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ADVENTHEALTH NORTH PINELLAS
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on medical record review and staff interview it was determined the registered nurse failed to supervise and evaluate care related to patient monitoring and implementation of physician orders for one (#3) of ten patients sampled.
Findings included:
1. Review of the medical record for patient #3 revealed the patient was admitted on 2/5/2016. Documentation revealed the patient's heart rate was tachycardic. Tachycardia is a heart rate that exceeds the normal resting rate. The American Heart Association defines tachycardia as a heart rate over 100 bpm (beats per minute) as accepted as tachycardia in adults. Review of the record revealed the patient's heart rate on admission was 122 bpm. Documentation revealed the patient remained tachycardic throughout the admission.
Review of the physician orders dated 2/6/2016 at 10:21 a.m. revealed an order for cardiac monitoring. Review of the order revealed the RN (Registered Nurse) signed and confirmed the physician's order on 2/6/2016 at 10:56 a.m. The medical record for patient #3 revealed cardiac monitoring of the patient was not implemented by the RN.
An interview with the facility's Risk Manager on 5/17/2016 at approximately 1:50 p.m. confirmed the above findings.
2. Review of the medical record for patient #3 revealed on 2/6/2016 at 10:21 a.m. the physician ordered monitoring of the patient's intake and output. Review of the record revealed nursing staff failed to monitor the patient's fluid intake by mouth.
An interview with the facility's Risk manager on 5/17/2016 at approximately 2:20 p.m. confirmed the above findings.
ADMINISTRATION OF DRUGS
Tag No.: A0405
Based on medical record review and staff interview it was determined the facility failed to ensure medications were administered according to the orders of the authorized member of the professional medical staff for one (#3) of ten patients sampled.
Findings included:
Review of the medical record for patient #3 revealed a physician's order dated 2/10/2016 at 10:23 p.m. for NS (Normal Saline) with Potassium 20 mEq (milliequivalent) IV (Intravenous) at 75 ml (milliliters) per hour.
Review of the record revealed no evidence the IV fluid was initiated by the nurse. Review of the record and interview with the RM (Risk Manager) on 5/17/2016 at approximately 2:35 p.m. confirmed the findings.