HospitalInspections.org

Based on a review of documentation and an interview with staff, the facility failed to ensure patient #2 was reassessed by a Registered Nurse at least every 12 hours, as evidenced by incomplete assessments.

Findings were:

Review of the clinical record for patient #2, a 12-year-old female, revealed the patient was admitted on 12/21/21 at 6:56 am with the diagnosis of Major Depressive Disorder, recurrent severe without psychotic features.

Review of the Physician Progress Note dated 12/26/21 at 8:00 am reflected "...Patient reports that she is using the wire from facemask to cut herself. Patient had fresh cutting marks on bilateral arms..."

Review of the nursing assessment for 12/26/21, 12/27/21, and 12/28/21 do not reflect any documentation related to fresh cutting marks on bilateral arms.

On 8/1/22, during an interview with Staff #5, she stated that nurses should chart any new skin issues on the shift skin assessment.

On 8/1/22, during an interview with Staff #1, she stated that she would expect the skin assessments to include any changes to the patient's skin.



In interviews with staff #1 and Staff # 5 on 8-1-22 confirmed that nursing assessments were not appropriately completed.

Based on record review and interview the facility failed to ensure that the Director of Nursing (DON) monitored and evaluated the nursing services provided as evidenced by 1 of 10 (#2) patients reviewed did not have discharge information reported to the provider.

Findings were:

Review of Patient #2's medical record reflected a Columbia-Suicide Severity Rating Scale Inpatient Setting - Discharge Screener
completed on 12/29/21 at 11:05 am. The form stated, "If YES is answered to question 2, 3, 4, 5, or 6 a psychiatrric practitioner must be notified prior to the patient leaving the facility." The patient answered "yes" to questions 2 and 3. There was no documentation that a psychiatric practitioner was notified.

During an interview on the afternoon of 8/1/22, Staff #1 confirmed these findings after reviewing the patient medical record. She confirmed that the expectation would be the nurse would notify the psychiatric practitioner.

No policy was provided to the surveyor when requested.