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MEDINA HOSPITAL
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on medical record review and staff interview, the facility failed to ensure a registered nurse evaluated the nursing care for one of ten medical records reviewed (Patient #1). The facility census was 119.
Findings include:
Review of the medical record for Patient #1 revealed urinary retention issues during this hospitalization. A Foley catheter was originally placed on 12/16/21 and was removed on 12/23/21 at 7:48 PM. A Foley catheter was ordered to be placed on 12/24/21 at 1:46 PM . The patient was discharged to another facility on 12/24/21 at 2:10 PM. The medical record lacked documentation a Foley catheter was placed on 12/24/21 prior to discharge. This was verified in an interview on 03/24/22 at 11:00 AM by Staff C.
On 03/24/22 at 12:15 PM, Staff E stated the order for the Foley for Patient #1 was received right before the patient left. Staff E could not remember placing the Foley catheter as ordered. Staff E stated he/she believed a conversation was had with the ordering physician and was directed to send the patient without the Foley. Staff E stated he/she could not recall all the details but that this conversation should have been documented but was not.