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Based on clinical record review, facility policies and staff interviews it was determined the registered nurse failed to supervise and evaluate the nursing care for 1 (#1) of 4 sampled patients. The continued use of this practice could result in a delay in patient treatment which may lead to patient injury and/or death

Findings include:

Patient #1's temperature fluctuated from within normal limits to elevated from the date of admission through 11/2/10. These fluctuations were noted in both the nursing and physicians documentation. Nursing documentation dated 11/3/10 revealed the patient's vital signs were documented at 5:00 a.m. The patient was assessed at 7:52 a.m. by a Licensed Practical Nurse but no vital signs were obtained. Review of nursing documentation revealed the patient was transferred to a Skilled Nursing Facility at 1:30 p.m. The last set of vital signs obtained were on the 7:00 p.m. to 7:00 a.m. shift. There were no vital signs taken on 7:00 a.m. to 7:00 p.m. shift prior to discharge at 1:30 p.m. There was no evidence of a nursing discharge summary or assessment being completed including vital signs. Review of the Skilled Nursing Facility admission nursing documentation showed an admission temperature of 102.8.

A review of the Nursing policy "Practice Standards" no policy number revised 9/2010 revealed Standard VII: b. vital signs are taken and recorded once per shift; the frequency of measurement is increased when abnormalities exist, and Standard IX: a. the discharge summary includes: 1) Response to treatment and care; current status.

An interview with the Director of Nursing conducted on 12/8/10 after review of the subjects clinical record, revealed no temperature was taken after 5:00 a.m. When questioning whether this was appropriate, the Director of Nursing responded the policy only calls for vitals every shift.

Based on clinical record review, facility policies and staff interviews it was determined the facility failed to ensure the nursing discharge summary was completed on 1 (#1) of 4 clinical records reviewed.

Findings include:

A review of patient #1's clinical record dated for 11/3/10 revealed the patient was assessed at 7:52 a.m. by a Licensed Practical Nurse. Further review of the patients clinical record revealed the patient was transferred to a skilled nursing facility at 1:30 p.m. without a nursing discharge summary being completed.

A review of the facility's policy titled Discharge Planning, policy # H-ML 10-013, revised 11/2009, revealed the following.
The review of the section indicted the Roles in Discharge Planning, Nurses: it stated "document discharge summary in the medical record."

A review of the Nursing policy, Practice Standards, no policy number, revised 9/2010 revealed the following.
Standard IX: a. the discharge summary includes: 1) Response to treatment and care; current status

An interview was conducted with a random staff nurse on 12/7/10 at approximately 3:30 p.m. During the interview the nurse was questioned as to when the discharge summary was documented and the response was the day of discharge.

An interview with the Director of Nursing conducted on 12/8/10 after review of the subjects clinical record, the Director verified there was no nursing discharge summary documented prior to the patient leaving the facility.