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SOUTHCOAST HOSPITAL GROUP, INC
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on interview the Hospital's Department of Nursing failed to ensure CNA #2 reported to the Nursing Supervisor that Patient #1 was too lethargic to be fed her/his dinner on 1/4/11.
Findings include:
CNA #2 was interviewed in person on 2/9/11 at 2:30 PM. CNA #2 remembered Patient #1 and that CNA #1 reported that Patient #1 was not doing well and was lethargic. CNA #2 said he would not have fed Patient #1 if he had not been instructed by the Resource Nurse and encouraged by Patient #1's family to feed Patient #1.
MEDICAL RECORD SERVICES
Tag No.: A0450
Based on review of documentation on Patient #1's medical record, dated 1/3/11, 1/4/11 and 1/5/11 indicated the Hospital failed to ensure that all physician orders and all progress notes were authenticated by the physician writing.
Findings included:
Review of Physician Order Sheets indicated that not all physician signatures were illegible.
Review of progress notes indicated dated 1/3/11, and 1/5/11 indicated signatures were illegible for the name.