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Based on record review and interview, the facility failed to ensure nursing notes that monitored the patient's condition and were available for physician review, were entered promptly and accurately in the patient's records for 1 of 3 patients (Patient #3), as shown by:

A. Three consecutive nursing assessment progress notes signed several days after nursing assessment completed, two days after the patient discharged to an emergency room via 911 EMS;

B. Inconsistency with documented nursing assessment notes with physician notes, and;

C. Inaccurate vital signs documented as done three hours after the patient had already discharged facility via 911 EMS.



Findings included:

Review of facility policy #NSG-02 titled "Documentation", last revised 1/1/23, showed that the purpose of documentation was to provide a chronologically continuous account of the patient's progress to help increase communication among care providers; Nurses are to document the patient's progress every 12-hour shift.

A. Nursing Assessment Notes not entered promptly into records:

Record review of Patient #3's medical chart showed the following:

85-year-old male admitted involuntarily to facility on 8/7/24 from nursing home. Reason for admission was due to decline in mental status; refusing meals and medications; assaultive; combative.

Discharge Summary from Dr.-Staff #D showed that on 8/12/24 at 8:47 am, the patient was transferred to Memorial Herman Hospital Katy's ER via 911 after he was observed in facility dayroom with change in mental status, looking pale, unable to respond to questions, with unstable vital signs including labored breathing.

Record review of three consecutive nursing assessments revealed they were performed and signed in a timely manner. However, each of the three assessments had entries for the Nursing Note narrative portion showing patient progress, signed three, four and five days after the assessments were done, and after partrient had already transferred to an ER via 911 EMS.

Records were reviewed in two separate types of computerized formats in an attempt clarify times and dates of entries. Both formats failed to show whether there were original nursing notes made at the same time the assessments were done, if there were original nursing notes made during the original assessments and then amended or added to, or, if all the nursing notes were made at the later dates stamped after the assessments were done. It was unclear what notes were available for the physician to review in real time for monitoring patient progress while the patient was still in the facility:

The 8/10/24 morning shift Nursing Assessment was done and signed on 8/10/24 at 3:21 pm by RN-Staff #G. However, the Nursing Note, which was part of the nursing assessment, was signed four days later by RN-Staff #G on 8/14/24 at 10:08 am, two days after the patient had discharged to ER.

The 8/10/24 evening shift Nursing Assessment was done and signed on 8/10/24 at 9:44 pm by RN-Staff #H. However, the Nursing Note, which was part of the nursing assessment, was signed five days later by RN-Staff #H on 8/15/24 at 2:52 am, three days after the patient had discharged to ER.

The 8/11/24 morning shift Nursing Assessment was done on 8/11/24 at 3:01 pm by RN-Staff #G. However, the Nursing Note, which was part of the nursing assessment, was signed three days later by RN-Staff #G on 8/14/24 at 10:03 am, two days after the patient had discharged to ER.

In addition to the nursing assessment notes, record review of the Multidisciplinary Progress notes for Patient #3 (separate from, and not contained in the Nursing Assessment notes) showed an entry for the date 8/10/24 by RN-Staff #G: "NP rose notified about patients' poor appetite, plan of care ongoing" However, it was signed on 8/14/24 at 10:07 am, after the patient emergently discharged on 8/12/24 at 8:47 am.

Further record review of Patient #3's Multidisciplinary Progress notes showed an entry for the date 8/11/24 by RN-Staff #G: "Incoming nurse notified about poor appetite and several attempts to feed patients which proved abortive and follow up required". However, it was signed on 8/14/24 at 10:06 am, after the patient emergently discharged on 8/12/24 at 8:47 am.

In an interview on 8/3/24 at 1:45 pm, DON-Staff #B acknowledged that although the nursing assessments were completed, the notes at the end of the assessments from Staff #G and #H were dated at later times.

B. Inconsistent documentation with Nursing Assessment notes:

Record review of Patient #3's clinical records showed there were three Psychiatric Progress Notes from Dr.-Staff #D made on 8/9/24, 8/10/24 and 8/11/24. These three notes showed the physician reviewed Nursing Assessment notes and included them in his progress notes, which were identical verbatim, including the exact same format and structure of the nursing notes ('copied and pasted'):

Psychiatric Progress notes from 8/9/24 included and used the identical 8/9/24 morning shift Nursing Assessment notes, signed 8/9/24 at 10:45 am by RN-Staff #K. And also, Psychiatric Progress notes from 8/10/24 included and used the identical 8/9/24 evening shift Nursing Assessment notes, signed 8/9/24 at 11:30 pm by RN-Staff #H.

However, Psychiatric Progress notes from 8/11/24 included all the identical information from the 8/11/24 Nursing Assessment morning shift notes, with the following exception: Per psychiatric notes; "meals consumed-fair appetite". Per Nursing Notes signed late by RN-Staff #G on 8/14/24 at 10:03 am; "meals consumed-poor appetite,; accepted ensure and coffee but refused solid food"

In an interview on 8/3/24 at 1:45 pm, DON-Staff #B acknowledged that although the nursing assessments were completed, the notes at the end of the assessments from Staff #G and #H were dated at later times.

C. Inaccurate vital signs documented:

Further record review of Patient #3's clinical records revealed per face sheet and clinical notes, that patient left facility via EMS ambulance at 8:37 am on 8/12/24:

Medical progress note from NP-Staff #F dated 8/12/24, signed 9:20 am, read: "8/12/24- found patient with RESP distress, O2 sat < 87% and congestive, less alert. nurse reported that patient has been not eating for past 2 days but VS stable. ordered gave to transfer to hospital via 911".

Discharge Summary from Dr.-Staff #D showed: "Patient transferred to hospital to Memorial Hermann Katy on 8/12 at 8:47am due to change in mental status. Pt was found in dayroom looking pale and unstable. Vitals were abnormal at, 02 sat below 90, HR 126, Labored breathing R-22, BP unable read, BS 154. unable to respond to assessment questions. It was reported that patient had refused food X 3days. Pt refused medications this am and at bedtime."

However, record review of Vital Signs document in Patient #3's chart, containing all vital signs records recorded during entire patient stay, showed vital signs taken on 8/12/24 at 11:44 am, entered by MHT-Staff #J (three hours after patient left facility): BP 141/88, 97% O2, 80 pulse, Resp=18, Temp 97.1.