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Based on record review and staff interview, the Registered Nurse failed to supervise and evaluate care to ensure a complete and appropriate assessment of the response to a nursing intervention for one (#5) of ten sampled patients was performed.

Findings included:

Patient #5's record revealed nursing documentation dated 1/25/16 at 5:02 a.m. noted the patient's blood pressure was 200/105. The Medication Administration Record documented the RN administered Vasotec 1.25 milligrams intravenously in accordance with the physician's orders. The documentation revealed the blood pressure was rechecked one minute later at 5:03 a.m. with no change. The blood pressure was not rechecked until 6:59 a.m., nearly two hours later.

An interview and record review was conducted with the nurse manager of the nursing unit on 2/2/15 at the time of the record review. She confirmed the finding patient #5's response to the intravenous blood pressure medication was not assessed in a timely manner.