HospitalInspections.org

Based on review of policies and procedures and medical records, and interviews with hospital staff, the hospital failed to ensure the registered nurse (RN) assessed, planned, supervised and reassessed/evaluated the nursing needs and care for each patient. This occurred in two of four patients (Patients #1 and 4) on the geriatric psychiatric units, whose medical records were reviewed and who were transferred to the emergency room.

Care/needs cannot be identified without complete baseline and ongoing assessments and evaluations.

Findings:

1. Patient #1 - The behavioral health tech recorded the patient had black stool/bowel movement on 11/22/12 and multiple watery stools on 11/23/12, with at least one that was black. Although the tech recorded these stools, the record did not contain documentation that the tech notified the RN or demonstrate the RN evaluated the patient after any of the stools, provided interventions, or communicated with the physician. The patient was transferred to the ER on the evening of 11/26/12.

On 08/08/13 at 1400, Staff G told the surveyor that techs notified the nurse any time the patient had two or more stools. She stated the techs charted the number and consistencies of the stools, but did not chart notification to the "charge nurse".

2. Patient #4 - The nursing assessments on the behavioral unit documented the patient's skin was WDL (within determined limits) and not skins interruptions were recorded, including the assessment for the date the patient was transferred to the emergency room, 11/24/12 around 1720. The initial nursing assessment by the medical-surgical RN on 11/24/12 at 2314 documented the patient had a full thickness decubitus on her coccyx that measured 2.0 cm (centimeters) by 2.5 cm by 0.5 cm. The behavioral supervising RN did not supervise and evaluate to ensure nursing staff did a complete and through patient skin assessment.