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Based on clinical record review, policy review and staff interview it was determined that the Registered Nurse failed to supervise and evaluate the nursing care for 7 ( #1, #2, #5, #6, #7, #8, #10) of 10 records reviewed related to assessments, care plans, patient education, and personal hygiene. This practice does not ensure patient safety and that goals are met.

Findings include:


The Registered Nurse (RN) did not complete the Care Plans for 6 (#1, #5, #6, #7, #8, #10) patient records reviewed. The RN did not complete the Interdisciplinary Education Records for 2 (#2, #7) patients. The RN did not ensure personal hygienic care was provided for 3 (#1, #7, #8) patients sampled. The RN did not complete the initial assessment for patient #2.

1. Patient #1 was admitted on 3/20/11 for complaints of chest pain and shortness of breath. The diagnosis included acute congestive heart failure, Myocardial infarction, unsteady gait, encephalopathy, and anemia. The patient's care plan was initiated but not resolved. Review of nursing documentation revealed the patient received oral care, a partial bath and urinary catheter care on 3/21/11. There was no evidence of any further personal or urinary catheter care provided.

2. Patient #2 was admitted on 3/16/11 for shortness of breath. The diagnosis included constipation, hyperlipidemia, hypertension, gastric esophageal reflux disease, and urinary retention. The patient's Interdisciplinary Education Record was not completed by nursing. The patient's initial assessment and admission database was completed by a Licensed Practical Nurse but not co-signed by a Registered Nurse.

3. Patient #5 was admitted on 3/27/11 for acute respiratory distress. The history included cardiac disease, hypertension, hypercholesterolemia, diabetes with retinopathy disease, and anemia. The plan of care was initiated but never resolved.

4. Patient #6 was admitted on 3/21/11 for Hypoxia. The history included carotid artery disease, hypertension, and benign prostatic hypertrophy, A review of the care plan revealed it was initiated but not resolved.

5. Patient #7 was admitted on 3/18/11 with altered mental status. The history included right hemiparesis and osteoarthritis. Review of the clinical flow sheet revealed the patient was incontinent of urine and bowel. Further review of the flow sheet revealed there was no documentation of any hygiene preformed during the hospitalization. A review of the care plan revealed the plan was initiated but not resolved prior to discharge. Review of the Interdisciplinary Education Record revealed there was no documentation by nursing.

6. Patient #8 was admitted on 3/19/11 for mental status changes. The history included Alzheimer's, dementia, bilateral stroke, diabetes, and osteoporosis. A review of the clinical flow sheet revealed no documentation of any hygiene being preformed. Further review of the flow sheet revealed the patient was incontinent of bowel and bladder. A review of the plan of care revealed it was initiated but not resolved at discharge.

7. Patient #10 was admitted on 3/24/11 for a fracture to the right foot. The history included alcohol abuse, severe symptomatic hypoglycemia, Type 1 diabetes and urinary tract infection. A review of the care plan revealed it was initiated but not resolved.

A review of the policy, "Patient Care Process" , policy# 100.185.74, effective 8/2009 revealed:
1. On page 1 of 3, Assessments, Each patient's need for nursing care is assessed by a Registered Nurse.
Paragraph #6, under the direction of the Registered Nurse, Licensed Practical Nurses who have demonstrated competency in physical assessment skills may assist in collecting information for reassessment.
2. On page 2 of 3, Problem Identification, 1) patient needs or problems are identified on admission by the Registered Nurse and documented on the Plan of Care/Problem list. 4) desired outcomes for patient learning ,guidelines for content to be taught and lists of available materials are identified on the Interdisciplinary Education Record.
3. On page 3 of 3, Evaluation, 1) the Registered Nurse will review/update the Plan of Care/Problem List once every 24 hours. If expected outcomes have been achieved, the problem is resolved and noted as "Met". Problems not resolved at discharge will be referred as appropriate.

A review of policy, "Foley Catheter Care", policy #182.00.40, effective 9/2010, revealed under paragraph for Preparation and Care, "care should be provided twice daily { a.m.(morning) care and hs( evening) care} and after every bowel movement or soilage."


An interview with the Director of Nursing and the Risk Manager was conducted on 3/30/11 at 8:30 a.m. confirmed the above findings.