HospitalInspections.org

Based on record review, review of policy and procedures, and staff interview it was determined the registered nurse failed to supervise and evaluate the nursing care, according to facility policy, for three (#1, #2, #3) of five records sampled. This does not ensure the patient's needs, condition, and the patient's response to interventions were monitored.

Findings include:

1. Review of the medical record for patient #1 revealed the patient was admitted on 3/04/11. Review of the daily nursing assessments revealed on 3/13/11 the patient was located in the PCU (Progressive Care Unit). The patient was assessed on 3/13/11 at 9:30 p.m. and then on 3/14/11 at 8:00 a.m. Review of nursing assessments on 3/1411 and 3/15/11 revealed the patient was not assessed for 10.5 hours.

Review of the facility ' s policy, "Assessment/Reassessment" , revealed patient's located in the PCU will be assessed at least every six hours.

Interview on 4/26/11 at 2:25 p.m. with the director of quality confirmed the findings.

2. Review of the medical record for patient #2 revealed the patient was admitted on 4/15/11. Review of the nursing assessments from the date of admission on 4/15/11 until expiration on 4/21/11 revealed there were no nursing assessments for the day shift (7:00 a.m.-7:00 p.m.) on 4/16/11 and 4/17/11.

Review of the facility policy, "Assessment/Reassessment", revealed the patient was to be assessed at least once every shift.

Interview with the director of quality on 4/26/11 at 2:25 p.m. confirmed the above findings.

3. Review of the medical record for patient #3 revealed the patient was admitted to the facility on 3/23/11. Review of the nursing assessments from the date of admission on 3/23/11 to discharge on 4/7/11 revealed there were no nursing assessments completed for the evening shift (7:00 p.m.-7:00 a.m.) on 3/26/11 and the day shift (7:00 a.m.-7:00 p.m.) on 3/28/11. Further review of the clinical record revealed a Registered Nurse (RN) failed to supervise and evaluate the patient for a twenty four hour period on the following dates: 3/26/11, 3/27/11, 4/1/11, and 4/4/11.

Interview on 4/26/11 at 2:25 p.m. with the director of quality confirmed the above findings.