HospitalInspections.org

Based on policy and procedure review, medical record review and staff interview, the a registered nurse failed to supervise and evaluate the care planned for each patient as required per facility policy and procedure and physician order related to assessment and documentation of vital signs; turning patients every 2 hours; and bathing patients daily for 4 of 5 (N1, N2, N3 and N5) closed patient medical records reviewed.

Findings:
1. Policy No.: A03-G titled, "Nursing Routines, Protocols and Guidelines", reviewed on 5/2/11 at 3:51 PM, indicated:
A. on pg. 1, under Routines/Guidelines section, Vital Signs: vital signs (TPR (temperature, pulse, respirations), BP (blood pressure), every 12 hours.
B. on pg. 2, under Routines/Guidelines section, Activity/Mobility: Bedfast patients turned. Document position (R - Repositioned, B - Back to bed), every 2 hours.
C. on pg. 1, under Routines/Guidelines section, Hygiene: patient bathed..., daily.

2. Review of closed patient medical records on 5/2/11 at 12:14 PM, indicated patient:
A. N1 was admitted to the facility on 3/29/11 at 14:37 PM for medical management of renal failure. Other documentation in the medical record included:
a. per Admission Orders dated 3/29/11 orders included, but were not limited to: vital signs to be assessed every 4 hours and on complete bed rest.
b. per Graphic Record, documentation of vital signs every 4 hours was lacking on: 3/31/11 noon and 4 PM; 4/1/11 at noon, 4 PM, and midnight; 4/2/11 at noon; 4/3/11 at noon and 4 PM; and on subsequent days following this until discharge on 4/22/11.
c. per Daily Nursing Flow Sheets dated 3/31/11 through discharge on 4/22/11, documentation of turning every 2 hours and bathing daily were lacking.

B. N2 was admitted to the facility on 3/25/11 at 19:15 PM for medical management of wounds. Other documentation in the medical record included:
a. per Admission Orders dated 3/25/11 orders included, but were not limited to: vital signs to be assessed every 8 hours and on complete bed rest.
b. documentation of vital signs every 8 hours was lacking on: 3/28/11 and 3/29/11 at 4 PM; and 4/19/11 at 8 PM.
c. per Daily Nursing Flow Sheets dated 3/25/11 through 5/2/11, documentation of turning every 2 hours and bathing daily were lacking.

C. N3 was admitted to the facility on 3/9/11 at 18:00 PM for medical management of pneumonia and acute respiratory failure. Other documentation in the medical record included:
a. per Admission Orders dated 3/9/11 orders included, but were not limited to: vital signs to be assessed every 4 hours and on complete bed rest.
b. per Graphic Record, documentation of vital signs every 4 hours was lacking on: 3/10/11 and 3/11/11 at 8 PM; 3/12/11 at 4 PM; 3/13/11 at 4 PM and midnight; 3/14/11 at 8 PM and midnight; and on subsequent days following this until discharge on 4/1/11.
c. per Daily Nursing Flow Sheets dated 3/9/11 through discharge on 4/1/11, documentation of turning every 2 hours and bathing daily were lacking.
D. N5 was admitted to the facility on 3/5/11 at 17:30 PM for medical management of wounds. Other documentation in the medical record included:
a. per Admission Orders dated 3/5/11 orders included, but were not limited to: vital signs to be assessed every 8 hours
b. per Graphic Record, documentation of vital signs every 8 hours was lacking on: 3/6/11 and 3/7/11 at 8 PM and 4 AM; 3/9/11 and 3/10/11 at 4 PM; 3/11/11 at 8 PM; 3/12/11 at midnight; and on subsequent days following this until discharge on 4/7/11.

3. Personnel P4 was interviewed on 5/2/11 at 12:29 PM and confirmed:
A. vital signs are to be assessed and documented on the Graphic Record every 4 hours unless ordered otherwise by the physician. The above-mentioned patients were lacking assessment and documentation of vital signs every 4 hours and/or as ordered as required by facility policy and procedure.
B. documentation of turning of patients who are on complete bedrest or require assistance is to be done every 2 hours by nursing personnel; and baths are to be completed daily and both are documented on the Daily Nursing Flow Sheet. This was lacking for the above-mentioned patients as required by facility policy and procedure.