HospitalInspections.org

Based on interview and medical record review, the facility failed to ensure RN supervision and evaluation of the nursing care for 1 of 1 emergency room patient (Patient #1) on 11/19/2022, in that hourly neurological assessments were not documented. The facility failed to follow policy.

Findings included:

A review of patients #1 medical record reflected Patient #1 was transferred via care flight air on 11/19/2022 at 12:42 PM for a subarachnoid hemorrhage which required a higher level of care. Record review revealed 1 of 1 patient (Patient #1) did not have documented hourly neurological assessments. Patient #1 subsequently developed a decline in their health and required medical interventions.

Record review of Hospital Policy and procedure titled "ED Vital Signs and Reassessment Documentation", effective 12/2020, page 2 ...Special Considerations ...1. Patients with altered sensorium and/or acute neurological deficits or changes should have neurological reassessments at a minimum every hour."

Record review of hospital Stroke Checklist stated ..."All ischemic and Hemorrhagic strokes need at a minimum of Q1 hour vital signs and NIHSS."

Record review of patient #1 medical record did not reflect documented hourly neurological assessments.

During an interview with Personnel #3 on 06/28/2023 at 12:25 PM confirmed the above findings and stated neurological assessments were not documented and the facility stroke checklist was not completed on patient #1. Personnel #3 confirmed the facility "Stroke Checklist and NIH flowsheet" was in effect prior to November 2022.

During an interview with personnel #8 on 06/28/2023 at 2:40 PM confirmed the above findings and stated hourly neurological assessments were not documented while in the emergency department. Personnel #8 stated the "Stroke Checklist and NIH flowsheet" was in effect prior to November 2022. Personnel #8 stated all neurological and vital sign compliance are populated and emailed to the unit managers to follow up with the appropriate staff.

During an interview with Personnel #18 on 06/29/2023 at 1:00 PM confirmed all verbal coaching with staff should be documented to allow for tracking and trending of staff members.

Record review of Personnel # 25 employee file on 06/29/2023 at 11:19 AM reflected no verbal coaching or corrective actions had been completed.