HospitalInspections.org

Based on record review, staff interview, and policy review, the hospital failed to ensure that a Registered Nurse (RN) validated the initial assessment for two of 32 Patients (#10 and #31) performed by a Licensed Practical Nurse (LPN) (Staff U and X). This deficient practice places patients at risk for not identifying all of the patient's needs and could lead to patient harm or death.

Findings include...

- Patient #31's record review showed an admission date of 01/14/18 with a diagnosis of hypertensive emergency (elevated blood pressure). LPN Staff X performed the initial admission assessment. The initial admission assessment completed by LPN Staff X lacked validation by an RN. According to the Daily Roster for this shift on 01/14/18, RN Staff N was on duty.

Interview on 01/31/18 at 11:45 AM, Credentialing RN, Staff V, confirmed the RN oversight of the initial assessment was not documented and stated,"based on the Daily Roster for the unit, RN Staff N should have provided the oversight."

- Patient #10's record review showed an admission date of 01/27/18 with a diagnosis of Pulmonary Emphysema (condition in which the air sacs of the lungs are damaged and enlarged causing problems with breathing). LPN Staff U performed the initial admission assessment. The initial admission assessment completed by LPN Staff U lacked validation by an RN.

Interview on 01/30/18 at 4:00PM, Administrative, Staff V, acknowledged that the Patient #10's initial assessment was performed by LPN Staff U and the record lacked documentation of RN oversight of the initial assesement.

Policy titled, "Admission, PCS GSS," directed, Specific functions carried out exclusively by the RN revolve around the areas of validation and determining patient care needs and Validate the initial assessment of the patient within two hours of admission or sooner if patient condition requires.