HospitalInspections.org

Based on interview and record review the nursing staff failed to ensure that patient needs are met by ongoing every 2 hourly complete assessments were done for 4 sampled patients (SP # 1, # 4, # 5 and #6) of 10 sampled patients.

The findings:

1. Review of SP #1 nursing assessments showed a complete assessment was not completed every 2 hours per the policy in the Critical Care Unit (CCU). On 12/3/2014 SP#1 last assessment of the capillary refill, nail color bed, the pulse, the musculoskeletal and the genitourinary was completed at 23:00 pm. The next assessments was not completed until 12/04/2014 at 03:00 am (4 hours later), and again at 07:00 am (4 hours later), at 11:00 am (4 hours later), at 15:00 pm (4 hours later), at 19:00 pm (4 hours later), and at 23:00 pm (4 hours later).

Review to of the ED nursing notes showed that SP #1 skin is intact, and normal. On 1/12/2015 the wound care notes showed pressure ulcers to the left and right foot with a 4x4 gauze roll by physician. The nursing assessments did not document an assessment or reassessments of the ulcers to the first and fifth toes.
On 1/11/2015 the physician notes showed that the patient had un-stage-able ulceration to the first and fifth metatarsophalangeal joint (left lower).


2. Review of sampled patient # 4 medical records showed that the patient was admitted on 12/30/2013. The patient chief complaint was fecal impaction and UTI (urinary tract infection). Review of the nursing assessments showed a complete assessment was not completed every 2 hours per the policy in the Critical Care Unit (CCU). On 02/17/2015 an assessment was completed at 00:15 am. The next assessment was not completed until 05:42 am (5 hours later).

Interview with the Director of the ICU/CCU units on 02/19/2015 at 10:05, she stated that hourly rounding is every 15 minutes and every two hour assessments and charting of the full assessments is completed. She also stated that Q (every) 1 hour neuro (neurological) checks and vital signs are done in both units.


3. A review of sampled patient #5's medical records showed that the patient was admitted on 02/18/2015. The patient's chief complaint was near syncope. Review of the nursing assessments showed that a reassessment was not completed every 2 hours per the policy in Critical Care Units (ICU (Intensive Care Unit) and CCU (Critical Care Units). On 02/18/15, an assessment was completed at 03:00 AM; the next assessment was not completed until 07:30 AM (4.5 hours later). The next assessment was completed at 11:00 AM (3.5 hours later). The next assessment was completed on 02/18/15 at 19:00 PM (8 hours later). Assessments were completed every 4 hours from 02/18/15 at 19:00 PM until 02/19/15 03:00 AM.

4. A review of sampled patient # 6's medical records showed that the patient was admitted on 01/09/2015. The patient's chief complaint was recurrent pneumonia and renal failure. Review of the nursing assessments showed that a reassessment was not completed every 2 hours per the policy in Critical Care Units. On 02/16/15, an assessment was completed at 19:00 PM; the next assessment was not completed until 23:00 PM (4 hours later). The next assessment was completed on 2/17/15 at 03:00 AM (4 hours later). Assessments were completed every 4 hours from 2/27/15 at 03:00 AM until 02/18/15 at 15:00 PM.

Interview on 02/19/15 at 3:35 PM with Registered Nurse- Staff A revealed that she has worked at the facility for 8 months. In this time, she has only worked in the ICU. She reported that physical assessments are to be completed every 4 hours. Neurological checks are completed every 2 hours. Assessments consist of a head to toe assessment which consists of checking the eyes for PERRLA, capillary refill, neurological deficits (weakness), lung sounds, heart sounds, abdomen, urinary status, skin, and edema.


A review of a hospital document titled Section: Assessment of Patients, Subject: Assessment and Reassessment Plan, last revised on 10/12 showed that in Critical Units, initial assessments and reassessments should be completed at a minimum of every 2 hours.

Based on interview and record review the nursing staff failed to ensure that patient needs are met by ongoing every 2 hourly complete assessments were done for 4 sampled patients (SP # 1, # 4, # 5 and #6) of 10 sampled patients.

The findings:

1. Review of SP #1 nursing assessments showed a complete assessment was not completed every 2 hours per the policy in the Critical Care Unit (CCU). On 12/3/2014 SP#1 last assessment of the capillary refill, nail color bed, the pulse, the musculoskeletal and the genitourinary was completed at 23:00 pm. The next assessments was not completed until 12/04/2014 at 03:00 am (4 hours later), and again at 07:00 am (4 hours later), at 11:00 am (4 hours later), at 15:00 pm (4 hours later), at 19:00 pm (4 hours later), and at 23:00 pm (4 hours later).

Review to of the ED nursing notes showed that SP #1 skin is intact, and normal. On 1/12/2015 the wound care notes showed pressure ulcers to the left and right foot with a 4x4 gauze roll by physician. The nursing assessments did not document an assessment or reassessments of the ulcers to the first and fifth toes.
On 1/11/2015 the physician notes showed that the patient had un-stage-able ulceration to the first and fifth metatarsophalangeal joint (left lower).


2. Review of sampled patient # 4 medical records showed that the patient was admitted on 12/30/2013. The patient chief complaint was fecal impaction and UTI (urinary tract infection). Review of the nursing assessments showed a complete assessment was not completed every 2 hours per the policy in the Critical Care Unit (CCU). On 02/17/2015 an assessment was completed at 00:15 am. The next assessment was not completed until 05:42 am (5 hours later).

Interview with the Director of the ICU/CCU units on 02/19/2015 at 10:05, she stated that hourly rounding is every 15 minutes and every two hour assessments and charting of the full assessments is completed. She also stated that Q (every) 1 hour neuro (neurological) checks and vital signs are done in both units.


3. A review of sampled patient #5's medical records showed that the patient was admitted on 02/18/2015. The patient's chief complaint was near syncope. Review of the nursing assessments showed that a reassessment was not completed every 2 hours per the policy in Critical Care Units (ICU (Intensive Care Unit) and CCU (Critical Care Units). On 02/18/15, an assessment was completed at 03:00 AM; the next assessment was not completed until 07:30 AM (4.5 hours later). The next assessment was completed at 11:00 AM (3.5 hours later). The next assessment was completed on 02/18/15 at 19:00 PM (8 hours later). Assessments were completed every 4 hours from 02/18/15 at 19:00 PM until 02/19/15 03:00 AM.

4. A review of sampled patient # 6's medical records showed that the patient was admitted on 01/09/2015. The patient's chief complaint was recurrent pneumonia and renal failure. Review of the nursing assessments showed that a reassessment was not completed every 2 hours per the policy in Critical Care Units. On 02/16/15, an assessment was completed at 19:00 PM; the next assessment was not completed until 23:00 PM (4 hours later). The next assessment was completed on 2/17/15 at 03:00 AM (4 hours later). Assessments were completed every 4 hours from 2/27/15 at 03:00 AM until 02/18/15 at 15:00 PM.

Interview on 02/19/15 at 3:35 PM with Registered Nurse- Staff A revealed that she has worked at the facility for 8 months. In this time, she has only worked in the ICU. She reported that physical assessments are to be completed every 4 hours. Neurological checks are completed every 2 hours. Assessments consist of a head to toe assessment which consists of checking the eyes for PERRLA, capillary refill, neurological deficits (weakness), lung sounds, heart sounds, abdomen, urinary status, skin, and edema.


A review of a hospital document titled Section: Assessment of Patients, Subject: Assessment and Reassessment Plan, last revised on 10/12 showed that in Critical Units, initial assessments and reassessments should be completed at a minimum of every 2 hours.