HospitalInspections.org

33787

Based on interview and record review the facility failed to ensure that the Registered Nurse performed every four (4) hours focus assessment on two (2) of 32 sampled patients (Patient 17 and Patient 32) as per hospital policy and procedure.

This failure had the potential for the Patient 17 and Patient 32 not to receive appropriate care and interventions in a timely manner.

Findings:

1. During a review of Patient 17's medical record on April 26, 2016 at 10 AM, the face sheet and the patient's history and physical revealed Resident 17 was admitted to the hospital on April 23, 2016 with diagnoses that included appendicitis (inflammation of the appendix ), abdominal pain for three (3) days, fever, and vomiting.

A review of Care Activity Assessment dated April 24, 2016, revealed, an admission physical assessment was done at 3:41 AM by an RN, and a shift assessment was done at 8:10 AM. There was no four (4) hours focus assessment done after the 8:10 AM shift assessment. There should be a focus assessment done at 12 PM.

2. During a review of Patient 32's medical record dated April 4, 2016, the face sheet and patient's history and physical revealed that Resident 32 was admitted on April 25, 2016, with diagnoses that included nausea, vomiting, and diarrhea.

A review of Patient 32's Care Activity Assessment dated April 25, 2016, revealed, that the patient had an initial assessment done at 10:30 AM on April 25, 2016. There was no other documented assessment done until 8:05 PM that day. Patient 32's focus assessment at 2:30 PM was not done.

During an interview with Registered Nurse (RN 1) on April 26, 2016 at 10:15 AM, RN 1 verified and confirmed that a focus assessment was not documented in Patient 17's medical record at 12 PM and Patient 32's focus assessment was not documented at 2:30 PM.

A concurrent interview was done with Registered Nurse (RN 2) who was assigned to Patient 32 during the shift, she stated that the patient was in the playroom and did not want to come out of the playroom for the assessment.

A review of the facility's policy and procedure titled "Patient Assessment" Policy No. 561 revised March 2016 indicated. C. Focused Assessment: This detailed nursing assessment focuses on a specific body system or systems relating to the presenting problems... Focused assessments are performed every four (4) hours in all units.