HospitalInspections.org

A. Based on document review and interview, the hospital failed to ensure that the RNs (registered nurses) followed the physician's orders regarding completion of neurovascular and neurological checks (e.g., presence of pulse, level of consciousness, pupillary response, etc.) for 1 of 7 (Pt. #1) clinical records reviewed.

Findings include:

1. The hospital's policy titled, "Documentation (charting) Guidelines" (12/2022) included, " ... IV. Clinical Guidelines ... 4. Documentation of Patient Assessments. Patient assessment will be documented, using (charting by exception) at minimum ..."

2. On 6/30/3035, the clinical record for Pt. #1 was reviewed. On 3/28/2025, Pt. #1 was admitted to the hospital due to left toe pain and underwent surgery on 4/2/2025 - Left femoral to anterior tibial bypass. Left great saphenous vein harvest (surgical procedure redirecting blood flow around a blockage in the leg and removal of a vein to replace or repair a blocked blood vessel). Pt #1 was transferred/admitted to the intensive care unit postoperatively. The clinical record indicated:

- On 4/2/2025, Pt. #1 underwent left femoral to distal anterior tibial bypass with left greater saphenous vein (vascular surgery of left leg). On 4/2/2025 at 7:00 PM, a physician's order indicated, " ... check pedal doppler tones (neurovascular checks) ... every 1 hour ..." However, doppler/neurovascular checks were not documented on 4/3/2025 from 12:00 AM through 7:00 AM (7 hours).

- On 4/03/2025 at 6:21 PM, a physician placed an order to perform neurological checks every one hour starting at 7:00 PM. However, hourly neurological assessments were not documented on 4/3/2025 from 8:01 PM through 11:59 PM (3 hours).

3. On 7/01/2025 at approximately 10:15 AM, findings were verified with E #8 (ICU Nurse Educator). E #8 validated that the doppler/neurovascular and neurological checks were not documented. E #8 stated that the RN should follow the physician's order.

B. Based on document review and interview, the hospital failed to follow their policy to ensure that the comprehensive pain assessment was completed for 1 of 3 (Pt. #1) clinical records reviewed.

Findings include:

1. On 6/30/3035, the hospital's policy titled, " "Pain management" (5/2024) was reviewed and indicated, "I ... to provide standards for the appropriate management of the physical and psychological symptoms associated with pain ... Appendix A: Assessment/Reassessment and Documentation Guidelines ... Comprehensive Pain Assessments (an in-depth assessment that includes pain intensity rating score, quality, location, onset, and frequency of pain). When to use: 1. On admission ..."

2. On 6/30/3035, the clinical record for Pt. #1 was reviewed. On 3/28/2025, Pt. #1 was in the ED for evaluation of left toe pain. On 3/28/2025 at 4:54 PM, Pt. #1 was admitted to the hospital's medical surgical unit. A nursing admission assessment was conducted; however, a comprehensive pain assessment was not completed.

3. On 7/01/2025 at approximately 10:15 AM, findings were discussed with E #8 (ICU Nurse Educator). E #8 validated that the comprehensive pain assessment was not documented. E #8 stated that a comprehensive pain assessment should be completed on admission.