HospitalInspections.org

Based on review of medical records and staff interview it was determined the facility failed to ensure a Registered Nurse supervised and evaluated the nursing care related to patient safety for 1 (#1) of 3 patients sampled. This practice does not ensure the patients safety, goals, and needs are being met.

Findings include:

Patient #1's nursing documentation from 5/11/10 to 6/01/10 revealed the patient was agitated at times and restless. Documentation by a Certified Nursing Assistant revealed the patient would strike his/her head on the side rail while in bed. Nursing documentation on 6/01/10 revealed the patient had developed bruising to the left side of the face and left eye. Repeated nursing documentation revealed the patient was restless and agitated at times.

Interview with the Risk Manager on 9/02/10 at 10:45 a.m. revealed s/he recalled observing the patient move her/his head in a back and forth in repetitive motion at times while lying in bed. There was no documentation the facility attempted to intervene and prevent injury to the patient despite documentation of the patient's continued restlessness and repetitive back and forth head motion.