HospitalInspections.org

Based on document review and interview the facility failed to provided nursing care and evaluation in a safe setting for 1 of 1 patient reviewed.

On 2/28/2012 at 10:00 hours (hrs) in the conference room the medical record for patient #1 was reviewed and revealed the following:
-Pt #1 was admitted on 11/16/2011
-Pt #1 admission diagnosis included the following
-History of low blood volume
-Protein Energy Malnutrition(PEM)
-Pt had been seen in an acute hospital prior to coming to the Long Term Acute Care hospital.
-Pt developed a nose bleed on 11/17/2011 documented in the respiratory therapy notes only (No corresponding nurses notes found)
-Pt was transfused with two (2) units of packed red blood cells on 11/18/2011. (No further nose bleed documented until)
-11/24/2011 0230 hrs Pt #1 called sister about her nose bleeding
-11/24/2011 0245 hrs first occurrence of nurses notation reads "pt having nose bleed ice pack applied over nose, no active bleeding noted, no distress noted will continue to monitor" There were no vital signs recorded or assessment of pain or contributing factors for the sudden nose bleed.
-11/24/2011 0415 hrs nurses notation reads "Pt checked nostril plugged with tissue, nose bleed still noted ice pack applied to nose. Pt still up at bedside chair no distress noted. Pt monitored closely" There were no vital signs recorded. There was no assessment of the patents own interventions to reduce her nose bleed by stuffing tissue in her nostrils.
-11/24/2011 0530 hrs nurses notation reads "Daughter here upset and agitated stating nurse would not tend to the patient needs. Reassured but remains agitated Dr. notified of nose bleed with orders noted. Daughter stated she's not concerned with labs ...she is still bleeding....She's going to wheel pt to the medical center emergency room if she doesn't stop bleeding. Nurse called Dr".
-11/24/2011 0530 physician's order for complete blood count (CBC)
-11/24/2011 0610 hrs Dr called and informed of situation order to "go ahead and send pt to medical center emergency room (ER).
-11/24/2011 0620 hrs "ambulance here picked patient up in stable condition alert and oriented no distress noted. daughter in room. (Actual nurses note is documented as 11/23/2011 0620 hrs for ambulance notification)
-11/24/2011 0945 hrs physician's re-admission orders read as follows;
-continue nasal packs
-Follow up with Earn, Nose and Throat (ENT) for removal of packing in 1-2 days
-11/24/2011 1140 hrs Pt returned from ER nurses note document packing to bilateral nose.
-11/25/2011 0735 hrs Respiratory therapy notes record, "I noticed her gauze was coming out of her nose, so I removed it...I informed the nurse of what I did she said the gauze wasn't supposed to come out".
-11/24/20122 0740 hrs respiratory notified nurse... patient had packing hanging out of nose and patient told respiratory to just take it out...charge nurse notified.
-11/24/2011 0800 hrs no nose bleed noted.


The facility failed to insure the RN assessed patient #1 who had a nose bleed. Patient #1's medical record documented she had been admitted with low blood volume and had already been transfused with two (2) units of packed red blood cells, prior to patient #1 developing a nose bleed on 11/24/2011. Patient #1's nose began to bleed at 0230 hrs and no vital signs were recorded until the ambulance was notified of the transfer at 0620. There was no complete assessment documented for patient #1's condition at the time of the nose bleed or any assessment of the effectiveness of the one intervention that the RN offered which was an ice pack to the outside of the nose. The nurse did not notify the physician until the patient's daughter demanded the transfer to the ER.
Upon return from the ER the re-admission orders were not followed when the respiratory therapist removed the nasal packing against physician orders and prior to notifying the RN that patient #1 had requested the packing out. The RN did not follow the physician's order by having patient #1 evaluated by ENT. The RN did not notify the physician of the removal of the packing for follow-up orders. The RN did not evaluate all aspects of the patient condition/and nursing interventions or provide nursing care as ordered by the physician.

