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NEUROPSYCHIATRIC HOSPITAL OF INDIANAPOLIS, LLC
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on document review and interview, a registered nurse failed to ensure assessments were accurate for one of ten medical records (MR) reviewed (patient 1).
Findings Include:
1. Review of patient 1's medical record (MR) indicated the following, Nursing Daily Assessments, including 8/6/17, days, Integumentary: Normal, 8/6/2017, nights, Integumentary: Normal, Dry, Multiple discolorations to buttocks (sic) arms, yellow, brown, purple, 8/7/2017, days, Integumentary: Normal, Pink, Dry/Warm, 8/12/2017, days, Integumentary: Normal. Discharge Summary 8/12/17, indicated, skin assessment: Patient does have some laceration upper lip as well as some facial bruising including some abrasion and bruising nasal bridge.
2. On 8/21/2017, at approximately 10:35 AM, in the conference room with N8 (Chief Executive Officer) confirmed, patient 1 had skin assessments that were not accurate.