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PAM HEALTH REHAB HOSPITAL OF HOUSTON HEIGHTS
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on interview and record review, the facility failed to ensure Registered Nurses (RN) assessed patients every twenty-four hours, as per facility policy (Patient ID#s: 2,5 and 13).
Findings included:
Review of facility policy titled " Nursing Documentation," dated September 2013, last reviewed March 28, 2022, stated "A patient focus assessment will be documented in the patient care record at least once per twenty-four hour period by a registered nurse."
Record review of medical record for Patient ID # 2 with Staff ID #52 showed there were no Registered Nurse Assessments completed on the following dates: 5/22/24, 5/23/24, 5/24/24, 5/25/24, 5/26/24, 5/27/24, 5/28/24, 5/29/24 for 8/8 inpatient days.
Record review of medical record for Patient ID # 5 with Staff ID #52 showed there were no Registered Nurse Assessments completed on the following dates: 5/25/24, 5/26/24, 5/27/24, 5/28/24 for 4/4 inpatient days.
Record review of medical record for Patient ID # 13 with Staff ID #52 showed there were no Registered Nurse Assessments completed on the following dates: 5/18/24, 5/20/24, 5/21/24, 5/22/24, 5/23/24 for 5/8 inpatient days.
Interview with Charge RN Staff ID # 59 on 5/30/24 at 10:45 AM, she was not able to verbalize or demonstrate the process that the facility utilized to ensure patients who were assigned to Licensed Vocational Nurses (LVN) received Registered Nurses assessments every 24 hours.
Interview with Director of Quality Staff ID # 52 on 5/30/24 at 11:30 AM, she stated that all patients should be assessed by an RN once every 24 hours. She confirmed this is a "current PI indicator" and she believed the facility was moving into the right director towards compliance." She confirmed that Patient ID #s 2, 5 and 13 record review did not support that RN assessments were occurring.
Interview with Nurse Manager Staff ID #54 on 5/30/24 at 1:00 pm, she stated "We are trying to have RNs do assessments every 24 hours." She stated she does "not always have enough RNs in staffing to accomplish this task." She reported that the facility has a total of 7.0 FTEs vacant for RN positions, which they have been actively recruiting to fill.