HospitalInspections.org

Based on record review and staff interview it was determined that the facility failed to ensure appropriate assessment by a registered nurse for 2 (#2#4) of 4 sampled patients.


Findings include:


1. Patient #2 was admitted to the facility on 7/6/10 with the chief complaint of left facial swelling and slight facial droop. The physician ordered neurological assessment to be performed every 2 hours. Review of nursing documentation revealed that the no assessment was performed from 5 a.m. and not again until 8:00 a.m. The staff did not perform another assessment until 12 noon.

2. Patient #4 was admitted to the facility on 8/6/10 with the chief complaint of visual disturbance with unsteady gait. The physician ordered neurological assessment to be performed every 4 hours. The following documentation of assessments was noted during record review:
8/7/10 - 8:30 a.m., 11:00 a.m., 2:00 p.m. and 9:00 p.m.
8/8/10 - 8:00 a.m. 12:00 noon, 4:00 p.m. and 8:00 p.m. No assessments were performed from midnight until 8:00 a.m.
8/9/10 - 8:00 a.m., 8:00 p.m. Only 2 assessments were performed on 8/9/10

3. During interview on 8/11/10 at approximately 2:00 p.m. the Director of Performance Improvement and Infection control confirmed the nursing staff had not followed the physician orders for neurological assessments as noted above.