HospitalInspections.org

Based on record review the facility failed to maintain inpatient medical records according to physcian's orders, including information necessary to monitor the patient's condition.

The findings include:

Facility Policy "Neurological Checks" included the following,
"Purpose: Neurological vital signs are performed to establish a base-line assessment and continued during hospitalization to assess for improvement or deterioration in the patient's condition.
Policy: Neurological Vital Signs should be ordered by a provider and performed by nursing staff. Frequency will be specified on the provider's orders. Neurological checks should include but are not limited to the Glascow Coma Scale (level of consciousness, movement, and speech); and assessment of pupils for size and reaction to light; and The National Institute of Health Stroke Scale (NIHSS) and/or the modified NIHSS.
If abnormalities are found or changes occur in the patient's neurological signs, they should be reported to the provider ...
Documentation: Neurological vital signs and the NIHSS should be documented in EMR flow sheet under the title Neuro/Mod. NIH or NIH Initial Stroke Scale ..."

Vital signs with neurological checks were ordered q 4 hours (every four hours) for the following patients:

Patient #19
3/11/19 at 2300 Full Neurological assessment
Gap = Next Neuro assessment
3/11/19 at 0733 Full Neuro Assessment

Patient #21
3/11/19 at 2049 Full Neurological assessment
Gap = Next Neuro assessment
3/12/19 at 0736 Full Neurological Assessment

Patient #22
3/11/19 at 2156 Full Neurological assessment
Gap = Next Neuro assessment
3/12/19 at 0753 Full Neurological assessment

Patient #23
3/10/19 at 1900 Full Neurological assessment
Gap = Next Neuro assessment
3/11/19 at 0707 Full Neurological assessment

A review of the medical records revealed, 4 of 5 patient's neurological checks were not done as ordered by the physician every 4 hours.