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Based on review of policies, review of closed medical records, and staff and patient interviews, the facility failed to supervise and evaluate nursing care of a patient by failing to document reassessments after administration of nausea medicine. (#6).

The findings include:

1. Review of policy, "Monitoring Patient Responses to Medications", with revision date of 03/16, revealed ".....3. Specific responses to 'as needed' medications are documented routinely on the MAR (medication administration record). Additional information may be documented in the patient notes or on specified flow sheets."

Closed medical record review of Patient #6 on 05/24/2016 through 05/25/2016 revealed a 90 year old male admitted on 03/03/2016 for same day surgery of open suprapubic (area above the bladder) prostatectomy (surgical removal of the prostate gland). Review of physician orders dated 03/03/2016 at 1943 revealed Zofran 4 mg (milligrams) IV (intravenous) every 6 hours as needed for nausea. Review of physician's progress notes dated 03/05/2016 at 1055 revealed "N/V (nausea and vomiting) this am. Urine still clear. Increase IVF (intravenous fluids). Reglan (medication for nausea) for n/v." Review of a "Patient Rounding tool" dated 03/05/2016 at 0900 with a late nursing note documented at 1438 revealed "Pt with nausea/emesis 175 cc (cubic centimeter) brown liquid gave Zofran 4 mg" at 0754. Review of MAR dated 03/05/2016 revealed administration of Zofran 4 mg IV at 0754 on 03/05/2016. Further review revealed patient expired on 03/06/2016 at 0320. Review of the record revealed no assessment of the patient's nausea or vomiting after the administration of the Zofran on 03/05/2015 at 0754.

Interview with MD #1 on 05/25/2016 at 1440 revealed the physician received information from the patient and family of nausea with vomiting. Further interview revealed Reglan (medication for nausea and vomiting) was ordered to assist with continued nausea.

Interview on 05/25/2016 at 1500 with AS #1 revealed the primary day nurse for Patient #6 on 03/05/2015 was a traveling nurse with a previous assignment and is no longer employed at the facility. Interview revealed the nurse is not available for interview.

Interview on 05/25/2016 at 1500 with AS #1 revealed the primary nurse did not follow the policy for reassessment of PRN medications. "We expect nurses to reassess the effects of the injectable medicines at least an hour after administration." Further interview revealed the nurse failed to reassess the patient after the administration of the nausea medicine.

NC00116036
NC00116032