HospitalInspections.org

Based on review of documentation and interview, it was determined that the facility failed to always provide complete physical examinations on admission to determine the physical status of each patient.

Findings were:

Facility document entitled "Basic Rights for All Patients" stated in part "You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs, and are treated with respect and dignity ...You have the right to be free from mistreatment, abuse, neglect and exploitation."

Facility policy entitled "Nursing Assessments" stated in part "A Nursing Assessment shall be conducted by a Registered Nurse within 8 hours of admission to assess the patient's status and safety on the unit and initiate the plan of care.
1. Within 8 hours of admission, the nurse assuming responsibility for the patient or designee shall conduct an Initial Nursing Assessment, which will include the following elements:
a) Health history, allergies and immunizations (for minors)
b) Review of systems
1) Vital signs
2) Elimination
3) Vision/hearing
4) Gynecological
5) Neurological
6) Cardiovascular
7) Respiratory
8) Alimentary
c) Pain assessment
d) Functional screen
e) Nutritional screen, BMI, Growth chart (for children)
f) Fall risk assessment
g) Abnormal Involuntary Movement Scale (AIMS)
h) Skin assessment
i) Crisis prevention plan
j) Teaching and orientation to unit
k) Goals for discharge
l) Admission note."

Patient # 1 was admitted 8/15/18. A full skin assessment was documented upon admission. However, in an interview with the Director of Nursing on 8/23/18, it was admitted that only the patient's forearms and calves were visualized, thereby not documenting injuries possibly sustained prior to her arrival at the hospital.

Based on review of documentation and interview, it was determined that the facility failed to provide a nursing care plan that accurately assessed the patient's nursing care needs.

Findings were:

Facility policy entitled "Nursing Assessments" stated in part "A Nursing Assessment shall be conducted by a Registered Nurse within 8 hours of admission to assess the patient's status and safety on the unit and initiate the plan of care.
2. Within 8 hours of admission, the nurse assuming responsibility for the patient or designee shall conduct an Initial Nursing Assessment, which will include the following elements:
m) Health history, allergies and immunizations (for minors)
n) Review of systems
9) Vital signs
10) Elimination
11) Vision/hearing
12) Gynecological
13) Neurological
14) Cardiovascular
15) Respiratory
16) Alimentary
o) Pain assessment
p) Functional screen
q) Nutritional screen, BMI, Growth chart (for children)
r) Fall risk assessment
s) Abnormal Involuntary Movement Scale (AIMS)
t) Skin assessment
u) Crisis prevention plan
v) Teaching and orientation to unit
w) Goals for discharge
x) Admission note."

Patient # 1 was admitted 8/15/18. A full skin assessment was documented upon admission. However, in an interview with the Director of Nursing on 8/23/18, it was admitted that only the patient's forearms and calves were visualized, thereby not documenting injuries possibly sustained prior to her arrival at the hospital. Because the skin assessment was not completed, it would be impossible to adequately plan nursing care specific to the patient.

The History and Physical dated 8/16/18 for the same patient stated patient "denies" any injuries but complained of "left heel pain due to repetitive sports injuries." Breasts and Genitalia examination were deferred as "Pt. has requested exam by outpatient PCP." Under "Chronic/Stable Medical Problems" physician wrote "Chronic pain-bilateral knees, lower back." Deferred/Referred Medical Problems: "None." Physician did not examine patient's skin to assess for prior injury.