HospitalInspections.org

Based on policy review, record review and interview, the facility failed to ensure nursing services were provided per physician orders for 1 of 4 (Patient #1) sampled patients.

The findings included:

1. Review of the facility's "NURSING POLICY AND PROCEDURE SUBJECT: DOCUMENTATION" policy (revised 11/19) revealed, " ...Document the patient's response to treatment as evaluated and reassess as the patient's condition warrants ...Daily Documentation ...Initial assessment every shift ...Special procedures/treatments/surgeries ..."

2. Review of the facility's "PHYSICIAN'S ORDERS: RECEIVING AND PROCESSING" policy (revised 3/21) revealed, " ...Physician orders are required prior to providing medical care to patients in the hospital ...To assure all physician orders have been processed and noted properly, the nurse assigned to the patient will review the physician orders received during his/her shift ..."

3. Medical record review for Patient #1 revealed an admission date of 9/23/2022 with diagnoses that included Pneumonia and recent Rotator Cuff surgery.

Review of a physician order on 9/23/2022 at 5:27 PM revealed Patient #1's shoulder dressing was to be removed.

Review of nursing documentation beginning 9/23/2022 through Patient #1's discharge on 9/24/2022 revealed no documentation the shoulder dressing was removed as ordered.

In an interview on 11/8/2022 at 9:30 AM Nurse Manager #1 verified there was no documentation Patient #1's shoulder dressing was removed as ordered.