HospitalInspections.org

Based on record review and interview, the hospital failed to ensure 24 hour nursing care was provided and assess the delivery of care to 1 of 2 inpatient units (Functional Independent Rehab Unit, FIRU).

Findings:
1) The FIRU unit did not have a scheduled nurse on the 11:00 pm - 7:00 am (night) shift for immediate bedside availability. This inpatient unit is specifically designed to transition patients from rehab to home that had experienced head injuries. The night shift was staffed only by Rehab Assistant ' s (RA ' s). In an interview with the Chief Nursing Officer (CNO), she stated that the House Supervisor was available in-house if needed.
Cross refer A0392 and A0395
2) The nursing staff did not identify the treatment needs and establish a nursing plan of care for each patient on the FIRU inpatient unit as required.
Cross refer A0396

Findings:
Based on review of records and interview, the hospital ' s nursing service did not have a licensed nurse scheduled for 1 of 2 inpatient medical units (Functional Independent Rehab Unit, FIRU) for immediate bedside care for the 11:00 pm - 7:00 am shift from 03/15/10 until 06/24/10.

Review of the " Master Schedule " for the FIRU unit from 03/15/10 until 06/24/10 showed that there were no RN ' s (registered nurses) or LVN ' s (licensed vocational nurses) scheduled from 11:00 pm until 7:00 am.

Review of the " Nurse Staffing " sheet for IRF (inpatient rehabilitation hospital) unit from 03/15/10 until 06/24/10 showed there was an RN scheduled as " charge nurse " from 7:00 pm until 7:00 am.

Review of the " 2010 Weekly Census " for the FIRU unit showed the following patients were admitted for medical care that required a licensed nurse for immediate availability of beside care if needed.
03/15/10 - 03/21/10: Patients #5, 9, 10, 11, and 12.
03/22/10 - 03/28/10: Patients #5, 9, 10, 11, and 12.
03/29/10 - 04/04/10: Patients # 5, 9, 10, 11, 12 and 14.
04/05/10 - 04/11/10: Patients # 5, 10, 11, and 14.
04/12/10 - 04/18/10: Patients # 5, 11, and 14.
04/19/10 - 04/25/10: Patients # 2, 3, 4, 8, and 14.
04/26/10 - 05/02/10: Patients # 2, 3, 4, 8, and 14.
05/03/10 - 05/09/10: Patients # 2, 3, 4, 8, and 14.
05/10/10 - 05/16/10: Patients # 2, 3, 4, 8, and 14.
05/17/10 - 05/23/10: Patients # 1, 2, 3, 4, 6 and 14.
05/24/10 - 05/30/10: Patients # 1, 2, 3, 4, 5, 6, and 14.
05/31/10 - 06/06/10: Patients # 1, 2, 3, 4, 5, 6, and 14.
06/07/10 - 06/13/10: Patients # 1, 2, 3, 4, 5, 6, and 14.
06/14/10 - 06/20/10: Patients # 1, 2, 3, 4, 5, 6, and 14.
06/21/10 - 06/24/10: Patients # 2, 3, 4, 5, 6, 14, 15, and 16.

The Nursing Policy and Procedure Manual, dated 04/01/2007, " Acuity Classification for Staffing " , requires, " Using the nursing process, patients needs will be assessed daily by the Administrative Supervisor and/or Charge Nurse ...Individual nursing personnel will be assigned to patients ...nursing hours are defined as total hours required in a 24 hour day to care for a given census of patients ...the staffing pattern is adjusted each shift ... "

The Nursing Policy and Procedure Manual, revised 07/28/08, " Plan for Provision of Patient Care " , requires, " The hospital ' s plan for the provision of nursing care is comprehensive and includes all clinical departments, services, units or areas of the hospital in which nursing care is provided to patients ...Within the department of nursing, care is delivered by Registered Nurses, Licensed Vocational Nurses and Certified Nursing Assistants ...Nursing care is provided 24 hours a day, seven days a week. There are Registered Nurses on duty in charge of the Nursing units at all times. "

