HospitalInspections.org

Based on review of policy and procedure, review of patient clinical charts, and interview with staff, it was determined the facility failed to provide care to all patients as needed by performing ongoing assessments of patient needs. Findings follow:
A. Review of CHI St. Vincent "Core Nursing Standards of Practice" policy effective date 03/12/2021, showed: Assessment- The registered nurse (RN) performs and/or oversees the collection of pertinent data and information relative to the patient's health or the situation. Data will be obtained by interview, observation, physical exam and review of the patient record.
1) A focused assessment for chief complaints should be completed withing 30 minutes of admission.
2) Physical assessment should be completed withing 4 hours of admission, within 4 hours of the start of each shift, and PRN for change in condition.
3) The registered nurse should screen patients for falls, skin risk, sepsis, mobility and suicide. The following screenings should be completed within 4 hours of admission, within 4 hours of start of each shift and PRN for change in patient condition: fall risk, skin risk, sepsis, and patient mobility/safe lift. A suicide risk screening should be completed upon admission and PRN.
B. Review of 20 clinical patient (#10 current patients and #10 discharged patients) charts showed that 3 (#13, #16, and #20) of 20 (#1-#20) patients did not have their admission assessment completed within the four hours allowed by policy:
1) Patient #13 was admitted to in-patient services on 06/23/2025 at 1:28 PM. The hospital charting system auto-initiated the "Admission Assessment and History using the Nursing Admission page" at 2:24 PM. The facility was unable to provide evidence that the admission assessment was completed by an RN prior to 7:57 PM on 06/23/2025.
2) Patient #16 was admitted to in-patient services on 06/04/2025 at 6:14 AM. The hospital charting system auto-initiated the "Admission Assessment and History using the Nursing Admission page" at 6:14 AM. The facility was unable to provide evidence that the admission assessment was completed by an RN prior to 5:16 PM on 06/04/2025.
3) Patient #20 was admitted to in-patient services on 05/09/2025 at 3:38 AM. The hospital charting system auto-initiated the "Admission Assessment and History using the Nursing Admission page" at 4:42 AM. The facility was unable to provide evidence that the admission assessment was completed by an RN prior to 7:30 PM on 05/09/2025.
C. Finding in A-B were confirmed with Chief Nursing Officer (CNO) during exit interview at 3:30PM on 07/02/2025.