HospitalInspections.org

Based on record review and staff interview it was determined the Registered Nurse failed supervise and evaluate care regarding measurement of intake and out put as order by the physician for 1 (#1) of 11 sampled patients. This practice may result in failure to identify patient's health care needs.

Findings include:

1. Patient #1 was admitted to the facility on 11/15/11 with chest pain, nausea, vomiting, diarrhea and dehydration. Physician's orders instructed for strict intake and output to be measured and documented. Review of the nursing documentation revealed that the nursing staff failed to document the amount of urine output on a consistent basis. The nursing staff documented the number of times the patient voided not the amount. During the hospitalization, the nursing staff documented several incidents of liquid stool, which also was not measured.

The manager of regulatory compliance was interviewed on 2/16/12 at approximately 1:00 p.m. She confirmed that the nursing staff failed to measure the patient's output as ordered