HospitalInspections.org

Based on observation, interview and record review, the hospital failed to insure the nursing process, including documentation by ancillary personnel was supervised and evaluated for 2 of 6 patients reviewed (#2 & 6).

Findings:

1. Patient #2's record reflected the patient had a pressure sore on the buttocks as documented on admission 07/06/2010. The record reflected in the daily assessment by nursing that the patient continued to have the pressure sore through discharge on 07/20/2010. The nursing assessment documented the patient should be repositioned every two hours. The record failed to consistently document repositioning the patient as reflected in lack of documentation by the nursing staff in the record from 6:12 a.m. on 07/14/2010 through 8:18 a.m. on 07/17/2010. The only documentation in the record of repositioning by staff was at 12:20 p.m. on 07/15/2010.

2. Patient #6's record had a nursing assessment on 07/31/2010 which documented that the patient should be repositioned every 2 hours. The record failed to reflect documentation by nursing staff from 4:10 a.m. on 08/01/2010 through 12 a.m. on 08/02/2010 and from 4:11 a.m. on 08/02/2010 though 2:11 p.m. on 08/02/2010.

Interview with the risk manager and nurse manager from post coronary care (PCU) on 08/03/2010 at 2:25 p.m. confirmed the findings.