HospitalInspections.org

Based on medical record review, document review and staff interview, it was determined that the registered nurse (RN) failed to supervise and evaluate the nursing care for 3 of 5 patients (Patient #'s 1, 3 and 5) in the sample. Findings included:

The hospital job description entitled "Registered Nurse" stated, "Registered Nurse provides direct nursing care to patients as prescribed by the physician and is under the direction and supervision of the appropriate facility nursing leadership...Performs treatments...as ordered by the physician...Documents patient care, findings, and responses to nursing interventions...Administer patient medications as prescribed by the physician...daily nursing assessments...Provides oversight of the treatment plan for patients...Ensure all assigned duties are carried out..."

The hospital policy entitled "Medication Ordering, Dispensing and Administration" stated, "...The order must contain...Directions for use...Each dose of medication administered must be properly recorded in the patient's medical record..."

Medical record review revealed the following:

A. Patient #1

1. Physician orders

a. 2/20/14 at 7:45 PM: mupirocin ointment (used to treat skin infections caused by bacteria) to be applied to "affected area" two times daily for Methicillin-resistant Staphylococcus aureus (MRSA - a bacteria)

- no evidence that the nurse clarified the 2/20/14 physician's order for wound care (no wound site identified)

b. 2/21/14 at 9:30 AM: Levaquin (antibiotic) daily for 3 days for treatment of a urinary tract infection (UTI)

- no evidence that the patient received the third dose of Levaquin on 2/24/14

c. 2/21/14 at 1:00 PM: daily wound assessment and document on medication administration record (MAR)

- no evidence that the nurse clarified the order for daily wound assessment (no wound site identified)
- no documented evidence that the wound was assessed as ordered from 2/21 - 3/6/14

d. 2/21/14 (no time of entry): egg crate mattress

- no evidence that the egg crate mattress was obtained/applied to patient's bed during the hospitalization

e. 3/1/14 at 12:30 PM: Cipro (antibiotic) two times a day for 10 days for treatment of a UTI

- no evidence that the patient received the Cipro two times a day on 3/1 and 3/2/14

On 4/8/14 between 9:02 AM and 9:31 AM, Chief Nursing Officer (CNO) A reviewed the medical record and confirmed these findings.

B. Patient #3

1. Physician order
- 3/30/14 at 11:00 AM: Risperdal (medication for mood disorders) 2 milligrams (mg) by mouth at 4:00 PM for delusions

- no evidence that the patient received the 4:00 PM dose of Risperdal on 4/5 and 4/6/14

CNO A confirmed this finding during an interview on 4/8/14 at 1:05 PM.

C. Patient #5

1. Physician order
- 4/2/14 at 2:00 PM: trazodone (used to treat depression) 75 mg at bedtime for sleep

- no evidence that the patient received the trazodone on 4/2/14 at bedtime

CNO A confirmed this finding during an interview on 4/8/14 at 2:01 PM.

Based on medical record review, policy review and staff interview, it was determined that for 1 of 5 patients (Patient #1) in the sample, staff failed to develop and/or revise the plan of care to reflect current needs. Findings include:

The hospital policy entitled "Interdisciplinary Treatment Plan..." stated, "...treatment plan establishes a series of patient outcome objectives and specific interventions...initial problem list is based on assessment of the patient's presenting problems, physical health...components...medical issues...initial problem list is aimed at acute, immediate symptoms/problems that need to be addressed by nursing staff during the first 72 hours...Problem(s)...presenting behavior, symptoms, impairments, etc. which warrant interventions...Within 72 hours of admission, members of the treatment team shall further develop the treatment plan based on a comprehensive assessment of the patient's presenting problems, physical health...Problem...is why the patient requires treatment...Interventions...must be singular in purpose and have a clear intent...treatment plan update will be completed every seven (7) days..."

Medical record review revealed:

A. Patient #1 (admitted 2/20/14)

1. Care Plan Problem: Pain Management

a. Intake Assessment dated 2/20/14 at 5:50 PM:
- left side and back pain

b. Physician order dated 2/21/14:
- egg crate mattress (pressure relieving)

c. Plan of care:
- failed to include the application of an egg crate mattress to the patient's bed

2. Care Plan Problem: Diabetes

a. Intake Assessment dated 2/20/14 at 5:50 PM:
- history of diabetes requiring the use of insulin injections
- patient did not know how to self-administer insulin

b. Physician order dated 2/20/14 at 7:45 PM:
- insulin to be administered 15 minutes prior to breakfast and at bedtime with blood glucose (sugar) monitoring to be performed 4 times a day

c. Plan of care failed to be revised to address:
- education and evaluation of the patient's skill level regarding insulin preparation/administration and blood glucose monitoring

3. Care Plan Problem: Fall Potential

a. Intake Assessment dated 2/20/14 at 5:50 PM:
- identified patient as fall risk, ambulated with walker, unsteady gait, required a safety device whenever patient was left alone, seek assistance with transfers

b. Initial/Admission Plan of care:
- failed to address the patient's need for a walker to promote safe ambulation

4. Care Plan Problem: MRSA (Methicillin-resistant Staphylococcus aureus - a bacteria)

a. Intake Assessment dated 2/20/14 at 5:50 PM:
- wound "left side" tested positive for MRSA currently being treated with mupirocin (used to treat skin infections caused by bacteria)

b. Physician order dated 2/20/14 at 7:45 PM:
- management of the medical condition - MRSA

c. History and physical dated 2/21/14 at 5:20 PM:
- revealed presence of a "Stage 2" ulceration of the left abdominal region

d. Initial/Admission Plan of care:
- failed to address interventions related to the MRSA infection
- failed to address the wound

5. Care Plan Problem: Urinary tract infection (UTI)

a. Intake Assessment dated 2/20/14 at 5:50 PM:
- history of UTI
- incontinent of urine

b. Physician orders:
- dated 2/21/14 at 9:30 AM for Levaquin (antibiotic) daily for 3 days for treatment of a UTI
- dated 3/1/14 at 12:30 PM for Cipro (antibiotic) two times a day for 10 days for treatment of a UTI

c. Plan of care:
- failed to be revised to include treatment of a UTI

On 4/8/14 between 8:55 AM and 9:31 AM, Chief Nursing Officer A reviewed the medical record and confirmed these findings.