HospitalInspections.org

Based on staff interview and record review, the hospital failed to assure that the Registered Nurse (RN) evaluated the care provision for 1 of 10 applicable patients in the sample. (Patient #1) Findings include:

Per record review on 12/19/11 and 12/20/11, Patient #1 had specialized medical needs and had complained to the physician and nursing staff about problems with impaired skin integrity around a wound/stoma. Although the needs were identified on the care plan, there was no evidence in the medical record of nursing monitoring and/or assessment of the altered skin integrity. During interview on 12/20/11 at 2 PM, the RN Clinical Manager and the RN staff nurse who authored the care plan confirmed there was not evidence in the medical record of nursing interventions nor monitoring and assessment of the patient's status regarding impaired skin integrity.

Based on staff interview and record review, the hospital failed to assure that the Registered Nurse (RN) developed a care plan and evaluated the care provision for 1 of 10 applicable patients in the sample. (Patient #1) Findings include:

Per record review on 12/19/11 and 12/20/11. Patient #1 had specialized medical needs that were not included on the nursing plan of care. Although the needs were stated on the care plan, there were no measurable goals and specific interventions to assure that nurses addressed these needs. During interview on 12/20/11 at 2 PM, the RN Clinical Manager and the RN staff nurse who authored the care plan confirmed that the 2 identified needs were not addressed in the care plan. The nurses also confirmed there was not evidence in the medical record of nursing interventions nor monitoring of the patient's status relative to these specialized needs.