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Based on record review and interview, the hospital failed to ensure the RN (Registered Nurse) supervised and evaluated the nursing care of each patient as evidenced by: failing to ensure that foley care for 1 (#3) of 5 (#1-#5) patients reviewed for Foley care was performed and documented in the medical record, failing to ensure that the attending physician and the patient's contact person was notified of a patient fall for 1 (#3) of 5 (#1-#5) patients reviewed for fall notification, and failing to ensure that a physician's X-ray order was clarified for 1 (#3) of 5 (#1-#5) patients reviewed for physician orders.

Findings:
A review of the hospital policy titled, "Urinary Catheter Management", as provided by S2DON as a current policy, revealed in part: Maintenance of Foley catheter- perform good peri-care with soap and water when bathing patient daily and after each bowel movement. Documentation of all Foley catheter care is required.

A review of the hospital policy titled, "Nursing Assessment and Care of the Patient", as provided by S2DON as a current policy, revealed in part: Changes in the patient status will result in a head-to-toe reassessment by the RN charge nurse and documented in the medical record and communicated to the physician. The nursing flow sheet shall be used to document assessment, treatments, and procedures every shift.

A review of the hospital policy titled, "Physician Orders, Clarification, and Verification", as provided by S2DON as a current policy, revealed in part: The nurse has a legal duty and moral obligation to clarify any physician order that is illegible, unclear, or clearly contraindicated before executing it. All orders that are clarified and verified for implementation will be signed off by the nurse as accepted for implementation.


Patient #3
The patient was an 87 year old female who had a fall at home and was admitted to the Rehab (Rehabilitation) Hospital on 06/16/17 for Rehab following an admission and discharge from an acute care hospital for a surgical repair of a left femur fracture and a left elbow fracture. The patient was transferred to the Rehab Hospital for intense inpatient Rehab on 06/16/17. The H&P (History and Physical) was performed on 06/17/17 by S7MD. The admitting physician, S7MD, in consult with the patient's orthopedic physician, ordered therapy 5 times a week for 3 hours each day, weight bearing as tolerated to LLE (left lower extremity) and non- weight bearing to LUE (left upper extremity) and the patient was placed on fall precaution protocols due to high fall score and status post-surgery. The patient had a Foley catheter in place upon admit to the Rehab Hospital. A review of the medical record revealed no documentation of Foley care being performed. On 06/18/17 at 10:30 a.m. the medical record revealed documentation that the patient became weak while being assisted by S8LPN from the wheelchair to the toilet and the patient was lowered to floor to her knees by S8LPN. The medical record further revealed that S8LPN notified S3RN, charge nurse, and an assessment was performed and documented by S3RN. S3RN documented that the patient had sustained no apparent injuries and documented that the patient denied any pain. There was no documented evidence that S3RN had notified the patient's physician, S7MD, or the patient's contact person (daughter) of the fall at 10:30 a.m. On 06/18/17 at 1:30 p.m. S3RN documented that the patient was complaining of pain to left knee with swelling noted. S3RN documented that the attending physician, S7MD, was notified at 1:30 p.m. and S3RN documented that the patient's daughter was at the bedside at this time. On 06/18/17 at 1:30 p.m., the medical record revealed that S7MD ordered X-rays of left hip and left knee to be done on 06/19/17. On 06/18/17 at 3:39 p.m., S7MD ordered to change X-ray order to "stat" in the a.m. on 06/19/17. On 06/20/17 the patient was transferred to an acute care hospital for further evaluation and treatment of the swelling and pain to the left knee.


In an interview on 12/05/17 at 10:30 a.m. with S3RN, charge nurse, he indicated that Patient #3 was admitted to the Rehab Hospital with a Foley catheter in place. He indicated that Foley care should be documented on the TAR (treatment administration record) every 12 hour shift and signed by the nurse. In a review of the patient's TAR and medical record with S3RN he indicated that there was no documented evidence that Foley care was performed on Patient #3 from 06/16/17 to 06/20/17 when the patient was transferred to an acute care hospital. S3RN indicated that he was the charge nurse on 06/18/17 when the incident with Patient #3 occurred in the bathroom with S8LPN. He indicated that since the patient was lowered to the floor that he did not consider it a fall. He did not remember if he notified the physician and the patient's contact person (daughter) of the incident, but he indicated that since he had no documentation of any phone calls or notifications in the medical record that he may not have notified them. He indicated that if he had notified them, he probably would have documented it in the medical record. S3RN was asked about the physician order on 06/18/17 that read "change X-rays to stat in a.m. on 06/19/17. S3RN indicated that he did not clarify the order with S7MD.

In an interview on 12/05/17 at 2:15 p.m. with S2DON, she indicated that Foley care on each shift should have been performed and documented on the TAR and indicated that without documentation of Foley care in the medical record that Foley care could not be verified as being performed by staff. S2DON was made aware of interviews on 12/05/17 at 10:30 a.m. with S3RN and on 12/11/17 at 3:30 p.m. with S4RN, S5RN, and S6LPN who indicated that a patient lowered to the floor by staff was not considered a fall. S2DON indicated that a patient lowered to the floor by staff was considered a fall and the physician and the contact person should be notified. S2DON further indicated that a "stat" order, per hospital policy, was to be performed within 2 hours and indicated that the RN should have clarified the order with the physician.