HospitalInspections.org

Based on record reviews and interviews, the facility failed to assess the vital signs and neurological checks, per the physician orders for 5 ( Sampled Patient #4, #6, #7, #8, ) of ten sampled patients.


The findings included:

Review of the facility's policy, " Assessment/Reassessment," (revised 01/13), stated that all patients are reassessed at regular interval in their care. These assessments are documented in a timely manner. Assessments are individualized to the patient and any additional information is noted as applicable to the individual.


Review of SP #4 medical record showed that on 05/21/15, the patient was admitted to PCU with a diagnosis of spinal stenosis and urinary tract infection (UTI). On 05/21/15, neuro ( neurological) checks were ordered to be completed every four hours. Review of the patient ' s medical record showed that neuro checks were not documented on the following dates: 05/22/15 at 4:00AM, 8:00AM, 12:00PM and 4:00PM. On 05/23/15 from 8:00AM to 8:00PM. From 05/24/25 at 12:00AM to 05/25/15 at 4:00AM. On 05/25/15 at 12:00PM, and on 05/26/15 at 4:00PM.

On 05/27/15 at 12:00PM, Staff H, Registered Nurse (RN), stated that neuro checks are completed every two to four hours, or per physician orders.


Record review of SP #6 indicated that the patient was admitted to 3 South on 05/23/15. On 5/25/15, the patient was transferred to Intensive Care Unit (ICU) for a change in condition and neuro checks were orders at the time to be completed every four hours for 24 hours. The order was renewed on 5/26/15 for an additional 24 hours. Neuro checks were not documented on 5/27/15at 12:00AM and 4:00PM.

On 05/29/15 at 1:50PM, Staff E, RN, stated that when she received the patient from ICU, she was told that the patient had neuro checks for 24 hours and that the 24 hours was up. She stated that she checked the orders and did not see any orders for neuro checks.


Record review of SP #7 showed that on 05/24/15, the patient was admitted to 2 West with a diagnosis of syncope with head injury. Neuro checks were ordered on 05/24/15 to be completed every four hours. Neuro checks were not documented 5/26/15 at 12:00PM and on 5/27/15 from 12:00AM to 8:00AM, and at 8:00PM.

On 05/27/15 at 12:00PM, Staff H, RN, stated that neuro checks are completed every two to four hours, or per physician orders.


Record review of SP #8 indicated that on 05/26/15, the patient was admitted to 2 West with a diagnosis of debility and weakness. Neuro checks were ordered on 05/26/15 to be completed every four hours. Neuro checks were not documented on 5/27/15 from 12:00AM to 4:00AM.

On 05/29/15 at 2:05PM, Staff G, RN, stated that she did not remember if neuro checks were ordered every shift or every four hours. She stated that neuro checks were completed on shift assessments and per physician orders.

Record review of SP #9 indicated that on 05/25/15, the patient was admitted to 3 West with a diagnosis of altered mental status (AMS). Neuro checks were ordered on 5/26/15 at 10:23AM to be completed every four hours. Neuro checks were not documented on the following dates: 5/26/15 at 12:00PM and 8:00PM; 5/27/15 at 12:00AM, and from 8:00AM to 8:00PM; and on 5/28/15 from 12:00am to 4:00AM.

On 05/29/15 at 2:16PM, Staff F, RN stated that it was not possible to do neuro checks on SP#9 because the patient was confused. She stated that the patient would not respond to commands and would not open his eyes. She stated that the patient was unable to move his extremities. She stated that neuro checks are documented every four hours and includes examination of pupil, commands, orientation, and movement of extremities.