HospitalInspections.org

Based upon record review and interview, the hospital failed to ensure the Registered Nurse conducted an evaluation on admission and throughout each patient's hospitalization. This was evidenced by the failure to document an accurate initial and on-going nursing assessments for one (#1) of seven medical records reviewed.

Findings:

Review of the medical record for patient #1 revealed the patient was admitted to the hospital on 06/20/19 for the chief complaint of Pneumonia, Congested Health Failure, and Acute Respiratory Failure. The patient also had a history of Atrial Fibrillation and was on the blood thinner medication Warfarin. Review of the initial admission nursing assessment dated 06/20/19 and the 12 hour nursing assessments (06/21/19-07/09/19) revealed the Registered Nurse documented the patient had "multiple large purple" bruises; however, no location or size of the bruises were identified.

Interview on 08/12/19 at 10:35 a.m. with Staff E revealed patient #1 had bruising to the abdomen and arm and agreed the location and size of the bruises was not documented.