HospitalInspections.org

Based on a review of facility documentation and staff interviews, the facility failed to maintain progress notes on each patient according to facility policy as 2 of 10 patient records reviewed [Patients #1 and #9] contained dates with missing nursing progress notes.

Findings were:

A review of patient medical records revealed the record of Patient #1 contained no nursing progress notes (i.e., no Nursing Flow Sheet) for the date of 10/27/15, a 24-hour period, though completed observation records for 10/27/15 were in the record.

Likewise, a review of the patient medical record of Patient #9 revealed no nursing progress notes (i.e. no Nursing Flow Sheet) for the date of 11/7/15, a 24-hour period, though completed observation records for 11/7/15 were in the record.

In an interview with Staff #1, Performance Improvement/Risk Management Director, and Staff #2, Chief Nursing Officer, on the morning of 11/11/15 in a small facility meeting room, they were asked where the nursing progress notes for the two patients were. Staff #2 stated she didn't know they weren't in the chart. She returned after several minutes of searching for the notes to state she couldn't find them. Staff #1 also went to look for the notes, but returned and stated, "It looks like those aren't going to be able to be located. We don't know what happened."

Facility policy entitled Patient Assessment Nursing Flow Sheet, last revised 11/15, stated in part: "POLICY: The Patient Assessment / Nursing Flow Sheet are utilized on all patients as a method of documentation and reassessment of the patient in order to communicate treatment provided and its results.

PURPOSE: To ensure an accurate and concise assessment and record of the patient's needs and treatment every shift. RN assessment will be completed at least every 12 hours.

PROCEDURE:
1.0 The 24 hour patient assessment / nursing flow sheet are the primary documentation for nursing staff. The RN completes the nursing flow sheet each shift and documents a progress notes as described by 3.0


2.0 The night shift RN will complete the form for each day..."

Facility policy entitled Re-Assessment of Patients, last revised 10/15, including the following:
"POLICY: It is the policy of El Paso Behavioral Health System to assess patients at time of admission, when transitioning to another level of care and at time of discharge. Additionally, reassessment occurs on an ongoing basis via daily assessment by a Registered Nurse, Psychiatrist and the Treatment Team reviews that occur weekly.

PROCEDURE

1. Reassessment is conducted by a Registered Nurse every shift at a minimum ...
2. R.N. findings from the reassessment are documented in the patient's chart..."