HospitalInspections.org

Based on document review and interview, nursing services failed to document reassessment and notification of abnormal temperature vital signs to provider in 7 of 10 (Patients 1, 2, 3, 6, 7, 8, and 9) medical records reviewed; failed to ensure that provider orders were noted and failed to document neurological assessments per provider order in 1 of 10 (patient 6) medical record reviewed.

Findings include:

1. Facility policy titled, "Vital Signs and Weights", PolicyStat ID 12386461, last approved 09/2022, indicated staff will report abnormal findings to the nurse and the nurse will notify the provider of findings.

2. Facility policy titled, "Assessment/Reassessment", PolicyStat ID 12386392, last approved 09/2022, indicated nursing staff will reassess each patient as warranted by the patient's medical condition and document findings.

3. Facility policy titled, "Assessment-Neurological", PolicyStat ID 12197156, last approved 08/2022, indicated nursing staff will evaluate the patient's neurological condition after suspected head injury or when requested by a provider and document on the Neurological Flow Sheet.

4. Facility policy titled, "Physician Orders/Receipt and Notation", PolicyStat ID 12197185, last approved 08/2022, indicated provider orders are to be noted and transcribed by nursing.

5. Review of Patient 1's medical record lacked documentation of reassessment or notification to the provider of abnormal temperature vital signs (normal value 97.5 Fahrenheit (F) to 99.9 F) as follows:
a. 06/23/23 night shift, 97.2 F
b. 06/24/23 day shift, 97.1 F
c. 06/24/23 night shift, 97.1 F
d. 06/30/23 day shift, 96.8 F
e. 07/03/23 day shift, 97.4 F
f. 07/07/23 night shift, 97.4 F

6. Review of Patient 2's medical record lacked documentation of reassessment or notification to the provider of abnormal temperature vital signs as follows:
a. 07/13/23 night shift, 97.3 F
b. 07/15/23 night shift, 97.3
c. 07/19/23 day shift, 96.1 F
d. 07/20/23 night shift, 97.3 F

7. Review of Patient 3's medical record lacked documentation of reassessment or notification to the provider of abnormal temperature vital signs as follows:
a. 07/06/23 admission, 97.1 F
b. 07/08/23 day shift, 97.2 F
c. 07/08/23 night shift, 97.2 F
d. 07/12/23 night shift, 97.1 F
e. 07/20/23 day shift, 97.3 F
f. 07/21/23 night shift, 96.9 F
g. 07/22/23 night shift, 97.2 F
h. 08/04/23 day shift, 97.3 F
i. 08/23/23 day shift, 97.3 F
j. 08/25/23 day shift, 97.2 F
k. 08/26/23 day shift, 97.3 F
l. 08/26/23 night shift, 97.1 F
m. 08/27/23 night shift, 97.0 F
n. 08/28/23 day shift, 96.5 F
o. 08/28/23 night shift, 96.0 F
p. 09/02/23 day shift, 96.7 F
q. 09/03/23 night shift, 97.3 F
r. 09/11/23 day shift, 97.2 F
s. 09/20/23 day shift, 97.3 F

8. Review of Patient 6's medical record indicated neurological assessments per fall protocol were ordered on 08/31/2023 after patient fell and MR lacked documentation of neurological assessments; provider admission orders dated 08/25/23 for laboratory orders for a complete blood count, complete metabolic panel, thyroid stimulating hormone, Hemoglobin A1c, ammonia level, and urinalysis with culture and sensitivity lacked documentation of nursing notation and were not carried out during hospital stay; medical record lacked documentation of reassessment or notification to the provider of abnormal temperature vital signs as follows:
a. 08/28/23 day shift, 97.1 F
b. 08/30/23 day shift, 97.1 F

9. Review of Patient 7's medical record lacked documentation of reassessment or notification to the provider of abnormal temperature vital signs as follows:
a. 08/30/23 day shift, 96.4 F
b. 09/04/23 day shift, 97.4 F

10. Review of Patient 8's medical record lacked documentation of reassessment or notification to the provider of abnormal temperature vital signs as follows:
a. 08/27/23 night shift, 97.0 F
b. 08/29/23 night shift, 97.4 F
c. 08/30/23 day shift, 97.4 F
d. 09/07/23 night shift, 96.2 F
e. 09/09/23 day shift, 96.4 F
f. 09/11/23 day shift, 96.4 F
g. 09/18/23 day shift, 96.6 F
h. 09/19/23 day shift, 95.5 F
i. 09/22/23 day shift, 97.4 F
j. 09/25/23 night shift, 97.2 F
k. 09/29/23 day shift, 97.1 F
l. 09/29/23 night shift, 97.0 F
m. 10/04/23 day shift, 96.6 F
n. 10/07/23 day shift, 96.6 F
o. 10/11/23 day shift, 96.6 F
p. 10/11/23 night shift, 97.1 F

11. Review of Patient 9's medical record lacked documentation of reassessment or notification to the provider of abnormal temperature vital signs as follows:
a. 08/30/23 day shift, 96.5 F
b. 09/01/23 day shift, 97.0 F
c. 09/01/23 night shift, 96.9 F
d. 09/07/23 day shift, 97.6 F
e. 09/07/23 night shift, 96.4 F
f. 09/09/23 day shift, 97.4 F
g. 09/14/23 night shift, 97.4 F

12. Interview with A3 (Director of Nursing) on 03/18/24 at approximately 3:30 p.m. confirmed that normal temperature range for patients is 97.5 degrees Fahrenheit (F) to 99.9 degrees F, if staff obtain an abnormal vital sign, they are to reassess vital sign and notify the provider of any abnormal vital sign findings.

13. Interview with A3 on 03/18/24 at approximately 5:20 p.m. confirmed that neurological assessments are done with a suspected head injury or per provider order; confirmed patient 6 had order for neurological assessments per policy. A3 at approximately at 6:30 p.m. confirmed patient 6 had an order for laboratory work and order was not noted nor completed as ordered; and patient 6 did not have a Neurological Assessment Form in their medical record.

14. Interview with A1 (Chief Executive Officer) and A3 on 03/18/24 at approximately 6:15 p.m. confirmed that patients 1, 2, 3, 6, 7, 8, and 9 had documentation of abnormal temperature vital signs documented in their medical records and medical records lacked reassessment of temperature or notification to provider of abnormal vital signs.

15. Interview with A2 (Risk Director) on 03/18/24 at approximately 6:35 p.m. confirmed that there was not a copy of the Neurological Assessment Form for patient 6.