HospitalInspections.org

Based on record review, interview and policy review, the facility failed to ensure evaluations of nursing care were documented and communicated to the physician. This affected one (Patient #1) of ten medical records reviewed. The facility census was 62.

Findings include:

Review of the medical record for Patient #1 revealed an admission date of 02/05/25. On 02/08/25 at 11:18 PM, Patient #1 was at the nurse's station moving a cup of water off the counter and became unsteady with the walker. Patient #1 fell on her buttocks and hit her head on the floor. Patient #1's blood pressure was 149/69, temperature 97.3, respirations 20, heart rate 119, oxygen level 98 percent, and blood sugar 347. Patient #1 was diabetic and her blood pressure and heart rate were elevated. Patient #1 was alert and oriented times three. Patient #1 reported her head hurt but would not rate the pain. Patient #1 was offered Tylenol and declined it. A neuro check was completed at the time of the fall with a score of 16. Patient #1's head was observed with no visible injuries at this time. No body injuries observed at this time. Patient #1 was assisted to bed. Patient #1 was educated on proper use of her walker.

An order dated 02/08/25 at 11:55 AM stated transfer to hospital for evaluation as patient fell, hit her head, and is on an anticoagulant. An order dated 02/09/25 at 12:43 AM ordered neurological checks every four hours while awake.

Review of the "Nursing - Neurological Flow Sheet" revealed multiple neuro checks completed on 02/08/25 and 02/09/25. On 02/08/24 at 11:20 PM and at 12:20 AM on 02/09/25, Patient #1's neuro checks were fully conscious, movement of all four extremities, hand grasps equal and strong, bilateral pupils 3 millimeters and brisk, and speech clear with a score of 12. On 02/09/25 at 6:40 AM, Patient #1's neuro checks were fully conscious, movement of all four extremities, hand grasps equal and strong, bilateral pupils 3 millimeters and sluggish, and speech clear with a score of 14. On 02/09/25 at 10:40 AM, Patient #1's neuro checks were lethargic, movement of all four extremities, hand grasps equal and strong, bilateral pupils 3 millimeters and sluggish, and speech slurred with a score of 16. On 02/09/25 at 2:17 PM, Patient #1's neuro checks were lethargic, movement of all four extremities, hand grasps equal and strong, bilateral pupils 5 millimeters and sluggish, and speech slurred with a score of 20.

On 02/09/25 at 3:20 PM, there was an order to transfer to ER due to high blood pressure and a previous fall.

On 02/09/25 at 2:17 PM, the nurse documented received report by night shift that Patient #1 fell on 02/08/25 at 11:18 PM. Neuro checks were initiated every four hours by provider order, but no order to send out was received. Patient #1's blood pressure was 168/90 an hour after administration of Hydralazine. The provider was notified. Patient #1 refused breakfast and lunch. Pupils were sluggish and Patient #1 was confused with a score of 20 on neuro checks. The provider ordered Patient #1 to be sent out to ER for further evaluation.

The medical record lacked documentation of physician or provider notification of the change in Patient #1's neurological status.

During an interview on 02/24/25 at 11:00 AM, Staff C stated that initially the Nurse Practitioner ordered Patient #1 to be sent out non-emergently, but transportation was not available until 8:00 AM. The nurse called the provider back and asked if Patient #1 should be sent emergently, and the provider stated that since Patient #1's vital signs and neuro check were stable and she was having minimal complaints of pain there was no need to send Patient #1 out emergently. The provider ordered neuro checks every four hours and to monitor Patient #1 and a provider would evaluate Patient #1 in the morning. On night shift, Patient #1 remained stable for neuro checks. Staff C stated that the nurse did not document the conversation with the provider in the medical record and did not discontinue the order to send the patient out.

On 02/25/25 at 3:00 PM, the Staff C showed contact information from the Nurse Practitioner that was sent to Staff C's phone. There was a call from the facility on 02/09/25 at 10:41 AM and a text message at noon on 02/09/25 regarding Patient #1. Staff C verified these notifications were not documented in the medical record.

Review of the "Assessment Neurological" policy, revised February 2024, revealed a registered nurse will provide the initial neurological assessment when a neurological deficit is suspected or an assessment is ordered by a provider. Changes will be reported to the provider immediately. Changes from the patent's baseline are to be communicated to the provider within 30 minutes.

Review of the "Change in Patient Condition Chain of Command Notification" policy, revised February 2024 revealed the nurse assigned to a patient is responsible for notification of and communication to the medical staff regarding significant changes or significant deterioration in patient condition and assuring their is a provider response. The nurse must document all findings in the medical record including patient assessment, interventions, and calls made to both the medical staff and the patient family.