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Based on hospital policy review, open and closed medical record review, and staff interviews, the hospital failed to provide adequate registered nurse supervision and evaluation of patient care for 2 of 10 records reviewed (#4 and #9).

The findings include:

Review of policy #6011.950 "Documentation - Nursing" revealed "...PROCEDURE: ...A. ...2. ...The registered nurse has the final responsibility for ensuring the completeness and accuracy of all admission information ...B. Daily Reassessment and Documentation 1. The patient is reassessed a minimum of every 12 hours and this documentation is recorded on the Nurses Progress notes ..."

1. Review of closed medical record for patient #4 revealed 45 year old female who presented to the Emergency Department on 5/22/15 at 0508 with diagnosis of depression and attempted suicide three days ago. Review revealed the patient was Involuntarily Committed, and was awaiting placement at a psychiatric facility. The patient was discharged on 5/26/15 at 1700 in the custody of law enforcement to an inpatient psychiatric facility. Review of this record revealed no VS (vital signs) documented between 5/23/15 at 2215 and 5/24/15 at 1300 (12hours 45min), and no VS documented between 5/24/15 at 1830 and 5/25/15 at 1200 (17hours 30min).

Review of an order written 5/25/15 at 1005 by Provider #3 revealed "...VS (vital signs) Q (every) 4 hr (4 hours) today." Review of nursing documentation revealed VS taken on 5/25/15 at 1200 with results: T-97.9, P-85, R-18, BP-141/77. Review of nursing documentation revealed VS taken on 5/25/15 at 2100 (9 hours later) with results: T-99.4, P-81, R-18, BP-156/92. Review revealed no other documented VS on 5/25/15.

Interview with CNO on 7/29/15 at 1230 revealed the hospital "Documentation - Nursing" policy regarding reassessment of patients was not followed. Interview with CNO on 7/29/15 at 1230 confirmed no other VS were documented on 5/25/15 and that the provider orders were not followed.

The interview further revealed that nursing care was not evaluated or supervised by the Registered Nurse.


2. Review of closed medical record for patient #9 revealed a 66 year old male admitted on 7/12/15 with diagnosis of urosepsis (blood infection that began as urinary infection).

Review of the "Patient Admission Assessment - Part 1 of 2" (form not dated) revealed an LPN (Licensed Practical Nurse) signature, and failed to reveal an RN signature.

Review of the "Patient Admission Assessment - Part 2 of 2" (form not dated) revealed an LPN signature, and failed to reveal an RN (Registered Nurse) signature.

Interview with the CNO confirmed the Patient Admission Assessment was completed by the LPN, and that nursing care was not evaluated or supervised by the Registered Nurse.

Based on hospital policy review, closed medical record review, and staff interviews, the hospital staff failed to date and/or sign all entries in the medical record for 3 of 10 records reviewed (#4, #8, and #9).

The findings include:

Review of policy #6011.950 "Documentation - Nursing" revealed "POLICY: Documentation in the medical record will be complete and accurate."

1. Review of closed medical record for patient #4 revealed 45 year old female presented to the Emergency Department on 5/22/15 at 0508 with diagnosis of depression and attempted suicide three days ago. The "treatment/orders" section on the ED "Physician Orders" form contained orders written by two different providers. Provider #1 wrote orders on admission (5/22/15) at 0515 and signed in the "provider signature/date" section, but failed to date the entry. Provider #2 wrote additional orders in the "treatment/orders" section at 0810 and failed to sign or date the entry.

Review of the "Emergency Physician Record - Psych Disorder, Suicide Attempt, Overdose" revealed that the form, completed by provider #1, was not dated.

Review of the "Emergency Physician Record - Chest Pain" revealed the form, completed by provider #3, was not dated or signed.

Review of the 3-page "Nurse's Progress Notes", completed on day of discharge (5/26/15) by Staff #1 and Staff #2, was not dated.


2. Review of closed medical record for patient #8 revealed a 74 year old male admitted on 5/31/15 with diagnosis pneumonia.

Review of "Adult Pneumonia Protocol Orders" failed to reveal a dated and timed signature of the provider.


3. Review of closed medical record for patient #9 revealed a 66 year old male admitted on 7/12/15 with diagnosis of urosepsis (blood infection that began as urinary infection).

Review of "Physician's Orders" sheet dated 713/15 revealed provider order "7/13/15, 0940, valium 5 mg PO @ 1015" with no provider signature.

Review of "PRN Admission Orders" dated 7/12/15 revealed no provider signature.

Review of "Physician's Orders" dated 7/15/15 @ 1135 revealed no provider signature.

Review of "Graphic Chart" revealed a FSBS (finger stick blood sugar) of 298 at 1130am. Review revealed the entry was not dated.

Review of "Frequent Monitoring Sheet for VS/I&O/Turning/Etc" revealed no date in the "date" section.

Review of the "Patient Admission Assessment - Part 1 of 2" revealed no date or time in the "date/time" section.

Review of the "Patient Admission Assessment - Part 2 of 2" revealed no date or time in the "date/time" section.

Review of the ED "Physician Order Form" revealed orders written by Unknown Provider under orders previously written by Provider #4. Unknown Provider order was not signed.

Interview with CEO 7/28/15 at 1600 revealed "we are aware that we have a problem with entries being signed, dated, etc. We are working to fix the issue."

Interview with CNO 7/29/15 at 1230 revealed "the expectation is that all entries be authenticated with signature, date, and time."


NC #00107469