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Based on the review of medical records and interview with hospital staff, it was determined that in one of three medical records of individuals discharged following the provision of hospital services, medical record # 2, the hospital failed to ensure the RN supervised and evaluated the nursing care for each patient. Findings:

The review of medical record # 2 revealed that the patient was discharged following ERCP (endoscopic retrograde cholangiopancreatography). Medical record # 2 contained written discharge instructions entitled "Colic" that applied to an infant. Patient # 2 did not have an infant. These instructions were not appropriate to the patient's condition and discharge plan.

The 5 C Nurse Manager was interviewed at 1045 hours on 02/25/2010. The Nurse Manager reported that the discharging RN entered an incorrect stroke in the electronic medical record. The RN failed to recognize and correct the error. The error resulted in the incorrect instructions being printed. The RN provided the incorrect instructions to the patient. The RN failed to recognize the provision of the inappropriate instructions at the time of discharge. This failed to ensure the RN provided the patient with appropriate information and instruction for post hospital care and failed to ensure the RN evaluated the nursing care of the patient.


These findings also reflect noncompliance with the following Oregon Administrative Rule for Hospitals:
OAR 333-510-0020(3) Nursing Care Management, The RN shall be responsible and accountable for managing the nursing care of his/her assigned patients.

Based on the review of medical records and interview with hospital staff, it was determined that in one of three medical records of individuals discharged following the provision of hospital services, medical record # 2, the hospital failed to ensure the patient received instructions that prepared the patient for post-hospital care. Findings:

The review of medical record # 2 revealed that the patient was discharged following ERCP (endoscopic retrograde cholangiopancreatography). Medical record # 2 contained written discharge instructions entitled "Colic" that applied to an infant. Patient # 2 did not have an infant. These instructions were not appropriate to the patient's condition and discharge plan.

The 5 C Nurse Manager was interviewed at 1045 hours on 02/25/2010. The Nurse Manager reported that the discharging RN entered an incorrect stroke in the electronic medical record. The RN failed to recognize and correct the error. The error resulted in the incorrect instructions being printed. The RN provided the incorrect instructions to the patient. The RN failed to recognize the provision of the inappropriate instructions at the time of discharge. This failed to ensure the RN provided the patient with appropriate information and instruction for post hospital care and failed to ensure the RN evaluated the nursing care of the patient.

Refer to the findings at A-0395.