HospitalInspections.org

Based on record review, policy review and staff interview, it was determined that the facility failed to ensure the registered nurse provided sufficient supervision to ensure appropriate care of 1 (#1) of 3 sampled patients. This practice does not ensure patient goals are met.


Finding include:

1. Patient #1 was admitted to the facility on 10/19/10 for brachytherapy for cervical cancer. Review of the physician orders revealed the patient was to be on strict bed rest with the head of bed elevated no more than 30 degrees. The physician also wrote an order for vital signs to be recorded every 4 hours. The facility's policy "Assessment and Reassessment of the Patient" # 3.02, revised 2/10 requires that the patient is to be assessed upon admission and at least during each shift thereafter. A document found in the medical record entitled "Nursing Instructions for Patients Treated with Brachytherapy Sources" requires the nursing staff to change the patients position every 2 hours.

2. Review of the patient's medical record revealed no evidence that the patient was repositioned every two hours. Review of the patient's problem list for the nursing care plan revealed that skin care was to be addressed. The facility's Skin Care protocol requires that the patient is to be repositioned every two hours and the patient's position is to be documented every two hours. This documentation could not be found.

3. Review of documentation of the vital signs revealed that the patient's vital signs were measured and documented on the times indicated below:
10/19/10 - 7:30 a.m., 12:15 p.m., 8:00 p.m.
10/20/10 - Midnight , 4:00 a.m., 8:00 a.m., 12:00 noon, 4:30 p.m., 8:00 p.m.
10/21/10 - Midnight, 4:00 a.m.
10/22/10 - 7:00 a.m.

4. Review of the patient's plan of care revealed the care of the patient receiving brachytherapy had not been selected as a nursing problem. The physician had written "Radiation Precautions" on the post procedure orders. The Oncology Educator was interviewed on 11/3/10 at approximately 2:00 p.m. She was asked what the Radiation Precautions protocol includes. She stated the protocol did not exist. She could not provide guidelines that are readily available for the nursing staff to follow regarding care of the patient receiving brachytherapy. During the exit interview on 11/3/10 at approximately 4:15 p.m., the Director of Nursing stated that the nurses are not to list problems for the care plan unless there are protocols available.

5. Review of nursing assessment revealed that the patient was not assessed during the 7 p.m. to 7 a.m. shift beginning on 10/20/10 and the 7 p.m. - 7 a.m. shift beginning on 10/21/10.

6. The physician wrote the order "no log roll" on the post procedure order. The Oncology educator, during interview on 11/3/10 at approximately 2:00 p.m. stated that the only way to reposition a patient with the implant in place is to log roll her. She also stated that the patient could not be adequately cared for without repositioning her. She confirmed that the order had not been questioned by the nursing staff.