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Based on review of hospital policy, open and closed medical record review, incident report and grievance review, and staff interview the facility staff failed to identify and investigate a grievance related to patient care for 2 of 2 patient complaints (Patient's #8 & #10)

Review of the hospital's policy and procedure "Patient Complaints/Grievance", last review date of 07/2012, revealed "...B. "Patient Grievance" means an oral or written complaint that is not immediately resolved at the time of the complaint by staff present. A patient grievance may be made by the patient or the patient's representative regarding, but not limited to, the patient's care...issues related to the hospital's compliance with the Medicare Hospital Conditions of Participation (CoP)... V. Procedure: B. Patient Complaints...complaints that have not been immediately resolved will be directed by staff addressing the patient concern to the department director or designee for investigation and resolution as a grievance...C. Patient Grievance: 1. Whether a patient/family grievance is received by hospital staff in person, by telephone or in writing, a Patient and Family Complaint/Grievance report shall be originated by staff receiving the grievance. The staff shall forward the Patient and Family Complaint/Grievance report to the manager/director of the affected department for investigation and resolution. 3. The manager/director will complete the investigation and confer with the Grievance Committee concerning the results and the planned response...No more than seven days shall elapse before a response is sent to the patient...4. Each issue defined as a grievance will be followed up with a written notice of decision from the manager/director. The written response will contain the following elements: date of receipt of Grievance, name of the hospital contact person for patient follow up if needed, steps taken to investigate, results of investigation, completion date..."

1. Closed medical record review on 01/14/2014 at 1500 revealed a 76 year old (Patient #8)admitted to the facility on 04/21/2013 with diagnosis of Genitourinary Bleed. Review of the Physician's History and Physical dictated 04/21/2013 at 1204 revealed "...History of Present Illness:...CT (computed tomography) of the abdomen and pelvis was performed, which shows the following: Large hematoma and possible hyperacute blood in the bladder with a Foley catheter (to drain urine) in place and a calcification (stone) immediately adjacent to the Foley bulb which may represent a recently passed stone, a punctuate nonobstructing stone is in the left kidney...patient has a WBC (white blood count) of 22.9 (normal 4,500 - 10,000), hemoglobin of 8.1 (normal 12.4 - 14.9)...patient was noted recently to have just completed some IV (intravenous) antibiotics for an aspiration pneumonia. He is a full code. He has a stage IV sacral decubitus ulcer. Patient is a PEG (percutaneous endoscopy gastrostomy) (feeding tube)..." Review of the medical history revealed the patient was status post CVA (cerebral vascular accident) with dysphasia (difficulty swallowing) and aspiration, and hypertension (high blood pressure).

Review of the physician's progress note dated 04/29/2013 at 1415 revealed "...son...is concerned about his dad's mouth care, thinks he is aspirating, thinks bigger caliber J-Tube (feeding tube) might be beneficial..." Review revealed the discussion with the son was conducted with the Nursing Unit Director, Case Manager (CM), Case Manage Director, and the nurse present.

Review of the RN (Registered Nurse) Nursing Notes dated 04/29/2013 at 1441 revealed "...the son spoke extensively with (name of physician), Case Management, (name) and myself about his concerns regarding his father's condition...the son expressed concerns about possible aspiration of his father's tube feeding..."

Review of the RN Case Management (CM) notes dated 04/26/2013 at 0846 revealed "CM phoned (name of son), patient's (pt) son this am (morning) regarding orders for discharge this afternoon...Son stated he was refusing to accept his father at home today. Son stated his father was not ready. CM reminded son of Important Message from Medicare and rights of appeal...patient's son continued to refuse to accept father at home today..." Continued review of notes dated 04/30/2013 at 1612 revealed "...son was reassured that care was being done at standard of practice and per nursing policy...." Continued review of the notes dated 05/06/2013 at 0814 revealed "...son also stated that he (pt) is not ready to leave the facility as all of his needs have not been addressed...son went on to discuss other medical concerns..." Continued review of the notes dated 05/07/2013 at 1057 revealed "...(name of son) started conversing about why he did not feel his father was ready to be discharged and what he felt was not done by nursing and what test he felt (like) still needed to be done..."

