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INDIANA UNIVERSITY HEALTH
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on document review and interview, nursing services failed to document vital signs as ordered per provider in 1 out of 10 patient (Patient 5) medical records reviewed.
Findings include:
1. Review of patient 5 medical record indicated provider order on 10/29/2024 indicated vital signs to be taken every 4 hours; medical record lacked the 4:00 a.m. vital signs on 11/01/2024.
2. Interview with A4 (Registered Nurse, Accreditation and Regulatory Compliance Consultant) on 12/02/2024 at approximately 2:25 p.m. confirmed vital signs were not completed as ordered on 11/01/2024 at 4:00 a.m.