HospitalInspections.org

During record review and interview, the facility failed ensure a registered nurse supervised and evaluated each patient care, in that,
during 2 of 2 admissions for Patient #1 NURSING did not document in the patient record:

a) complete assessments and re-assessments daily (Missing items: 3/15/2021 SI/Pain/Skin; 3/18/2021 SI; 3/24/2021 PM Assessment; 3/28/2021 Skin; 3/31/2021 Pain [not applicable]; 4/01/2021 AM and PM RN Assessment)

b) re-assessments after issues warranted re-assessment (Missing post issue: 3/26/2021 (3), 3/30/2021 (2)); AND

c) communication with a minor's family and physician (1/18/2021, 3/26/2021 (3), 3/30/2021 (2)).

Findings were

a) There was no documented (specified) assessment for Patient #1 on/for:
3/15/2021 SI (Suicidal Ideation)/Pain/Skin; 3/18/2021 SI; 3/24/2021 PM Assessment; 3/28/2021 Skin; 3/31/2021 Pain [assessment tated pain not applicable]; and 4/01/2021 AM and PM - RN Assessment.

b) There was no documented post incident re-assessment in the patient record after Patient #1 issue on/for:
3/26/2021 attacked/pushed by another patient; 3/26/2021 attacked/punched by another patient; 3/26/2021 fell onto the floor hitting his head in group session; 3/30/2021 discovery of possible arm injury; AND 3/30/2021 punched wall.

c) There was no documented communication with the minor's family an/or physician for Patient #1's issues:
1/18/2021 Communication to the Physician - stated during group, he wanted to kill (named staff); 3/26/2021 Communication to family and physician - attacked/pushed by another patient; 3/26/2021 Communication to family and physician - attacked/punched by another patient; 3/26/2021 Communication to family and physician - fell onto the floor hitting his head in group session; 3/30/2021 Communication to family and physician - discovery of possible arm injury occuring on 3/29/2021; AND 3/30/2021 Communication to family and physician - punched wall.

During an interview and record review on 4/06/2021 at 10:20, Personnel #2 was informed of the above chart review findings. Personnel #2 reviewed the records and confirmed the above findings.

The 6/25/2020, revised "Patient Assessment and Treatment Process" required, "provides assessments to determine what type of care is required to meet a patient's initial needs as well as his/her needs as they change...assessment and re-assessment information is communicated to the Physician...The patient and/or family/significant other, if appropriate, are included in the assessment...identification of newly identified problems to be addressed..."

The January 2021, reviewed/revised "Incident Reporting" policy required, "...If an incident involves a patient, staff must chart relevant information in the patient's medical record..."

Based on record review and interview, the facility failed to ensure medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient's progress and response to medications and services for each patient, in that,

there was no documented physician progress notes for Patient #1 on 1/21/2021 and 1/22/2021.

Findings were

There were no documented physician progress notes for Patient #1 on 1/21/2021 and 1/22/2021.

During an interview on 4/06/2021 at 11:49 AM, Personnel #7 stated, "No physician notes were found for 1/21/2021 and 1/22/2021."