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A. Based on a review of Hospital policy, and Hospital stated practice, clinical record review, and staff interview, it was determined that, for 1 of 10 (Pt. #1) clinical records reviewed, the Hospital failed to notified the patient's family regarding a change in the patient's condition as well as the need for the use of a restraint.

Findings include:

1. Hospital policy #90.017.031 entitled, "Utilization of Restraint and Seclusion," was reviewed on 5/3/10 at approximately 3:30 P.M. The policy requires, "... the family will be informed of the need to use restraint as soon as is practicable after initiation..."

2. The Hospital practice, as stated by the Telemetry Unit Nursing Director on 5/3/10 at approximately 2:20 P.M., is that the nurse should notify the patient's family whenever there is a negative change in the patient's condition, and whenever there is a need for the use of a restraint.

3. The clinical record for Pt. #1 was reviewed on 5/3/10 at approximately 9:30 A.M. This was an 87-year-old female admitted on 1/22/10 with Upper/Lower Gastrointestinal Bleeding. The record also included nursing neurological assessments documented at least twice daily during Pt. #1's hospitalization. The assessments indicated that Pt. #1 was alert and oriented to person, place, time and event. However, the first documentation that indicated Pt. #1 was confused, was dated 1/26/10 at 2:10 A.M., by the night shift nurse. The record also included documentation, by the day shift nurse, at 9:35 A.M. on 1/26/10, that Pt. #1 was agitated, confused, and only oriented to person (herself). The record further included that Pt. #1 was placed in restraints on 1/26/10 at 9:00 A.M. for cognitive impairment with inability to follow directions and interference with medical devices. The record lacked documentation that the nurse notified Pt. #1's family of the change in Pt. #1's condition and the need for restraints.

4. The above findings were confirmed with the Telemetry Unit Nursing Director on 5/3/10 at approximately 2:20 P.M.

A. Based on a review of Hospital policy, clinical record review, and staff interview, it was determined that, for 1 of 10 (Pt. #1) clinical records reviewed, the nurse failed to ensure the physician was notified of a patient who exhibited a negative change in condition/status.

Findings include:

1. Hospital policy #67.118.217 entitled, "Physician Notification: Patient Condition Changes..." was reviewed on 5/3/10 at approximately 3:00 P.M. The policy requires, "The nurse caring for the patient will notify the physician of any negative changes in the patient condition from previous nursing assessment."

2. The clinical record for Pt. #1 was reviewed on 5/3/10 at approximately 9:30 A.M. This was an 87-year-old female admitted on 1/22/10 with Upper/Lower Gastrointestinal Bleeding. The record included documentation that the patient was taking an anticoagulant (blood thinning medication), prior to admission, however a physician's order to discontinue aspirin and Coumadin (an anticoagulant) for 2 weeks, was written on 1/23/10. The physician's progress note dated 1/25/10 indicated that Coumadin was on hold because of gastrointestinal bleeding, and that the patient and family understood that without Coumadin there was a risk of stroke. The record also included nursing assessments, including neurological assessments documented at least twice daily during Pt. #1's hospitalization. The assessments indicated that Pt. #1 was alert and oriented to person, place, time and event. However, the first documentation that indicated Pt. #1 was confused was dated 1/26/10 at 2:10 A.M. by the night shift nurse. The record lacked documentation that the night shift nurse notified the physician of the change in Pt. #1's condition, based on a change from the previous nursing assessments.

The record included further documentation, by the day shift nurse, at 9:35 A.M. on 1/26/10, that Pt. #1 was agitated, confused, and only oriented to person (herself). The record lacked documentation, until 1/26/10 at 1:39 P.M. that the physician was notified of the change in Pt. #1's condition. The neurological note dated 1/26/10 (untimed) included the following impression: "Altered Mental Status, likely... new stroke on CT head." The record included that the CT scan of the head was performed 1/26/10 at 2:12 P.M.

3. The above findings were confirmed with the Telemetry Unit Nursing Director on 5/3/10 at approximately 2:20 and 4:00 P.M.


B. Based on a review of Hospital policy, and Hospital stated practice, clinical record review, and staff interview, it was determined that, for 1 of 10 (Pt. #1) clinical records reviewed, the Hospital failed to ensure nursing documentation was completed in accordance with Hospital policy.

Findings include:

1. Hospital policy #67.118.257 entitled, "Documentation Guidelines" was reviewed on 5/3/10 at approximately 3:15 P.M. The policy requires, "PIEP Documentation... All ad hoc documentation that is not covered by Nursing Power Forms... will be completed using the PIEP method... Problems, Interventions, Evaluation, Plan..."

2. The Hospital documentation practice, as stated by the Telemetry Unit Nursing Director on 5/3/10 at approximately 2:20 P.M., is that the nurse should chart a PIEP (Problems, Interventions, Evaluation, Plan) note at the end of each shift.

3. The clinical record for Pt. #1 was reviewed on 5/3/10 at approximately 9:30 A.M. This was an 87-year-old female admitted on 1/22/10 with Upper/Lower Gastrointestinal Bleeding. The record also included nursing neurological assessments documented at least twice daily during Pt. #1's hospitalization. The assessments indicated that Pt. #1 was alert and oriented to person, place, time and event. However, the first documentation that indicated Pt. #1 was confused, was dated 1/26/10 at 2:10 A.M. by the night shift nurse. The record lacked documentation that the night shift nurse notified the physician of the change in Pt. #1's condition, based on a change from the previous nursing assessments. In addition, the clinical record lacked PIEP documentation at the end of the night shift (1/25/10 7:00 P.M.-1/26/10 7:00 A.M.).

4. The above findings were confirmed with the Telemetry Unit Nursing Director on 5/3/10 at approximately 2:20 P.M.