HospitalInspections.org
Bringing transparency to federal inspections
NORTON CLARK HOSPITAL
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on document review and interview, the facility failed to ensure a registered nurse evaluated the care provided to 1 of 5 patients (patient #1).
Findings include:
1. Review of patient #1 medical record indicated the following:
(A) An order was written on 7/5/11 for 4x4 border gauze to ulcer on right leg every other day. The medical record lacked documentation that the treatment was carried out per order. Per record review, the gauze was changed only on 7/6/11 and 7/12/11.
(B) The medical record indicated that the patient had only one (1) bowel movement during the hospitalization (BM on 7/6/11). The record lacked documentation that the lack of a bowel movement was reported to the physician or was addressed during the stay. The patient was discharged on 7/12/11.
2. Staff member #2 indicated the following in interview at 2:45 p.m.:
(A) He/she verified that the medical record lacked documentation that the physician orders for dressing to the right leg were followed and that the lack of a bowel movement was reported or addressed.
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on document review and interview, the facility failed to ensure a registered nurse evaluated the care provided to 1 of 5 patients (patient #1).
Findings include:
1. Review of patient #1 medical record indicated the following:
(A) An order was written on 7/5/11 for 4x4 border gauze to ulcer on right leg every other day. The medical record lacked documentation that the treatment was carried out per order. Per record review, the gauze was changed only on 7/6/11 and 7/12/11.
(B) The medical record indicated that the patient had only one (1) bowel movement during the hospitalization (BM on 7/6/11). The record lacked documentation that the lack of a bowel movement was reported to the physician or was addressed during the stay. The patient was discharged on 7/12/11.
2. Staff member #2 indicated the following in interview at 2:45 p.m.:
(A) He/she verified that the medical record lacked documentation that the physician orders for dressing to the right leg were followed and that the lack of a bowel movement was reported or addressed.