Margaret Mary Community Hospital

The skilled nurse failed to ensure visits followed the frequency ordered on the plan of care in 1 of 9 active patients (#5) and 1 of 4 discharged patients (#9) receiving skilled nursing in a sample of 13 records reviewed.

The agency failed to include patient-specific teaching and goals with measurable outcomes in the plan of care in 3 of 9 active records reviewed and 2 of 4 discharged records reviewed in a sample of 13. (#4,5,9,11,13) Findings include: 1. Record review of patient number four, start of care on…

The Registered nurse failed to ensure that the physician was made aware that orders could not be followed for the assessments and needs for a patient in 1 of 13 skilled patients reviewed.

The Registered nurse failed to include patient-specific teaching and goals with measurable outcomes in the plan of care in 3 of 9 active records reviewed and 2 of 4 discharged records reviewed in a sample of 13. (#4,5,9,11,13) Findings include: 1. Record review of patient number four, start of care…

The skilled nurse failed to ensure visits followed the frequency ordered on the plan of care in 1 of 9 active patients (#5) and 1 of 4 discharged patients (#9) receiving skilled nursing in a sample of 13 records reviewed.

The Registered nurse failed to communicate changes in visits of a patient in 1 of 13 skilled patients in a sample of 13 records reviewed.

The agency failed to ensure the clinical record failed to contain consistent information in regards of a RN attempting to schedule visits after discharge without an order for 1 of 4 discharged records reviewed in a sample of 14. (#9) Findings included: The plan of care for patient number nine, for…