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INDIANA UNIVERSITY HEALTH
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on document review and interview, Nursing Administration failed to ensure that supervision of patient care was completed in 1 of 10 medical records reviewed (Patient 5).
Findings Include:
1. Medical record for patient #5 indicated order placed by Pharmacist for daily weights on 01/28/22 to start 01/29/22, and co-signed by physician.
2. Review of MR for patient #5 indicated weights documented on 01/31/22 and 02/22/22 only.
3. Interview on 04/11/22 at 11:36 am with P51 (Clinical Nurse Specialist) confirmed lack of documentation of daily weights from date of order on 01/28/22 to time of discharge on 03/01/22.