HospitalInspections.org

Based on records review and staff interview it was determined the registered nurse failed to supervise and evaluate nursing care to meet the needs of patients with seizures for 2 (#3, #8) of 10 sampled patients.

Findings include:

1. Patient #3 was admitted to the facility on 12/13/2013 with a chief complaint of abdominal pain. The initial nursing assessment dated 12/14/13 at 4:30 a.m. indicated the patient arrived to the nursing unit in stable condition. The patient was assessed and the physician was contacted for orders.

The nursing documentation on 12/14/13 at 10:17 a.m. signed by the Registered Nurse (RN) stated at 9:49 a.m. the patient experienced a seizure. 12/15/14 the neurology consultant recommended to place the patient on seizure precautions.

The review of nursing documentation from 12/14/2013 to 12/20/2013 failed to reveal evidence the nursing Plan of Care was updated to include seizure precautions and that seizure precautions were implemented.

2. Patient #8 was admitted on 4/30/2014 at 12:11 p.m. with syncope and possible seizure.

Review of the patient's Plan of Care indicated the nursing intervention for seizure precautions was added to the care plan on 5/1/14 at 10:46 a.m., a period of approximately 22 hours following admission. The detailed review of the nursing assessments performed between 4/30/14 at 4:08 p.m. and 5/1/14 at 8:00 p.m. failed to reveal evidence seizure precautions had been implemented.

On 5/2/14 at approximately 4:10 p.m. an interview with the 2C Unit Clinical Coordinator revealed the care plan for seizure precautions includes the padding of the side rails.

The Risk Manager confirmed the findings of failure to update the care plan for seizure precautions and implementation of seizure precaution for both patients on 5/2/2014 at approximately 4:15 p.m.