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Based on record review and staff interview it was determined that the Registered Nurse failed to supervise and evaluate nursing care related to assessments and implementation of physician orders for 3 (#1, #3, #4) of 10 sampled patients. This practice does not ensure patient goals are met.


Findings include:


1. Patient #1 was admitted on 5/11/11 to the Intensive Care Unit (ICU) and transferred to 1 North on 5/13/11. The 24 Hour Nursing Care Record required that the patient's pain level be assessed at the beginning of each shift and that it be documented. Review of the record for the 7 p.m. to 7 a.m. on 5/13/11 shift revealed the nurse failed to document the initial pain assessment on the form. She also failed to document vital signs, which were to assessed at 8:00 p.m. Documentation in the medical record at 7:30 p.m. noted the patient's intravenous (IV) access had been lost. There was no documentation in the medical record regarding when it had been lost or that there had been any attempt to restart it prior to 10:00 p.m.

The Chief Nursing Officer (CNO) was interviewed on 5/19/11 at approximately 1:30 p.m. She stated that the IV had been lost when the patient was in radiology for a swallow study. The CNO confirmed the lack of appropriate assessment and failure to reestablish the IV access in a timely manner.

2. Patient #3 was admitted to the facility on 5/11/11. The patient was diagnosed with renal failure and was receiving peritoneal dialysis. The physician wrote an order for strict intake and output and daily weights to be recorded. Review of the medical record revealed that a weight was not recorded on 5/15/11. There was no documentation of intake and output on any day. Pain assessments were also not documented for the 7 p.m. to 7 a.m. shifts on 5/12/11 and 5/14/11.

3. Patient #4 was admitted to the facility on 5/12/11. The patient was diagnosed with altered mental status and generalized seizures. The physician wrote an order for vital signs to be assessed every 4 hours. Review of the medical record revealed the vital signs were not documented every 4 hours as ordered on 5/12/11.

Based on record review and staff interview it was determined the facility failed to provide medication as ordered by the physician for 1 (#1) 10 of sampled patients. This practice does not ensure effective medication therapy.

Findings include:

Patient #1's physician order dated 5/11/11 instructed for Avelox 400 milligrams daily. Review of the Medication Administration Record revealed that the medication was not administered on 5/13/11.

The Chief Nursing Officer confirmed there was no evidence the medication was administered during interview on 5/19/11 at 1:30 p.m.

Based on record review and staff interview it was determined the facility failed to provide medication as ordered by the physician for 1 (#1) 10 of sampled patients. This practice does not ensure effective medication therapy.

Findings include:

Patient #1's physician order dated 5/11/11 instructed for Avelox 400 milligrams daily. Review of the Medication Administration Record revealed that the medication was not administered on 5/13/11.

The Chief Nursing Officer confirmed there was no evidence the medication was administered during interview on 5/19/11 at 1:30 p.m.