HospitalInspections.org

Based on interviews and review of clinical records and policy it was determined that the Registered Nurse failed to evaluate and supervise patient care related to assessments and reassessments for 2 (#1,#3,) of 3 records reviewed. This practice does not ensure patient safety and goals are met.

Findings include:

Review of the policy for "Assessment and Reassessment" # 2-1-003, revised on 4/10 revealed under Nursing Services, section (c.) the assessment components to be addressed in the reassessment timeframe include, but not limited to : Vital signs and assessment of system related to chief complaint. Under the Unit Specific Time Frames for the Long Term Acute Care (LTAC) section a reassessment is to be done every 8 hours and more frequently as needed.

1. Patient# 1's nursing documentation revealed the patient was not assessed every 8 hours per the policy on assessments and reassessments for 9 random days between 4/23/10 to 5/9/10.

On 4/23/10 the patient was assessed at 8:00 a.m., then again at 7:00 p.m., there was no reassessment for 11 hours.
On 4/26/10 the patient was assessed at 7:30 a.m. and then at 7:00 p.m., there were no reassessments documented for 11 ? hours.
On 4/27/10 a reassessment was completed at 12:00 a.m., at 7:00 a.m. and at 7:50 p.m. there were no documented reassessments for almost 13 hours.
On 4/28/10 a reassessment was done at 9:00 a.m. and at 7:00 p.m. there were no reassessments for 10 hours.
On 5/2/10 a reassessment was done at 8:00 a.m. and at 8:00 p.m., there were no documented reassessments for 12 hours.
On 5/4/10 an assessment was done at 7:00 a.m. and at 6:25 p.m. there were no documented reassessments for over 11 hours.
On 5/6/10 an assessment was done at 9:30 a.m. and at 7:50 p.m., there were no documented reassessments for over 10 hours
On 5/8/10 an assessment was done at 9:00 a.m. and at 6:30 p.m. there were no documented reassessments for almost 10 hours
On 5/9/10 an assessment was done at 7:00 a.m. and at 7:45 p.m. there were no documented reassessments done for over 12 hours.

2. Patient #3's nursing documentation revealed the patient was not reassessed for 12 or more hours between assessments from the time of admission on 7/17/10 to 7/19/10.

The patient was admitted on 7/16/10 at 7:00 p.m. and an admission assessment was completed.
The next nursing assessment was on 7/17/10 (no entry time) and another nursing assessment was done at 3:00 a.m. on 7/18/10.
A nursing assessment was completed on 7/18/10 (no time) and at 9:00 p.m. and at 8:00 a.m. on 7/19/10.

An interview with the Director of Clinical Services, the Director of Quality Management and the Chief Executive Officer on 7/19/10 at approximately 3:00 p.m., after review of the clinical records and policies, confirmed the findings.