Based on document review and interview the facility failed to insure a Registered Nurse provided nursing care and evaluation for 1 of 1 patient reviewed.


On 2/28/2012 at 10:00 hours (hrs) in the conference room the medical record for patient #1 was reviewed and revealed the following:
-Pt #1 was admitted on 11/16/2011
-Pt #1 admission diagnosis included the following
-History of low blood volume
-Protein Energy Malnutrition(PEM)
-Pt had been seen in an acute hospital prior to coming to the Long Term Acute Care hospital.
-Pt developed a nose bleed on 11/17/2011 documented in the respiratory therapy notes only (No corresponding nurses notes found)
-Pt was transfused with two (2) units of packed red blood cells on 11/18/2011. (No further nose bleed documented until)
-11/24/2011 0230 hrs Pt #1 called sister about her nose bleeding
-11/24/2011 0245 hrs first occurrence of nurses notation reads "pt having nose bleed ice pack applied over nose, no active bleeding noted, no distress noted will continue to monitor" There were no vital signs recorded or assessment of pain or contributing factors for the sudden nose bleed.
-11/24/2011 0415 hrs nurses notation reads "Pt checked nostril plugged with tissue, nose bleed still noted ice pack applied to nose. Pt still up at bedside chair no distress noted. Pt monitored closely" There were no vital signs recorded. There was no assessment of the patents own interventions to reduce her nose bleed by stuffing tissue in her nostrils.
-11/24/2011 0530 hrs nurses notation reads "Daughter here upset and agitated stating nurse would not tend to the patient needs. Reassured but remains agitated Dr. notified of nose bleed with orders noted. Daughter stated she's not concerned with labs ...she is still bleeding....She's going to wheel pt to the medical center emergency room if she doesn't stop bleeding. Nurse called Dr".
-11/24/2011 0530 physician's order for complete blood count (CBC)
-11/24/2011 0610 hrs Dr called and informed of situation order to "go ahead and send pt to medical center emergency room (ER).
-11/24/2011 0620 hrs "ambulance here picked patient up in stable condition alert and oriented no distress noted. daughter in room. (Actual nurses note is documented as 11/23/2011 0620 hrs for ambulance notification)
-11/24/2011 0945 hrs physician's re-admission orders read as follows;
-continue nasal packs
-Follow up with Earn, Nose and Throat (ENT) for removal of packing in 1-2 days
-11/24/2011 1140 hrs Pt returned from ER nurses note document packing to bilateral nose.
-11/25/2011 0735 hrs Respiratory therapy notes record, "I noticed her gauze was coming out of her nose, so I removed it...I informed the nurse of what I did she said the gauze wasn't supposed to come out".
-11/24/20122 0740 hrs respiratory notified nurse... patient had packing hanging out of nose and patient told respiratory to just take it out...charge nurse notified.
-11/24/2011 0800 hrs no nose bleed noted.


The facility failed to insure the RN assessed patient #1 who had a nose bleed. Patient #1's medical record documented she had been admitted with low blood volume and had already been transfused with two (2) units of packed red blood cells, prior to patient #1 developing a nose bleed on 11/24/2011. Patient #1's nose began to bleed at 0230 hrs and no vital signs were recorded until the ambulance was notified of the transfer at 0620. There was no complete assessment documented for patient #1's condition at the time of the nose bleed or any assessment of the effectiveness of the one intervention that the RN offered which was an ice pack to the outside of the nose. The nurse did not notify the physician until the patient's daughter demanded the transfer to the ER.
Upon return from the ER the re-admission orders were not followed when the respiratory therapist removed the nasal packing against physician orders and prior to notifying the RN that patient #1 had requested the packing out. The RN did not follow the physician's order by having patient #1 evaluated by ENT. The RN did not notify the physician of the removal of the packing for follow-up orders. The RN did not evaluate all aspects of the patient condition/and nursing interventions or provide nursing care as ordered by the physician.