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INGALLS MEMORIAL HOSPITAL
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on document review and interview, it was determined that for 1 of 5 patients' (Pt. #1) clinical records reviewed requiring peritoneal dialysis, the Hospital failed to notify the physician regarding delay in the implementation of the dialysis order, to ensure that a registered nurse supervised and evaluated the patient's care.
Findings include:
1. On 10/29/2020, the clinical record of Pt. #1 was reviewed. Pt. #1 was admitted to the Hospital on 9/7/2020 with a diagnosis of end-stage renal disease. The clinical record included:
- MD #2's (Nephrologist) peritoneal dialysis (PD) order dated 9/7/2020 at 5:01 PM included, " ...2.5 L (liters) 2.5% Dianeal (type of dialysis solution) every six hours."
- E #1's (Registered Nurse) progress note on 9/7/2020 at 9:45 PM included, "(Pt. #1) received in ICU ... as a new admission from ER (Emergency Department) ..."
- The clinical record indicated that Pt. #1 needed to start PD during the night shift on 9/7/2020. However, E #3 (ICU Manager) clarified that Pt. #1's dialysis was initiated on 9/8/2020 between 10:00 AM and 11:00 AM (approximately 12 hours after Pt. #1's admission). The clinical record lacked documentation that a physician was notified of the delay in implementing the PD order.
2. On 10/29/2020, the Hospital's Job Description for Registered Nurses (effective 4/18) included, " ...II. The Registered Nurse assumes primary responsibility for the ... implementation and evaluation of nursing care for assigned patients ... III ... Coordinates patient care services with the physician ..."
3. On 10/29/2020, the Hospital's policy titled, "Peritoneal Dialysis" (reviewed by the Hospital on 12/31/19) included, " ...Documentation ... Unexpected outcomes and related treatment ..."
4. On 10/29/2020 at approximately 1:30 PM, findings were discussed with E #3 (Manager, ICU). E #3 stated that the nurse should have notified the physician regarding the delay in the implementation of the dialysis order. E #3 could not provide documentation that a physician was notified.