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JOHNSON REGIONAL MEDICAL CENTER

1100 EAST POPLAR STREET

CLARKSVILLE, AR 72830

EMERGENCY SERVICES POLICIES

Tag No.: A1104

Based on clinical record review, policy and procedure review and interview, it was determined the Facility failed to follow the policy in that each Emergency Department patient was not assessed by a Registered Nurse for 5 (#2, #5, #6, #7 and #10) of 10 (#1-#10) Emergency Department records reviewed. The failed practice did not allow for the development of a plan of care to meet the needs of the patient based on an assessment by the RN and had the potential to affect all patients seen in the Emergency Department. The findings follow:

A. Review of Patient #2's clinical record on 08/05/14 revealed there was no evidence of a Registered Nurse Assessment. The findings were confirmed in an interview with the Assistant Administrator of Patient Care on 08/05/14 at 1100.
B. Review of Patient #5's clinical record on 08/05/14 revealed there was no evidence of a Registered Nurse Assessment. The findings were confirmed in an interview with the Assistant Administrator of Patient Care on 08/05/14 at 1110.
C. Review of Patient #6's clinical record on 08/05/14 revealed there was no evidence of a Registered Nurse Assessment. The findings were confirmed in an interview with the Assistant Administrator of Patient Care on 08/05/14 at 1110.
D. Review of Patient #7's clinical record on 08/05/14 revealed there was no evidence of a Registered Nurse Assessment. The findings were confirmed in an interview with the Assistant Administrator of Patient Care on 08/05/14 at 1125.
E. Review of Patient #10's clinical record on 08/05/14 revealed there was no evidence of a Registered Nurse Assessment. The findings were confirmed in an interview with the Assistant Administrator of Patient Care on 08/05/14 at 1140.
F. Review of the "ED (Emergency Department) Nursing Documentation Standard" provided by the Assistant Administrator of Patient Care on 08/05/14 revealed, "The Primary RN (Registered Nurse) needs to complete the 'Nursing Focused' assessment on each patient. It allows us to give a basic assessment on the patient, and is already an established standard of care."