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CHRISTUS ST MICHAEL HEALTH SYSTEM
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on record review and interview, the facility failed to assure neurologic (neuro) assessments were conducted as per physician order for one of one patient.
Findings include:
Review of the medical record revealed an order for " neuro checks every 2 hours times 24 hours, then every shift, " on the Stroke/TIA Admission Orders, written on 5/23/2009 at 2:25pm and initiated at 4:02pm. There was no subsequent order regarding neurologic checks.
Review of the document titled, " Neurological Assessment Sheet, " revealed neurological checks completed at the following times:
5/23/2009- at 4:02pm, 8:00pm, 10:00pm, and midnight (no check at 6:00pm)
5/24/2009- at 2:00am, 6:00am, 8:00am, noon, and 4:00pm (no check at 4:00am, 10:00am, 2:00pm, or 6:00pm)
In an interview in the Administrative Library on 6/22/11 at 2:00pm, staff#1 confirmed the missing neurologic checks on the Neurological Assessment Sheet.