HospitalInspections.org

Based on record review and staff interview it was determined that the Registered Nurse failed to supervise and evaluate nursing care by failing to follow physician ordered plan of care for one (#2) of three patients sampled. The practice does not ensure patient safety and goals are maintained.

Findings include:

Patient #2's operative report noted an abdominal procedure was performed on 4/12/10 and a urinary catheter was placed during the procedure. The patient arrived to the nursing unit at 11:00 a.m. following the surgery. Review of the nursing documentation revealed on 4/12/10 at 5:00 p.m. the RN (Registered Nurse) discontinued the patient's urinary catheter. Review of nursing documentation indicated the urinary catheter had to be reinserted on 4/13/10 at 1:00 a.m. after the patient was unable to void. Review of the physician orders revealed no order for the catheter to be discontinued. Interview with the Director of Women and Children's Unit on 6/04/10 at 1:00 p.m. confirmed there was no order to discontinue the catheter.