HospitalInspections.org

Based on medical record review and staff interview it was determined the facility failed to ensure the nursing staff provided care and services to meet the needs for one (Patient #2) of four sampled patients.

Findings included:

The History and Physical dated 1/22/19 at 11:32 p.m. was signed by the attending physician. The document indicated Patient #2 was being admitted for generalized weakness, dizziness, and complaints of fever, chills, and a sensation of fainting for about the past week and a half. The note included Patient #2 experienced significant orthostatic hypotension (drop in blood pressure associated with changes in position). The note included Patient #2 had a past medical history that included dementia and bipolar disorder.

The Nurses Notes dated 1/23/19 at 12:50 and signed by the Registered Nurse (RN) assigned to the care of Patient #2, documented Patient #2 had an unwitnessed fall earlier in the morning. The note described Patient #2 as being found agitated and requesting to go to the bathroom. The note documented the author left the patient unattended in order to get equipment to measure the patient's blood pressure prior to having the patient stand up. The nurse found the patient on the floor when she returned.

The report of the x-ray of the right shoulder dated 1/23/19 at 11:28 a.m. was signed by the radiologist. The findings included a questionable mild dislocation of the right shoulder and suggested clinical correlation to confirm the finding. There was no evidence of an acute fracture.

The Vice President of Quality and Patient Safety confirmed the finding the nurse failed to ensure the patient's safety by leaving Patient #2 unattended when the patient indicated an urgent need to use the bathroom.