HospitalInspections.org

Based on record review and interview, the hospital failed to ensure the RN supervised and evaluated the care of each patient as evidenced by failing to follow physicians' orders for 2 Patients (#1, #4) of 2 current patients reviewed for labs.
Findings:

Patient #1
Review of the medical record for Patient #1 revealed she was a 44 year old admitted on 02/28/2020 for a stage IV sacral pressure ulcer and a urinary tract infection. She was admitted to the hospital for IV antibiotics and wound care.

Review of the physician orders dated 02/29/2020 stated CBC, CMP, ESR, CRP and Pre-Albumin in the AM.

Review of the lab reports revealed the following completed labs:
02/29/2020 ESR, CMP, CRP, and Pre-Albumin results
03/01/2020 no labs (no CBC, CMP, ESR, CRP, and Pre-Albumin)

In an interview on 03/03/2020 at 11:40 a.m. with S2NM, she verified Patient #1 had no labs drawn on 03/01/2020 and there was a physician's order on 02/29/2020 for labs in the AM.

Patient #4
Review of the medical record for Patient #4 revealed he was a 63 year old male admitted on 02/03/2020 for sepsis. She was admitted to the hospital for IV antibiotics.

Review of the physician's orders dated 02/03/2020 stated CBC and CMP every Monday and Thursday.

Review of the lab reports revealed the following:
02/06/2020 (Thursday) CMP results (no CBC)

In an interview on 03/03/2020 at 12:45 p.m. with S2NM, she verified no CBC labs results documented on Patient #4 on 02/06/2020 and there was an order 0n 02/03/2020 for a CBC and CMP every Monday and Thursday.

In an interview on 03/03/2020 at 2:00 p.m. with S1CEO, she verified there were no CBC, CMP, ESR, CRP or Pre-Albumin lab results for Patient #1 on 03/01/2020. She further verified there were no CBC lab results for Patient #4 on 02/06/2020.