HospitalInspections.org

Based on record review and interview, the facility's registered nurses (RNs) did not supervise and evaluate the nursing care of 2 of 10 patients (Patient #1 an #10) in that the patients had blood pressure (BP) readings below the normal values and did not notify physicians.

Findings included:

-Patient #1 was admitted on 3/4/15 for "metabolic encephalopathy." A "Graphic Record Form" filled out by nurses indicated Patient #1 had BP readings that were below normal values. There was no documentation that a nurse notified the physician for the following dates:
3/8/15=90/48 and 83/51
3/9/15=96/46 and 86/44
3/10/15=100/49
3/11/15=86/47, 96/46, and 98/49
3/14/15=106/48
3/15/15=85/35
3/17/15=122/49

-Patient #10 was admitted on 12/12/15 for "status post fall with left humerus fracture..." A "Graphic Record Form" filled out by nurses indicated Patient #10 had BP readings that were below normal values. There was no documentation that a nurse notified the physician for the following dates:
12/19/15=126/47
12/22/15=146/49
12/27/15=112/48

In an interview on 5/26/15 at 1:30 PM, Physician #5 was asked if nurses notify him when a patient's blood pressure was low. He replied he at times was notified.

In an interview on 5/26/15 at approximately 2:40 PM, Personnel #1 was informed of the above findings. Personnel #1 stated usually the technicians obtain the patient's vital signs and if it was not within the normal values the vital signs would be reported to the primary care nurse. The primary care nurse must document what they have done to address the issues of low blood pressure.

Policy "Nursing Scope of Services" revised 9/1/14 required "Specialized rehabilitation nursing provides planning and care in the following areas: Rehabilitation diagnosis, course of treatment, plan of care and expected outcomes, disease and comorbidity management..."

Based on record review and interview, the facility did not ensure that nursing staff developed and kept current nursing care plans for 2 of 10 patients (Patient #1 an #10) who had blood pressure (BP) readings below the normal values.

Findings included:

-Patient #1 was admitted on 3/4/15 for "metabolic encephalopathy." A "Graphic Record Form" filled out by nurses indicated Patient #1 had BP readings below the normal values. There was no documentation that a nurse updated the nursing care plan of Patient #1 on the following dates when Patient #1 had BPs below the normal values:
3/8/15=90/48 and 83/51
3/9/15=96/46 and 86/44
3/10/15=100/49
3/11/15=86/47, 96/46, and 98/49
3/14/15=106/48
3/15/15=85/35
3/17/15=122/49

-Patient #10 was admitted on 12/12/15 for "status post fall with left humerus fracture..." A "Graphic Record Form" filled out by nurses indicated Patient #1 had BP readings below the normal values. There was no documentation that a nurse updated the nursing care plan of Patient #10 on the following dates when Patient #1 had BPs below the normal values:
12/19/15=126/47
12/22/15=146/49
12/27/15=112/48

In an interview on 5/26/15 at approximately 2:40 PM, Personnel #1 was informed of the above findings. Personnel #1 confirmed if there were changes in patient status, these changes must be reflected in the nurse's plan of care.

Policy "Rehabilitation Program and Plan of Care" revised 10/22/14 required "15. In addition to the interdisciplinary plan of care, nursing continues to tack specific patient problems identified on the admission nursing plan of care, an within their daily documentation as appropriate."

Based on record review and interview, the facility did not have qualified personnel to develop discharge planning evaluations in that 2 of 2 case managers (Personnel # 7 and #8) assigned to develop discharge planning evaluations were licensed vocational nurses (LVNs). The facility's position description for case managers required at a minimum a licensed registered nurse (RN).

Findings included:

Personnel #7 and Personnel #8 indicated they were both LVNs and were hired on 5/2/11 and 11/27/11 respectively. The facility's requirement for case managers as indicated in the position descriptions was a licensed registered nurse.

Review of medical records on 5/26/15 Personnel #7 was responsible for discharge planning evaluations of the following:
-Patient #1 who was admitted and discharged on 3/4/15 and 3/17/15 respectively for "metabolic encephalopathy."
-Patient #3 who was admitted and discharged on 1/27/15 and 2/6/15 respectively for "metabolic encephalopathy..."
-Patient #4 who was admitted and discharged on 1/13/15 and 1/25/15 respectively for "debility, status post gastroenteritis..."
-Patient #7 who was admitted and discharged on 3/9/15 and 3/27/15 respectively for "debility, ESRD (end stage renal disease)..."

Review of medical records on 5/26/15 Personnel #8 was responsible for discharge planning evaluations of the following:
-Patient #2 who was admitted and discharged on 4/27/15 and 5/6/15 respectively for "debility, metabolic encephalopathy..."
-Patient #5 who was admitted and discharged on 4/28/15 and 5/18/15 respectively for "debility..."
-Patient #6 who was admitted and discharged on 1/30/15 and 2/4/15 respectively for "critical illness myopathy..."
-Patient #8 who was admitted and discharged on 4/9/15 and 4/24/15 respectively for "encephalopathy..."
-Patient #9 who was admitted and discharged on 4/1/15 and 4/16/15 respectively for "pulmonary valve disorder..."
-Patient #10 who was admitted and discharged on 12/12/15 and 12/30/15 respectively for "status fall with left humerus fracture..."

In an interview on 5/26/15 at 2:10 PM, Personnel #1 and #4 were informed of the above findings. Personnel #4 confirmed that Personnel #7 and #8 were LVNs and the requirement for case manager was a RN.

Policy "Position Description" revised 7/15/13 required "Minimum skills...(including licensure...)...1. Master's Degree in Social Work or RN license required..."