HospitalInspections.org

Based on medical record review, policy review, and staff interview, the hospital staff failed to supervise and evaluate nursing personnel and adhere to hospital policy for 5 out of 10 patients (#1,10, 11,16 & 17) admitted to 5 West Unit.

Findings:
Review of policy, "Nursing Assessment for Observation of Patients on 5 West OBS partly stated:
"...IV. Evaluation
A. Ongoing re-evaluation and assessments will be completed throughout the duration of the patient's stay in
the OBS Unit.
B. The patient's response to interventions ordered by the primary or provider will be documented in the EMR. "

Patient #1 medical record revealed:
- On 3/15/24 at 1059, pt #1 transferred to 5 West OBS floor from Post Anesthesia Care Unit: (PACU)
- Physician orders : SCD (sequential compression device)
- Patient was discharged home on 3/17/24 at 1457.
- No documentation for ordered SCDs were implemented throughout hospitalization.
Review of the charts for patients 10, 11, 16, & 17 revealed no documentation of ordered SCDs being implemented.
An interview on 10/15/24 conducted with staff #6 and staff # 10 confirmed there was no documentation of implementation of the physician ordered SCDs and the nurses did not follow the hospital policy.