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Based on staff interviews and clinical records reviews it was determined that the Registered Nurse failed to supervise and evaluate nursing care for the use of oxygen and intravenous therapy for two (#3, #2) of three records reviewed. This practice does not ensure patient safety and that patient goals are met.

Findings include:

1. Patient #3's physician admission orders dated 2/11/10 instructed to initiate intravenous (IV) fluids at 125 milliliters (ml) per hour. Nursing admission documentation indicated the patient was admitted at 12:40 p.m. Nursing documentation on 2/11/10 at 1:15 p.m., 4:15 p.m. and 5:15 p.m. showed the IV fluid was infusing at 125 ml per hour. The intake record dated 2/11/10 did not show evidence of how much IV fluid the patient received from 1:00 p.m. to 7:00 p.m. (day shift).

Review of nursing documentation dated 2/11/10 for the night shift (7:00 p.m. to 7:00 a.m.) showed the IV fluid was infusing at 125 ml per hour. The intake record for the same time period indicated the patient received 1000 ml; the patient should have received approximately 1500 ml from 7:00 p.m. to 7:00 a.m. Nursing documentation dated 7/12/10 at 7:25 a.m. revealed the IV fluid was infusing at 125 ml per hour. Review of IV fluid intake for the day shift (7:00 a.m. to 7:00 p.m.) showed an intake of 1050 ml. Physician orders dated 2/12/10, no time but prior to 11:55 a.m., instructed to decrease the IV fluid to 75 ml per hour. Physician orders at 4:00 p.m. instructed to decrease the IV fluid to 25 ml per hour. Review of nursing documentation and the intake record did not show evidence of the time the IV fluid rate had been decreased as ordered. There was no evidence of an accurate evaluation of the amount of IV fluid the patient received.
Interview with the Director of Quality Management, Risk Manager, and Nurse Educator, after they reviewed the clinical record, on 4/7/10 at approximately 1:40 p.m. confirmed the above findings.

2. Patient #3's Emergency Department physician orders instructed to admit the patient to telemetry and that the patient was on two liters of oxygen via nasal cannula.
Review of nursing documentation from admission on 2/11/10 at 12:40 p.m. to the time of transfer to the Intensive Care Unit (ICU) on 2/12/10 at 12:06 p.m. revealed no evidence of oxygen being administered, discontinued, or the oxygenation saturation level being evaluated. The ICU nursing documentation on transfer showed the patient was diaphoretic, pale, had an increased heart rate, was lethargic, and hypoxic with a low oxygen saturation level of 74%. Interview with the Director of Quality Management, Risk Manager, and Nurse Educator, after they reviewed the clinical record, on 4/7/10 at approximately 1:40 p.m. confirmed the above findings.

3. Patient #2's physician's order instructed for oxygen at two liters via nasal cannula. Review of nursing documentation from admission on 2/26/10 to discharge did not reveal if the oxygen was administered, discontinued, or an evaluation of the oxygen saturation level.

Based on staff interviews and clinical records reviews it was determined that the facility failed to provide medications in accordance with physician orders for two (#3, #2) of three records reviewed. This practice does not ensure safe and effective medication management.

Findings include:

1. Patient #3's physician admission orders dated 2/11/10 instructed to initiate intravenous (IV) fluids at 125 milliliters (ml) per hour. Nursing admission documentation indicated the patient was admitted at 12:40 p.m. Nursing documentation on 2/11/10 at 1:15 p.m., 4:15 p.m. and 5:15 p.m. showed the IV fluid was infusing at 125 ml per hour. The intake record dated 2/11/10 did not show evidence of how much IV fluid the patient received from 1:00 p.m. to 7:00 p.m. (day shift).

Review of nursing documentation dated 2/11/10 for the night shift (7:00 p.m. to 7:00 a.m.) showed the IV fluid was infusing at 125 ml per hour. The intake record for the same time period indicated the patient received 1000 ml; the patient should have received approximately 1500 ml from 7:00 p.m. to 7:00 a.m. Nursing documentation dated 7/12/10 at 7:25 a.m. revealed the IV fluid was infusing at 125 ml per hour. Review of IV fluid intake for the day shift (7:00 a.m. to 7:00 p.m.) showed an intake of 1050 ml. Physician orders dated 2/12/10, no time but prior to 11:55 a.m., instructed to decrease the IV fluid to 75 ml per hour. Physician orders at 4:00 p.m. instructed to decrease the IV fluid to 25 ml per hour. Review of nursing documentation and the intake record did not show evidence of the time the IV fluid rate had been decreased as ordered. The intake documentation did not how evidence of the IV fluid being administered as ordered.
Interview with the Director of Quality Management, Risk Manager, and Nurse Educator, after they reviewed the clinical record, on 4/7/10 at approximately 1:40 p.m. confirmed the above findings.

2. Patient #2's physician's order instructed for Levaquin 500 milligrams (mg) daily. Review of the Medication Administration Record (MAR) showed no evidence of the Medication being administered on 2/26/10 and 2/27/10. Interview with the Director of Quality Management, Risk Manager, and Nurse Educator, after they reviewed the clinical record, on 4/7/10 at approximately 1:40 p.m. confirmed the above findings.