HospitalInspections.org

Based on medical record review, policy review and interview, nursing staff did not ensure that adequate was received from Patient #1's group home in order to complete a comprehensive assessment and implement a plan of care based on the patient's health care needs. Failure to properly assess care needs places patients at risk for inadequate treatment and potential adverse events.

Findings include:

Review of nursing note on 06/29/16 at 08:37 AM indicates Patient #1 is at baseline with poor judgement, poor safety awareness and poor attention/concentration.

Review of the history & physical (H&P) dated 06/29/16, signed off by the Nurse Practitioner (NP) at 09:42 PM revealed Patient #1 lives in a group home and is non-verbal. The principal problem is sepsis and the source is the lung with a history of aspiration pneumonia.

Review of nursing admission assessment screenings dated 06/30/16 at 02:13 AM and 02:15 AM revealed Staff # 21, registered nurse (RN) documented a nutritional screening for Patient #1 indicating no difficulty swallowing or chewing. A functional screening indicates a change in mobility, activities of daily living (ADL) status and communication in the last week, but is not specific and does not include whether Patient #1 has the ability to feed himself or if assist was required. An ADL screening was not performed. No evidence was found to indicate group home staff were contacted for assessment information.

Telephone interview on 10/4/16 at 04:00 PM with Staff # 21, RN revealed Patient #1 was accompanied by group home staff to the floor upon admission from the Emergency Department. The group home staff did not want to surrender the " red book " to Staff # 21. The "red book" is the group home medical record that includes medical history, advance directives and any special care instructions for patients. Staff # 21 did a quick review of the " red book " to review some of the ADL components and interviewed the group home staff member. Staff # 21 did not recall asking about special precautions with eating, however, the group home staff member told him that Patient #1 "can take his medication whole, without any problem." Staff # 21 documented in the admission note that Patient #1 had no difficulties chewing or swallowing.

Interview on 09/23/16 at 01:30 PM with Staff # 12, RN revealed the "red book" from the group home was not with Patient #1 on the floor.

Review of the physician progress notes dated 6/30/16 at 08:00 AM revealed Patient #1 was getting up to the bathroom and suddenly went unresponsive. During the code, Patient #1 was suctioned and some digested food matter returned. Patient #1 was vented and transferred to the intensive care unit (ICU).

Interview on 09/23/16 at 1:30 PM with Staff # 15, RN revealed she was present at the 06/30/16 "code". Patient #1 had a tray of food in front of him and scrambled eggs were noted in his mouth. Staff #15 indicated "red books" accompany patients approximately 50 % of the time when they come to the hospital. The books are helpful and detail a patient ' s medical history, medications, special care needs, behaviors, etc. She recalled that staff were looking for Patient #1's "red book" and called the group home for it.

Review of the Nursing Practice Manual, last revised 4/2016 indicates that patient admission assessment documentation is completed by the Registered Nurse within 24 hours and includes interviews with the patient/family/significant others to obtain essential information for assessment and care planning. This assessment includes initial admission screens (functional screen, nutritional screen ect.). The nurse plans and reviews the patient ' s care with the patient/family/significant other.

No evidence was found to indicate nursing staff had essential information in order to implement a plan of care for Patient #1 who was non-verbal and unable to provide staff with needed information.