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Based on interview and record review, the facility failed to ensure Neurological Assessments were performed and documented every four hours as ordered by the physician for 1 of 30 sampled patients (Patient 1) when:

1. For Patient 1, Neurological Assessments (level of consciousness, orientation level, cognition, Glascow Coma Scale (neurological scale), motor function/sensation assessment) were not completed by the Registered Nurse (RN 1), following a physician order.

These failures had the potential for Patient 1 to have undetected neurologic changes which could have led to further illness, injury and or death.


Findings:

1. A review of PT 1's admission record (demographic and medical information) indicated Patient 1 had a history of cerebral venousthrombosis (clot in the brain), chronic migraine headaches, increased intracranial pressure (increase pressure in the brain), Ventriculo-peritoneal shunt (tube from the brain to the abdominal cavity), portal venous thrombosis (clot in the liver) admitted on March 1, 2018, for acute abdominal pain.

During a concurrent interview, and review of Patient 1's clinical record, with the Hematology/Oncology Manager (HOM 1), HOM 1 and the Clinical Educator (EDU 1) on December 17, 2019, at 1:40 PM, the clinical record showed a physician order, dated March 4, 2018, at 12:16 PM, as follows: "Neurological Checks (Neurological Assessment), frequency every four hours."

Review of Patient 1's documented Neurological Checks dated March 4, 2018, at 8 AM, indicated "oriented, alert, lethargic (tiredness), follows commands, poor safety awareness, eye opening spontaneous, best verbal response; confused, best motor response; obeys commands."

Review of Patient 1's documented Neurological Checks dated March 6, 2018, at 12 PM, revealed there was no documented evidence of a Neurological Assessment (neurological check) to have been completed.

Review of Patient 1's documented Neurological Checks dated March 6, 2018, at 4 PM, revealed there was no documented evidence of a Neurological Assessment (neurological check) to have been completed.

Review of Patient 1's documented Neurological Checks dated March 6, 2018, at 8 PM, indicated: "Lethargic, follows commands, poor safety awareness; eye opening spontaneous, best verbal response; confused, best motor response; obeys commands".

During an interview on December 17, 2019, at 3:50 PM, with HOM 1, and the Hematology/Oncology Manager 2 (HOM 2) and EDU 1, HOM 1 confirmed the order placed on March 4, 2018, at 12:16 PM, was active from March 4, 12:16 PM, through March 6, 2018, at 10:42 PM. HOM 1 stated, "Yes that order was active." HOM 1 was asked if the neurological assessment (neurological checks) should have been completed by RN 1 on March 4, 2018, at 12 PM, and March 4, 2018, at 4 PM, HOM 1 stated, "Yes they should have been done and documented."

A request for the facility policy and procedure for patient neurological assessments resulted in the facility unable to provide a policy related to documentation of conducting neurological assessment and reassessment.