Review of the hospital's incident reports and grievance log on 01/15/2014 revealed no documentation of an incident report or grievance for the Patient #8

Interview on 01/15/2014 1405 with Nursing Unit Director revealed "I am familiar with (name of patient) (#8) and primarily his son. I remember the son had concerns about his father getting a J-tube placed. I had a conference with the son, CM director, RN (name) who is no longer employed here, and the CM assigned to the patient (#8). He wanted the J-tube placed by a physician at another facility and we arranged for that to happen and the patient was brought back after that. The son called and left me a voice mail concerning something but I can't remember what the voice mails was about.. I do recall that I spoke with him...but can't recall what it was about or what I did. I had at least two conversations, maybe more, with the son regarding what I'm not sure...I do recall he wanted to fire the attending physician because he wasn't satisfied with the physician's care and management. I spoke with administration regarding the process for a families' request to replace a physician. The attending physician was replaced with the hospitalist who took over the patient's care on 04/26/2013...Now that we are discussing the patient I seem to recall some of his issues was with nursing and appropriate tube feeding and aspiration. No I did not file an incident report or a grievance and maybe we should have considered this complaint a grievance because he continued to talk to me about patient care issues..." Interview confirmed the staff failed to follow the hospital's grievance policy.

Interview on 01/16/2014 at 1030 with RN revealed "yes I do remember this patient (#8). He'd had a stroke and I was the CM...I remember a conversation with his son...every time we talked he had multiple complaints about the nursing care, the feeding tubes, turning the patient and I told him he needed to report these concerns to the Director of the unit (name)...No I did not file an incident report or a grievance ... " Interview confirmed the staff failed to follow the hospital's grievance policy.


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2. Closed medical record review conducted January 14, 2014 through January 17, 2014 revealed patient #10, a 22-year-old presented to hospital October 31, 2013 with right-sided stomach pain for one (1) week. Review of the radiological imaging results revealed swelling and holes in the appendix. Further review revealed the patient underwent surgical removal of the appendix. Review revealed from October 31, 2013 to November 4, 2013; the patient had a patient-control analgesic for pain control. Further review revealed October 31, 2013 at 1719, an engineering work order for an alarm was placed for the patient's room assignment. Further review revealed October 31,2013 from 1855 to 1925, Engineer #1 was onsite and repaired the patient's an alarm. Further review revealed the patient was discharged from the hospital November 4, 2013.

Review revealed November 5, 2013; the hospital received a written grievance, via e-mail, related to pain control issues and call bell malfunctioning. Further review revealed the grievance was assigned to Director #1. Further review revealed the grievance was closed in seven (7) days. Further review revealed a letter, dated November 9, 2013. Further review revealed the letter was the hospital acknowledgement to the grievance. Review revealed no documentation of the hospital conducting an investigation related to the grievance.

Interview conducted January 17, 2014 at 1140 with Director #2 revealed the director was made aware of the grievance by Director #3 on November 5, 2013, the receipt date of the grievance. Further interview revealed Director #2 and #3 communicated via e-mail related to the grievance. Interview revealed no documentation of e-mail correspondences nor investigative documentation was available. Interview confirmed Director #2 did not follow the hospital's grievance process.

Interview conducted January 17, 2014 at 1200 with Director #3 revealed the director was aware of a grievance filed by the patient. Further interview revealed the director forwarded the grievance to Director #2. Further interview revealed Director #2 and Director #3 corresponded via e-mail related to the grievance. Interview revealed no documentation of e-mail correspondences nor investigative documentation was available. Interview confirmed Director #3 did not follow the hospital's grievance process.

Based on hospital policy review, open and closed medical records review, observation during tours and staff and patient interviews the nursing staff failed to supervise and evaluate the nursing care for patients by: A) failing to document the verification of feeding tube placement for 3 of 4 patients with tube feedings reviewed (#1, #3 and #8); B) failing to assess and document the patient's pain level for 3 of 4 patients reviewed (#1, #3 and #8); and C) failing to document position changes and turning every 2 hours for patients at high risk for skin breakdown for 3 of 6 patients reveiwed (#2, #3 and #8).

The findings include:

A. Review of the hospital's policy and procedure "Procedure for Care of Patient with Enteral Nutrition Closed, Open, Intermittent and Bolus Feedings" revised date of 11/2007 revealed "PROCEDURE: Use the following steps to set up and administer the formula:...16. Verify correct placement of feeding tube and assess gastric residual volume ...Residual volume that is greater or equal to 250mls (milliliters) Enteral (intestinal/stomach) feeding should be held and the physician notified. 17. Irrigate feeding tube with a minimum of 30-60 ml water. Feeding tubes must be flushed at least every 4 hours during continuous feeding, before and after each intermittent feeding and before and after medication administration through the tube to prevent feeding tubes from clogging ....Documentation should include: Residual amount including time."

