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ORLANDO HEALTH ORLANDO REGIONAL MEDICAL CENTER
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on interview and record review, the facility failed to ensure that a registered nurse supervised the nursing care of a patient in the form of determining a need for an "as needed" behavioral medication and, once administered, determining its effectiveness for 1 of 10 sampled patients (#1).
Findings:
A review of the medical record of patient #1 was performed. The patient was admitted to the facility on 5/22/14. Physician orders of 5/27/14 at 11:04 AM read, "Haldol give 1 to 3 MG IV push every 2 hours PRN (as needed) for agitation Start on 27 May 2014, stop on 22 April 2015 - IVP (Intravenous Push). Administer over 3-5 minutes." The order was entered by a registered nurse (RN) who also gave it to the patient on the same day. The time of the order entry was 11:02 AM on 5/27/14. This was a verbal order from the physician. It is unknown whether or not the nurse entered the order in the computer after having first receiving verbal authorization from the physician at an earlier time. The physician eventually signed the order at 12:37 PM on 5/27/14
There was no mention in the medical record on 5/27/14 of any behavior which necessitated the giving of this medication on that day. The Medication Administration Record (MAR) revealed that Haldol was given on 5/27/14 at 10 AM by the same RN who had entered the order (above). In addition, there was no mention in the record in a reasonable time period after the Haldol was given as to whether or not it had been effective for any specific behavior.
There was no mention in the medical record on 5/28/14 of any behavior which necessitated the giving of this medication on that day. The MAR revealed that Haldol was given on 5/28/14 at 1:37 AM by an RN. In addition, there was no mention in the record in a reasonable time period after the Haldol was given as to whether or not it had been effective for any specific behavior.
In not attesting for the need for an as-needed medication or confirming whether or not the medication, as given, was effective for any type of behavior, the involved RNs were not adequately supervising the care of the patient.
During an interview of the Risk Manager at approximately 5 PM on 12/17/14, she confirmed the finding.