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INTEGRIS HEALTH EDMOND HOSPITAL
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on record review and interview, the hospital failed to ensure monitoring for one (Patient #3) of five patients reviewed.
Findings:
Patient #3
Review of the medical record showed the patient was admitted to the NICU for respiratory distress and did not show nursing documentation of oxygen therapy. Specifically:
1. A physician's progress note dated 07/10/25 at 7:54 PM read in part, "Plan of Service: NICU ...Intensive ...respiratory monitoring ...Diagnosis: Pneumomediastinum ...Plan: Continue HFNC 5 LPM ...Follow FiO2."
2. The Infant/NICU Vitals flowsheet dated 07/10/25 showed no documentation for O2 Device, FiO2 or Oxygen Flow Rate from 10:00 PM - until hospital discharge on 07/11/25 at 3:05 AM. (5 hours)
3. An operative note dated 07/11/25 at 2:43 AM read in part, "Procedure Date: 07/11/2025 Procedure Time: 02:31 Indications: Tension pneumothorax ...a chest tube was inserted."
4. A nursing note dated 07/11/25 at 2:47 AM read in part, "Transfer team left at 3:05 AM."
On 08/27/25 at 4:15 PM, Staff J reviewed the medical record and stated oxygen therapy was to have been charted hourly or more frequently if there were changes in the patient.
On 08/28/25 at 11:06 AM, Staff G stated nurses in the special care nursery (NICU) were expected to chart HFNC and vital signs every hour to see how a baby was doing.