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Based on observation, interview and record review, the hospital failed to ensure the proper performance of the nursing services for 2 (Patients #5 and #8) of 11 patients sampled. Patient #5 was receiving wound care without documented orders. Patient #8 was ordered to have supplemental oxygen at 2 liters per minute (Lpm) without humidity and was receiving 4 Lpm with humidity. The standard of practice for nursing is to follow documented physician orders. The director of the nursing service is responsible to ensure the nursing staff are following the standards of practice.


The findings include:


Review of the hospital's Nursing Clinical Policy titled Plan for Patient Care (revised 11/12) revealed a description of nursing practice to include in section II.2.: "The administration of medications and treatments as prescribed or authorized by the duly licensed independent practitioner authorized by the laws of this state to prescribe such medications and treatments."

1. During the review of Patient #5's medical record at 2:00 p.m. on 3/10/14, with the Clinical Manager of the Intensive Care Unit (ICU) the following information was found: On 3/5/14 at 10:09 a.m., the Registered Nurse (RN) documented: "I.V. (intravenous) stopped; and when disconnected I.V. site dislodged and skin tear occurred with Tegaderm (used to cover and secure I.V. sites to protect at-risk skin) removal. Dr. [name] at bedside and is aware. Covered with Vaseline gauze (a fine mesh, absorbent gauze impregnated with white petrolatum) and Telfa (a non-adherent dressing that minimizes wound trauma; will not disrupt healing tissue by sticking to wound), secured with soft net and Kerlix (bandage to cushion and protect wound areas). Pt. (patient) tolerated w/o (without) incident, will continue to monitor."
Review of physician orders for Patient #5 found no documentation this treatment of the wound was ordered by the physician.


2. During an observational tour on 3/10/14 at 11:07 a.m., visited Patient #8 in his room. Patient #8 was seated with supplemental oxygen via a nasal cannula. The oxygen flow was set at 4 Lpm with a humidifier in place.

Review of the physician orders documenting oxygen flow at 2 Lpm, not humidified.

During an interview on 3/10/14 at 12:00 p.m., the Director of Nursing (DON) said order had not changed and was still at 2 Lpm, not humidified.

During an interview on 3/10/14 at at 12:13 p.m., the Medical-Surgical (Med-Surg) Manager reported she has just confirmed with the doctor Patient #8's oxygen should be at 4 Lpm. She said, "I don't know how long its been on 4 Lpm."

During an interview on 3/10/14 at 12:20 p.m., staff Licensed Practical Nurse B explained the nurses set up the oxygen. He said "In report they told me he was on 4 (Lpm). [The patient] said he took 4 (Lpm) at home."