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FAIRLAWN REHAB HOSP, AN AFFILIATE OF ENCOMPASS HLT
CONTENT OF RECORD: ORDERS,NOTES,REPORTS
Tag No.: A0467
Based on documentation review the Rehabilitation Hospital failed to ensure that: 1) the Daily Nursing Assessments were completed for 1 of 10 patients (Patient #1), and 2) the Medication Administration Record was completed for 1 of 10 patients (Patient #1).
Findings included:
1) The Rehabilitation Hospital's Policy/Procedure titled Interdisciplinary Daily Documentation effective 9/10, indicated all patients will have a nursing assessment conducted every 24 hours at a minimum. The assessment is made up of a systematic review of neurologic, cardiovascular, integumentary, gastrointestinal, genitourinary, and pulmonary sections. Additional sections include pain and cognitive sections as well as a check-off to indicate the identification band is on and legible. Each section was to be completed and additional findings may be recorded in narrative notes. If findings are abnormal a narrative note will be written with a description.
Review of Patient #1's Daily Nursing Assessments, dated 11/8/10 to 11/15/10 indicated the following:
> 11/8/10: the integumentary, genitourinary, pulmonary, pain and psychosocial sections were not completed.
> 11/9/10: the genitourinary, pain, presence/legibility of name band, and psychosocial sections were not completed.
> 11/10/10: the psychosocial section was not completed
> 11/12/10: the cardiovascular and integumentary sections were not completed.
> 11/13/10: localized edema was checked off as present however; the specific location or a narrative of the abnormal finding was not documented.
> 11/14/10: localized edema was checked off as present however; the specific location or a narrative of the abnormal finding was not documented.
The nurse assigned to Patient #1 from 7:00 A.M. until 11:00 P.M. on 11/13/10 and 11/14/10 (Nurse #5) was interviewed on 5/18/11 at 4:20 P.M. Nurse #5 said it was her practice to observe patients lower extremities when they were out of bed and sitting for signs of edema. Nurse #5 said Patient #1 had some edema in the left leg but, there was no evidence of redness, inflammation, or hardness.
2) The Pharmacy Activity Report and Daily Narrative Note dated 11/14/10, indicated Patient #1 was medicated with Tylenol at approximately 8:00 A.M. and 7:00 P.M.
Review of Patient #1's Pain Medication Administration Record indicated that Tylenol was not documented as administered on 11/14/10.