HospitalInspections.org

Based on a review of facility documentation, medical records (MR), and staff interviews (EMP) it was determined the facility failed to provide evidence in the medical record that a registered nurse (licensed professional nurse) supervised and evaluated nursing care of each patient for 4 of 20 medical records reviewed. (MR1, MR2, MR7, and MR9).


Findings include:


On April 3, 2024, review of facility policy, POL 6511361, "Licensed Practical Nurse (LPN) Role ", last approved September 26, 2023, revealed: " ... It is the policy that AHN utilizes and allows the Licensed Practical Nurse (LPN) to function as a member of the health care team ... The LPN may participate in planning, implementation, and evaluation of nursing care using focused assessment in settings where nursing takes place. ...". Further review of this policy revealed: "... Terms and Definitions: Focused assessment - Appraisal of an individual's current status and situation, which contributes to [the] comprehensive assessment by the licensed professional nurse and supports ongoing data collection. ...".


Review of MR1 revealed that the patient was cared for by a licensed practical nurse (EMP6) between February 25, 2024, at 7:00 PM, and February 26, 2024, at 7:00 AM. Further review of MR1 revealed no documentation to support that a registered nurse supervised nursing care or evaluated the patient during this shift.


Review of MR2 revealed that the patient was cared for by a licensed practical nurse (EMP11) between March 30, 2024, at 7:00 PM, and March 31, 2024, at 7:00 AM. Further review of MR2 revealed no documentation to support that a registered nurse supervised nursing care or evaluated the patient during this shift.


Review of MR7 revealed that the patient was cared for by a licensed practical nurse (EMP11) between March 28, 2024, at 7:00 AM, and March 28, 2024, at 7:00 PM. Further review of MR7 revealed no documentation to support that a registered nurse supervised nursing care or evaluated the patient during this shift.


Review of MR9 revealed that the patient was cared for by a licensed practical nurse (EMP11) on March 27, 2024 and March 28, 2024 from 7:00 AM to 7:00 PM. Further review of MR9 revealed no documentation to support that a registered nurse supervised nursing care or evaluated the patient during the shifts(s).


The above findings were confirmed for MR1, MR2, and MR7 during MR review with EMP4 on April 3, 2024, between 12:00 PM and 1:50 PM.


The above finding for MR9 was confirmed on April 3, 2024, during MR review with EMP5 on April 3, 2024, at 12:21 PM.

Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined licensed nurses providing services in the facility failed to document patient hand-off communication per facility policy for 13 of 20 medical records reviewed (MR1, MR2, MR4, MR5, MR6, MR8, MR9, MR11, MR13, MR16, MR18, MR19, and MR20)


Findings include:


Review of facility policy, "Patient Hand-Off Communication", last approved 6/8/2022, revealed: " ... Overview Statement ... Current, accurate information related to a patient's care, treatment/services and clinical status will be communicated when transferring the care of a patient between or among members of the heath care team/providers. ... Administration A. Intra-departmental Communication 1. Change of shift report or when care is temporarily assigned to another licensed nurse within the patient care unit. ...".


Review of MR1 revealed no evidence of patient hand-off communication on February 25, 2024, at 7:00 AM.


Review of MR2 revealed no evidence of patient hand-off communication on March 30, 2024, at 7:00 PM.


Review of MR4 revealed no evidence of patient hand-off communication on April 2, 2024, at 7:00 AM.


Review of MR5 revealed no evidence of patient hand-off communication on March 25, 2024, at 7:00 AM, and on March 29, 2024, at 7:00 AM.


Review of MR6 revealed no evidence of patient hand-off communication on the following dates and times:
March 29, 2024 at 7:00 AM
March 30, 2024 at 7:00 PM
April 1, 2024 at 7:00 AM
April 2, 2024 at 7:00 AM


Review of MR8 revealed no evidence of patient hand-off communication on the following dates and times:
March 31, 2024 at 7:00 AM
April 1, 2024 at 7:00 PM
April 2, 2024 at 7:00 AM
April 3, 2024 at 7:00 AM


Review of MR9 revealed no evidence of patient hand-off communicaton on the following dates and times:
March 27, 2024 at 7:00 AM
April 2, 2024 at 7:00 AM and 7:00 PM
April 3, 2024 at 7:00 AM


Review of MR11 revealed no evidence of patient hand-off communication on the following dates and times:
March 26, 2024 at 7:00 PM
March 27, 2024 at 7:00 AM
March 28, 2024 at 7:00 PM


Review of MR13 revealed no evidence of patient hand-off communication on March 24, 2024, at 7:00 AM.


Review of MR16 revealed no evidence of patient hand-off communication on April 2, 2024, at 7:00 AM and at 7:00 PM.


Review of MR18 revealed no evidence of patient hand-off communication on April 2, 2024, at 7:00 PM


Review of MR19 revealed no evidence of patient hand-off communication on April 2, 2024, at 7:00 AM and 7:00 PM.


Review of MR20 revealed no evidence of patient hand-off communication on April 1, 2024, at 7:00PM.


The above findings for MR1, MR2, MR4, MR5, MR6 and MR8 were confirmed during medical record review with EMP4 on April 3, 2024, between 12:00 PM and 1:50 PM.


