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Based on medical record review, nursing staff failed to to supervise and evaluate nursing care provided to Patient #1 upon admission. Specifically, nursing staff did not notify the physician regarding the bump on the patient's head and complaints of a headache that may have resulted from Patient #1's hitting himself in the head prior to admission.

Findings:

Review of the Nurses' Progress Note dated 4/8/2011 revealed Patient #1 advised the nurse that when he feels like he is losing control he has a tendency to hit his head against the wall. On 4/9/2011 Patient #1 wrote to the nurse that his head hurts from hitting himself in the head prior to admission.
Review of the Patient Centered Interdisciplinary Assessment dated 4/9/2011 revealed Patient #1 has a bump on his head. There is a nurse's signature on the form that the assessment was reviewed.
There is no evidence in the medical record that nursing staff notified the physician about
Patient #1's bump on his head and complaints of head pain due to hitting himself in the head prior to admission.