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.
|ORLANDO HEALTH||52 W UNDERWOOD ST ORLANDO, FL 32806||May 3, 2018|
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|Based on interview and record review, the hospital failed to ensure that a registered nurse (RN) supervised the nursing care of a patient in the final stage of pregnancy through documenting whether or not appropriate symptoms were discussed in a telephone conversation with a physician for 1 of 20 sampled patients (#1).
A review of the medical record pf patient #1 was performed. The patient was assessed in triage at the desk, on 1/19/18 at 1:23 AM.
A nurse's note of 1/19/18 at 1:45 AM by RN A read, "Vaginal exam...1/100 (1 centimeter dilated, 100% effaced), BBOW (Bulging Bag of Water) unable to feel presenting part....Cervical Dilation: 1. Cervical Effacement (%): 100....Bishop Score: 7."
A nurse's note at 2:16 AM on 1/19/18 by RN A read, "Paged Dr...." At 2:23 AM RN A's note read, "Dr...return call inform pt (patient) status 37 wks (weeks), G3P2 (gravida 3 para 2), breech and 1 CM (centimeter) on Tue (Tuesday), irreg (irregular) ctx (contractions), 1/100 unable to feel presenting part, still breech reactive cat (category) 1 tracing. Order to medicate pt with vistaril 100 MG (milligrams) and DC (discharge)." The pertinent symptom of a bulging bag of water was not documented as having been discussed with the physician.
A review of hospital policy "Assessment and Reassessment of Patients" revealed the following: "Documentation: As appropriate in the medical record." Since the pertinent symptom of a bulging bag of water was not documented as being part of the report to the physician, the nurse was not in compliance with this policy.
The finding was confirmed in a telephone interview with the Risk Manager on 5/04/18 at approximately 2:30 PM.