HospitalInspections.org

A. Based on medical record review, document review and interview it was revealed the facility failed to follow nursing policies and procedures by not documenting shift assessments per policy on seven (7) out of ten (10) patients (patient #1, 2, 3, 4, 5, 6 and 9). This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

A medical record review was conducted for patient #1. The patient was transferred to the facility on 12/15/21 with a status of probable cause. The patient was admitted with a primary diagnosis of schizoaffective disorder, bipolar type, and other diagnoses of autism spectrum disorder and intellectual developmental disorder (IDD). There were no "Nursing Shift Evaluations" documented on 01/22/22, 01/23/22, 01/27/22, 01/29/22 and 01/30/22. The patient remains hospitalized on unit Edward One (E1).

A medical record review was completed for patient #3. The patient was admitted to the facility after a suicide attempt, by cutting wrists with an electrical cord, on 12/22/21. The patient's diagnosis is borderline personality disorder. There were no "Nursing Shift Evaluations" documented on 01/01/22, 01/07/22, 01/09/22 and 01/22/22. The patient remains hospitalized on unit E1.

A medical record review was completed for patient #4. The patient was admitted to the facility on 12/23/21 with a diagnosis of bipolar disorder. There is no documented "Nursing Shift Evaluations" on 01/02/22, 01/07/22, 01/08/22, 01/09/22, 01/17/22, 01/18/22 and 01/19/22. The patient remains hospitalized on unit Nancy One (N1).

A medical record review was completed for patient #5. The patient was admitted to the facility on 12/03/21 with a diagnosis of schizoaffective disorder. There is no documented "Nursing Shift Evaluations" on 01/06/22, 01/28/22, 01/29/22 and 01/30/22. The patient remains hospitalized on unit Charlie One (C1).

A medical record review was completed for patient #6. The patient was admitted to the facility on 12/21/21 with a diagnosis of schizophrenia. There is no documented "Nursing Shift Evaluations" on 01/19/22, 01/24/22, 01/29/22 and 02/02/22. The patient remains hospitalized on unit C2.

A medical record review was completed for patient #9. The patient was admitted to the facility on 12/29/21 with a diagnosis of schizophrenia. There is no documented "Nursing Shift Evaluations" on 01/06/22, 01/10/22, 01/29/22 and 01/30/22. The patient remains hospitalized on unit C2.

A policy titled "Nursing Documentation," effective date 01/07/22, was reviewed. The policy states in part, "Nursing shift notes...A complete nursing shift note, including a head-to-toe assessment, will be completed on day and evening shift in the SHA Nursing Shift Evaluation Note. The RN will document at least once on Day or Evening Shift. The LPN will report any abnormalities to the unit RN. Night shift will document a brief narrative summary of the shift, the patient's observation level, any safety precautions, the patient's vital signs, and any areas that need addressed for the shift ..."

An interview was conducted with the Barcode Medication Administration Coordinator (BMAC) on 02/09/22 at 11:30 a.m. The BMAC confirmed no additional "Nursing Shift Evaluations" were located for the missing dates for patients #1, 2, 3, 4, 5, 6 and 9. An action plan was already developed to address this issue; however, it had not been implemented yet.

B. Based on medical record review, document review and interview it was revealed the facility failed to follow nursing policies and procedures by not documenting a Nursing Admission Assessment for one (1) out of ten (10) patients, patient #1. This failure has the potential to negatively impact all patients admitted to the facility for care.

Findings include:

A medical record review was conducted for patient #1. The patient was transferred to the facility on 12/15/21 with a status of probable cause. The patient was admitted with a primary diagnosis of schizoaffective disorder, bipolar type, and other diagnoses of autism spectrum disorder and intellectual developmental disorder (IDD). There was no documentation of a "Nursing Admission Assessment." The patient remains hospitalized on unit E1.

A policy titled, "Nursing Admission Assessment," effective date 10/02/18, was reviewed. The policy states in part, "...The Nursing Admission Assessment will be completed on all patients admitted to this facility within 24 (twenty-four) hours of admission ...An attempt to complete the assessment should occur on each shift, documented as to the reason it was not completed and will be passed on in Shift Report. An addendum to the Nursing Admission Assessment needs to be added each shift until completed ..."

An interview was conducted with the BMAC on 02/08/22 at 11:45 a.m. The BMAC was unable to find a "Nursing Admission Assessment" in patient #1's medical record.