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Based on record review, staff interview and documentation review, the governing body failed to ensure the medical staff completed and documented the evaluation of Patient #1 after the nursing staff placed the patient on the "Sick Call List" on 08/24/17.

Findings included ....

NPM 3-99, titled "Assessing Change in Physical Status," revised May 28, 2013, showed, Notify the General Medical Officer and Nurse Practitioner via documentation on the "sick call" list when a non-urgent situation presents and document notification in the nursing progress not in Avatar.

The hospital's Administrative Call List for Weekends/Holidays, titled "Weekend Sick Call" showed, the day shift supervisor must call each unit to determine if any individuals in care are ill and need to be seen by the General Medical Officer or Psychiatrist. Completed the listing of individual in care on the appropriate log sheet- one listing for the General Medical Officer and the one listing for the Psychiatrist. (Samples attached). Present the listing to the General Medical Office and the Psychiatrist on duty. File a copy of the listings in the "Sick Call" notebook.

A review of the medical record showed Patient #1 had a history of headaches, the last episode documented on 06/09/17, and Tylenol 650 milligrams received for pain. On 08/23/17 at 8:28 PM showed the nursing staff administered a onetime dose of Motrin 600 milligrams (mg) for a headache after the medical team examined the patient.

Nursing note dated 08/24/17 at 6:20 AM showed the patient woke up complaining of a headache (numeric score seven of 10, with zero meaning no pain 10-the worst pain), administered Tylenol 650 milligram, and placed on the sick call list. The nursing staff administered the next dose of Tylenol 650 milligrams on 08/24/17 at 11:41 PM (numeric score six of 10).

The surveyor conducted a telephone interview with Employee #4 Nursing Performance Improvement Officer on July 29, 2019, at approximately noon regarding the "Sick Call" list.

According to Employee #4, patients can be placed on the sick call list at any time to be seen by the medical team. The sick call list prompts the medical team to evaluate the patients.

The medical record showed that the medical team ordered Motrin 600mg every eight hours for headaches on 08/25/17 at 12:42 PM.

Nursing shift note dated 08/25/17 at 5:49 PM showed the patient refused all her scheduled medicine but took Tylenol this morning and later in the afternoon "requested something stronger because Tylenol was not helping." She was assessed and vital signs checked and within normal limits ("WNL")." The Nurse Practitioner covering called a new order for Motrin 600 mg given at 2:08 PM by mouth. The patient monitored after the Motrin, sleeping no further distress noted, seen watching TV in the dayroom, and verbalized feeling better.

The medical record lacked documented evidence that the medical team evaluated the patient after the nursing placed her on the sick call list. The medical team assessed the patient on 08/26/17 at 11:00 AM.

1. Based on medical record review and policy review, the nursing staff failed to complete and document pain reassessment after medication intervention for Patient #1 in one of three patients reviewed for pain management.

Findings included ...

Record review of the hospital's policy titled, "Pain Assessment and Management" dated 2/2010, showed that the nursing staff 'reassess the severity of the pain using a scale within one hour after administration of pain medication to monitor the effectiveness of the medication. Notify the General Medical Officer GMO) for pain that isn't relieved as ordered and when the patient consistently reports pain of greater than 4/10 for 24 to 48 hours ...

Review of Patient #1's medical record showed the Nurse Practitioner (NP) ordered acetaminophen (Tylenol) 650 milligrams (mg) every four to six hours by mouth for pain as needed.

Review of the electronic Medication Administration Record (eMAR) showed that nursing staff administered Tylenol 650 mgs on 08/24/17 at 6:12 AM in response to the patient's complaint of pain, voiced at a score of "6-7." The numeric pain scale utilizes a scoring system of zero to 10 with zero, meaning no pain and 10 indicating the worst pain. The medical record lacked documented evidence the nursing staff completed a reassessment after one hour post medication administration.

The practice lacked evidence that the nursing followed the hospital's pain assessment and management policy.

1.Based on medical record review, policy review, the nursing staff failed to notify the General Medical Officer (GMO) in a timely matter after an acute change in Patient #1's condition.

