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Based on interviews and review of documentation, and Hospital policy, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for Patient #1.

Findings included:

Review of the policy titled: Patient Progress Documentation indicated that nursing staff must document related progress towards patient outcomes and the plan of care.

Review of nursing documentation for the evening shift on 1/11/11 indicated Patient #1 was having frequent stools, continued buttock redness. There was no documentation to indicate a plan of care for the redness and no documentation to indicate treatment was provided.

Based on documentation review and staff interview the nursing staff failed to develop a nursing care plan to address Patient #1's reddened, excoriated skin on his/her buttocks with with appropriate interventions to reduce irritation on the buttocks.

Findings include:

Review of Hospital policies and procedures related to patient progress documentation indicated documentation was required for implementation of the plan of care and a patient's progress or response.

Review of the Admission Nursing Assessment dated 1/10/11 indicated Patient #1 was alert and oriented with a soft distended abdomen, hyperactive bowel sounds, and watery diarrhea.

Nurse #1's documentation indicated Patient #1 continued with constant liquid stool and anti-diarrhea medications were administered as ordered. Patient #1's rectal area was described as red and inflamed and Lidocaine was applied twice. There was documentation to indicate a moisture barrier was applied.

Review of nursing documentation for the evening shift on 1/11/11 indicated Patient #1's frequent stooling and reddened buttocks continued.

Continued review of Patient #1's medical record indicated no plan of care for the treatment of red/inflamed and excoriated buttocks.

Nurse #3, the nurse assigned to care for Patient #1 on the 1/12/11 and 1/13/11 during the day shift was interviewed in person on 3/8/11 at 1:30 PM. Nurse #3 said Patient #1's buttocks were red and excoriated, but there were no broken areas or pressure ulcers and topical lotions were constantly being applied to the excoriated areas. However there was no plan of care documented.

Review of Nurse #3's documentation dated 1/12/11 indicated Patient #1 continued with liquid stools and excoriated buttocks.

Continued review of skin assessments dated 1/12/11, 1/13/11 and 1/14/11 indicated Patient #1's rectal area remained red and excoriated. Nursing documentation did not consistently indicate treatments provided to the excoriated skin and/or the response to treatment.

Based on interview and documentation review, it was determined that nursing staff failed to administer medications in accordance with physician's orders and acceptable standards of practice and and failed to administer IV fluids as ordered.

Findings included:

Review of Patient #1's Admission Orders for NPH insulin 20 units and 5 units of Lispro indicated the doses of insulin were to be administered to be administered every evening (8:00 PM).

Review of Patient #1's MAR dated 1/11/11 indicated the PM dose of NPH was administered at 10:50 PM, not 8:00 PM as was indicated.


Review of Hospital polices/procedures related to the administration of medications indicated each medication is assigned a scheduled administration time and medications may be given 1/2 hours before or 1/2 hour after that schedule time.

Review of Physician Orders dated 1/11/11 at 11:11 AM indicated an order for lactated ringers at 30 milliters (ml)/hour (hr).

Review of nursing documentation completed on 1/11/11 at 11:19 AM indicated Patient #1's IV fluids were changed from normal saline to lactated ringers, but the rate entered into the record was 150 ml/hr instead of 30 ml/hr. Documentation did not indicated how much IV fluid Patient #1 received during the day shift.

Review of Nurse #2's documentation from 3:00 PM to 11:00 PM on 1/11/11 indicated Patient #1 received 1,111 ml of IV fluid, not 240 ml as ordered.