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ADVENTHEALTH TAMPA
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on observation, clinical record review and interview it was determined the registered nurse failed to supervise the dialysis treatment to ensure the physician orders were implemented for three (#1, #2, #3) of ten records sampled.
Findings included:
1. A review of the physician order sheet and dialysis treatment flow sheets for Patient #1 revealed Hemodialysis Treatment orders for a blood flow rate (BFR) of 350.
A review of treatment date 08/27/2015 revealed the patient's BFR was ran at 250. A review of treatment date 08/28/2015 revealed the patient's BFR was ran at 300.
2. A review of the physician order sheet and dialysis treatment flow sheets for patient #2 revealed Hemodialysis Treatment orders for a blood flow rate (BFR) of 350.
Observation of the Dialysis treatment on 04/12/2016 at approximately 10:00 a.m. and review of dialysis orders with the machine settings revealed order for BFR of 350. The machine setting was a BFR at 300. The dialysis nurse confirmed order and reset the machine to BFR of 350. Record review of dialysis treatment sheet for 04/12/2016 revealed a BFR of 350 without documentation of incorrect setting or the correction of setting.
Interview with dialysis team lead on 04/12/2016 at approximately 2:00 p.m. confirmed the documentation should reflect the actual BFR and documentation of any changes or corrections to the BFR.
3. A review of the physician order sheet and dialysis treatment flow sheets for patient #3 revealed Hemodialysis Treatment orders for a blood flow rate (BFR) of 350.
Observation of the Dialysis treatment on 04/11/2016 at approximately 9:30 a.m. and review of dialysis orders with machine settings revealed an order for BFR of 350. The machine setting was BFR at 300. The dialysis team lead confirmed the order and reset machine to BFR of 350.
On 04/11/2016 at 3:10 p.m. the dialysis flow sheet was review with health information reviewer and revealed the documentation of the dialysis treatment revealed BFR was ran at 350 without documentation of incorrect setting or the correction of setting being made.
Interview with dialysis team lead on 04/12/2016 at approximately 2:00 p.m. confirmed the documentation should reflect the actual BFR and documentation of any changes or corrections to the BFR.
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