HospitalInspections.org

Based on record review, observation and interview, Registered Nurses failed to ensure adequate supervision of patients by staff according to physician orders and the care plan for 2 of 4 patients (Patients# 1 and 2). This may have resulted in a delay of necessary medical care for Patient #1 who was admitted to the hospital on 08/20/18 with the diagnosis of stroke.

The findings included:

1) Patient #1 was admitted to the facility on 03/12/18. Review of Precaution/Supervision Orders revealed Patient #1's most recent order, with status as "active," had been in place since 04/17/18 for supervision frequency (every) 30 minutes.

Evidence of 30-minute checks for Patient #1 were requested. The Director of Nursing reported the facility uses both electronic and paper records for "face checks." Logs from the electronic system were requested beginning 08/16/18 and compared to the paper records. Comparison of the 2 logs revealed no evidence of "face checks" on 08/17/18 between 8:31 PM and 9:46 PM or between 10:05 PM and 11:04 PM; no evidence of "face checks" on 08/18/18 between 5:45 AM and 7:02 AM or between 7:53 and 9:47 AM; and no evidence of "face checks" on 08/19/18 between 3:00 PM and 5:16 PM, between 5:42 PM and 7:22 PM, or between 8:05 PM and 9:28 PM.

Face Check Sheets for 08/01/18 through 08/21/18 had initials for Registered Nurse Assessment on 10 out of 40 12-hour shifts and only 3 selections out of 40 to indicate A, B, or C for whether they recommend to continue, increase, or decrease the current frequency of observations.

During interview on 12/04/18 at 4:20 PM the Director of Nursing stated the Registered Nurses should co-sign under "RN Assessment" for review of the Face Check Sheet and to indicate A, B, or C for whether they recommend to continue, increase, or decrease the current frequency of observations.

A nurse's note dated/timed for 08/20/18 at 10:42 AM documented Patient #1 was lying on the floor naked, kicked at staff when approached, presented a danger to himself and others, that de-escalation methods were unsuccessful, and he was medicated for agitation.

A nurse's note dated/timed for 08/20/18 at 1:20 PM documented Patient #1 was sent the hospital to rule out stroke at approximately 1:39 PM. However, the "face check sheet" for 08/19/18 to 08/20/18 documented that on 08/20/18 Patient #1 was "in room awake" every 30 minutes between 11:00 AM and 11:00 PM. A nurse's note dated/timed for 08/20/18 at 8:00 PM documented Patient #1 was admitted to the hospital with the diagnosis of stroke. However, the "face check sheet" for 08/20/18 through 08/21/18 documented Patient #1 was "in room asleep" every 30 minutes from 11:30 PM on 08/20/18 to 12:30 AM on 08/21/18, no entries for 1:00 AM and 1:30 AM, and again that he was "in room asleep" every 30 minutes from 2:00 AM until 6:30 AM, and that he was "in room awake" from 7:00 AM to 11:00 AM.

Picture records of the electronic "face checks" for Patient #1 were reviewed and revealed a group picture in a common area on 08/20/18 at 5:24 PM that documented Patient #1's activity as "mealtime" and his current behavior as "cooperative" although he was in the hospital at that time An entry on 08/20/18 at 6:37 PM documented Patient #1's activity as "hospital" and his current behavior as "cooperative." A group picture of multiple persons was tagged as including Patient #1 on 08/20/18 at 8:40 PM and documented Patient #1's activity as "recreational activity," behavior "cooperative," and a Note "sing happy birthday" (sic) after the nurse learned he was admitted to the hospital for stroke.

2) Electronic and paper records of 30 minute checks for Patient #2 were requested. The logs documented Patient #2 was also on 30 minute checks. Comparison of the 2 logs revealed no entries for 30 minute checks on 10/02/18 between 00:06 AM and 1:15 AM; between 10/04/18 at 11:15 PM and 10/05/18 at 1:15 AM; on 10/04/18 between 4:45 AM and 5:45 AM; on 10/12/18 between 5:15 AM and 7:07 AM; on 10/14/18 between 3:15 PM and 4:45 PM; on 10/16/17 between 3:45 AM and 4:45 AM; on 10/17/18 between 1:45 PM and 5:45 PM, between 8:45 PM and 10:08 PM, or between 10:08 PM and 11:15 PM; on 10/20/18 between 4:15 PM and 11:15 PM; on 10/23/18 between 4:15 PM and 5:45 PM; and on 10/24/18 between 3:15 PM and 11:15 PM.

During interview on 12/04/18 at 5:00 PM, the Compliance Officer stated a person on 30 minute checks must be checked every 30 minutes. During interview on 12/04/18 at 5:00 PM, the Director of Nursing, Assistant Administrator, and Risk Manager were apprised of numerous gaps in routine "face checks" and acknowledged staff should not document face checks for a person that they do not see, and that staff may not be "tagging" group pictures appropriately.

Policies and Procedures for "face checks" were requested but not provided by 5:00 PM on 12/04/18.