HospitalInspections.org
Bringing transparency to federal inspections
ASSURANCE HEALTH PSYCHIATRIC HOSPITAL
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on document review and interview, nursing services failed to obtain provider ordered labs in 1 of 10 (Patient 2) medical records reviewed.
Findings include:
1. Review of Patient 2's medical record indicated the following:
a. The patient was admitted on 12/27/2024
b. On Saturday, 01/04/2025, at 6:09 p.m. the provider ordered a Basic Metabolic Panel (BMP) and a Lithium level to be drawn on Mondays and Thursdays. MR indicated the order was noted on Sunday, 01/05/2025, at 7:39 a.m. MR lacked documentation that lab was drawn and completed as ordered on Monday, 01/06/2025.
c. Patient 2 was discharged on Tuesday, 01/07/2025, in stable condition.
2. Interview with A1 (Quality Manager) on 03/03/2025 at approximately 10:45 a.m. confirmed nursing staff failed to obtain Basic Metabolic Panel and Lithium level as ordered by the provider during patient 2's hospitalization.