HospitalInspections.org

Based on review of documentation and interview with staff, it was determined the nursing staff failed to supervise and evaluate the nursing care of patient #1. The nursing staff failed to reassess patient #1 and failed to notify the physician in a timely manner of a change in condition.

Findings included:
During a review of the medical record of patient #1 the following was revealed:

1. A document entitled, "Skilled Observation/Assessment Performed," stated, on 6/21/11 at 9:00am, the staff nurse charted, "Urine color-yellow, Urine clarity- clear."

2. A document entitled, "Skilled Observation/Assessment Performed," stated, on 6/21/11 at 1920 the staff nurse charted, "Urine color- Yellow (scratched out), red, Urine clarity- clear."

3. A document entitled, "Nursing Progress Notes," stated, on 6/21/11 at 2130 the staff nurse charted, "Wife reports that pt urine has blood in it, urine in urinal red. Pt denies pain/discomfort." According to the medical record of patient #1 provided to the surveyor at the time of the survey, there were no reassessments documented by the night nursing staff or documentation by the night nursing staff that the physician was notified of patient #1's change in condition. The first documented notification the physician was informed of patient #1's condition, was on 6/22/11 at 7:30am by the day nurse when a physician order was received.

4. A document entitled, "Skilled Observation/Assessment Performed," stated, on 6/22/11 at 9:00am, the staff nurse charted, "Urine color- red, Urine clarity-bloody."

A review of facility policy number 8.13 entitled, "Standards of Care/Standard of Nursing Care," stated, "All patients can expect to have the management of their medical needs met by nurses who are able to promptly identify changes in health status, plan appropriate interventions, and evaluate the effectiveness of care delivered."

A review of facility policy number 3.15 entitled, "Hospital plan for Patient Care, Treatment and Services, Appendix A Nursing Services," stated, "A Registered Nurse must assess the patient each shift and when the patient's condition changes."

A review of facility policy number 3.16 entitled, "Patient Assessment/Reassessment" stated, "II. Reassessment, 3. Additional reassessment will be performed anytime there is a significant change in a patient's condition."

The above was confirmed the afternoon of 11/28/11 in interviews with staff members #7, and #13.