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Based on record review and interview, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:
1) The RN failed to ensure weight was obtained and documented on admission for 1 (#5) of 5 patient records reviewed for physician orders related to daily weights.
2) The RN failed to ensure wounds were assessed and documented upon admit for 1 (#5) of 3 patients reviewed for wound care from a total of 5 records.
3) The RN failed to ensure accurate I&O were maintained on patients with urinary catheters for 1 (#5) of 5 records reviewed with urinary catheters.
4) The RN failed to ensure medications were not left at the bedside without a physician order for 1 (#5) of 5 records reviewed for medications.
Findings:

1) The RN failed to ensure weight was obtained and documented on admission for 1 (#5) of 5 patient records reviewed for physician orders related to daily weights.
Patient #5
Review of the Routine Admission Orders dated 06/15/17 revealed physician order for daily weights.

Review of the Interdisciplinary Admission Evaluation dated 06/15/17 revealed there was no documented admission weight.

Interview on 11/07/17 at 11:30 a.m. with S2DON confirmed that there should have been a weight obtained and documented upon admission.

2) The RN failed to ensure wounds were assessed and documented upon admit for 1 (#5) of 3 patients reviewed for wound care from a total of 5 records.
Patient #5
Review of the Interdisciplinary Admission Evaluation dated 06/15/17 revealed there was no documented wounds and skin was assessed as warm, pale, dry, and loose.
Review of the Skin Wound Assessment Form dated 06/16/17 at 7:45 p.m. revealed documentation of wound to left upper dorsalary, and left ventral elbow area with photo and measurements and treatment orders. The patient was admitted on 06/15/17 at 12:00 p.m.

Review of the hospital policy titled Wound Care, Document Number NUR 17.88, revised 12/12 revealed in part: B. Nursing Interventions, 1) Risk assessment should be performed upon admission, weekly, or change in skin condition. 6) Photographs of wounds will be taken on admission, weekly and on discovery of a new wound. All photographs of wounds will have current date and patient name, and placed on the Skin and Wound Assessment form and signed by the nurse taking picture/completing the form.

Interview on 11/07/17 at 11:30 a.m. with S2DON confirmed that there should have been an assessment of all wounds on admit with photographs and measurements obtained upon admission.

3) The RN failed to ensure accurate I&O were maintained on patients with urinary catheters for 1 (#5) of 5 records reviewed with urinary catheters.
Patient #5
Review of the Interdisciplinary Admission Evaluation dated 06/15/17 revealed documentation for a urinary catheter but type and size were not documented upon admit.

Review of the Intake and Output sheet dated as follows:
- 06/15/17 revealed a documented total of 600 ml output.
- 06/16/17 revealed no documented measured amounts from catheter for day shift, only x1 at 7:00 a.m., 10:00 a.m., 12:00 p.m., and 3:00 p.m.
- 06/17/17 revealed no documentation for day shift
The indwelling catheter was d/c'd on 06/17/17.

Review of the hospital policy titled Intake and Output, Document Number 17.90, revised 7/17 revealed in part: The following will provide guidance accordingly for patients who should have I & O monitored. 2. Patients with Indwelling/Suprapubic catheters.

Interview on 11/07/17 at 11:30 a.m. with S2DON confirmed that should measure and document on I&O sheet amount for all patients with urinary catheters per policy.

4) The RN failed to ensure medications were not left at the bedside without a physician order for 1 (#5) of 5 records reviewed for medications.
Patient #5
Review of the Physicians Orders dated 06/20/17 revealed Milk of Magnesia (MOM) 60 ml po time's one dose now. Miralax 17gm po in liquid times one dose now then Miralax 17gm po in liquid q hs.

Further review of the Physicians Orders revealed no orders for medications to be left at the patient's bedside for self-administration by patient/family.

Review of hospital policy titled Self-Administration of Medications, Document Number NUR 17.78, revised 01/17 revealed in part: A. Physician must order medications for patient to keep at the bedside and independently self-administer.

Interview on 11/07/17 at 2:30 p.m. with S4RN confirmed that she did on 06/20/17 take Miralax and MOM to give to the patient and left the medications in the room at bedside.

Interview on 11/07/17 at 11:30 a.m. with S2DON confirmed that no medications are to be left at the bedside without a physician's order.