In an interview with the Chief Nursing Officer (CNO, Personnel #5) on the morning of 06/25/10, she was asked if she is responsible for the daily operations of the nursing service and determining the staffing and/or scheduling needs of the nursing personnel to provide nursing care for the hospital. She stated, " Yes. " She was then asked to review the nurse staffing sheets for the FIRU unit. She was asked if there was a licensed nurse scheduled on the FIRU unit for the 11:00 pm - 07:00 am shift from 03/15/10 until 06/24/10. She stated, " No, there was not. " She was then asked if nursing services followed the hospital policies and procedures regarding the required provision of nursing care to all patients. She stated, " No. "

Findings:

Based on review of records and interview, an RN did not supervise and evaluate the nursing care provided to 12 of 12 patients ' (Patient ' s # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12) from 02/08/10 to 06/24/10 on the 11:00 pm - 7:00 am shift in the FIRU unit.

Review of the " Master Schedule " for the FIRU unit from 03/15/10 until 06/24/10 showed that there were no RN ' s (registered nurses) or LVN ' s (licensed vocational nurses) scheduled from 11:00 pm until 7:00 am. The only staffing scheduled for 11:00 pm until 7:00 am were " Rehab Assistants. "

The patient medical records did not have any nursing documentation reflecting nursing evaluations or assessment of nursing care provided to the following patients on the 11:00 pm to 07:00 am shifts for the following dates:
Patient #1, Admission diagnosis (DX): TBI (traumatic brain injury), nurses notes from 05/17/10 - 06/13/10.
Patient #2, DX: history of Hemorrhagic CVA (cerebrovascular accident), nurses notes from 04/22/10 - 06/23/10.
Patient #3, DX: Right hemorrhagic stroke, nurses notes from 04/23/10 - 06/24/10.
Patient #4, DX: Hypoxic encephalopathy, nurses notes from 04/22/10 - 06/24/10.
Patient #5, DX: TBI, nurses notes from 03/15/10 - 04/25/10.
Patient #6, DX: TBI, nurses notes from 05/24/10 - 06/24/10.
Patient #7, DX: Multiple sclerosis (MS), nurses notes from 02/08/10 - 02/15/10.
Patient #8, DX: Post left subarachnoid hemorrhage, nurses notes from 04/21/10 - 05/10/10.
Patient #9, DX: Stroke with right hemiplegia, nurses notes from 03/20/10 - 03/30/10.
Patient #10, DX: Post left intracranial hemorrhage with craniotomy, nurses notes from 03/18/10 - 04/06/10.
Patient #11, DX: Left intracranial hemorrhage, nurses notes from 03/17/10 - 04/15/10
Patient #12, DX: Left CVA with right hemiparesis, nurses notes from 03/16/10 - 04/01/10.

The Nursing Policy and Procedure Manual, revised 07/28/08, " Reassessment of Patients " , requires, " An RN/LVN will perform a nursing reassessment under the following conditions: 1. At the beginning of each shift. 2. When there has been a significant change in the patient ' s condition. 3. To determine the patients response to treatment. 4. When a significant change occurs in the patient ' s diagnosis ...The Registered Nurse is charged with the responsibility for assessment ...each patient is reassessed on a routine basis each shift ...The data used for this reassessment is documented in the Patient Care Record as the shift assessment. "

The Nursing Policy and Procedure Manual, revised 07/28/08, " Scope of Practice " , requires, " Nursing services will provide within the scope of practice defined by the State of Texas ...The registered nurse shall assist in the determination of healthcare needs of clients and shall: 1. Utilize a systematic approach to provide individualized, goal-directed, nursing care by: a. performing comprehensive nursing assessments regarding the health status of the client; b. making nursing diagnoses that serve as the basis for the strategy of care; c. developing a plan of care based on the assessment and nursing diagnosis; d. implementing nursing care; and e. evaluating the client ' s responses to nursing interventions ... "

In an interview with the CNO, (Personnel #5) on the afternoon of 07/01/10, she was asked to review the above medical records. She was then asked if the above medical records reflected the evaluation of the nursing care provided on the 11:00 pm to 7:00 am shifts. She stated, " No, they do not. " She was then asked if the hospital policies and procedures were followed regarding the required supervision and evaluation of the patients. She stated, " No. "

Findings:

Based on review of records, the Texas Nurse Practice Act and interview, the nursing staff failed to develop and keep current a nursing care plan for 12 of 12 patients ' (Patient ' s # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12) from 02/08/10 to 06/24/10 in the FIRU unit.

