HospitalInspections.org

Based on policy review, document review, record review, and staff interviews it was determined the facility failed to ensure the nursing staff documented nursing care and services in compliance with facility policies for two (#3, #10) of 10 sampled patients.

Findings included:

The review of the policy titled Assessment and Reassessment, reference number WFD.PC.002, revised 12/2016, indicated the nursing staff was required to document reassessments of intensive care patients' conditions at a minimum of every four hours.

The review of the staffing assignment sheet revealed RN A was assigned to care for Patient #3 and Patient #10 for the 7 am-7 pm shift in the intensive care unit on December 19, 2017.

The review of the Shift Assessment for Patient #3 revealed RN A documented a comprehensive nursing assessment at 8:00 a.m. on 12/19/17. The detailed review of the record revealed no documentation of the reassessment of the patient until 4:15 p.m.

The review of the Shift Assessment for Patient #10 revealed RN A documented a comprehensive nursing assessment at 8:00 a.m. on 12/19/17. The detailed review of the record revealed no documentation of the reassessment of the patient until 5:00 p.m.

An interview was conducted with the Interim Director of Critical Care on 2/27/2018 at 11:00 a.m. The Director indicated the standard practice in the intensive care unit was for nursing staff to document patient reassessments every two hours and document either the patient's condition was unchanged from the initial Shift Assessment, or document details of the change in condition.

An interview was conducted with the Chief Nursing Officer (CNO) on 2/28/18 at 12:30 p.m. The CNO confirmed the nursing documentation for Patient #3 and Patient #10 on 12/19/17 was not in compliance with facility policy and standard nursing practice in the intensive care unit.