HospitalInspections.org

Based on record review and interview, it was determined, that for 1 of 10 records reviewed (Pt. #1), that the Hospital failed to ensure the patient were reassessed every 8 hours, as required by policy.

Findings include:

1. Hospital policy #50230.282 (600), revised 3/30/12, titled " Assessment / Reassessment Plan required " Reassessments and documentation are to be performed a minimum of every eight hours in acute care settings ..."

2. The clinical record for Pt. #1 was reviewed and included that Pt. #1 was an 86 year old female, arriving in the ED on 8/10/12 at 5:35 PM, with complaints of "nausea [for] several days, open wounds on legs." The ED nursing assessment dated 8/10/12 at 7:30 PM, included, "Patient has healing wounds on forearms and legs ... seeping peripheral edema in four extremities ..." The ED physician's assessment dated 8/10/12 at 7:57 PM, also included open lower extremity wounds and pitting edema. Pt. #1 was admitted to 7 South, an acute care unit, on 8/11/12 at 1:20 AM. Reassessment was not done for Pt. #1's lower extremities at least every 8 hours for 5 of 11 periods between 8/11/12 and 8/14/12.

3. An interview was conducted with the 7 South Nursing Manager on 10/16/12 at approximately 11:30 AM. The Manager stated that Pt. #1's lower extremity reassessments had not been completed every 8 hours for 5 periods during Pt. #1's hospitalization.