The facilities Nursing Administration staff revealed "Lippencott's Nursing Advisor, copyright 2012" is used for guidelines and policies for performing nursing procedures. Review of the Lippencott's Nursing Advisor, copyright 2012, Nursing Procedures and Skills: Enteral feeding tube insertion gastric and duodenal provided by Nursing Administration revealed "...Special Considerations: Check gastric residual contents before each feeding. Feeding should be held if residual volumes are greater than 200ml on two successive assessments. Successful aspiration also confirms correct tube placement ...if no gastric secretions return, the tube may be in the esophagus....flush the feeding tube every 4 hours with up to 20-30 ml of normal saline solution or warm water to maintain patency ..."

1. Open medical record review of Patient #1 on 01/14/2014 revealed a 66 year male admitted on 01/09/2014 with diagnosis of fever. Review of the admitting physician's History and Physical (H&P) dictated 01/09/2014 at 1653 revealed medical history included end-stage renal disease with hemodialyis, DM (diabetes), Hypertension (high blood pressure), Atrial Fibrillation (irregular heart beat) history of multiple CVA (cerebral vascular accidents) (stroke), and failure to thrive, status post PEG (feeding tube) placement. Review of the Physician's "Assessment and Plan" revealed "...6. Failure to thrive. We will consult dietitian and continue his tube feedings ..."

Review of the Physician's orders dated 01/10/2014 revealed an order for Nepro (tube feeding) 1 can bolus feed three times a day. Continued review of the orders dated 01/15/2015 revealed the bolus feeds were discontinued. Continued review of the orders dated 01/15/2014 at 1042 revealed continuous tube feeding orders for Nepro at 40 ml/hr (milliliters per hour). Review of orders revealed no order to discontinue or hold flushes of the tube.

Review of the Nurses Intake and Output Gastric/Feeding Tube flow sheet dated 01/11/2014 revealed documentation of tube feeding placement verification at 0000, 0800, and 1400. Continued review revealed no documentation of tube placement verification or flushing from 01/11/2014 at 1400 through 01/16/2014 at 0700 (4 days and 17 hours [hrs] since last feeding tube placement verification).

Review of the Nurses Notes revealed no documentation of feeding tube placement from 01/11/2014 at 1400 through 01/16/2014 at 0700 (4 days and 17 hours since last feeding tube placement verification)

Interview on 01/14/2014 at 1255 with RN #6 revealed "continuous tube feedings are to be flushed and checked for placement twice a shift, every 4 hours. If the residual is more than 200 ml's then we would stop the feeding and call the doctor ...yes we should document that we verified placement on the NG flow sheet, how much residual the patient had and how much water we flushed the tube with ..." Interview confirmed the nursing staff failed to document verification of feeding tube placement per hospital policy.

Interview on 01/16/2014 at 1410 with Nursing Management revealed "continuous tube feedings should have placement and residual verified every 4 hours to ensure proper tube placement to prevent aspiration ...I find no documentation in this chart (Pt#1) that the feeding tube placement was verified per our policy ...I don't see that the flushes were completed either ..." Interview confirmed the nursing staff failed to document verification of feeding tube placement per hospital policy.

2. Open medical record review on 01/16/2014 of Patient #3 revealed a 62 year old female admitted on 01/06/2014 with a diagnosis of respiratory failure. Review of the physician's History and Physical (H&P) dictated 01/07/2014 at 00:00 revealed "...when she came to the Emergency Room (ER) ...patient was immediately intubated in the ER for respiratory failure...placed on mechanical ventilation, unresponsive and sedated ..."

Review of the physician orders dated 01/08/2014 at 0740 revealed "Continuous Nepro (tube feeding) 20 advance by 10 ml/hr every 6-8 hrs as tolerated to goal of 35 ml/hr. No auto flushes at this time." Continued review revealed a physician order dated 01/16/2014 at 1118 "Nasogastric Tube Removal ...clear liquid diet."

Review of the Nurses Intake and Output Gastric/Feeding Tube flow sheet dated 01/07/2014 at 0800 revealed "placement checked". Continued review revealed "tube clamped" documented on 01/07/2014 at 1200 and 1600. Continued review revealed no documentation of time the tube was unclamped. Continued review revealed the next documented tube verification of placement on 01/08/2014 at 0805 (27 hrs and 55 minutes [mins.] from last tube placement verfication) Continued review revealed the next tube placement verification was documented on 01/08/2014 at 1551 (7 hrs and 45 minutes from last placement verification). Continued review revealed the next documented tube placement verification on 01/12/2014 at 0000 (midnight) (2 days and 4 hrs from last tube placement verification).

