In separate state Department of Health investigations, both Carlisle Regional Medical Center and Penn State Milton S. Hershey Medical Center were cited for failing to report patient care.
The most recent investigation occurred at Carlisle Regional Medical Center on Feb. 4, when Department of Health investigators made an unannounced onsite special monitoring visit. There, investigators cited the facility for failing to develop nursing policies that provide nursing staff with methods of documenting nursing care provided to patients.
For seven of the 11 medical records investigators reviewed, the department found the facility did not have policies to address documentation of nursing assessments. There were incomplete Nursing Documentation Forms in regard to intake and output, and medical records without documentation or assessments of intravenous sites.
CRMC filed a plan of correction saying the chief nursing officer developed two new policies on Feb. 4 on vital signs and intake and output. The officer also reviewed but made no changes to the IV access guidelines policy.
The hospital added education for the two new policies and one unchanged policy began Feb. 7 with staff meetings three times a day. Education continued through March 11. The hospital said there will also be a weekly audit of 10 inpatient medical surgical charts to determine compliance with the three policies. The audit started Feb. 11 and will continue for eight weeks or until charts reach at least 90 percent compliance for three consecutive weeks.
Hershey Medical Center
The Department of Health earlier made an unannounced onsite complaint investigation on Jan. 14 at Hershey Medical Center and also cited the hospital for its patient care records.
The department said the hospital failed to follow its adopted policy to ensure that pertinent documentation related to patient care and services provided was included in medical records.
A review for six of seven medical records found there was often no documented evidence that a patient was offered, assisted or refused AM care, including a bath. The department said the hospital’s policy also did not address the documentation of care during the day shift.
Hershey Medical Center filed a plan of correction that by Feb. 1, the standard of care for inpatients would include basic patient care — including a bath — as the responsibility of the registered nurse or patient care assistant, every patient offered a bath every day and required documentation of a bath or refusal sometime in the 24-hour period. The standard of care will then be distributed to all clinical staff.
By Feb. 13, the hospital said the nurse manager would require documentation in writing that staff reviewed the standard of care and signatures of staff to verify ability to appropriately bathe a patient and document it in the medical record.
Nursing unit leadership would also begin rounds on all patients three times a week, and at least 50 percent of patients will be assessed and asked if they were offered to be given a bath or shower every day.
Leadership would also initiate chart audits to maintain compliance.
Since the Jan. 14 onsite investigation, Hershey Medical Center has had two onsite complaint investigations and one occupancy survey, all of which they were found to be in compliance.