HospitalInspections.org

Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient as evidenced by failing to document intake and output every shift as ordered by the physician for 4 (#2, #3, #4, #5) of 5 (#1, #2, #3, #4, #5) patients reviewed.

Findings:

Review of the hospital's policy titled, "Intake and Output" revealed in part, intake and output will be recorded on the nursing flow sheet and graphics form by the RN or LPN assigned to the patient every shift.

Patient #2
Review of Patient #2's medical record revealed a physician's order dated 03/23/2022 intake and output every shift. Review of the vital signs/intake and output records flow sheets revealed no documentation of intake for Patient #2 on the following shifts:
A.M. shift: 03/24/2022 - 03/26/2022
P.M. shift: 03/25/2022

Review of the vital signs/intake and output records flow sheets revealed no documentation of output for Patient #2 on the following shifts:
A.M. shift: 03/25/2022 and 03/26/2022
P.M. shift: 03/25/2022

Patient #3
Review of Patient #3's medical record revealed a physician's order dated 02/23/2022 intake and output every shift. Review of the vital signs/intake and output records flow sheets revealed no documentation of intake for Patient #3 on the following shifts:
A.M. shift: 03/04/2022, 03/05/2022, 03/07/2022 - 03/09/2022, 03/11/2022, 03/19/2022 - 03/22/2022, 03/25/2022, 03/27/2022 - 03/29/2022, 04/15/2022, 04/17/2022, 04/18/2022, 04/20/2022, 04/22/2022 - 04/24/2022, 05/03/2022, 05/07/2022, and 05/09/2022
P.M. shift: 03/06/2022, 03/07/2022 - 03/09/2022, 03/17/2022, 03/21/2022, 03/23/2022, 03/25/2022 - 03/28/2022, 04/15/2022, 05/01/2022, 05/02/2022, 05/04/2022, and 05/07/2022

Review of the vital signs/intake and output records flow sheets revealed no documentation of output for Patient #3 on the following shifts:
A.M. shift: 03/04/2022, 03/05/2022, 03/07/2022 - 03/09/2022, 03/11/2022, 03/19/2022, 03/21/2022, 03/22/2022, 03/25/2022, 03/27/2022 - 03/29/2022, 04/10/2022, 04/15/2022, 04/17/2022, 04/18/2022, 04/20/2022, 04/22/2022, 04/23/2022, 05/03/2022, 05/07/2022, and 05/09/2022
P.M. shift: 03/06/2022 - 03/09/2022, 03/17/2022, 03/21/2022, 03/23/2022, 03/25/2022 - 03/28/2022, 04/15/2022, 04/18/2022, 04/22/2022, 05/01/2022, 05/02/2022, and 05/04/2022

Review of Patient #3's medical record revealed no vital signs/intake and output records flow sheets for 03/30/2022 - 04/08/2022; 04/19/2022; 04/25/2022 - 04/29/2022; 05/05/2022; and 05/08/2022.

Patient #4
Review of Patient #4's medical record revealed a physician's order dated 04/14/2022 intake and output every shift. Review of the vital signs/intake and output records flow sheets revealed no documentation of intake for Patient #4 on the following shifts:
A.M. shift: 04/23/2022, 04/24/2022, 04/26/2022, and 05/09/2022
P.M. shift: 04/23/2022, 04/24/2022, 05/06/2022, and 05/07/2022

Review of the vital signs/intake and output records flow sheets revealed no documentation of output for Patient #4 on the following shifts:
A.M. shift: 04/24/2022, 04/26/2022, and 05/09/2022
P.M. shift: 05/06/2022

Review of Patient #4's medical record revealed no vital signs/intake and output records flow sheets for 04/15/2022 - 04/21/2022; 04/27/2022 - 05/05/2022; and 05/08/2022.

Patient #5
Review of Patient #5's medical record revealed a physician's order dated 04/19/2022 intake and output every shift. Review of the vital signs/intake and output records flow sheets revealed no documentation of intake for Patient #5 on the following shifts:
A.M. shift: 04/22/2022, 04/24/2022 - 04/26/2022, and 05/08/2022
P.M. shift: 04/20/2022, 04/21/2022, 04/27/2022, 05/02/2022 - 05/04/2022, 05/06/2022, and 05/09/2022

Review of the vital signs/intake and output records flow sheets revealed no documentation of output for Patient #5 on the following shifts:
A.M. shift: 04/22/2022, 04/24/2022, 04/26/2022, 04/27/2022, 05/07/2022, and 05/08/2022
P.M. shift: 04/21/2022, 04/27/2022, 05/04/2022, 05/06/2022, and 05/09/2022

In an interview on 05/10/2022 at 4:30 p.m. S2DON verified the above stated findings.