HospitalInspections.org

Based on staff interviews and facility document review, the facility failed to provide a nursing assessment to 5 out of 20 sampled patients (Sample Patient #2, #11, #17, #19, and #20).

This failure contributed to patient's physical symptoms being undocumented in the medical record and potentially being left untreated.

FINDINGS:

1. The facility did not ensure nursing assessments were conducted on 5 out of 20 sampled emergency room patients (Sample Patients #2, #11, #17, #19, and #20).

a) A review of 20 emergency room medical records was completed on 04/30/13 with the facility's Emergency Room (ER) Nurse Educator. Five (Sample Patient #2, #11, #17, #19, and #20) out of 20 sampled medical records did not include a documented physical assessment by the Registered Nurse (RN) providing care for the patient.

Sample Patient #2 arrived to the Emergency Room (ER) on 04/14/13 with a complaint of abdominal pain. The nursing notes for physical assessment were documented at 1350 on 04/14/13 under the section "GI/GU" (Gastrointestinal/Genitourinary) and stated," Bowel Sounds Active". There was no other documented physical assessment by the Registered Nurse (RN). The ER's Nurse Educator verified these findings and stated this was "not a complete assessment".

Sample Patient #11 arrived to the ER on 04/14/13 with a complaint of shortness of breath. Sample Patient #11's medical record did not include a documented physical assessment by the Registered Nurse (RN). The facility's ER Nurse Educator verified that Sample Patient #11's medical record did not contain a documented physical assessment by the RN.

Sample Patient #17 arrived to the ER on 04/17/13 with a complaint of shortness of breath. Sample Patient #17's medical record did not include a documented assessment by the Registered Nurse (RN).The facility's ER Nurse Educator verified that Sample Patient #17's medical record did not contain a documented physical assessment by the RN.

Sample Patient #19 arrived to the ER on 04/21/13 with a complaint of chest pain. The patient's medical record did not contain a documented physical assessment by the RN. The facility's ER Nurse Educator verified that Sample Patient #19's medical record did not contain a documented physical assessment by the RN.

Sample Patient #20 arrived to the ER on 04/20/13 with a complaint of shoulder pain. The patient's medical record did not contain a documented physical assessment by the RN. The facility's ER Nurse Educator verified that Sample Patient #20's medical record did not contain a documented physical assessment by the RN.


b) During the review of medical records, an interview was conducted with the facility's ER Nurse Educator. The ER Nurse Educator stated that it was his/her expectation that nursing staff would be documenting a physical assessment on every emergency room patient. The ER Nurse Educator stated that documentation of physical assessments was, "lacking" in several of the sampled patient medical records.

c) On 04/30/13 at 2:30 p.m., an interview was conducted with the facility's ER Nurse Manager. The ER Nurse Manager stated it was his/her expectation that all patients in the emergency room would receive a physical assessment by the Registered Nurse upon being roomed.


d) The facility's policy, "Patient Assessment, Reassessment, and Changes in the Patient Condition", was reviewed. The policy stated," Registered Nurse (RN) assesses the patient's individualized response to illness and/or injury, and uses the Nursing process as the framework for collecting and analyzing data. The Nursing Process includes: assessment, including physical, psychosocial, complete medical history, pain, nutritional, functional, discharge needs of the patient while taking into consideration of age appropriateness, cultural, language, and religious preferences and ability to learn". The facility's Manager of Regulatory Affairs verified this was the current policy.