HospitalInspections.org

Based on clinical record review, policy and procedure review and interview, it was determined the Facility failed to assure a Registered Nurse provided supervision for the care of each patient admitted to the Facility in that 14 (#6-#9 and #11-#20) of 17 (#4 - #20) inpatient clinical records lacked documentation by a Registered Nurse for each 12 hour shift. It could not be assured each patient's care needs and response to treatment would be identified and evaluated. The failed practice affected patients #6-#9 and #11 - #20 and was likely to affect all patients admitted to the Facility. The findings were:

A. Clinical record review on 12/02-12/04/14 revealed the lack of Registered Nurse (RN) documentation for each 12 hour shift for 14 (#6-#9 and #11-#20) of 17 (#4 - #20) inpatient clinical records as follows:
1) Patient #6 was admitted on 11/20/14 at 1437. No RN shift documentation: 11/22 and 11/23/14 (0700); 11/26, 11/27 and 11/29/14 (1900). Verified by the Chief Nursing Officer (CNO) on 12/03/14 at 1540.
2) Patient #7 was admitted on 11/11/14 at 1308. No RN shift documentation:11/12 and 11/23/14 (0700); 11/13, 11/18, 11/25, 11/26, 11/27 and 12/02/14 (1900). Verified by the Director of Quality and Risk Management on 12/03/14 at 1625.
3) Patient #8 was admitted on 12/01/14 at 1005. No RN shift documentation: 12/01/14 (1900). Verified by the Director of Quality and Risk Management on 12/03/14 at 1650.
4) Patient #9 was admitted on 11/18/14 at 1325. No RN shift documentation:11/20, 11/22, 11/23, 11/24, 11/25, 11/28, and 11/29/14 (0700); 12/01 and 12/02/14 (1900). Verified by RN #1 on 12/04/140 at 0920.
5) Patient #11 was admitted on 11/23/14 at 1325. No RN shift documentation: 11/27, 11/30 and 12/03/14 (0700). Verified by Director of Quality and Risk Management on 12/04/14 at 1000.
6) Patient #12 was admitted on 11/15/14 at 1134. No RN shift documentation: 12/02/14 (0700). Verified by Director of Quality and Risk Management on 12/04/14 at 1030.
7) Patient #13 was admitted on 11/21/14 at 1550. No RN shift documentation: 11/21 through 11/28/14 (1900); and 12/01 - 12/03/14 (1900). Verified by Director of Quality and Risk Management on 12/04/14 at 1130.
8) Patient #14 was admitted on 12/01/14 at 1145. No RN shift documentation: 12/02 and 12/03/14 (1900). Verified by the Director of Quality and Risk Management on 12/04/14 at 1135/14.
9) Patient #15 was admitted on 12/01/14 at 1625. No RN shift documentation: 12/01 through 12/03/14 (1900). Verified by the Director of Quality and Risk Management on 12/04/14 at 1145.
10) Patient #16 was admitted on 11/17/14 at 1655. No RN shift documentation: 11/18 through 11/29/14 (1900); 12/01 and 12/02/14 (1900). Verified by the Director of Quality and Risk Management on 12/04/14 at 1215.
11) Patient #17 was admitted on 11/24/14 at 1655. No RN shift documentation:11/25 through 11/30/14 (0700) and 12/02/14 (0700). Verified by the Director of Quality and Risk Management on 12/04/14 at 1232.
12) Patient #18 was admitted on 11/26/14 at 1520. No RN shift documentation: 11/26 and 11/27/14 (1900); 11/30, 12/02 and 12/03/14 (0700). Verified by the Director of Quality and Risk Management on 12/04/14 at 1245.
13) Patient #19 was admitted on 12/01/14 at 1550. No RN shift documentation: 12/02 and 12/03/14 (0700). Verified by the Director of Quality and Risk Management on 12/04/14 at 1300.
14) Patient #20 was admitted on 11/18/14 at 1630. No RN shift documentation: 11/19 through 11/22/14 (0700); 11/24 through 11/30/14 (0700); 12/02 and 12/03/14 (0700). Verified by the Director of Quality and Risk Management on 12/04/14 at 1325.

B. The policy for nursing documentation was requested and received on 12/04/14 at 0830. The policy "Interdisciplinary Daily Documentation" contained the statement "Daily Nursing assessments: All patients will have a RN assessment conducted every 24 hours at a minimum. If patient is under an acute watch, RN assessment will be performed every 12 hours" and "an RN must enter a narrative note on patient's condition on all LPN (Licensed Practical Nurse) assigned patients."