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Based on record review and interviews the facility failed to assess a patient (Patient #10) after a change in condition in 1 of 4 patients who were transferred to another facility for a higher level of care.

Findings include:

Facility policies:

The policy, Daily Patient Assessment read, reassessment may occur more frequently but no less than the following: Step Down Patients: A minimum of two complete assessments per shift and focused assessments every eight hours and as needed for changes in patient status. Telemetry Patients: A complete assessment at the beginning of each shift and focused assessments every eight hours and as needed for changes in patient status.

Definitions: Complete Assessment: A head-to-toe assessment including vital signs and major systems review. Focused Assessment: An assessment of the significant problems related to the patient's diagnosis and/or identified nursing problems.

Reference:

PVMC Critical Care Normal Expectations for the Care of the Telemetry, Step Down and ICU (Intensive Care Unit) Patients: Vital signs and patient assessments are completed at the beginning of each shift and; Routine to do's: ICU patients: Shift assessment every 4 hours and with focused assessment as needed for status changes. Step Down Patients: Shift assessment every four hours with focused assessment as needed for status changes. Telemetry Patients: Complete assessment every six hours with focused assessment as needed for status changes.

1. The facility failed to provide a focused neurological assessment following a change in condition after Patient #10 had a decrease in Glasgow Coma Scale (GCS, a neurological scale used to assess a person's level of consciousness. The minimum score: three, indicates a comatose state. The maximum: 15, indicates a person who is fully awake and alert).

a. On 5/9/19 at 4:27 p.m., an interview was conducted with the director of the intensive care unit (ICU, Director #2). Director #2 stated nurses in the step down unit were required to document a patient assessment at least every four hours. Director #2 stated if a patient had a status change, such as a neurological change, or a decrease in their GCS, that would require a more focused, in depth assessment to monitor for a change in condition or decompensation (when a body system can no longer compensate for a deficiency).

b. Record review for Patient #10 revealed from 12/1/18 until 12/4/18, when Patient #10's neurological status decreased to a GCS of 6, nursing staff did not perform a focused neurological exam. This was in contrast to policy which indicated changes in neurological status required a focused, in depth assessment to monitor for changes in condition or decompensation. Examples included:

i. According to the ED (emergency department) Disposition Patient #10 was admitted on 11/30/18, to the medical telemetry unit (a unit with heart monitors used to monitor the electrical activity of the heart) with a diagnosis of urinary tract infection (an infection of the urinary system), and back pain. At 8:55 p.m., according to the Head to Toe Assessment Flowsheet, Glasgow Coma Scale (GCS flowsheet), Patient #10's GCS was documented at 15.

ii. On 12/1/18 at 9:15 a.m., according to the GCS flowsheet Patient #10 had a GCS of 13. On continued review of the GCS flowsheet, Patient's #10's GCS remained 13 until 12/3/18.

There was no documentation of a focused neurological exam by the registered nurse (RN) from 12/1/18 until 12/3/19 after the patient had a decreased GCS from 15 to 13.

Patient #10's GCS remained 13 until, according to the Physician Progress Notes, written on 12/3/18 at 9:09 a.m., Patient #10 was taken emergently for a cardiac catheterization procedure.

iii. On 12/3/19 at 5:02 p.m., according to the Orders, a neurology consult was requested for altered mental status, possible seizure.

At 5:11 p.m., according to the Orders, an order was placed to transfer Patient #10 to the Step Down unit.

At 6:43 p.m., according to the GCS flowsheet, Patient #10 was documented to have a GCS of 10.

On review of the medical record, there was no documentation of a focused neurological exam by nursing staff for Patient #10 after a decrease in GCS was documented on 12/3/19 at 6:43 p.m.

iv. On 12/4/18 at 8:00 a.m., according to the GCS flowsheet, Patient #10's GCS was documented as 6. There was no focused neurological exam done until 3:30 p.m., at which time RN #1 documented in the Neurological Flowsheet Note Patient #10 was documented to have decreased movement of his left side.

c. On 5/9/19 at 12:18 p.m., an interview was conducted with RN #1 who cared for Patient #10 on 12/3/18 day shift and also on 12/4/18 day shift when Patient #10 had decreased movement to the left side. RN #1 stated a focused neurological exam should be completed at the beginning of the shift, every four hours and anytime there were abnormal findings in the patient's exam. RN #1 stated the neurological exams were important to determine the extent of the neurological issue, and to determine if the findings were new or chronic.

A review of Patient #10's medical record was done with RN #1. After review, RN #1 stated there had been no focused neurological nursing assessments completed by nursing staff until 12/4/18 at 3:30 p.m.

RN #1 confirmed he documented a decrease in GCS of 6 on 12/4/18 at 8:00 a.m., and had not documented a focused neurological exam after the decrease in GCS. RN #1 confirmed the prior GCS documented was a 10. RN #1 stated he did not always check the GCS from the prior shift to compare a change in GCS on his shift. RN #1 stated he should have documented a more thorough neurological exam. RN #1 stated he was unable to determine when the neurological changes began for Patient #10 prior to 3:30 p.m. on 12/4/18.