HospitalInspections.org

Based on document review and staff interview it was determined for 1 of 4 (Pt #2) patients with skin integrity diagnoses, the Critical Access Hospital (CAH) failed to ensure a nursing care plan was developed and implemented in accordance with physician orders. This failure has the potential to affect all patients receiving services for skin integrity issues,currently a census of 6.

Findings include:

1. On 9/4/19 at 10:00 AM, the medical record of Pt #2 was reviewed. On 8/23/19 at 11:00 AM, Pt #2 was a direct inpatient admit from the Physician's office for diagnoses of hypernatremia, dehydration, hypoxia and altered mental status. On 8/23/19 at 11:00 AM, the Physician wrote an order for Pt #2 to be repositioned hourly. Documentation indicated Pt #2 was turned every two hours and not hourly as ordered.

2. On 9/5/19 at 12:00 PM, a request for a physician order policy was made. At 2:00 PM, an interview was conducted with the Chief Nursing Officer (E#1). E#1 stated, "we don't have a policy for handwritten orders. The expected procedure is for the House Supervisor to enter the handwritten orders into the electronic medical system. The Pharmacist and House Supervisor review the orders. The House Supervisor then reports the orders to the assigned nurse. The assigned nurse reports to the CNA (Certified Nursing Assistant) for implementation." E#1 reviewed the medical record of Pt #2 and confirmed the documentation indicated Pt #2 was only turned every two hours and not hourly as ordered.