HospitalInspections.org

Based on medical record review, interview, and policy review, a registered nurse failed to document a nursing assessment at least once every shift in one of ten charts reviewed (Patient #4). Failure to perform a nursing assessment every shift puts all patients at risk of not receiving appropriate oversite of medical, social, and psychological needs and interventions.

Findings include:

- Patient #4's open medical record review on 5/16/2017 revealed no documentation a nursing assessment was completed during the 7am to 7pm shift on 5/15/2017.

Interview with RN Staff C on 5/16/2017 acknowledged that nursing assessments are to be performed at a minimum of once per shift with exceptions only if the assessments are documented more frequently. The assessment is to include the following elements: vital signs, pain assessment and interventions, neurological assessment, gastrointestinal assessment with documentation of bowel movements, skin assessment, nutrition to include meal intake, activities of daily living (ADL's), and any cause for use of restraints. The assessments are normally performed at the beginning of each shift. Nursing Care Plans and education are updated every shift as well and at least one element is to be updated each shift.

Policy titled "Assessment-Interdisciplinary Patient Care-TUKH-Marillac" reviewed on 5/16/2017 directs " ...A physical assessment will be documented each shift as applicable to the patient's condition (i.e. skin integrity of patients in diapers; patients with medical devises; patients with wounds; other injuries; etc.) ..."