HospitalInspections.org

Based on record review and staff interview, it was determined that the Registered Nurse failed to supervise and evaluate nursing care to ensure care was provided according to physician orders for two (#1, #5) of six sampled patients. This practice does not provide for safe delivery of care.

Findings include:

1. Patient #5 was admitted on 3/21/11 for
abdominal surgery. The post operative
physician orders included an order to
strip the Jackson-Pratt drain and record
the drainage every 8 hours. Review of
nursing documentation revealed that the
nursing staff was recording the drainage
every 12 hours, not every 8 as ordered.
Physician order dated 3/23/11 instructed the
nursing staff to assist the patient in
ambulating to the Nurses' station three times
per day. Nursing documentation noted at
3:50 p.m. on 3/23/11 that the patient
ambulated around the nurse's station. There
was no documentation that the patient
ambulated after that time.

The Risk Manager who was present
during the record review confirmed
the above findings.

The physician ordered that an incentive
spirometer be provided to the patient
for use every hour on 3/21/11, following
the surgery. Review of the medical
record revealed no evidence that the
patient received the incentive
spirometer until 8:00 a.m. on 3/22/11.

During interview on 3/24/11 at
approximately 11:00 a.m. a staff nurse
confirmed that the incentive spirometer
had been given to the patient on 3/22/11,
not immediately post operatively on
3/21/11 as ordered.

2. Patient #1 was admitted to the facility for abdominal surgery on 1/20/11. She was transferred to the Progressive Intensive Care Unit (PICU) on 1/31/11. Review of the physician transfer orders revealed the patient was to be out of bed in a chair with Physical Therapist (PT) daily. Review of the PT notes revealed on 2/4/11 the patient was off the floor and that nursing was getting the patient out of bed. There was no note that the therapist returned at a later time to perform the ordered therapy. Review of the medical record revealed there was no evidence of PT working with the patient on 2/10/11. PT did not provide care on (weekend days) 2/5/11, 2/6/11, 2/12/11 and 2/13/11. There was no evidence that the Registered Nurse intervened to assess why PT was not provided or the physician was aware of the services not being provided as ordered.

The Risk Manager was interviewed on 3/24/11 at approximately 8:30 a.m. She stated that the PT department had a protocol for determining which patients will receive PT services on the weekends. The Risk Manager confirm there was no evidence that PT provided care to the patient on 2/4/11 and 2/10/11 or that the nursing staff assisted the patient to be up in a chair.