HospitalInspections.org

Based on staff interview and medical record reviews, it was determined that the facility failed to maintain the nursing assessments as part of the completed medical records for one of two (#1) sampled patients.

Findings were:

Review of patient #1's medical record revealed that nursing assessments/reassessments were not documented for 7 of 43 days that the patient was in the facility. The 24 Hour Patient Based on review of medical records, policies and procedures, and staff interview, it was determined that the facility lacked an effective system to ensure the completion of medical records.

Findings were:

Patient #1's medical record lacked documented evidence of the 24 Hour Patient Record notes for the patient's hospital day # 2, #3, #4, #5, #6 and #7.

These notes were not able to be found by the facility Human Resource Department representative.

The facility's policy entitled "Assessment/Reassessment" issued August 2003 indicated that at the time of admission the patient would have his/her needs assessed by a registered nurse. The policy further stated that a reassessment would be performed every 24 hours or more frequently by a registered nurse as indicated by the patient's condition and reassessed every 12 hours by a licensed staff member.

Review of the facility's policy entitled "Skin Assessment and Maintenance of Skin Integrity" dated 5/21/07, specified that documentation for the patient's skin assessment would be documented on the patient's 24 Hour Patient Record (RH-NU-709-2).

During interview #4 on 5/25/10 at 2:00 p.m. in the conference room, the Director of Clinical Services stated that he/she was unable to locate the 24 Hour Patient Records for patient #1's hospital day #2 thru #6.