HospitalInspections.org

Based on review of facility documents, medical records (MR1) and interview with staff (EMP) it was determined the facility failed to ensure the implementation of their adopted policy for physican orders for one of one medical records reviewed. (MR1)

Findings include:

Review on August 24, 2020, of facility policy "Patient Care Process: Including Admission, Assessment/Reassessment And Patient Plan of Care," revised July 2020, revealed "C. Orders: During change of shift report, the nurse will review all orders from his/her shift with the oncoming nurse. D. Plan of Care (Care Plan): 1. The RN will coordinate the planning, implementation, and evaluation of the plan of care. 2. The plan of care will be reviewed/revised as patient care needs are identified and/or when the patient ' s needs change. 3. The RN will evaluate and record the patient ' s progress toward the outcome(s) per the plan of care from admission through discharge. E. Documentation: Assessment, plan of care, teaching, interventions, and reassessment are documented."

Review on August 24, 2020, of MR1 physician documentation "Physician Orders" dated April 10, 2020, revealed "Continuous Pulse Oximetry."

Review of MR1 nursing documentation "Nursing Note" dated April 11, 2020, at 5:20 AM revealed "Went into patient's room to reattach disconnected SPO2 monitor ... Patient was found unresponsive with no pulse or respirations ..."

Interview on August 24, 2020, with EMP1 confirmed on April 11, 2020, at 2:30 AM OTH1 did not document a change in the patient's condition that affected the ordered continuous pulse oximetry and confirmed there was no documentation the practioner was notified of a change in the patient's noncompliance and treatment.