HospitalInspections.org

Based on a review of documentation and interview, the facility failed to ensure the patient right to receive care in a safe setting.

Findings included:

Facility Based Policy entitled, "Neurological [neuro] Assessment" stated in part,
"The nurse will provide neurological assessment and reassessment when a neurological deficit is suspected or the assessments are ordered by a provider ...
Ill. PROCEDURE;
A. Nursing staff will evaluate the patient's neurological status as necessary.
B. Neurological assessments will be documented on the Vital Sign and Neurological Check Sheet.
C. The areas on the neurological assessment that will be addressed and documented are:
1. Vital Signs [VS] -temperature, pulse, respirations, blood pressure
2. Level of consciousness -Alert
3. Orientation -time, person, place
4. Hand grasps-equal or unequal, strong or weak
5. Speech-clear or slurred
6. Pupils-equal; round, reactive to light and accommodation
D. Enter a progress note documenting action taken as a result of the neurological check.
E. Notify the provider with any new deficits."

Only one (#12) of two patients (#2 and 12) with documented issues that would require neuro checks had the results of the check documented per policy.

Review of the medical record for Patient #2 revealed the following:
* A nursing note on 02/22/21 at 1534 stated, "Pt [patient] had informed staff about a peer having contraband earlier in the day. Peer physically assaulted by punching him 3 times in the jaw/neck/head. Peer restrained and separated from pt. Pt neuro checks WNL [within normal limits]. VS stable. Provided ice pack. Slight redness to R neck below jaw and L jaw. PRN [as needed] pain med declined. Parent was notified. Will monitor pt."
* Review of this patient's medical record revealed that no neuro checks were actually documented. Only documented vital signs were documented on 02/22/21 at 0900, 1100, and 1800. Vitals were WNL.

Per the facility Chief Nursing Officer, neuro checks were not documented, the only documentation of neuro checks was the note above on 02/22/21, "Pt neuro checks WNL".

The above findings were verified on 09/21/21 with the facility Chief Executive Officer.