HospitalInspections.org

Based on record review and interview, the RN did not supervise the care of one of one applicable patient (citing patient # 1) to ensure physician orders were followed. Findings include the following:

Review of the medical record of patient # 1 revealed a physician ' s order, written on 8/25/10 at 12:30 PM for a " sleep log " to be kept. An order was written to discontinue the sleep log on 9/7/10 at 10:30 AM. Further review of the medical record revealed the sleep log (formatted in hourly increments) was incomplete for 13 of the 14 days it was ordered. The following dates and times were blank on the log:

8/25/10 1 PM - 6 PM
8/26/10 8 AM - 8 PM, 11 PM
8/27/10 1 AM - 6 AM
8/29/10 4 PM - 7 PM
8/30/10 10 AM - 6 PM
8/31/10 6 AM - 11 AM, 1 PM - 6 PM
9/1/10 no log
9/2/10 no log
9/3/10 no log
9/4/10 no log
9/5/10 7 AM - 6 PM
9/6/10 7 AM, 11 AM
9/7/10 9 AM - 10 AM

In an interview on 11/2/10 at 11:20 AM, Personnel # 51 acknowledged the incomplete sleep log.