The above findings for MR9, MR11, MR13, MR16, MR18, MR19, and MR20 were confirmed during medical record review with EMP5 on April 3, 2024, between 12:10 PM and 1:40 PM.
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Based on a review of facility documents, medical records (MR), and employee interview (EMP), it was determined licensed nurses providing services in the facility failed to document purposeful hourly rounding per facility policy for 13 of 20 medical records reviewed (MR1, MR6, MR8, MR9, MR10, MR11, MR13, MR14, MR15, MR17, MR18, MR19 and MR20).


Findings include:


Review of facility's "Purposeful Hourly Rounds", last approved 7/31/2023, revealed: " ... The purpose of this policy is provide guidelines for patient care needs that are to be addressed during hourly rounds. ... The RN/GN/LPN/PCTs will: 1. Perform rounds on each patient a. Every 1 hour between the hours of 7am - 11pm b. Every 2 hours between the hours of 12am - 7am. ... 3. Documentation of hourly rounds occurs in the EMR. ...".


Review of MR1 revealed hourly rounds were not documented on February 25, 2024, between 9:00 PM and 7:00 AM.


Review of MR6 revealed hourly rounds were not documented on the following dates and times:
March 31, 2024 at 1:00 AM and 3:00 AM
April 1, 2024 at 1:00 PM, 3:00 PM, 4:00 PM, and 5:00 PM
April 2, 2024 at 3:00 AM, 4:00 PM and 5:00 PM


Review of MR8 revealed hourly rounds were not documented on the following dates and times:
April 2, 2024 between 10:00 AM and 5:00 PM
April 1, 2024 between 10:00 AM and 3:00 PM
March 31, 2024, between 11:00 AM and 2:00 PM


Review of MR9 revealed hourly rounds were not documented on the following dates and times:
March 27, 2024 between 11:00 AM and 4:00 PM
March 28, 2024 between 10:00 AM and 3:00 PM.
March 28, 2024 at 5:00 PM and 6:00 PM.


Review of MR10 revealed hourly rounds were not documented on the following dates and times:
March 30, 2024: 12:00 AM, 2:00 AM, 4:00 AM, 6:00 AM., 08:00 AM, 9:00 AM, 10:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00 PM, 6:00 PM, 9:00 PM, 10:00 PM, and 11:00 PM.
March 31, 2024: 12:00 AM, 2:00 AM, 4:00 AM, 9:00 AM, 10:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00 PM, 4:00 PM, 5:00 PM, 6:00 PM, 9:00 PM, and 10:00 PM.


Review of MR11 revealed hourly rounds were not documented on the following dates and times:
March 27, 2024 at 2:00 PM
March 28, 2024: 10:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00 PM, 4:00 PM, 5:00 PM, and 6:00 PM.


Review of MR13 revealed hourly rounds were not documented on the following dates and times:
March 24, 2024: 09:00AM, 09:00 PM, 10:00 PM, and 11:00PM
March 25, 2024: 12:00 AM, 2:00 AM, 4:00 AM, 8:00 PM, 10:00 PM, and 11:00 PM
March 26, 2024: 10:00 PM


Review of MR14 revealed hourly rounds were not documented at the following times:
March 22, 2024 at 2:00 AM, 4:00 AM, 7:00 AM, 9:00 AM, 10:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00 PM, 4:00 PM; 5:00 PM, 6:00 PM, 7:00 PM, 8:00 PM, 9:00 PM, and 11:00 PM.


Review of MR15 revealed hourly rounds were not documented at the following times: April 2, 2024 at 8:00 AM, 9:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00PM, 4;00 PM, 5:00 PM, and 6:00 PM.


Review of MR17 revealed that every two hour rounds were not documented at the following times: March 27, 2024 at 12:00 AM, 2:00 AM, 4:00 AM, and 6:00 AM. .


Review of MR18 revealed hourly rounds were not documented at the following times: April 2, 2024, at 2:00 PM, 3:00PM, 4;00 PM, 5:00 PM, 10:00 PM, and 11:00 PM.


Review of MR19 revealed hourly rounds were not documented at the following times: April 2, 2024, at 07:00 AM, 8:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 3:00PM, 4:00 PM, 5:00 PM, and 6:00 PM.


Review of MR20 revealed hourly rounds were not documented at the following times: April 1, 2024, at 9:00 AM, 10:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00PM, 4;00 PM, 6:00 PM and 11:00 PM.


The above findings for MR1, MR6 and MR8 were confirmed during medical record review with EMP4 on April 3, 2024 between 12:00 PM and 1:50 PM.


The above findings for MR9, MR10, MR11, MR13, MR14, MR15, MR17, MR18, MR19 and MR20 were confirmed during medical record review with EMP5 on April 3, 2024 between 12:15 PM and 1:40PM.

Based on interview (EMP), it was determined the facility failed to have policies and procedures in place establishing which outpatient departments, if any, are not required under hospital policy to have a registered nurse present.


Findings include:


During a facility survey on April 3, 2024, the facility was unable provide policies and procedures addressing which outpatient departments, if any, are not required under hospital policy to have a registered nurse present.


The above was confirmed with EMP1 on April 3, 2024, at 11:25 AM.