Medical Advice (AMA)" , next review date September 2024 revealed, "...Staff shall take all appropriate measures to have the patient sign the form; if they won't sign, "Patient refuses to sign" shall be noted in the space provided for patient's signature. The RN should also sign and note the exact time and date of the refusal ..."
Review of nursing disposition in MR1 dated November 13, 2023, 03:55, on February 27, 2024, revealed, "...Did patient sign AMA/Declination of Services form? Yes-Consequence explained ..."
A request was made to EMP1 on February 28, 2024, at approximately 10:30 AM for the AMA/Declination of Services form signed by PT1. None provided.
Interview with EMP2 on February 29, 2024, confirmed no signed AMA/Declination of Services form was found for MR1. Further interview with EMP confirmed the form should have been present in the record.
| | Plan of Correction - To be completed: 05/31/2024
All emergency department nurses will be required to review the policy and sign off in attestation that they agree to follow it going forward. This will be completed by April 8, 2024. Chart audits will be completed for all patients who leave the emergency department prior to their discharge from April 8, 2024 through May 31, 2024 to assure compliance to the policy as well as accuracy in documentation.
This deficiency citation and plan of correction will be presented at the next Patient Safety Committee Meeting as well as the next Compliance Meeting. Minutes of the Patient Safety Committee are shared with the board. Once the monitoring period has ended on May 31, 2024, the results of that monitoring will again be presented to these committees in demonstration of this compliance.
The Director of the Emergency Department will be responsible to monitor the continued implementation of this plan of correction.
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