HospitalInspections.org

Based on document review and interview, the facility failed to complete Neuro checks per order and/or policy for 1 of 10 patients (patient #1).

Findings include;

1. Facility policy titled Fall Prevention last revised 3/28/22 indicates that if a patient strikes their head, neuro checks are to occur every 15 minutes times 4, every 30 minutes times 2 and every hour times 4.

2. Review of patient #1 medical record indicated the patient was admitted 10/21/22 and had a fall at 12:45 a.m. on 10/27/22 and struck their head. An order was received at 0300 hours on 10/27/22 for Neuro checks every 2 hours to stop at 0100 hours on 10/28/22. The medical record lacked documentation that the Neuro checks were completed per order. A note at 0459 a.m. on 10/27/22 indicated Neuro checks were within normal limits. The medical record lacked documentation of a Neuro check after 0459 on 10/27/22 until 0800 on 10/28/22.

3. Staff member #5 (Assistant Chief Nursing Officer) verified in interview at approximately 2:30 p.m. on 12/19/22 that the medical record for patient #1 lacked documentation of Neuro checks completed per order.

Based on document review and interview, the facility failed to ensure medical records documented accurately the course of treatment for 1 of 10 patients (patient #5).

Findings include;

1. Review of patient #5 medical record indicated the patient was admitted 10/25/22 and nurses notes dated 10/26/22 at 0245 hours indicated the patient had a fall and the nurses note indicated an order was received to send the patient to the emergency room (ER) . Per nurses note, the patient was transported at 0345 hours. The medical record lacked an order to send the patient to the ER and lacked documentation of the findings and what time the patient returned to the facility. There was no further documentation related to the ER visit.

2. Staff member #5 (Assistant Chief Nursing Officer) verified in interview at approximately 2:30 p.m. on 12/19/22 that the medical record for patient #5 lacked an order to send the patient to the ER and lacked documentation of the findings and what time the patient returned to the facility.