HospitalInspections.org

Based on interview, record review and review of facility policy, the facility failed to ensure that 1 of 10 sampled patient records contained documentation of nurse reassessment/assessment of the patient's status and condition following an incident of self-inflicted injury which required transfer to a higher level of care. The facility did not obtain the hospital emergency department diagnostic results of 12/18/17 for physician availability to use in making assessments of the patient's condition, to justify continued hospitalization, to support the diagnosis, to describe the patient's progress, and to describe the patient's response to medications, interventions, and services, in planning the patient's care, and in making decisions on the provision of care to the patient (#1).

Findings:

Patient #1's record revealed an 18 year old admitted to the facility on 12/17/17 under a Baker Act. A physician's telephone order, dated 12/18/17 at 12:15 AM, read, "Send to ER emergency room for evaluation - Head trauma."

A physician's order, dated 12/18/17 at 9 AM, read, "Please obtain hospital record 12/18/17, including notes, diagnostics, CT scan head/maxillofacial, lab tests, etc."

Review of the nurses' notes dated 12/18/18 read, "admitted to the unit" with nurse's signature written.
12:35 AM - "Pt sent to the ER for evaluation of possible head trauma" with nurse's signature written.
4:30 AM - "Pt back to facility on a stretcher, was medically cleared. Geodon administered at hospital as per verbal reports - will monitor". Nurse's signature written.

Nurses' notes did not documented the events that occurred or proceeded the patient's need for the higher level of care transfer. The nurses' notes did not document an assessment or reassessment of the patient completed prior to the transfer. The nurses' notes did not document that the physician was contacted, and there was no documentation of a nursing reassessment that documented the condition or status of the patient upon his return from the hospital emergency room. There was no documentation or description observed of any patient somatic injuries for 12/18/17.

A History and Physical, dated 12/18/17 at 9 AM by the advanced registered nurse practitioner, read, "multiple abrasions, swollen face/hematoma (periorbital) abrasion lips dry blood/lips....Head trauma, facial bruising/hematoma, periorbital hematoma, abrasions/lips."

Review of hospital policy "Patient Reassessment Policy # PC-57 Nursing Department", revised April 2017 read,
"Procedure: #1 Reassessment is conducted by a Registered Nurse as noted in the above policy statement. Additionally, reassessment occurs in the following circumstances: a. Change in the patient's condition.... #3 If an adult patient is identified as having bruising or self-injurious behavior, the nurse will assess the patient injuries by utilizing the daily adult skin assessment form and document findings....#4 RN findings from the reassessment are documented in the patient's chart....VI. Documentation - Documentation in the medical record, as indicated."

On 2/07/18 at 3:20 PM, the Chief Nursing Officer (CNO) related the facility completes and sends a transfer form which includes documentation of patient information, diagnosis, reason for transfer and vital signs. A transfer form for patient #1 for 12/18/17 was not found in the record. The CNO confirmed the 12/18/17 transfer form was not in the record, and related the original was apparently sent with the patient and not returned. The CNO verbalized there should have been documented reassessments by nursing regarding the patient's condition following the self-injurious behaviors that sent the patient to the emergency room.

An "Observation note of patient progress" documented by the hospital's mental health technician assigned for one on one supervision, dated 12/19/17 at 12 AM, read, "Pt could not sleep due to his head hurting from his bleeding ears."

The nurse's note, dated 12/19/17, had a check mark beside "No changes identified", under the section marked "Changes in clinical presentation." There was no assessment/reassessment observed regarding ""bleeding ear".

Review of the patient's medication administration record dated 12/19/17 reflected at 12:47 AM, Vistaril 25 milligrams (mg.) and Tylenol 650 mg. were given with a pain scale of 10/10. The patient was reassessed at 1:47 AM with a 4/10 pain scale, indicating improvement in pain.

On 2/07/18 at 12:15 PM, the CNO related their hospital was not sent any paperwork regarding tests or diagnostics completed by the treating emergency room for the visit of 12/18/17. He said they began trying to get the patient's medical records upon physician order and related they were not aware of the results of the patient's CT of the head until after the patient was discharged on 12/21/17 for further evaluation at the request of their physicians. "A computerized tomography (CT) scan combines a series of X-ray images taken from different angles and uses computer processing to create cross-sectional images, or slices, of the bones, blood vessels and soft tissues inside your body. CT scan images provide more detailed information than plain X-rays do." (Mayoclinic.org).