HospitalInspections.org

Based on interviews and review of one of one applicable medical record it was determined the Hospital's medical staff failed to appropriately assess the Patient and provide appropriate timely treatment.

Findings include:

1.) Review of the Patient's medical record indicated a medical screening examination was performed after the Patient arrived in the ED on 2/2/10. The time of the examination was not documented. The examination did not indicate the Patient's speech, insight, concentration or gait were evaluated.

2.) (Review of nursing documentation dated 2/4/10 and indicated that neurological vital signs checks were not performed every fours as ordered. Nursing documentation on 2/4/10 at 12:00 AM indicated the Patient was confused and Oxazepam was given per protocol. At 5:00 AM, the Patient was incontinent of urine, restless and climbing out of bed. Neurological vital signs were not documented. Nursing documentation at 8:00 AM did not accurately indicated the Patient's neurological signs. Nurse #3 said the Patient's arm strength was weaker on the left. There were no further neurological vital signs documented on 2/4/10.) The Physician Assistant the first time she saw the Patient was on 2/4/10. The Physician Assistant said the Patient was doing a little better and said she based her assessment on the medical progress notes that she read from the prior days. Review of medical documentation dated indicated there was no thorough neurological examination and no plan to evaluate the changes identified by nursing.

3.) Nursing documentation at 7:00 AM on 2/5/10 indicated that the Patient GCS was 7. A Medical Progress Note dated 2/5/10 and time at approximately 10:40 AM by the Physician Assistant indicated the Patient was lethargic, disoriented and did not eat. The Patient appeared more jaundice. There were no signs of active bleeding and the Patient's anemia was thought to be secondary to liver disease. The plan was to continue with the CIWA protocol and hold physical therapy secondary to mental status changes.

4.) Review of a Medical Progress Note dated 2/5/10 and time at approximately 10:40 AM indicated a thorough neurological examination was not documented.

5.) A head CT scan was ordered on 2/5/10 approximately 5 hours after the Patient was noted to have significant mental status changes.

Based on record review and interview, the Hospital failed to consistently complete neurological signs on one patient's (Patient), per the Physician's order.

Findings include:

1.) Review of the Patient's medical records, on 2/2/10 indicated the Patient fell prior to her hospitalization and sustained a small occipital scalp abrasion and also an a left elbow abrasion with a hematoma.

2.) Review of the treatment plan and physician orders, dated 2/3/10 at 10:30 PM indicated neurological checks every four hours times 12 hours.

3.) Review of nursing documentation dated 2/4/10 indicated that neurological vital signs checks were not performed every fours as ordered. Nursing documentation dated 2/4/10 at 4:00 AM indicated that neurological vital signs checks were within normal limits. However, the details of the neurological vital signs that include pupil response to light and motor strength of extremities were not documented on the Neuro Sings flow sheet.

4.) Nurse #3, the nurse assigned to the Patient on 2/4/10 during the day shift was interviewed in person on 4/15/10 at 11:15 AM. Nurse #3 reviewed her documentation of the Patient's neurological vital signs documented at 8:00 AM indicated did not accurately document the Patient's neurological signs. Nurse #3 said she assessed that the Patient's arm strength was weaker on the left.

5.) There were no neurological vital signs documented on 2/4/10 at 12:00 PM to indicate they were performed every four hours for 12 hours as ordered on 2/3/10 at 10:30 PM.

Based on review of one of one applicable medical record it was determined the Hospital failed to ensure that all enteries into the Patient's record were timed.

Findings include:

1.) The Patient's medical record indicated a medical screening examination was performed after the Patient arrived in the ED on 2/2/10. The time of the examination was not documented.

2.) Review of the Patient's 2/2/10 Admission Orders, not timed included orders for routine vital signs, activity as tolerated, intravenous fluids, blood testing, nutrition, social service, psychiatric and physical therapy consults and medications including Fondaparinux (medication that delays blood clotting) and vitamins.

3.) Review of the medical progress note, dated 2/3/10, time not documented, indicated the Patient stated she felt well.