HospitalInspections.org

Based on document review nursing staff failed to supervise the nursing care for Patient #1. Specifically, physician orders were not carried out in regard to physical therapy/occupational therapy (PT/OT) evaluation and Visiting Nurse Association (VNA) referral for Patient #1.

Findings include:

Review of Physician's Order sheet dated 1/1/11 revealed PT/OT evaluation and treatment for status post below knee amputation and neuropathy. There is no evidence in the medical record that PT/OT evaluated the patient.

Review of Physician's Order Sheet dated 1/2/11 revealed VNA for care of right heel ulcer. There is no evidence in the medical record that this order was carried out.

Based on document review a registered nurse, social worker, or other qualified personnel failed to develop and supervise the post discharge needs for Patient #1.

Findings include:

Review of Discharge Instructions dated 1/2/11 revealed no evidence of the name of the physician and phone number, diet, activity, orthopedic care, and nursing health care instructions for diabetes. Also, there was no evidence the discharge planning referral to VNA was obtained as ordered.

This patient had four visits to the hospital over six days. There was no evidence this patient's post discharge needs were assessed by a discharge planner.

Based on document review a registered nurse, social worker, or other qualified personnel failed to develop and supervise the post discharge needs for Patient #1.

Findings include:

Review of Discharge Instructions dated 1/2/11 revealed no evidence of the name of the physician and phone number, diet, activity, orthopedic care, and nursing health care instructions for diabetes. Also, there was no evidence the discharge planning referral to VNA was obtained as ordered.

This patient had four visits to the hospital over six days. There was no evidence this patient's post discharge needs were assessed by a discharge planner.