HospitalInspections.org

Based on document review and interview the registered nurse failed to document the events related to a patient's death for one (1) of ten (10) medical records (MR's) reviewed.

Findings include:

1. The facility policy titled, Death of a Client, number 11.2.024I, indicated the charge nurse would notify 911, and the coroner. All documentation of the event and subsequent management would be documented by the charge nurse in the MR. This policy was last revised on 07/26/2023.

2. Patient # 10's MR was reviewed on 02/14/2024 and lacked the following documentation:
a. Events leading up to patient # 10's death.
b. Notification of 911.
c. Notification of the coroner.
d. Notification of supervisor.
e. Notification of family.

3. In interview on 02/14/2024 with administrative staff member A # 2 (Chief Compliance Officer/Vice President Facilities & Safety), confirmed the MR lacked the documentation.