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Based on medical record review, staff interview, and policy review, the facility failed to ensure the registered nurse supervised and evaluated the nursing care (A395).

Based on medical record review, staff interview, and policy review, the facility failed to ensure the registered nurse supervised and evaluated the nursing care for one of ten medical records reviewed (Patient #2). This could affect all patients receiving services from this facility. The active patient census was 70.

Findings include:

Review of Policy and Procedure Number C41-N titled, Change in Patient Condition Early Recognition and Intervention, revised 04/01/21, revealed the purpose is to identify changes in condition to address and prevent further deterioration and define responsibility for physician notification. Assessment and basic recommendations stated a complete head to toe assessment is to be performed with consultation as appropriate among the clinical team and includes a review of current labs. It is the charge nurse's responsibility to ensure that the process to assess the patient occurs in a timely fashion, and to gather other relevant data.

Review of the medical record for Patient #2 revealed the patient was involved in a motor vehicle/motorcycle accident on 04/25/21 which resulted in multiple trauma injuries. The patient was hospitalized at an acute care hospital with diagnoses to include pancreatic and liver contusions, grade three renal laceration, multiple rib fractures with pulmonary contusion, pelvic and iliac spine fractures, and grade two blunt injury to the right internal carotid artery. During the course of the hospitalization the patient underwent surgery on 05/29/21 for a jejunal perforation which was complicated by an acute deep vein thrombsis and septic shock. The patient was stabilized and transferred to this hospital on 06/25/21 at 10:23 AM for medical management and post operative care.

1. Review of the physician orders for Patient #2 dated 06/25/21 at 10:23 AM revealed a wound care consult for an abdominal surgical wound measuring 14 centimeters (cm) x 9 cm x 0.2 cm with two Jackson Pratt drains (drains inserted to gently remove fluid from the body using a suctioning effect) in place. The wound orders from 06/25/21 through 06/30/21 noted the dressing was to be changed twice daily by cleansing with normal saline, patting dry, applying cloropactin (topical antiseptic) on gauze, apply to site, and cover with abdominal dressing. The wound care orders changed on 06/30/21 through 07/02/21 to once daily by cleansing with normal saline, patting dry, applying hydrogel (dressing that promotes healing and provides moisture) to the wound bed, cover with an abdominal dressing and securing with medipore tape. Review of the nursing documentation revealed on 06/28/21, 06/29/21, and 07/02/21 there was no documentation wound care was provided. This finding was confirmed with Staff D on 11/04/21 at 2:06 PM.

2. Review of the physician orders for Patient #2 dated 06/29/21 at 10:30 AM revealed an order for intravenous sodium chloride 0.9% to be infused continuously at 75 milliliters/hour (ml/hr) for hyponatremia (decreased sodium). Review of the nursing documentation noted a 22 gauge intravenous (IV) catheter was placed to the posterior right hand on 06/29/21 at 11:08 AM. Review of the medication administration record revealed the intravenous infusion was stopped on 06/29/21 at 11:59 PM through 06/30/21 at 6:33 AM. A new bag of sodium chloride 0.9% was not started until 07/01/21 at 1:31 PM. Staff D confirmed on 11/04/21 at 2:21 PM there was no physician order to stop the intravenous infusion.

3. Review of the laboratory results for Patient #2 revealed a complete blood count result dated 07/05/21 at 11:46 AM which noted a significant increase in the patient's white blood count from 14.07 thousands of cells per microliter of blood (K/mcL) on 07/01/21 to 27.38 K/mcL. The medical record lacked evidence the physician was notified of the increase in the patient's white blood count. Review of the nursing documentation noted the physician was not notified until 07/06/21 at 11:42 PM. The patient had a (CT) scan performed on 07/06/21 in which multiple new intra-abdominal abscesses were identified.

4. Review of the nursing documentation dated 07/06/21 at 2:49 PM noted the patient reported not feeling well and refused wound care with three attempts. There was no evidence the physician was notified the patient refused wound care.

Interview with Staff F on 11/03/21 at 2:40 PM revealed if there was an abnormal lab value he/she would call and report to the physician for further orders.

This substantiates Substantial Allegation OH00127171.