HospitalInspections.org

Based on record review and interview, the nurse did not do a further assessment or reassessment one of one patient (ID#2) and did not notify the physician regarding the current status of patient (ID#2).

Findings Include:

Record review facility policy "Case at the End of Life" dated 04/16/2018, stated
F. End-of-life care includes Involving patient and family in every aspect of care, including decision-making process of end-of-life issues.

Record review of facility policy "Assessment/Reassessment of Patient Guideline" last review 06/26/2023, stated:
6. Need for further assessment/reassessment,
a. The information gathered per policy for each treatment setting above may indicate the need for more data regarding the patient's physical, psychological, or social status. The list will include but not limited to, situations or patient conditions that would require further assessment. (include the dying patient).

Record review of the nursing progress note dated 03/29/2023 at 1636 by staff nurse (ID#P), revealed the physician was not called until 1652 and was pronounced dead at 1638.

Record view of the grievance investigation note, dated 06/08/2023 at 1100, revealed, Dr. (ID#Q) did not have recollection of the events of the case.

Interview with the RN (ID #O) on 08/04/2023 at 1010, stated she investigated this issue and spoke to nurse (ID#P) and discovered she had not documented her actions, or notified the physician about the change in patient condition, per the request of the family. However, nurse (ID#P) stated she spent most of her time with patient (ID#2).