The patient medical records did not have a nursing care plan for the following patients:
Patient #1, DX: TBI, from 05/17/10 - 06/14/10.
Patient #2, DX: history of Hemorrhagic CVA, from 04/22/10 - 06/24/10.
Patient #3, DX: Right hemorrhagic stroke, from 04/23/10 - 06/24/10.
Patient #4, DX: Hypoxic encephalopathy, from 04/21/10 - 06/24/10.
Patient #5, DX: TBI, 02/22/10 - 04/26/10.
Patient #6, DX: TBI, from 05/21/10 - 06/25/10.
Patient #7, DX: MS, from 02/08/10 - 02/16/10.
Patient #8, DX: Post left subarachnoid hemorrhage, from 04/21/10 - 05/11/10.
Patient #9, DX: Stroke with right hemiplegia, from 02/19/10 - 03/31/10.
Patient #10, DX: Post left intracranial hemorrhage with craniotomy, from 03/18/10 - 04/07/10.
Patient #11, DX: Left intracranial hemorrhage, from 03/17/10 - 04/16/10
Patient #12, DX: Left CVA with right hemiparesis, from 03/15/10 - 04/02/10.

The Nursing Policy and Procedure Manual, revised 07/28/08, " Plan for Provision of Patient Care " , requires, " Upon admission to any inpatient unit, the patient will receive an initial nursing assessment that included a head to toe assessment, identification of treatment needs and establishment of a nursing plan of care ...the needs of each patient are assessed by the appropriate discipline to establish base line date ...the information generated through the analysis of assessment data is integrated to identify and prioritize the patient ' s needs for care ...further data gathered and evaluated throughout the patient ' s stay is used to determine the need for further assessment and to develop modifications to the plan of care ...reassessment is based on continued desire for care, response to care and change in patient status ...analysis of the admission data collected and nursing physical assessment is the responsibility of the RN in all settings which nursing care is provided ...completion of the admission assessment process must occur within eight (8) hours of admission ...must analyze data and physical assessment information to identify patient problems or needs and will initiate and individualize a plan of care ...the plan for care will be evaluated and updated on a daily basis by the RN/LVN on all units ... "

The Nursing Policy and Procedure Manual, revised 07/28/2008, " Reassessment of Patients " , requires, " Certain events in the course of the patient ' s progress towards health restoration make it necessary to reassess the need for care and reassess and/or revise the Nursing Plan of Care. The Registered Nurse is charged with the responsibility for assessment ... "

The Nursing Policy and Procedure Manual, revised 07/28/08, " Organizational Structure " , requires, " The Nursing Service Department provides the following services ...assessment of all patients nursing needs ...planning and implementation of nursing care to all patients ...evaluation of the nursing care received ...

The Nursing Policy and Procedure Manual, revised 07/28/08, " Scope of Practice " , requires, " Nursing services will provide within the scope of practice defined by the State of Texas ...The registered nurse shall assist in the determination of healthcare needs of clients and shall: 1. Utilize a systematic approach to provide individualized, goal-directed, nursing care by: a. performing comprehensive nursing assessments regarding the health status of the client; b. making nursing diagnoses that serve as the basis for the strategy of care; c. developing a plan of care based on the assessment and nursing diagnosis; d. implementing nursing care; and e. evaluating the client ' s responses to nursing interventions ... "

Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule ?217.11, " Standards of Nursing Practice " , requires, " (3) Standards specific to Registered Nurses, The registered nurse shall assist in the determination of healthcare needs of clients and shall: (A) Utilize a systematic approach to provide individualized, goal-directed, nursing care by: (i) performing comprehensive nursing assessments regarding the health status of the client; ii) making nursing diagnoses that serve as the basis for the strategy of care; (iii) developing a plan of care based on the assessment and nursing diagnosis; (iv) implementing nursing care; and (v) evaluating the client's responses to nursing interventions. "

In an interview with the CNO, (Personnel #5) on the afternoon of 07/01/10, she was asked to review the above medical records. She was then asked if the above medical records contained a nursing care plan. She stated, " No, they do not. " She was then asked if the hospital policies and procedures were followed regarding the required nursing care plan for all patients. She stated, " No. "