HospitalInspections.org

Based on interview and record review, the facility failed to ensure that an RN evaluated 1 of 1 patients (Patient #1) in accordance with accepted standards of nursing practice and hospital policy as shown by:

a. Nursing failing to properly assess pain for Patient #1, and;
b. Nursing failing to address and document change of condition during their nursing
shifts for Patient #1.

Findings included:


Facility policy titled "Nursing Documentation", ID# 10880647 last revised 12/2021 stated that a patient's pain is documented with a description of intensity using a 1-10 pain scale (with 10 being the most intense), location of the pain and a description of the pain such aching, crushing, dull, heavy, sharp, jabbing, etc. will be documented.

Another facility policy titled "Documentation", ID# 11248529 last revised 3/2022 stated that medical records documentation should be pertinent, concise and reflect the patient's status. The documentation will be specific in description and measurable, reporting the patient's status throughout the course of treatment. In addition, this policy stated that the registered nurse's daily shift assessment must be completed before the end of the shift.

In an interview on 10/10/22 at 2:00 pm with Nurse Manager-Staff #E regarding the timing documentation of charting for the daily nursing assessments in the electronic records, he stated that the initial time shown on the assessment form was entered by the nurse and the electronic signature was automatically stamped when the nurse signed it after completing the assessment.

In another interview on 10/11/22 at 2:00 pm with Corporate Risk Manager-Staff-#K, she was asked about the timing of data entries into the electronic medical records. Staff #K also confirmed that the nurse entered the initial time of assessment manually, then the electronic signature stamp would populate the bottom portion of the assessment field when a nurse had completed the form.

In an interview on 10/11/22 at 2:15 pm, Performance Improvement Manager-(PI) Staff #B stated the dates and times of data entry shown in the electronic health records (EHR) where documented when a nurse manually entered a time and date of a note, and when the nurse completed and signed the entry, which was automatically stamped with an electronic signature. Staff #B was then presented with several daily nursing assessment shift entries documented in the EHR from RN-Staff #F that were signed with times and dates past the end of his nursing shifts. Staff #B stated these entries were considered late documentation.


Record review at time of survey of Patient #1's clinical records showed the following:

The 10/1/22, 7a-7p day shift nursing assessment was done by RN-Staff #F. It was dated to start on 10/1/22 at 9:19 am and was completed and signed late on 10/4/22 at 7:44 pm, over three days after start time. The notes stated "Patient not eating. Registered nurse encouraged patient to eat and drink and also educated patient on importance but patient still refused. Attending psychiatrist notified of patient's behavior".

The 10/1/22, 7p-7a evening shift nursing assessment was done by RN-Staff #L. It was dated to start on 10/1/22 at 9:07 pm and it was signed and completed 10/1/22 at 9:56 pm. It did not address patient's behavior of not eating.

The 10/2/22, 7a-7p day shift nursing assessment was done by RN-Staff #F. It was dated to start on 10/2/22 at 10:20 am. It was signed and completed late, two days after on 10/4/22 at 7:43 pm. At the end of the narrative note it stated that Patient #1 notified nurse he was throwing up and a H & P (History & Physical) was ordered. There was no other information regarding assessing the patient for onset of symptoms, onset and history of vomiting and there were no current vital signs documented. In addition, the narrative stated that the patient was encouraged to take medications "for condition" and patient refused. However, the patient had not yet had the H & P performed (it was done on 10/3/22) and there were not yet any associated meds ordered for nausea and vomiting.

The 10/2/22, 7p-7a day shift nursing assessment was done by RN-Staff #L. It was dated to start on 10/2/22 at 9:50 pm and was signed and completed on the same day at 10:54 pm. There was nothing written in the assessment notes addressing the patient throwing up or having any abdominal distress.


Interdisciplinary Progress Notes dated 10/3/22 at 7:49 am and signed 7:58 am from Nurse Practitioner (FNP)-Staff # G, showed she had seen and examined Patient #1 for abdominal pain with nausea, which had started 10/2/22 per the patient. For the pain, there was no documentation of intensity measured (on a scale of 1-10), or location, nature, duration/timing, or exacerbation/ameliorating factors.

The 10/3/22, 7a-7p day shift nursing assessment was done by RN-Staff #I. It was dated to start on 10/3/22 at 1:45 pm and was completed the same day at 2:00 pm. It stated that the patient had seen the nurse practitioner that day ("today"), but there was nothing documented for the entire shift regarding the patient's abdominal distress, including pain intensity, location, onset, quality, timing/duration, exacerbating/ameliorating factors, and nothing documented about nausea and vomiting. The only item that addressed pain in the assessment was a box which was checked that indicated "no pain".

The 10/3/22, 7p-7a evening shift assessment was done by RN-Staff #J. It was dated to start at 7:43 pm and signed and completed on 10/4/22 at 5:41 am. There was nothing addressed regarding the patient's pain or nausea and vomiting.

The 10/4/22, 7a-7p day shift nursing assessment was done by RN-Staff #F. It was dated to start at 2:15 pm but was not completed and signed until 7:31 pm. The note inaccurately stated the patient notified nurse he was throwing up and a history & physical exam was done today by the nurse practitioner. However, the nurse practitioner had seen the patient the previous day on 10/3/22, in the morning around 8:00 am.


A nursing progress note on 10/4/22 at 7:25 pm and signed the same day at 8:12 pm, made by RN-Staff #E, stated that during the discharge process on 10/4/22, Patient #1 became sweaty, was hyperventilating at 32 breaths per minute, heart rate was 240 beats per minute, and oxygen saturation was 62%. A code blue (medical emergency event) was announced/called in the facility. EMS was then telephoned at 6:29 pm, arrived to the scene at 6:43 pm, and took the patient to the lobby, then treated patient in the ambulance at 6:50 pm. This note entry was the last one in the patient's chart regarding this incident.