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SUNDANCE HOSPITAL
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on interviews and record review the hospital failed to ensure RN's (Registered Nurses) evaluted patient needs for 2 of 10 patients (Patient #1 and Patient #7) whose elevated blood pressure and/or vital signs were not evaluated and/or not obtained.
Findings Included:
1) (Patient #1's) Behavioral Health Integrative Psychiatric Assessment dated 02/22/14 timed at 7:30 PM, reflected, "Patient hearing voices attempted to overdose on his medication...marijuana two grams a day since 2008...used (02/22/14) four grams..."
The 02/24/14 nursing shift assessment and progress note reflected, "Vital signs...blood pressure 152/91..." No follow-up blood pressure was found documented in the medical record.
The 02/25/14 nursing shift assessment and progress note reflected, "Vital signs...150/90..." No follow-up blood pressure was found documented in the medical record.
The 02/26/14 nursing shift assessment and progress note reflected, "Vital signs...pulse 124...blood pressure 153/109..." No follow-up blood pressure and or pulse check was documented in the medical record.
On 05/19/14 at 3:02 PM, Personnel #11 was interviewed. Personnel #11 reviewed (Patient #1's) medical record documentation. Personnel #11 stated nursing should have re-assessed and/or evaluated (Patient #1's) blood pressure and pulse.
2) (Patient #7's) nursing shift assessment and progress note dated 05/17/14 reflected, "Headache Tylenol 650 mg (milligrams)...withdrawn, coherent..." The vital sign section which included the B/P section was left blank.
(Patient #7's) nursing shift assessment and progress note dated 05/18/14 reflected no vital signs and/or blood pressure was documented as taken.
On 05/19/14 at 03:02 PM, Personnel #11 was interviewed. Personnel #11 reviewed (Patient #7's) medical record. Personnel #11 stated nursing personnel should have taken and/or documented (Patient #7's) vital signs.
The policy and procedure entitled, "Assessment and Reassessments of Patients" with an issue date of 11/15/10 reflected, " Assessment/reassessment patient information are documented in the patient's medical record...RN will reassess the patient based on the patient needs...patient problems, responses to treatment, and changes in patient condition are identified and documented each shift by a licensed nurse..."