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AUSTIN LAKES HOSPITAL
PATIENT RIGHTS: CARE IN SAFE SETTING
Tag No.: A0144
Based on review of the patient record and interview with staff, the hospital staff failed to document that patient #1 sustained a fracture to his right hand on 4/21/2011.
Findings were:
A review of the clinical record for patient #1 revealed that there was a physician's order on 4/21/2011 at 10:50 am "x-ray to rt. hand and wrist." Assigned radiologist report at 1:26 pm revealed the patient had indeed a fracture to his right hand. The psychiatrist documented on the history and physical that, "the fracture happened while he was here." A review of the clinical nursing notes revealed no mention of the x-ray, any assessment of the patient's hand or pain related to the fracture. This was confirmed in interview on 4/29/2011 with the house supervisor.
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on a review of the clinical record for patient #1, it was not ensured that a registered nurse reviewed and supervised the care of patient #1.
Findings were:
A review of the clinical record revealed there was no physical assessment of patient #1 after it was determined by the physician and confirmed by x-ray that the patient sustained a fractured right hand. In addition, there was no incident report as to how the injury occurred. The last nursing note for the 7 am to 7 pm shift occurred at 10:15 am and was signed off by the RN at 1835 (6:35 pm). There was no further documented nursing assessment of the patient's hand (discharge 4/27/2011). This was confirmed in interview on 4/29/2011 with the house supervisor.
CONTENT OF RECORD
Tag No.: A0449
Based on review of the patient record and interview with staff, the hospital staff failed to document any nursing assessment reflecting that patient #1 sustained a fracture to his right hand on 4/21/2011.
Findings were:
A review of the clinical record for patient #1 revealed that there was a physician's order on 4/21/2011 at 10:50 am "x-ray to rt. hand and wrist." Assigned radiologist report at 1:26 pm revealed the patient indeed had a fracture to his right hand. It was described by the psychiatrist as a "boxer's fracture." The psychiatrist documented on the history and physical that, "the fracture happened while he was here." A review of the clinical nursing notes revealed no documentation of the x-ray and no assessment of the patient's hand or pain related to the fracture. There was no further documentation of any assessment of the hand fracture; patient #1 was discharged on 4/27/2011. In addition, there was no incident report as to how the injury occurred. This was confirmed in interview on 4/29/2011 with the house supervisor.