HospitalInspections.org

Based on document reviews and interviews, the RN did not supervise the care of one of one applicable patient to ensure physician orders were followed. Findings include the following:

1. On June 21, 2010, the physician wrote orders prior to patient's discharge to a skilled nursing facility (SNF) for nursing staff to "remove all staples and apply steri-strips".

2. Documentation in patient's clinical record revealed that he had two sites where staples had been placed:

a. The right side of his head from a laceration suffered from a fall on June 9, 2010.
b. The staples at patient's surgical site from a colon resection also on June 9, 2010.

3. Nursing documented on June 21, 2010 the following: "removed staples steri-strips". Nursing had not documented the site or sites from where the staples had been removed.

4. During an interview with the patient's spouse on August 11, 2010 at 11:30 a.m., she alleged that her husband had been discharged to a SNF with the staples remaining in his scalp. She stated she noted this when reviewing a copy of her husband's record and felt the staff had "lied" when they had documented the removal of staples.

5. Interviews with administrative staff (#50 and #51) at 4:30 p.m. on August 11, 2010 confirmed they could not verify from the documentation in the patient's clinical record that the patient's staples from both sites had been removed.

6. It was confirmed that the scalp staples had been removed at the SNF. Documentation obtained from the SNF on August 12, 2010 showed this had been done on June 23, 2010 at 10:30 a.m.