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NORTHWEST HEALTH- PORTER
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on document review and interview, nursing failed to follow policy in discharging AMAs 10 of 10 patients discharged with an AMA, Against Medical Advice (Pt11, Pt12, Pt13, P14, P15, Pt16, Pt17, Pt18, Pt19 and Pt20).
Findings Include:
1. Review of policy titled: Against Medical Advice last reviewed on 02/2019, indicated after patient leaves (AMA) an Event Report is to be completed.
2. Review of medical records indicated patients (Pt11, Pt12, Pt13, P14, P15, Pt16, Pt17, Pt18, Pt19 and Pt20) left AMA.
3. Review of Event Reports lacked documentation patients (Pt11, Pt12, Pt13, P14, P15, Pt16, Pt17, Pt18, Pt19 and Pt20) left AMA.
4. Interview on 08/20/20 at 10:40 am EST with P54 (Risk Management) confirmed that 10 of 10 MR reviewed with AMAs listed as the discharge did not have an Event Report completed.
PATIENT CARE ASSIGNMENTS
Tag No.: A0397
Based on document review and interview, nursing failed to ensure completed annual competency in 1 of 3 (P61) registered nurse personnel files reviewed.
Findings Include:
1. Facility unable to locate policy requiring completion of annual competencies for Registered Nurses.
2. Review of P61's (Registered Nurse) personnel file lacked documentation of annual completed competencies for 2019 up to 08/20/20.
3. Interview with P53 (Chief Nursing Officer) on 08/20/20 at 12:50 pm confirmed completion of annual competencies are required and if not completed on Skill Day or attended make-up days for completion, nurse is to be removed from the schedule.
4. Interview with P65 (Director of Inpatient Rehabilitation Unit) on 08/20/20 at 1:00 pm confirmed that P62 was not removed from schedule when competencies were not completed..."should have happened".