HospitalInspections.org

Bases on interview and record review the nursing staff failed to address, reassess and monitor the patient symptoms after medications were ordered.

Findings:

Record review of the facility policy on "Nursing Documentation", dated 11/2018, stated;

C. Daily Reassessment:
Patients who are on precautions will have an assessment completed and documented every shift. Those who are not will have this documented once per day. In addition, nursing notes will document interventions and response to interventions.

Any changes in the patient's status (to include behavioral, physical, emotional, special precaution, and/or variances in care or outcomes)
Attending physician notified of change in patient status.

Record review on 07/19/2019 at 1315 of nursing documentation dated 05/23/2019 revealed no documentation of follow-up, reassessment or monitoring of symptoms after medications were ordered for patient (ID #1) who was diagnosed with vulvocandidiasis.

Interview on 07/19/2019 at 1:15 p.m. with registered nurse, staff (ID #L) who stated she documented on the patient on 05/23/2019, 05/28/2019, 05/30/2019 06/02/2019, 06/04/2019, and 06/05/2019. she stated,
"I do not see any documentation or follow-up for this issue".
"I should have documented something and followed up".