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ST VINCENT MEDICAL CENTER/NORTH
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on clinical record review and policy and procedure review, it was determined a Registered Nurse (RN) failed to supervise and evaluate the nursing care in that two (#1 and #5) of six (#1-#6) patient's clinical records did not contain documentation that Intake and Output was performed every 12 hours as ordered. Failure to obtain Intake and Output totals did not give the physician the information necessary to make clinical decisions. The failed practice affected Patients # 1 and # 5. Findings follow.
A. Review of Patient #1's clinical record showed a physicians order dated 01/08/18 at 8:20 AM for Intake and Output measurement every 12 hours. Review of the clinical record showed intake was not recorded in three out of four opportunities and output was not recorded in two out of three opportunities from 01/08/18 to 01/09/18. Findings were verified with RN #6 and RN #1 on 01/09/18 at 1:45 PM.
B. Review of Patient #5's clinical record showed physicians order dated 01/05/18 at 12:23 AM for intake and output measurement every 12 hours. Review of the clinical record showed output was not recorded for 6 out of 13 opportunities from 01/05/18 to 01/09/15. Findings were verified with RN #6 and RN #1 on 01/09/18 at 2:10 PM.
NURSING CARE PLAN
Tag No.: A0396
Based on clinical record review and policy and procedure review it was determined that one of ten (#1-10) patient's records did not have a care plan initiated upon admission. Failure to initiate a plan of care on admission does not ensure the Registered Nurse (RN) can evaluate and plan nursing interventions in response to the identified patient needs. The failed practice affected Patient #7. Findings follow:
A. Review of Facility policy and procedure titled "Documentation: Patient Assessment and Coordination of Care" showed, "III. A. 1. The IPOCs (Interdisciplinary Plan of Care) will be initiated and prioritized or rejected in the EMR (Electronic Medical Record) by the shift primary RN within 24 hours of admission for all inpatients." Findings were verified with RN #1 and RN # 6 on 01/09/18 at 2:15 PM.
B. Review of Patient #7's clinical record showed no care plan had been initiated on admission. Findings were verified with RN #6 and RN #1 on 01/09/18 at 2:15 PM.