The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|ADVENTHEALTH LAKE WALES||410 S 11TH ST LAKE WALES, FL 33853||April 14, 2011|
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and staff interview it was determined that the Registered Nurse failed to supervise nursing care related to physician orders for daily weights for two (#8, #9) of 10 sampled patients. This practice does not ensure needed information is obtained to develop a plan of care.
1. Patient #8 was admitted on [DATE] with the diagnosis of renal insuffiencey, upper gastrointestinal bleed and history of stroke. The physician ordered daily weights at 6 a.m. to be recorded. Review of nursing documentation revealed the weight was not recorded on 4/13/11.
2. Patient #9 was admitted on [DATE] with the diagnosis of renal failure. Review of the physician admitting orders revealed daily weights were to be documented each day at 6:00 a.m. due to the diagnosis of renal failure. Review of nursing documentation revealed that the weight was not documented on 4/13/11.
The nursing director who was in attendance during the record review on 4/14/11 confirmed the above findings.