HospitalInspections.org

Based on review of medical records, hospital documents, interviews and hospital policy/procedure, it was determined that the hospital failed to require that a registered nurse supervise and evaluate the nursing care of each patient as evidenced by failing to document nursing assessments after a change in condition for 1 of 1 patient (patient #3).

Findings include:

Facility Policy and Procedure titled "Nursing Reassessment of Patients" revealed: "...Every patient will be reassessed by a RN a minimum of once every eight hours and each time there is a change in the patient's condition with documentation of the applicable findings including an update to the treatment plan as indicated...RN is responsible for patient assessment and re-assessment...list of Significant Events that require the RN to perform a reassessment of a patient may include but is not limited to the following...Patient makes a suicide attempt or self harm gesture...."

Facility Policy and Procedure titled "Nursing Standards of Care/Practice" revealed: "...Reassessment of the patient shall be performed and documented by the RN...."

Patient # 3 was admitted on 6/8/12, with a diagnosis of Mood Disorder and Polysubstance Dependency. Patient had a history of self harm behaviors: overdosing and swallowing objects in the past.

RN #32's Nurses Notes dated 6/9/12 at 1600, revealed: "...Pt (patient) stated he swallowed a pencil. Pt showed no sx (signs) of distress. Pt walking around unit talking with peers Dr (MD # 1) notified. received order to place patient on PIC status to closely monitor the patient for his safety...."

Nurse Manager # 9 confirmed in an interview conducted on 6/26/12 at 1620, that there was no documentation by RN #32 of the assessment of patient #3's mental and physical status after this event.