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SOUTH FLORIDA BAPTIST HOSPITAL
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on medical record review and staff interview it was determined the registered nurse failed to supervise and evaluate nursing care related to the patient's bowel function for one (#3) of 11 patients sampled.
Findings include:
Patient #3 was admitted on 12/02/2013. A review of the electronic medical record noted two areas to chart output. An area labeled for bowel movement revealed the patient had a total of 5 bowel movements (BM) from 12/13/2013 to 12/31/2013 on the following dates:
1 BM on 12/03/2013 between 10 and 11 a.m.
1 BM on 12/28/2013 between 6 and 7 p.m.
1 BM on 12/30/2013 between 2 and 3 a.m.
1 BM on 12/31/2013 between 4 and 5 a.m.
1 BM on 12/31/2013 between 8 and 9 a.m.
Further review of the chart with the risk manager and a charge nurse revealed another section was identified as a place to document bowel movements with the output logged as a "yes" on the following dates:
Yes on 12/04/2013
Yes on 12/05/2013
Yes on 12/06/2013
Flatus (gas) on 12/09/2013 and 12/11/2013
Yes on 12/13/2013
Flatus (gas) on 12/16/2013, 12/17/2013, 12/20/2013, 12/21/2013
Yes on 12/26/2013
Yes on 12/27/2013
Yes on 12/29/2013
Interview on 03/19/2014 at 11:45 a.m. with the Risk Manager confirmed there was no consistent documentation of a bowel movement for the patient. The Risk Manager confirmed no documentation of bowel movements from 12/03/2013 to 12/28/2013 (25 days) in the first section or in the second section from 12/06/2013 to 12/13/2013 (7 days) and 12/13/2013 to 12/26/2013 (13 days).
ADMINISTRATION OF DRUGS
Tag No.: A0405
Based on clinical record review and staff interview it was determined the nursing staff failed to administer tap water enemas according to physician orders for 1 (#3) of 11 sampled patients.
Findings include:
Patient #3's physician order sheet revealed an order for a tap water enema on 12/23/2013.
A detailed review of the patient's entire medical record did not produce any documentation of the patient receiving the physician ordered tap water enema.
The review was confirmed by the risk manager and charge nurse who assisted in the chart review on 03/19/2014 at approximately 1:00 p.m.