HospitalInspections.org

Based on record review and staff interview, it was determined that the nursing staff failed to implement the nursing care plan for two (#1,#3) of five sampled patients.


Findings include:

1. Patient #1 was admitted to the facility on 1/22/11 and expired on 2/24/11. The physician documented in the History and Physical the patient had colon cancer with metastasis to the liver and lungs. Review of the nursing documentation revealed that the nursing care plan included skin care as one of the nursing problems to be addressed. The plan of care included repositioning the patient at least every 2 hours. It also required documentation of the patient's position every two hours and assessment of the patient's skin at least every shift. Review of the medical record revealed that the nursing staff failed to document the patient's position on the following dates:
1/23/11 - position not documented from 4:00 a.m. until 8:00 a.m.
2/16/11 - position not documented from 2:00 a.m. until 6:00 a.m. and from 4:00 p.m. until 8:00 p.m.
2/23/11 - position not documented from 4:00 p.m. until 8:00 p.m. and from 11:00 p.m. until 5:00 a.m. on 2/24/11
2/24/11 - position not documented from 5:00 a.m. until 12:00 noon

Review of the documentation of the skin assessment revealed that the assessment was not documented on 2/19/11.

Nursing documentation indicated that a stage II pressure ulcer was noticed on 2/23/11 at 3:00 a.m. The nursing staff failed to ensure the patient was reposition for approximately 10 total hours after the pressure ulcer was identified. During interview on 3/2/11 the Director of Nursing confirmed the lack of evidence of repositioning on the dates noted above.

2. Patient #3 was admitted to the facility on 3/1/11. The History and Physical indicated the patient had cirrhosis of the liver. The physician ordered fluid restriction of 1500 ccs on 3/1/11. Review of the intake and output record revealed the staff did not document fluid intake from 1:26 p.m. on 3/2/11 until 7:00 a.m. on 3/3/11. During interview on 3/3/11 at approximately 9:30 a.m. the Director of Nursing confirmed there was no evidence that the nursing staff had monitored the fluid intake as ordered.

Based on record review and staff interview, it was determined that the facility failed to administer medication as ordered for one (#3) of five sampled patients.



Findings include:

Review of physician orders for patient #1 revealed an order for Lasix 40 milligrams every 12 hours times 3 doses written by the physician on 3/1/11. The first dose was given at 6:30 p.m. on 3/1/11. The 2nd dose was administered at 6:21 a.m. on 3/2/11. The third dose was not administered until 9:00 p.m., which was 14 1/3 hours after the second dose. There was no documentation of why the dose was administered late. During interview on 3/3/11 at approximately 9:30 a.m. the Director of Nursing confirmed the above finding.