HospitalInspections.org

Based on document review and interview, the facility nursing staff failed to follow facility policy by not supervising, evaluating, and assigning assistive staff in accordance with patient needs and staff competency in 1 (P1) of 10 patient medical records reviewed.

Findings Include:

1. Facility policy for: "Nursing Service And Staffing," Policy Number PC535, last reviewed 02/24/2023, indicated under Staffing and Delivery of Care: The Registered Nurse shall supervise and evaluate the nursing care for each patient, and assigns the nursing care to other personnel in accordance with the patient's needs and specialized qualifications and competencies of the nursing coworker present.

2. P1's MR indicated on 05/04/2024, PCT1, Patient Care Technician, did have P1 sit on a bed in the fully lowered position in an effort to obtain the patient's weight. On 05/04/2024 at 2130 hours P1 complained of severe pain to the right hip, requiring transfer out for emergency evaluation.

3. F1's incident reporting system indicated on 05/04/2024, PCT1, Patient Care Technician, did have P1 sit on a bed in the fully lowered position in an effort to obtain the patient's weight. The staff member did not understand that starting in the lowest position is not required to obtain a correct patient weight on the facility beds.

4. On 09/30/2024 at 1530 hours, S2, Director of Quality, and S3, Director of Nursing, confirmed that PCT1, Patient Care Technician incorrectly had P1's bed set too low while attempting to weigh a patient with recent hip surgery on 05/04/2024. Additionally, this may have contributed to a hip realignment for P1 requiring additional therapy, and potentially another surgery.