cms_PR: 15
Data source: Big Local News · About: big-local-datasette
rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
15 | RYDER MEMORIAL HOSPITAL INC | 405018 | 355 AVE FONT MARTELO | HUMACAO | PR | 792 | 2017-05-04 | 385 | D | 0 | 1 | ZOYB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a recertification extended survey, Record Review (R.R.) with the Registered Nurse (RN) (Employee #1) during a recertification survey performed from 5/2/17 thru 5/4/17, it was determine that the facility failed to ensure that physicians participate actively supervising the services that residents (R) receive at the facility, for 1 out of 28 (R#1). Findings include: 1. During R.R. R #1 on 5/2/17 at 1:00 pm it was found between the nurses notes a Urinalysis Report from 4/21/17 12:02 pm, that was not signed by the physician as evidence of evaluation of the results. 2. The laboratory result of 4/21/17 12:02 pm that was altered included: a. Clarity: Turbid (normal range: Clear) b. Leukocytes: Large (normal range: Negative) c. [MEDICATION NAME]: Positive (normal range: Negative) d. Glucose: 150 mg/dL (normal range: Negative) e. Blood: Small (normal range: Negative) f. RBC (Red Blood Cell): 8-30 (normal range: g. WBC ([NAME] Blood Cell): Over 50 (normal range: h. [NAME] Blood Cell Clump: Many (normal range: i. Bacteria: Many (3+) (normal range: j. Budding Yeast: Few (normal range: During interview with RN (Employee #1) on 5/3/17 at 11:00 am, she stated: If the laboratory results does not have the signature of the physician it probably because it has not been informed. Let me call the physician and confirm this information. 3. During R.R. on 5/3/17 at 12:00 pm was found evidence of telephone medical order: Catheterize and perform a urinalysis, urine culture and notify physician the laboratory results. 4. During R.R. R#1 on 5/3/17 at 11:15 am was found that there was no evidence of the altered urinalysis report being notified to the physician for 4/21/17. There was found that there is no evidence on the physician progress notes [REDACTED]. During interview with Nursing Supervisor (Employee #4) on 5/3/17 at 11:30 am, she stated: If the urinalysis was miss place and archive between the nursing notes that is probably the reason of why the physician did not see the results. Nursing staff should have identified that urinalysis report and notified the physician immediately. During interview with the Physician (Employee #5) on 5/3/17 at 1:15 pm, she stated: It is possible that I have not seen that urinalysis report because I always write my signature when I evaluate them. I ordered a new urinalysis and urine culture. | 2020-09-01 |