HospitalInspections.org

Based on record review and staff interview the facility failed to ensure enough nursing numbers to ensure that the nurses followed the Medical/Surgical (Med/Surg) protocol by documenting every shift for turning and repositioning for 1 patient (#1) of 20 patients sampled.

Findings.

Review of the nursing care and services for patient #1 revealed that the Med/Surg protocol (contains turning and repositioning) was not consistently followed for this patient. The protocol is signed off each shift by the nurse in charge and is done for 9/9/10, 9/10/10 and 9/11/10 but not for 9/12/10 and 9/13/10. On admission and immediately post-operative the patient required assistance for mobility and on discharge required moderate assistance. The patient was discharged home with Home Health and a CPM machine to be used on the knee for range of motion.

Review of the facility policy, revealed that the protocol for Med/Surg relates to the nursing standards of care which is given to each patient and is signed by the nurse at the end of each shift. This protocol contains all of the basic nursing standards of care and is computerized for the nursing staff.

Interview with the Interim Chief Nursing Officer (CNO) on 12/20/10 at 4:00 PM, revealed that after reviewing the record for patient #1 the documentation for the Med/Surg protocol is not documented daily on the nursing flow sheet.

Review of the staffing schedule showed that it appeared that there was an adequate amount of staff available to provide the needs of the patients on that unit.

Based on record review and staff interview the facility failed to ensure that discharge information was accurate and completed for 2 patient (#1 and #19) of 20 patients sampled in relation to skin care and medical information.

Findings:

Record review of the discharge information for patient #1, revealed discharge instructions documented by nursing which included follow up Medical Doctor (MD) appointments, diet, medications, and assistive devices. However, under the skin section there is no mention of an abrasion or blister on the coccyx of the patient and no instructions to care for it. There is documentation in the nursing notes that an abrasion is present on the coccyx on 9/12/10 and 9/13/10 and that Aloe Vera was applied to it by the nurse.

Record review for patient #19, revealed that there was no discharge summary in the patient's record and the patient had been admitted on 9/21/10 and discharged on 9/22/10. A search of the Health Information Management department failed to turn up a summary for patient #1.

Interview with the Chief Nursing Officer (CNO) on 12/20/10 at 4:00 PM, revealed that the skin abrasion should have been noted on the discharge instructions and that the discharge summary somehow got missed. The CNO also indicated that the physician responsible for doing the summary was no longer on the staff. The CNO contacted the physician in question and he completed the summary on that day.