Review of the Nurses Notes revealed no documentation of feeding tube placement verification from 01/08/2014 at 1551 through 01/12/2014 at 0000 (3 days, 4 hrs, and 51 minutes)

Interview on 01/14/2014 at 1255 with RN #6 revealed "continuous tube feedings are to be flushed and checked for placement twice a shift, every 4 hours. If the residual is more than 200 ml's then we would stop the feeding and call the doctor ...yes we should document that we verified placement on the NG flow sheet, how much residual the patient had and how much water we flushed the tube with ..." Interview confirmed the nursing staff failed to document verification of feeding tube placement per hospital policy.

Interview on 01/16/2014 at 1410 with Nursing Management revealed "continuous tube feedings should have placement and residual verified every 4 hours to ensure proper tube placement to prevent aspiration ...I find no documentation in this patient's (Patient #3) chart ( that the feeding tube placement was verified per our policy ...I don't see that the flushes were completed either ..." Interview confirmed the nursing staff failed to document verification of feeding tube placement per hospital policy.

3. Closed medical record review on 01/14/2014 at 1500 of Patient #8 revealed a 76 year old admitted to the facility on 04/21/2013 with diagnosis of Genitourinary Bleed. Review of the Physician's History and Physical dictated 04/21/2013 at 1204 revealed "...History of Present Illness...Patient is a PEG (percutaneous endoscopy gastrostomy) (feeding tube) tube feeder ....Abdomen: G-tube in place" Review of the medical history revealed the patient was status post CVA (cerebral vascular accident) with dysphasia (difficulty swallowing) and aspiration, and hypertension (high blood pressure).

Review of the physician's orders dated 04/21/2013 at 1145 revealed "Tube feeds: ISO-Source 1.2 at 90 ml/hr. continuous...elevate HOB (head of bed) 45 degrees at all times...Aspiration Precautions..." Continued review of orders dated 04/29/2013 at 1523 revealed "tube feeding formula, osmolite 1.2, 30, gastric tube, continuous..." Continued review of orders dated 05/03/2013 at 1541 revealed "tube feeding formula, Osmolite 1.2 ml/hour to goal of 80 ml/hr, continuous ...aspiration precautions ..."

Review of the Nurses Intake and Output Gastric/Feeding Tube flow sheet dated 04/22/2013 at 2026 revealed "continuous feed, tube placement confirmation : aspiration". Continued review revealed the next documented tube placement confirmation on 04/24/2013 at 0800 (36 hrs and 26 mins from last documented confirmation). Continued review of tube placement confirmation dated 04/24/2013 at 2122 revealed "feeding tube placement confirmation : Ausculation". Continued review revealed the next documented tube placement confirmation documented on 04/25/2013 at 2144 (24 hrs and 22 minutes from last placement verification).

Interview on 01/15/2014 at 0920 with RN #9 revealed "tube placement should be verified every 4 hours with flushes. Amount of flush volume is documented at end of shift for a total amount but tube placement verification should be documented every 4 hrs when flushes are done. I do not see the verification of tube placement documented every 4 hrs for this patient (Patient#8). I can not find but one documented tube placment verification on the 22nd and the 24th and there should be documented placement checks every 4 hours." Interview confirmed the nursing staff failed to document verification of feeding tube placement per hospital policy.

