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UNITED REGIONAL HEALTH CARE SYSTEM
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on record review and interview, the facility's registered nurse (RN) did not supervise and evaluate the nursing care for Patient #7, in that the RN did not promptly reassess the patient after administering pain medications twice on 11/8/16.
Findings Included:
On 11/8/16 at 11:18 AM Personnel #8 administered 0.5 mg Dilauded IV to Patient #7. At 12:18 PM Personnel #5 administered 0.5 mg Dilauded IV. There is no evidence that Personnel #7 reassessed the pain level after administering pain medication. There is no evidence that Personnel #5 assessed the pain level of Patient #7 prior to administering a second dose of pain medication or after administering a second dose of pain medication.
During and interview on 1/25/17 at 1:00 PM Personnel #5 verified there was not a reassessment of the pain level after either dose of Dilauded was given.
The policy tilted Pain Assessment, Reassessment and Management dated 12/1/10 and revised 12/31/13 reflected...Questions related to pain...intensity of pain using age or condition appropriate assessment tools...Reassessment is recommended to occur within 15-60 minutes following treatment...
SUPERVISION OF CONTRACT STAFF
Tag No.: A0398
Based on interview and record review the non-employee licensed nurse working at the hospital did not adhere to the policies and procedures of the hospital, in that Personnel #5 did not follow the policy and procedure when disconnecting the IV (intravenous) line from Patient #7's venous access port.
Findings Included:
Patient #7 was admitted to the ER (Emergency Room) for Sickle Cell Crisis on 11/8/16. Personnel #5 disconnected the IV from the venous access port at 12:20 PM Personnel #5 charted "removed the port access Huber needle."
During and interview on 1/25/17 at 1:00 PM Personnel#5 verified that she removed the Huber needle from the venous access port. Personnel#5 stated that she did not chart that she flushed the port with normal saline. When questioned about why she did not chart the normal saline flush, Personnel #5 stated she did not normally chart that she the flushes the ports. When Personnel #5 was asked if Normal Saline is a drug and should therefore be charted, Personnel #5 answered yes.
CVAD (central venous access device) Essentials, the training guide and guidelines for the facility for using CVADs reflected...flush with 10 ml of normal saline before and after each use...