HospitalInspections.org

Based on review of documents and staff interview it was determined the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care for one (1) of one (1) patient's reviewed for whom a complaint regarding nursing care was lodged (patient#1). This failure creates the potential for the nursing care of all patients to be adversely impacted.

Findings include:

1. The State Agency received a complaint regarding the nursing care of patient #1. This complaint regarded the care and condition of the patient at the time of discharge on 11/04/11.

2. Review of hospital documentation revealed the hospital also received a similar complaint on 11/11/11. The 11/11/11 investigation notes made by the 3 P Nurse Manager were reviewed. The Nurse Manager noted the patient was discharged at 1735 and the last nurse's note was made at 1509. The Nurse Manager noted the responsible (discharge) nurse was on vacation and the issue would be discussed with the discharge nurse upon her return to work on 11/21/11.

3. Interview was conducted with the 3 P Nurse Manager in both the late morning and early afternoon of 12/12/11. She confirmed the nurse is expected to document a note at the time of discharge. The Nurse Manager stated she had not yet spoken with the discharge nurse related to the complaint about the patient's care and condition at discharge or the lack of a discharge note. She stated the discharge nurse had not returned to work on 11/21/11 as expected but did return on 12/2/11.

4. The Discharge Nurse was interviewed in the morning of 12/13/11. She confirmed she returned to work on 12/2/11. She also stated hospital staff had not spoken to her about the complaint prior to the arrival of the State Agency surveyors on 12/12/11.