HospitalInspections.org

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure nursing assessments by two (2) Registered Nurses (RN's) yielded correct patient information so that medical record documentation was accurate for one (1) of ten (10) patients (Patient #3).

The findings include:

Interview with the Quality Improvement (QI) Nurse on 11/04/14 at 2:45 PM, revealed the facility had no specific policy on accuracy of nursing assessments and documentation. However, review of the facility's policy titled, "Nursing Medical Record Reviews", revised 08/2014, revealed it stated its purpose was to ensure accurate and complete documentation regarding patient care and treatment in order to maintain quality patient care. Further review of the Policy revealed it provided a mechanism for reviewing nursing documentation of patient medical records, and results from chart reviews would be used for nursing education and in employee evaluations.

Review of Patient #3's medical record revealed the facility admitted the resident on 10/18/14, from the Emergency Department (ED), with diagnoses which included Chest Pain. Record review revealed Patient #3 arrived on the telemetry unit, 3 Center, on 10/19/14 at 4:00 AM. Review of the Nursing Admission Assessment completed on 10/19/14 at 7:00 AM revealed it listed the assessment for Patient #3's Ears, Eyes, Nose, and Throat (EENT) as within defined limits (WDL), and no abnormalities were noted. Review of the Nurse's Flow Sheet dated 10/20/14 at 7:00 AM revealed RN #3 documented Patient #3's eyes were WDL. However, continued review of the Nurse's Flow Sheet revealed on 10/20/14 at 7:15 PM, RN #1 assessed and documented on the Flow Sheet Patient #3 was blind in both eyes. Review of the Nurse's Flow Sheet dated 10/21/14 at 5:54 PM, revealed RN #2 documented Patient #3 was blind in both eyes. Further review of the record revealed neither the History and Physical (H&P) performed on 10/19/14 at 10:47 AM by the Advanced Practice Registered Nurse (APRN), nor the Discharge Summary completed on 10/22/14 at 12:07 PM by the Physician's Assistant (PA) revealed no documented evidence of Patient #3 having any visual impairment.

Interview with RN #1 on 11/04/14 at 1:40 PM, revealed she did document Patient #3 was blind in both eyes because she was given that information in the patient hand-off report received from RN #3. She revealed she did not ask Patient #3 if he/she was blind in both eyes; however stated she should have done this to verify the accuracy of her documentation in the patient's record.

Interview with RN #3 on 11/04/14 at 2:00 PM, revealed she did not recall giving any information about Patient #3 having any visual problems to RN #1 because she had charted Patient #3's eyes were WDL on 10/20/14 at 7:00 AM.

Interview with the Nurse Manager of the Intensive Care Unit (ICU), on 10/31/14 at 9:50 AM, revealed RN #2 was on medical leave and could not be interviewed.

Interview, on 11/04/14 at 4:15 PM, with the Nurse Manager of 3 Center, where Patient #3 had been a patient, revealed she expected nurses to investigate a finding which was to be documented on the Nursing Admission Assessment, such as, blind in both eyes, instead of charting from the information given during nursing rounds/patient hand off report. She further revealed RN #1 and RN #2 should have done investigated and verified the findings before documenting.