HospitalInspections.org

Based on standard work process review, medical record review, and staff interview, hospital nursing staff failed to document vital signs per hospital process for 1 of 6 Involuntary Commitment (IVC) patients (Patient #11); and failed to document a nurses note per hospital process for 2 of 6 IVC patients (Patients #11 and #2).

Findings included:

Review of a hospital standard work process titled, "General Management of IVC Patients" effective 10/01/2017, revealed, "...Vital signs will be taken and documented in (Electronic Medical Record [EMR]) every 4 hours ... All IVC patients will have a nurses note documented in (EMR) a minimum of every 2 hours..."

1. Review on 12/13/2017 at 1300 of the medical record for Patient #11 revealed a 31-year-old male that presented to the Emergency Department (ED) on 10/10/2017 at 1619 with a chief complaint of IVC. Review of nursing documentation revealed vital sign documentation every 4 hours; and nurses note documentation every 2 hours; beginning on 10/10/2017 at 1625 through 10/11/2017 at 0410. No evidence of vital sign or nurses note documentation was evident from 10/11/2017 at 0410 through 10/11/2017 at 1407 (9 hours and 57 minutes). Vital sign measurement, and nurses note documentation resumed on 10/11/2017 at 1407 and continued every 4 and 2 hours respectively, until 10/13/2017 at 1000, at which time Patient #11 was transferred to another facility.

Interview with Administrative Staff (AS) #1 on 12/13/2017 at 1525 revealed the standard work process for IVC patients was to document a nursing note every 2 hours, and vital signs every 4 hours. Interview confirmed the nursing staff did not follow the hospital's standard work process for documenting a nursing note every 2 hours and vital signs every 4 hours on an IVC patient.

Interview was conducted with Registered Nurse #1 on 12/13/2017 at 1558, who was assigned to Patient #11 on 10/11/2017. Interview revealed she did not recall Patient #11, and could provide no explanation for the lapse in documentation of vital signs and nursing notes.

2. Review on 12/13/2017 at 1100 of the medical record for Patient #2 revealed an 11-year-old male that presented to the ED on 12/11/2017 at 1040 with a chief complaint of disruptive behavior and assault of his grandmother. Review of nursing documentation revealed a nursing note documented on 12/11/2017 at 1046, 1125, 1224, 1433, 1530, 1547, 1951 (2 hours and 4 minutes late), 2057 and 2100. Further review of nursing notes revealed no available documentation of a nursing note on 12/11/2017 at 1730 and 2300. Review of nursing documentation revealed a nursing note documented on 12/12/2017 at 0150 (50 minutes late), 0652 (3 hours and 2 minutes late), 0830, 0915, 1015, 1038, 1226, 1412, 1526, 1559, 1604, 1629 and 2011 (1 hour and 42 minutes late). Further review of nursing notes revealed no available documentation of a nursing note on 12/12/2017 at 0100, 0350, 0550, 1829 and 2211. Review of nursing documentation revealed a nursing note documented on 12/13/2017 at 0104 (53 minutes late), 0700 (3 hours and 56 minutes late), 0900, 0951 and 1043. Further review of nursing notes revealed no available documentation of a nursing note on 12/13/2017 at 0011, 0304 and 0504.

Interview with AS #1 on 12/13/2017 at 1520 revealed the standard work process for IVC patients was to document a nursing note every 2 hours. Interview revealed the nursing staff are expected to document a nursing note at least every 2 hours. Interview confirmed the nursing staff did not follow the hospital's standard work process for documenting a nursing note every 2 hours on an IVC patient.

NC00133411