HospitalInspections.org

Based on clinical record review and interview, it was determined a Registered Nurse (RN) failed to supervise and evaluate the nursing care in that six of six (#12, and #14-#18) clinical records did not contain evidence the following physician's orders were performed: intake and output measured and recorded every four hours, neurological checks measured and recorded every four hours, vital signs measured and recorded every two hours, a surgical drain output was not measured and recorded hourly, POSS (Pasero Opiod-induced Sedation Scale) was not measured and recorded every two hours and Nursing Incentive Spirometry was not performed and recorded every hour while on a PCA (patient controlled analgesia) pump. In addition, a RN failed to supervise and evaluate the nursing care for two (#14 and #15) of 20 (#1-#20) patients in that Room Service Capability was not documented on admission. Failure of the RN to ensure performance of and documentation of intake and output every four hours, neurological checks every four hours, vital signs every two hours, surgical drain output hourly and POSS scale results every two hours did not provide the physicians information needed to make adjustments in the patient's care. Failure to administer incentive spirometery every one hour had the potential to allow adverse respiratory events such as pneumonia to invade and overcome the patient. Failure to assess and document Room Service Capability did not ensure staff were aware of the patient's abilities to manage meals. The failed practice was likely to affect Patient #12, #14, #15, #16 #17 and #18. Findings follow:

A. Review of Patient #12's clinical record revealed orders authored by Physician #2 on 09/15/16 for intake and output measurement every four hours and notify physician if less than 120 milliliters (ml) and neurological checks every four hours. Review of Patient #12's clinical record revealed no evidence on 09/15/16, 09/16/16 and 09/17/16 the intake and output and neurological checks were performed and documented as ordered. The above findings were verified by the Clinical Informaticist at 1023 on 06/14/17.

B. Review of Patient #14's clinical record revealed no assessment of Room Service Capability. The above findings were verified by the Clinical Informaticist at 1455 on 06/14/17.

C. Review of Patient #15's clinical record revealed orders authored by Physician #4 at 1523 on 06/09/17 for vital signs every two hours and POSS scale performed every two hours while on PCA pump. Review of Patient #15's clinical record revealed the following: no evidence vital signs were obtained every two hours from 06/09/17 at 1523 through 06/15/17 at 0848; no evidence POSS scale was performed every two hours from 06/09/17 through 06/15/17 at 0848. Review of the clinical record revealed the PCA pump was started at 1349 on 06/09/17 and was still in use as of 0848 on 06/15/17. Review of Patient #15's clinical record revealed orders authored by APRN (Advanced Practice Registered Nurse) #1 for Nursing Incentive Spirometery every one hour while awake. Review of Patient #15's clinical record revealed no evidence Nursing Incentive Spirometery was performed every hour while awake from 0733 to 1920 on 06/12/17, no evidence after 1208 it was performed until 0005 on 06/13/17, and none performed from 0845 on 06/14/17 through 0900 on 06/15/17. Review of Patient #15's clinical record also revealed no Room Service Capability assessment. The above findings were verified by the Clinical Informaticist at 0910 on 06/15/17.

D. Review of Patient #16's clinical record revealed orders authored by Physician #5 at 0250 on 06/07/17 to record intake and output and notify physician if less than 120 mls every four hours. Review of Patient #16's clinical record revealed no documentation intake and output was measured every four hours on 06/08/17, 06/09/17, 06/10/17, 06/12/17 and 06/13/17. Review of Patient #16's clinical record revealed orders authored by APRN #1 at 1619 on 06/14/17 to keep drain collapsed and empty every one hour. Review of the clinical record revealed no documentation the drain was emptied every hour on 06/14/17 from 1621 to 1910, from 2216 to 0858 on 06/15/17. The above findings were verified by the Clinical Informaticist at 0935 on 06/15/17.

E. Review of Patient #17's clinical record revealed orders authored by Physician #1 at 1401 on 06/08/17 for POSS Scale every two hours while on PCA pump. Review of Patient #17's clinical record revealed no evidence the POSS Scale was performed every two hours on 06/08/17, 06/09/17, 06/10/17, 06/11/17 and 06/12/17. Review of the clinical record revealed the PCA pump was started at 1535 on 06/08/17 and was discontinued at 0518 on 06/13/17. The above findings were verified by the Clinical Outcomes Supervisor at 1006 on 06/15/17.

F. Review of Patient #18's clinical record revealed orders authored by Physician #6 at 1307 on 06/11/17 for neurological checks every four hours. Review of Patient #18's clinical record revealed no evidence neurological checks were performed every four hours from 2003 on 06/11/17 to 0818 on 06/12/17 and from 0818 to 1620 on 06/12/17. The above findings were verified by the Clinical Outcomes Supervisor at 0902 on 06/15/17.