B. Review of the hospital's policy and procedure"Pain Management" last review date of 03/2012 revealed "...every patient shall be assessed for pain and have their pain treated and managed on an ongoing basis wherever patient care is rendered ...DEFINITIONS: ...2. Pain Assessment/Reassessment Tools: A. Subjective 1) Measurements tools used to rate and record a patient ' s perception of his/her pain. The numeric 0 - 10 scale (0=no pain, 1-3=mild pain, 4-6=moderate pain, 7-10=severe pain). Preferred scale for Adults and older children. A) The Wong-Baker face scale (a series of pictures of faces that range from: 'the happiest face (best feeling)' to 'the saddest face (worst feeling)' ...B. Objective: 1) Behavioral cues of pain: crying, facial grimacing, thrashing about or lying still with eyes shut (stoic behavior) ...3) Indicators of relief: sleeping, snoring, laughing ...V. POLICY: A. ASSESSMENT: 1. all licensed staff will assess and monitor patients for presence of pain and document findings per policy. 2) An initial pain assessment will be completed on all patients on admission and every shift. The following criteria will be assessed and documented. a. presence of pain b. intensity of the pain using a 0 to 10 pain scale ...or other appropriate for the patient ...5. Pain assessment tools used are appropriate for the patient's developmental, physical, emotional, and cognitive status. The assessment tool may be used by showing a diagram to the patient and asking the patient to indicate the appropriate rating or by simply asking the patient for a verbal response ...When verbal report is not possible, nurses should observe for behavioral clues to pain. The objective pain scale will be used for nonverbal patients ...B. Non-verbal Patients: 1. Assess for moaning, grimacing, and restlessness 2. Use Wong-Baker pain scale if patient is able ...REASSESSMENT: c. with every routine patient assessment at a minimum of every 12 hours ...2. the following criteria will be assessed and documented during the reassessment of pain. a. time of reassessment b. Intensity of pain using a 0 to 10 pains scale or other scale appropriate for the patient ..."

1. Open medical record review on 01/14/2014 of Patient #1 revealed a 66 year male admitted on 01/09/2014 with diagnosis of fever. Review of the admitting physician's History and Physical (H&P) dictated 01/09/2014 at 1653 revealed medical history included end-stage renal disease with hemodialyis, DM (diabetes), Hypertension (high blood pressure), Atrial Fibrillation (abnormal heart rate), history of multiple CVA (cerebral vascular accidents) (stroke), and failure to thrive, status post PEG (feeding tube) placement. Review of the Physician's "Assessment and Plan" revealed "...6. Failure to thrive. We will consult dietitian and continue his tube feedings... "

Review of the Nursing Pain Assessment flow sheet on 01/10/2014 at 0930 revealed a pain score of "2". On 01/10/2014 at 1917 the documented pain score is "0". Continued review revealed the next documented pain score on 01/12/2014 at 0940 revealed a pain score of "0" (38 hrs [hours] and 23 mins [minutes] from last pain assessment) Continued review of the pain assessment flow sheet dated 01/12/2014 at 1954 revealed a subjective pain assessment "sleeping". Continued review revealed the next documented pain assessment on 01/13/2014 at 1920 (23 hrs and 34 mins since last documented assessment). Continued review revealed on 01/14/2014 at 2222 a subjective pain assessment "sleeping" Continued review revealed the next documented pain assessment on 01/15/2014 at 2008 revealed a pain score of "3" (22 hrs and 14 mins from last documented pain assessment)

Review of the Nurses Notes revealed no documentation of pain assessment.

Interview on 01/15/2014 at 1500 with RN #8 revealed "...pain assessments are completed at least once per shift every 12 hours. You document a pain score using the Wong-Baker scale or if the patient is nonverbal you can still use the Wong-Baker score by assessing their nonverbal behavioral cues such as grimacing ...yes we are suppose to document the pain assessment for every patient ..." Interview confirmed the nursing staff failed to assess and document a patient's pain assessment every shift per hospital policy.

Interview during tour on 01/16/2013 at 0850 with RN #10 revealed "we are to assess the patient's pain each shift and document their pain level on the flow sheet ...we use the Wong-Baker scale or for nonverbal patient's we use behavioral signs for pain assessment ...we are expected to assess and document the patient's pain at least every 12 hours."

Interview on 01/16/2014 at 1500 with RN #9 revealed "the nursing pain assessments for this patient (#1) are not documented every shift per the hospital's policy and procedure...if it's not documented then you have no way of knowing it was done..." Interview confirmed the nursing staff failed to assess and document a patient's pain assessment every shift per hospital policy.

2. Open medical record review on 01/16/2014 of Patient #3 revealed a 62 year old female admitted on 01/06/2014 at 2308 with diagnosis of Respiratory Failure and placed on ventilatory (breathing machine) support. Review of the Physician's H&P dated 01/07/2014 at 0000 revealed "patient continued on mechanical ventilation ...Past Medical History: Coronary artery disease, ischemic cardiomyopathy/CHF (congestive heart failure), history of cardiac arrest, chronic anemia ..., insulin - dependent type 2 diabetes..."

