HospitalInspections.org

Based on Record review and interview, the hospital failed to ensure organized nursing services were available and supervised to provide services per the facilities policies and procedures for:

1. Six (Patients #2, 12, 13, 16, 17, and 18) of 20 patients needing nursing assessments.
2. Seven (Patients # 2, 11, 12, 13, 16, 17, and 18) of 20 patients needing nursing shift assessments, and
3. Six (patients 1, 6, 11, 13, 14, and 15) of 20 patients needing pain reassessments.

Findings:

A policy titled, "16464168 Nursing Assessment and Documentation" stated in part that the admission assessment was completed by the RN within 24 hours of admission to the facility.

A policy title, "Nursing Assessment and Nursing Process" stated that the admission assessment would be completed within 24 hours of admission and that shift assessments would be completed at least once a shift.

Pts #2, 12, 13, 16, 17 and 18
A review of the clinical records showed no nursing admission assessment.

Pts #2, 11, 12, 13, 16, 17, and 18
A review of the clinical record records showed no nursing shift assessments.

Pts #1, 6, 11, 13, 14, and 15
A reviw of the clincial records showed no pain reassessments.

During an interview with employee Y on 11/20/2024 at 10:00 a.m. employee Y stated:
1. They didn't know why the assessments were not completed for patients #1, 2, 6, 11, 12, 13, 14, 15, 16, 17, and 18.
2. An admission assessment should have been completed on every patient admitted to the hospital within 24 hours of admission.



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Based on record review and interview, the facility failed to ensure one of 20 (Pt #6) patient's administration of pain medication was consistent with orders for the pain level reported.

findings:

Pt #6
A review of orders showed Tylenol for pain rated between 1-4.
A review of clinical documentation showed:
1. on 10/06/2024 employee AA assessed the patients pain level as a "5,"
2. Employee AA administered Tylenol for the patient's pain. Documentation showed no orders for pain rated above four (on 1-10 scale) and no documented communication/coordination by Employee AA for additional orders for pain medication rated higher than four.

On 11/19/2024 at 1:15 p.m., Employee C stated that it was error on the nurse's part and the nurse should have called the provider for a new order for pain medication.