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ENCOMPASS HEALTH REHABILITATION HOSPITAL OF LARGO
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on record review, policy review and staff interview it was determined the registered nurse failed to supervise and evaluate nursing care related to reassessing patients in a timely manner for changes in condition and ensuring appropriate nursing interventions were implemented to meet the needs for one (#4) of ten sampled patients.
Findings included:
Patient #4's clinical record noted the patient was admitted on 11/23/16 at 4:02 p.m. and transferred to a higher level of care on 11/28/16 at 12:18 p.m. due to a change in condition.
The consultation report by the internal medicine physician dated 11/24/16 at 1:58 p.m. included documentation Patient #4 was alert and oriented to person, place and time.
Patient #4 was assessed by the Speech Therapist daily from 11/24/17 through 11/27/16. The Speech Therapy note dated 11/27/17 at 3:08 p.m. indicated the therapist determined Patient #4 was hallucinating. The patient was complaining of seeing bugs crawling on her and her bedside table. The note included documentation the change in the patient's condition was reported to nursing and communicated to the physician.
Patient #4 was assessed by the Registered Nurse on 11/27/16 at 9:00 a.m. At 7:00 p.m. the patient was assessed by the on coming nurse assuming the care at the start of the night shift (7P to 7A). The review failed to reveal reassessment of Patient #4 in response to the patient's change in condition. There was no evidence of any nursing intervention with regard to the report of the patient hallucinating.
The facility policy "Assessment/Reassessment", policy number NSG 150, revised 6/2015 was reviewed on 6/15/17. The policy indicated when there was a significant change in the patient's condition, a full reassessment was performed.
An interview and record review were conducted with the nurse manager on 6/15/17 at 10:00 a.m. The nurse manager confirmed the finding the nursing staff failed to reassess Patient #4 and take appropriate nursing action in response to the patient's significant change in condition.