HospitalInspections.org

Based on interview and record review the hospital failed to ensure 1 of 1 RN (Registered Nurse) evaluated 1 of 1 patient (Patient #1's) medical needs. (Patient #1) complained of right ankle pain on 03/07/13. No medical intervention and/or evaluation was provided prior to (Patient #1's) transfer to a secondary Hospital (Hospital B) for continued psychiatric treatment.

Findings included:

(Patient #1's) application for Temporary Mental Health Services dated 03/06/13, reflected, "Psychosis, paranoid delusions and assaultive threats and behavior...arrested at the ER (emergency room) for hostile behavior..."

The nursing admission assessment dated 03/06/13 timed at 14:30 PM reflected, "Assistive devices...none...motor activity coordinated...gait, able to maintain balance...full range of motion...health history...psychiatric treatment, heart disease, hypertension and congestive heart failure...no pain on admission...41 year old admitted involuntarily...brought in from jail..."

The 03/07/13 Patient Rounds Progress Note timed at 06:30 AM reflected, "Patient soiled his bed and wet all over the room...with urine...patient cleaned up placed in wheelchair...refuses to ambulate...patient very intrusive parking wheelchair at nursing station...constantly re-directed..."

The 03/07/13 timed at 07:00 AM nursing note reflected, "Pain...to right ankle...uses wheelchair as needed...patient pleasant with appropriate behavior...easily re-directed away from nursing station..." No further documentation was found in the medical record which indicated the RN evaluated (Patient #1's) right ankle and/or informed the physician. No evidence was found which indicated treatment was provided.

The 03/07/13 untimed narrative assessment reflected, "Patient discharged to court. All belongings sent with patient...belongings sent with patient..."

Hospital B's nursing observation note dated 03/07/13 reflected, "Client has a swollen right ankle sustained...at the previous hospital..."

On 04/25/13 at 01:55 PM Personnel #14 was interviewed. Personnel #14 was asked to review (Patient #1's) medical record. Personnel #14 stated she thought (Patient #1's) complaint regarding pain in his right foot was something which occurred previously. Personnel #14 stated (Patient #1) wanted his foot wrapped. Personnel #14 was asked by the surveyor whether she evaluated/assessed (Patient #1's) right ankle. Personnel #14 stated she did not get close enough to look at (Patient #1's) foot. Personnel #14 was asked if the physician was notified regarding (Patient #1's) complaint. Personnel #14 stated she did not think to notify the physician.

The Patient/Assessment Nursing Flow Sheet policy with a revised date of 12.2006 reflected, "Documentation in the progress notes (narrative explanation) is performed by nursing staff...the RN must document abnormal findings...interventions utilized for patient...patient response to the interventions..."