HospitalInspections.org

Based on clinical record review and interview, it was determined staff failed to follow Physician's Orders regarding enuretic protocols for one of one patient (Patient #2). The failed practice did not ensure Patient #2 was assessed periodically at night in an effort to prevent bedwetting. Findings follow:

A. Review of the clinical record for Patient #2 revealed an order for enuretic protocol beginning on 10/30/14 through discharge on 02/17/15.

B. Review Session Information (Nurse's Notes) under Enuretic Protocol revealed Patients are to be assessed at midnight, 0300 and 0600 to determine if the patient needs to use the restroom, whether they voided or refused, whether the bed is wet or dry and whether or not the linens needed to be changed. There was no documentation under Enuretic Protocol in Patient #2's clinical record during the entire admission.

C. During an interview on 06/09/15 at 1230, the Administrator confirmed there was no Enuretic Protocol documentation in Patient #2's clinical record.