HospitalInspections.org

Based on record review and interview the registered nurse did not supervise and evaluate the nursing care for seven patients (ID#2,3,4,5,8,9,10) of 12 records reviewed.

Findings Included:

Record review of the facility policy "Nursing Services: Interdisciplinary Plan of Care (IPOC) via Electronic Medical Record" dated 08/20/22, stated:
The IPOC will be initiated on admission by the RN and reviewed every 24 hours by the RN".

Record review on 2/16/2023 between 10-12 pm revealed the following:

Patient (ID#2) was a 75-year-old admitted 02/09/23 for septicemia and noted to have skin blisters, and a history of diabetes. The patient did not have diabetes or skin care addressed in the plan of care.

Patient (ID#3) was an 82-year-old admitted 02/02/23 for severe sepsis and was incontinent with a history of diabetes revealed no documentation of turning on the following dates:
03/12/2023 between 4pm-8pm,
02/13/2023 between 8pm-6am,
02/14/2023 between 8pm-4am,
02/15/2023 between 10 am-6pm

Patient (ID#4) was a 68-year-old admitted 02/14/2023 for infectious and parasitic disease and a history of diabetes. Diabetes was not addressed in the plan of care.

Patient (ID#5) was an 88-year-old admitted 01/18/23 for GI obstruction and a history of diabetes. Diabetes was not addressed in the plan of care.

Patient (ID#8) was a 77-year-old admitted 02/14/23 for major hip/knee joint replacement with a a history of hypotension, and chest pain, which was not addressed in the plan of care.

Patient (ID#9) was an 83-year-old admitted 02/10/2023 for minor skin issues and a history of diabetes, GI Bleed, and falls. Diabetes was not addressed in the care plan.

Patient (ID#10) was a 67-year-old admitted 02/11/2023 for fractured hip and pelvis, and a history of diabetes and falls. Diabetes, skin integrity and safety were not addressed in the plan of care.

Interview with charge nurse (ID #54) on 02/16/2024 during chart review confirmed the above findings noted in the patients' record.