HospitalInspections.org

Based on a review of documentation and interview, the facility failed to ensure that all records contained all relevant vital signs and other information necessary to monitor the patient's condition.

Findings included:

Review of the medical record for Patient #1 revealed:
* The patient had a physician order for vital signs every four hours entered on 5/12/15 at 6:49 PM.
* On 05/13/15 vitals were documented at 11:30 PM and again on 05/14/15 at 7:00 AM. A set of vital signs should have been assessed and documented per order around 3:00 AM on 05/14/15.
* A physician order for a routine "Electroencephalogram Awake + Asleep" due to "Clinical History new personality changes eval for subclinical seizure activity" was entered on 05/13/15 at 8:55 AM.
* A nursing note on 05/14/15 at 9:00 AM stated, "Spouse at bedside, enquiring [sic] re EEG, explained that it is planned to be completed today."
* A physician note on 05/14/15 at 8:47 AM stated in part, "An electrocephalogram is pending for today to look for subclinical seizure. Provided this is unremarkable, likely will transfer the patient back to rehabilitation for ongoing care and outpatient neurological followup."
* The patient's medical record contained no explanation for why there was delay of 24 hours between the test being ordered on 05/13/15 and performed on 05/14/15.
* In an interview on 09/10/15, staff member # 1 verified that the facility does not have policy in place to define and designate timeframes (Routine, STAT) for the completion of neurological tests such as EEGs.

Regarding Patient # 1, the facility failed to ensure that vital signs were monitored and documented per physician order. The facility failed to ensure that a neurological test for subclinical seizures was completed within 24 hours, there was no docuemtned reason for the delay in obtaining this test. The facility also failed to define timeframes to complete standard neurological tests such as EEG. In an interview on 09/10/15, staff member # 1 verified the above findings.