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CENTRA HEALTH, INC
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on interviews, medical record review and facility document review, the facility staff failed to evaluate and assess one (1) of three (3) patient's care needs according to facility policy. Patient #1 (P1)
The findings include:
On 1/8/24 at 2:15 p.m., a review of three (3) patient records included in the survey sample was conducted with Staff Members #6, #8, and #9.
A hospitalist progress note for Patient #1 (P1) documented on 5/17/23 at 10:56 p.m. noted, "...Patient had a fall tonight, with hematoma of the forehead, CT head obtained, showing acute left frontal subdural hematoma measuring 11 mm in thickness, Patient has been confused per nursing, even prior to the fall, no change in (P1's) mentation, no headache, Continue with frequent neurochecks, every 4 hours headache (sic). Discussed with neurosurgery (physician name) on call tonight, (physician) agreed with discontinuation of heparin, and repeat CT head in 6 hours. Neurosurgery consult in the morning...".
A review of P1's Post Fall Follow up on 5/17/23 at 10:30 p.m. documented "...Fall Follow Up With Head Strike - no change, reassess q4 hrs for 48 hours...".
A review of the nursing flowsheet from 5/17/23 at 8:00 p.m. through 5/19/23 at 9:36 a.m. revealed that P1's assigned nurses performed neurology checks on P1 at the following dates and times:
5/18/23 at 2:00 a.m.
5/18/23 at 8:00 a.m.
5/18/23 at 12:00 p.m.
5/18/23 at 2:30 p.m.
5/18/23 at 9:30 p.m.
5/19/23 at 9:36 a.m.
Staff Member #1 (SM1) confirmed in an interview on 1/9/24 at 11:00 a.m., that the dates and times listed on the nursing flowsheet for P1's neurology checks were correct and the neurology checks were not completed every four (4) hours for forty-eight (48) hours after P1's fall.
A review of the facility's policy titled "Patient Care Services Falls Risk Assessment/Preventative Measures", last reviewed 6/12/23, stated in part:
"...10. Document "Fall Follow-up" every 4 hours for 48 in the event of a Head Strike".
The findings were discussed with Staff Members #1, #4, #19, #22 and #23 at the exit conference on 1/9/24 at 1:40 p.m.