HospitalInspections.org

Based on observation, interview, and record review, the facility staff failed to document a nursing assessment in the medical record for 1 (P-2) of 13 patients reviewed, resulting in less than-optimal outcomes for the patient. Findings include:

On 12/5/2024 at 1330, P-2's incident report filed on 4/3/2024 was reviewed with Risk Manager Staff DD. According to ED Nurse Staff N's note, Staff N revealed "The prior nurse told me that the patient was restrained (on 4/3/2024 at 2145) but did not mention that the patient said he was injured. When I talked to the patient, he told me one side of his face hurt from having his head pushed down when he was restrained. His cheek was slightly red, but I honestly probably would not have noticed if the patient did point it out to me. There was no laceration or swelling that I remember. I told him that this can happened if he was resistive while being restrained but he keeps saying "I was assaulted and I want to talk to you manager." Charge RN Staff II was contacted.

The Charge RN Staff II note revealed "Following 0700 (on 4/4/2024) RN shift changed, writer (Staff II) was informed that this patient had swelling and bruising present on the right side of his face. The patient stated to the new RN that the injury occurred at the time restraints were applied. The patient believed he received the injury from a security officer."

According to P-2's medical record, Staff N documented in the medical record activity of daily living activities notes for P-2 on 4/4/2024 at 0723, 0753, 0832, 0946, 1036, 1134, 1247, the ED Patient Transfer note at 1118, and the Discharge Summary ED note at 1307 and there was no documentation of any skin redness or bruising in P-2's medical record as reported by P-2 and the incident report.

On 12/5/2024 at 1100, ED Nurse Manager Staff J was asked if they expected Staff N to document in the medical record the reported bruising that P-2 told them, and they said "yes." When asked if that would initiate a follow-up assessment from a Physician or Advanced Practice Provider and they said "yes."

According to the facility's policy "Nursing Ongoing Assessment," dated 3/2024, the policy revealed that a "Focused Assessment" was an "Assessment of specific body system related to the patient diagnosis or complaint" and "A focused Assessment is completed and documented with any of the following: Patients course of treatment."

According to the facility's policy "Event/Incident Reporting - Patients, Visitors, Volunteers, and Non-Employed Staff," dated 1/2024, the policy revealed that under the "Patient Event or Injury" section, "Document the factual circumstances of the event in the medical record."