HospitalInspections.org

Based on medical record review, hospital document and policy review and staff interview, it was determined that the registered nurse (RN) failed to supervise and evaluate the nursing care for 1 of 6 patients (Patient #3) in the sample. Findings included:

The hospital's "Registered Nurse - Position Description" stated, "...Essential Job Function...Performs...physician orders in a timely manner..."

The hospital policy entitled "Guidelines for Nursing Care" stated, "...physician orders...checked and...signed off by nurse..."

The hospital policy entitled "Nursing Documentation" stated, "...Medication Administration Record (MAR)...the nurse administering medication...completes documentation on the MAR..."

A. Review of Patient #3's medical record revealed:

1. Physician Orders dated 9/11/19:

"Change dressing to left hip incision daily. Cleanse with NSS (normal saline solution) and pat dry, apply bacitracin ointment and apply island (adhesive gauze) dressing."

2. No evidence that the RN:
- documented the administration of medication to the left hip incision on the MAR
- performed left hip wound care on 9/12, 9/13 and 9/15/19 as per the physician order

These findings were confirmed by Nurse Manager A on 9/19/19 at 2:20 PM. In addition, Nurse Manager A stated that the nurse should have documented the administration of the wound care medication on the MAR.

Based on medical record review, policy review and staff interview, it was determined that for 1 of 6 patients in the sample (Patient #1), staff failed to develop and/or revise the nursing care plan to reflect current patient needs. Findings included:

The hospital policy entitled "Care Plan" stated, "...Care plan is initiated by an RN (registered nurse) on admission...The care plan will include the identified patient problems, the goals to work toward, and the interventions to be utilized...Care plan is reviewed and updated with any changes as needed by appropriate disciplines...All clinical disciplines must review their specialty areas and update...to maintain current patient status needs/interventions..."

A. Review of Patient #1's medical record revealed:

1. Patient admitted to hospital on 7/25/19.

2. Nursing Daily Assessment, dated 7/25/19, documented "Patient has foley (indwelling urinary catheter)".

3. No evidence the care plan identified or addressed the foley catheter.

Interview with Director Quality Management A on 9/19/19 between 3:45 PM and 4:25 PM confirmed this finding.

Based on medical record review, policy review and staff interview, it was determined that for 1 of 3 discharged patients (Patient #1) in the sample, staff failed to provide the necessary medical information for referral for discharge follow-up care. Findings included:

The hospital policy entitled "Discharge/Transition Planning" stated, "...Document in the medical record any post-discharge follow-up plan of care needs...Communicate and coordinate with healthcare providers across the continuum...Confirm necessary medical information sent to post discharge provider...Confirm necessary medical information received and acceptance for post discharge needs..."

Review of Patient #1's medical record revealed:

1. Discharged to home on 8/12/19 with home health care and follow-up appointments.

2. Urinalysis completed on 8/12/19 showed moderate amount of bacteria present in urine (normal reference range: none).

3. No evidence abnormal urinalysis results were communicated to health care providers for discharge follow-up care.

During an interview on 9/19/19 between 4:25 PM and 4:35 PM, Director of Quality Management A confirmed these findings.