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Based on record review and interview, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for 3 of 10 (Patient #2, #7, and #11) patients, in that,
Patient #2's, #7's, and #11's record did not document surgical wound care for their respective admissions.

Findings Included

Patient #2's record did not document surgical wound care or notification to the physician for wound care orders during the 8/27/15 admission.

Patient #7's record did not document surgical wound care or notification to the physician for wound care orders during the 11/04/15 admission.

Patient #11's record did not document surgical wound care or notification to the physician for wound care orders during the 1/16/16 admission.

During an interview and electronics record review, 2/1/16 ending at 4:18 PM, Personnel #5 was asked for the surgical wound care documentation for Patient #2 and #7. Personnel #5 stated, "I don't see anything documented." Personnel #5 was asked to see surgical wound care orders or notification to the physician for wound care orders. Personnel #5 stated, "I don't see any."

During an interview and electronics record review, 2/2/16 ending at 11:17 AM, Personnel #5 was asked for the surgical wound care documentation for Patient #11. Personnel #5 stated, "I don't see anything documented." Personnel #5 was asked to see surgical wound care orders or notification to the physician for wound care orders. Personnel #5 stated, "I don't see any."

The facility's May 2015 last reviewed, "Plan for the Provision of Care" policy required, "organized and systematic processes designed to ensure the delivery of safe, effective, and timely care and treatment. Providing patient services and the delivery of patient care require specialized knowledge, judgement, and skill derived from the principles of biological, physical, behavioral, psychological, and medical sciences...patient services will be planned, coordinated, provided, delegated, and supervised by professional health care providers who recognize the physical, emotional, and spiritual needs of each person...professionals function collaboratively as part of a multidisciplinary team to achieve positive patient outcomes..."

Based on record review and interview, the facility failed to counsel the patient on the discharge plan to prepare him for the post-hospital care for 1 of 10 patients (Patient #2), in that, Patient #2's signed discharge instructions did not clearly direct the patient on what home medications to continue or to stop post discharge from the 8/27/15 admission.

Findings Included

Patient #2's signed discharge instructions did not clearly direct the patient on what home medications to continue or to stop post discharge from the 8/27/15 admission.

During an interview and electronics record review, 2/1/16 ending at 4:18 PM, Personnel #5 was asked for the signed discharge instructions for Patient #2. Personnel #5 was asked if the instructions clearly directed the patient on what home medications to continue or to stop. Personnel #5 stated, "No. Usually they complete the check boxes to show (the patient) what to take."

The facility's May 2015 last reviewed, "Plan for the Provision of Care" policy required, "Discharge planning...to assist the patient in...attaining the highest possible degree of independence post-discharge...A summary of all instructions to the patient and family/significant other are written by each discipline..."