The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|SUMMERSVILLE REGIONAL MEDICAL CENTER||400 FAIRVIEW HEIGHTS ROAD SUMMERSVILLE, WV 26651||April 10, 2014|
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on document review, record review and staff interview, it was determined the facility failed to ensure a registered nurse (RN) supervised and evaluated the nursing care of all patients in one (1) of one (1) clinical records reviewed for documentation relevant to the condition of a patient (patient #1). This has the potential to negatively impact all patients when nursing is not assessing, supervising or evaluating care rendered to patients.
1. Hospital policy titled: "Documentation of Nursing Care", states, in part: "Daily Nursing Assessment: Shall include the Head to toe Assessment. Head to Toe assessment will be completed at the beginning of each shift. Patient care notes will address any changes in the patient conditions, nursing interventions other than those addressed on the Nursing Work-list. Skin Integrity Assessment every 12 hours. At least once a shift-Care Plans should reflect any changes in patients' condition as well as any additional information showing an accurate detailed depiction of the patient's situation/condition."
2. Review of the clinical record for patient #1 revealed she was admitted on [DATE] and discharged on [DATE]. Nursing failed to assess and document the skin changes occurring relative to the bruising found on the patient's labia, buttocks, abdomen and back.
3. Review of the care plan revealed it was not updated to include the information relative to the above listed bruising, under the skin assessment.
4. Nursing documented a full skin assessment as being "within normal limits" every twelve (12) hours, though they knew the bruising was an abnormal condition.
5. During an interview with RN #2 on 4/9/14 at 0945, she revealed she only looked at the bruise the Certified Nursing Assistant (CNA) told her about, but documented her skin assessment as being within normal limits (WNL). The care plan was not updated to include the skin integrity.
6. An interview conducted with RN #3 revealed she was told about the bruising, but did not assess nor document it "because everyone knew about it", yet documented the patient's skin assessment as being WNL. She did not update the care plan to include skin integrity.
7. The LPN was interviewed on 4/9/14 and revealed she was the wound care nurse on the unit during this patient's admission. She did not assess the bruising on the patient. She also did not update the care plan to reflect the skin integrity of this patient.
8. Review of the medical record for patient #1 revealed skin assessments had been completed every twelve hours as per hospital policy, but all assessments were documented as WNL without mention of the bruising. The care plan was not updated to reflect the skin integrity of this patient.
9. This medical record was reviewed with the Nursing Supervisor on 4/8/14 at 0915 and she agreed with these findings.