HospitalInspections.org

Based on medical record reviews and interview with staff, it was determined the hospital failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care for three (3) of ten (10) patients reviewed (patients #1, 9 and 10) relative to provision of personal care, care of a wound and following physician's orders. This has the potential to negatively affect the quality of nursing care provided to all patients.

Findings include:

1. Review of the medical record for patient #1 revealed the patient was assessed as being high risk for skin breakdown on the day of admission on 12/24/2012. The nursing care plan developed at the time of admission directed staff to turn the patient every two (2) hours as a preventive measure. Review of the nursing notes revealed there was no documented evidence the patient was turned at least every two (2) hours on 12/24/12, 12/25/12, 12/26/12, 12/27/12, 12/28/12 and 12/29/2012. The RN failed to ensure the patient's care plan was followed relative to being turned at least every two (2) hours.

2. A RN (Staff #4) was interviewed on 2/5/2013 at 8:30 a.m. She stated she cared for patient #1 on 12/30/2012 on the 7 a.m. to 7 p.m. shift and that the patient's mouth was "dry and crusty" when she made a.m. rounds with the Patient Care Assistant (PCA) at 7 a.m. Documentation in the medical record indicates that oral care was not provided for the patient during the 7 a.m. to 7 p.m. shift until 1:00 p.m. on 12/30/2012. The RN failed to ensure the PCA provided mouth care as needed in at least one (1) instance.

3. The Charge Nurse reviewed the medical record and discussed the care of the patient on 2/6/2013 at 2:55 p.m. and she concurred with the findings.

4. Review of the medical record for patient #9 revealed the patient was admitted on 12/17/2012 and was discharged on 12/20/2012. There was a physician order dated 12/17/2012 for "daily weights". The daily weight was recorded on 12/17/12 and 12/20/2012. There was no daily weight recorded on 12/18/12 or 12/19/1012. The RN failed to ensure the weight was obtained and recorded daily as ordered.

5. The record was reviewed with the Charge Nurse on 2/5/2013 and she concurred with the findings.

6. Review of the medical record for patient #10 revealed the patient was admitted from home on 12/18/2012 and was discharged to a nursing home on 12/21/2012. At the time of the nursing assessments documented each shift, it was noted the patient had a "dressing" to a wound on the right breast. The Physical Therapist documented an evaluation on 12/18/2012 and noted "wound care per RN (Registered Nurse). There was never a description of the wound by the nursing staff, nor were there specific entries to reflect the nursing staff had or had not changed the dressing during the entire admission. At the time of the discharge to the nursing home, the nursing staff failed to document the wound and/or wound care instructions were conveyed to the nursing home staff.

7. The record was reviewed with the Charge Nurse on 2/7/2013 at 9:00 a.m., and she concurred with the findings.