HospitalInspections.org

Based on document review and interview, the Registered Nurse failed to follow the P&P (Policy & Procedure) related to Medical Record Completion for "complete" shift assessment entries, in the patients MR (Medical Record), for 1 of 7 closed MR's reviewed (Patient # 9).

Findings include:

1. Review of established hospital policy titled: "TIMELINESS OF NURSING MEDICAL RECORD COMPLETION", indicated on page 1, under PROCEDURE, 1. "All medical record entries must be", "complete" in written form, "by the person who is responsible for the documentation", and under 3. "A complete head to toe shift assessment will be completed every shift by the nurse".

2. Review of Patient # 9 MR, indicated the following:
A. Patient noted to have unwitnessed fall on 11/19/2019 at 8:00 pm.
B. Medical progress note on 11/21/2019, reflected "Skin-warm, dry, no rash. Bruising, mild swelling to left head".
C. Nursing daily notes lacked documentation of complete skin assessment as indicated by no skin issues on 11/21/2019. Note on 11/20/2019 (day shift) reflected "bruises", with lack of entry for location. Note on 11/22/2109 lacked entry for current skin issues. Note on 11/23/2019 (day shift) noted "bruises", with lack of entry for location.


3. In interview on 1/13/2020 at approximately 4:10 pm, and on 1/14/2020 at approximately 10:00 am, with A # 1 (Chief Executive Officer), the following was confirmed:
A. That the MR for Patient # 9, had inconsistent documentation for skin assessments by nursing staff, after the patient fall on 11/19/2019.
B. That Nursing staff is responsible for completing a head to toe assessment at least once daily and documenting findings.

4. No further documentation was provided prior to exit.