Findings included ....

Record review of the hospital's policy titled, "General Medical Service and Transfer Off-site for Non- Emergency Medical Assessment and Treatment," revised 12/15/14, showed, (f) In all situations, the RN shall document the assessment and notifications, including time of notification and who was notified.

Review of Patient # 1's medical record showed that the patient experienced a Change in Status on 08/23/17 because of a headache. On 08/26/17 a 4:04 PM, the nursing staff documented that the Patient #1 status changed after breakfast. "Consumed 100% of her breakfast and returned to her room. However, the writer noted that Individual in Care (Patient #1) appeared confused, disoriented, and unable to respond to questions." The nursing staff assessed the patient at 8:53 AM and 9:30 AM, the Nursing Supervisor and the Psychiatrist was notified of the patient's condition during rounds at approximatley 9:30 AM- no new orders given.

The surveyor conducted a telephone interview with Employee #11, Psychiatry Resident on August 7, 2019, at approximately 5:10 PM, regarding the IIC's change in mental status. Employee #11 said "the nurse said the patient had 'a headache', did not mention altered mental status. I asked the nurse to call the GMO as well, and the nurse said they called the GMO." According to Employee #11, the nursing staff notified the GMO before reporting the patient's headaches to psychiatry on 08/26/17.

The GMO evaluated Patient #1 at approximately 11:00 AM and 1:00 PM on 08/26/17.

The medical record lacked documented evidence that the nursing staff notified the GMO of the patient's acute change in condition: confused, disoriented and unable to respond to questions on 08/26/17 at approximately 9:00 AM. However, per Employee #11, the nursing staff notified the medical team prior to notifying psychiatry on 08/26/17.

The practice lacked evidence that the nursing staff followed the Nurse Procedure Manual protocol for documentation regarding physician notification.


2. Based on medical record review, and policy review, the nursing staff, failed document progress notes for 08/24/17, day and night shifts for Patient #1 after a change in physical status related to headaches.

Findings included ....

Record review of the hospital's policy from Nurse Procedural Manual (NPM) titled "Assessing Change in Physical Status", revised 05/28/13, showed, " ...All Recovery Assistants (RA's shall: observe individuals for any change is physical status. Notify RN of observed physical changes as well as changed reported by the individual in care, families or visitors. Documents observation and communications to the RN in a narrative progress note in Avatar. Monitor and provide care as ordered by physician and/or directed by a RN. In all situations the RN shall: Continue to monitor and assess the individual and provide any care ordered by the GMO or NP and clinically indicated ...If the individual is not transferred to another medical facility, documents a narrative progress note in Avatar at least every shift for 72 hours following the individual's initial change in physical status to reflected continued nursing observation and reassessments, the individual's response to interventions and recommendations for change in plan of care if indicated.'

Review of Patient # 1's medical record showed the patient had a change in status relative to a headache documented on 08/23/17, at approximately 8:13 PM by the General Medical Officer (GMO). The GMO evaluated Patient #1 and ordered a one-time dose of Motrin 600 milligrams (mg) by mouth. The nursing staff administered the Motrin at 8:28 PM for a numeric pain score "6-7" on a scale of zero to 10. The numeric pain scale indicates zero, meaning no pain and 10 indicating the worst pain. The nursing staff reassessed the patient in one hour at 9:28 PM using the Pain Assessment tool. The patient verbalized a pain score of '0-1', after administration of pain medications.

A nursing note dated 08/24/17, at 6:20 AM showed the patient "she went to bed slept all night and woke up this morning complaining of a severe headache ... Nursing will continue to monitor."

According to the electronic Medication Administration Record (eMAR), the nurse administered Tylenol 650 milligrams at 6:12 AM on 08/24/19 for a numeric pain score of seven of 10 for a headache.

The next documented nursing progress note was dated on 08/25/17 at 05:49 PM. The record lacked evidence of nursing progress notes for two (2) shifts (12 hours) following the patient's change in status.

The practice lacked evidence that the nursing staff followed the hospital's policy for documenting at least every shift after a patient has a change in status.

Cross reference A-0049 Governing Body