HospitalInspections.org

Based on medical record review and interview, the facility failed to provide adequate nursing supervision to ensure physician orders were followed for one patient (#8) of fifteen sampled patients.

The findings included:

Patient #8 was admitted to the facility on July 31, 2012, with diagnoses including Left Periprosthetic Femur Fracture.

Medical record review of the History and Physical dated July 31, 2012, revealed, "...Diabetes...Anemia...evidence of numerous skin tears all over the extremities..."

Medical record review of a physician's order dated July 31, 2012, revealed, "VS q8h (vital signs every eight hours)."

Medical record review of an Operative Report dated August 1, 2012, revealed, "...wound was irrigated and all points of bleeding were cauterized...knee then placed in immobilizer...Steristrips were placed to reinforce the wound..."

Medical record review of a Flowsheet dated August 2, 2012, revealed no documentation vital signs were obtained between 12:00 a.m. and 11:04 a.m. Medical record review of Flowsheets dated August 3 and August 4, 2012, revealed no documentation vital signs were obtained between 7:05 a.m. and 12:00 a.m. Continued review of a Flowsheet dated August 4, 2012, revealed no documentation vital signs were obtained between 6:00 a.m. and 3:55 p.m. Medical record review of a Flowsheet dated August 5, 2012, revealed no documentation vital signs were obtained between 6:00 a.m. and 4:56 p.m. Medical record review of a Flowsheet dated August 6, 2012, revealed no documentation vital signs were obtained between 6:30 a.m. and 4:52 p.m. Medical record review revealed no additional documentation regarding vital signs.

Interview with the Director of Quality on May 31, 2013, at 1:18 p.m., in an executive conference room, confirmed the facility failed to provide adequate nursing supervision to ensure the physician's order was followed.

C/O: #31217