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Based on record review and interview, the hospital failed to ensure the registered nurse supervised and evaluated the nursing care of each patient as evidenced by 1) failing to ensure that catheter care was performed for 3 of 3 sampled patients with indwelling Foley catheters (Patient #1, 2, 3) and 2) failing to ensure intake was monitored for 3 of 3 sampled patients with orders for intake monitoring (Patient #1, 2, 3).
Findings:

1) Failing to ensure that catheter care was performed for 3 of 3 sampled patients with indwelling Foley catheters (Patient #1, 2, 3)

Patient #1
Review of the medical record for Patient #1 revealed an admit date of 08/08/2025 and a discharge date of 08/22/2025. The patient was admitted with an indwelling Foley catheter which remained the entire stay.

Review of the record revealed an ADL form was completed twice daily, including documentation of Foley catheter care. Review of the ADL forms dated 08/16/2025 through discharge on 08/22/205 revealed no documented evidence that catheter care had been performed. Many of the days had "n/a" documented under the catheter care section.

On 09/23/2025 at 11:00 AM, S2CNO reviewed Patient #1's record and confirmed there was no documented evidence of catheter care on the above dates. S2CNO further confirmed that catheter care should be performed each shift, twice daily.

Patient #2
Review of the medical record for current Patient #2 revealed an admit date of 09/04/2025. The patient was admitted with an indwelling Foley catheter.

Review of the record revealed an ADL form was completed twice daily, including documentation of Foley catheter care. Review of the ADL forms dated 09/20/2025 through 09/22/205 revealed no documented evidence that catheter care had been performed. Several of the entries had "n/a" documented under the catheter care section.

On 09/23/2025 at 12:30 PM, S2CNO reviewed Patient #2's record and confirmed there was no documented evidence of catheter care on the above dates. S2CNO further confirmed that catheter care should be performed each shift, twice daily.

Patient #3
Review of the medical record for current Patient #3 revealed an admit date of 09/05/2025. The patient was admitted with an indwelling Foley catheter.

Review of the record revealed an ADL form was completed twice daily, including documentation of Foley catheter care. Review of the ADL forms dated 09/19/2025 through 09/22/205 revealed catheter care was only documented as performed once. Several of the entries had "n/a" documented under the catheter care section.

On 09/23/2025 at 1:30 PM, S2CNO reviewed Patient #3's record and confirmed there was no documented evidence that catheter care was performed at least twice daily on the above dates.


2) Failing to ensure intake was monitored for 3 of 3 sampled patients with orders for intake monitoring (Patient #1, 2, 3)

Patient #1
Review of the medical record for Patient #1 revealed an admit date of 08/08/2025 and a discharge date of 08/22/2025. The patient was admitted with orders for tube feedings per an NG tube. The order for tube feedings was discontinued on 08/18/2025 and a regular diet was ordered.

Review of the patient's intake documentation revealed the following:
08/21/25 - Ate 200% breakfast, 250% lunch, 250% dinner. No fluid intake was documented.
08/20/25 - No fluid intake documented for this day.
08/18/25 - No tube feeding intake documented for this day.
08/17/25 - No tube feeding intake documented for day shift.
08/16/25 - No tube feeding intake documented for day shift.
08/15/25 - No tube feeding intake documented for day shift.

On 09/23/2025 at 11:10 AM, S3RD reviewed Patient #1's record and confirmed the lack of intake documentation of tube feeding/fluids on the above dates. When asked how the patient could eat 200% percent of breakfast, as noted on 08/21/2025, S3RD stated she was unsure. S3RD further confirmed that accurate fluid intake monitoring should have been performed for this patient.

Patient #2
Review of the medical record for current Patient #2 revealed an admit date of 09/04/2025. The patient was admitted with orders for tube feedings and the order was changed on 09/19/2025 for a pureed diet.

Review of the patient's intake documentation revealed the following:
09/22/25 - No meal intake or fluid intake documented for the day.
09/21/25 - No meal intake documented for the day.
09/19/25 - No fluid intake documented on day shift. No meal intake documented.
09/18/25 - No tube feeding intake documented for this day.

On 09/23/2025 at 12:30 PM, S2CNO reviewed Patient #2's record and confirmed the lack of intake documentation of tube feeding/fluids on the above dates. S2CNO confirmed the patient should be receiving accurate intake monitoring.

Patient #3
Review of the medical record for current Patient #3 revealed an admit date of 09/05/2025. The patient was admitted with orders for continuous tube feedings.

Review of the patient's intake documentation revealed the following:
09/22/25 - No tube feeding intake documented for day shift.
09/21/25 - No tube feeding intake documented for this day.
09/20/25 - No tube feeding intake documented for this day.

On 09/23/2025 at 1:30 PM, S2CNO reviewed Patient #3's record and confirmed the lack of intake documentation of tube feeding on the above dates. S2CNO confirmed the patient should be receiving accurate intake monitoring.