Review of the Nursing Pain Assessment flow sheet on 01/12/2014 at 1941 revealed a "nurse observation of pain: no symptoms". Continued review of revealed the next documented pain assessment on 01/13/2014 at 1913 revealed "calm" (23 hrs and 28 mins from last documented assessment). Continued review of the next documented pain assessment on 01/14/2014 at 1715 revealed "Nurse Observation of pain: No symptoms" . Continued review of the next documented pain assessment on 01/15/2014 at 2015 revealed "Nurse Observation of pain: No symptoms. Pain Score: 0" (27 hrs from last documented pain assessment).

Interview during tour on 01/16/2013 at 0850 with RN #10 revealed "we are to assess the patient's pain each shift and document their pain level on the flow sheet ...we use the Wong-Baker scale or for nonverbal patient's we use behavioral signs for pain assessment ...we are expected to assess and document the patient's pain at least once a shift."

Interview on 01/16/2014 at 1500 with RN #9 revealed "the nursing pain assessments for this patient (#2) are not documented every shift per the hospital's policy and procedure...if it's not documented then you have no way of knowing it was done ..." Interview confirmed the nursing staff failed to assess and document a patient's pain assessment every shift per hospital policy.

3. Closed medical record review on 01/14/2014 at 1500 of Patient #8 revealed a 76 year old male admitted on 04/21/2013 with a diagnosis of Genitourinary Bleeding. Review of the Physician's H&P dictated on 04/21/2013 at 1204 revealed "resident of (Name of Rehabilitation Center) who comes to the Emergency Room (ED) after the nursing staff has noted some blood in the patient's diaper ....The patient has urologic history of stones and a stent apparently recently place ....He has a stage IV sacral decubitus ulcer. Patient is a PEG (percutaneous endoscopic gastrostomy) (feeding tube) tube feeder ...he has a significant Stage IV decubitus ulcer with tunneling ..."

Review of the Nursing Pain Assessment flow sheet dated 04/21/2014 at 1113 revealed a documented pain score of "0". Continued review of the next documented pain assessment on 04/22/2014 at 1500 revealed "Nurse Observation: calm" (27 hrs and 47 mins from last assessment). Continued review revealed a documented pain assessment on 04/24/2013 at 1600. Continued review of the next documented pain assessment on 04/29/2013 at 2110 revealed "Nurse Observation: calm, unable to score" (4 days, 5hrs, and 10 mins from last documented assessment).

Interview during tour on 01/16/2013 at 0850 with RN #10 revealed "we are to assess the patient's pain each shift and document their pain level on the flow sheet ...we use the Wong-Baker scale or for nonverbal patient's we use behavioral signs for pain assessment ...we are expected to assess and document the patient's pain at least once a shift."

Interview on 01/14/2014 at 1545 with RN #9 revealed "the nursing pain assessments for this patient (#8) are not documented every shift per the hospital's policy and procedure ...if it's not documented then you have no way of knowing it was done ..." Interview confirmed the nursing staff failed to assess and document a patient ' s pain assessment every shift per hospital policy.

C. Review of the hospital's Policy and Procedure "Pressure Ulcer Prevention and Management" last revised date of 03/2012 revealed "Nurse performs Braden Risk Assessment to identify patient at Risk for Skin Break down and implement prevention process ...Any pressure ulcer identified as Stage II or higher requires a physician notification ...POLICY: 1) The Braden Risk Assessment Tool is used to assess and document patients' risk for skin breakdown. The Braden Risk Assessment Tool will be done on all inpatients to measure functional capabilities of the patient to contribute to higher or lower risk for pressure tolerance. A lower score indicate higher risk for potential breakdown. 2) The Braden Scale is completed by a nurse on admission; and then at each shift ...PROCEDURE: A. Documentation: the skin assessment will be documented on nursing flow sheet daily. B. Skin Assessment Screening: a. Score 15-18: Patient is at mild risk for skin breakdown or pressure ulcer development ...b. Score 14 and below: Patient is "High Risk" for skin breakdown or pressure ulcer development: 1. Turning schedule if applicable, turn every two hours ...Pressure Ulcer Prevention and Stage I Protocol: Patient's at risk for breakdown ...Braden Score < 15 ...Stage I Breakdown: Redness over boney prominence, skin is intact: ...3. Reposition every 2 hours and document ...6. Patient is to be turned every 1 to 2 hours and must be documented in nurse's notes ...Stage II Breakdown: Partial thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as a blister or shallow crater ...3. Reposition every 2 hours and document ...6. Patient is to be turned every 1 to 2 hours and must be documented in nurse's notes ...Stage III Breakdown: full thickness loss. Subcutaneous fat may be visible but bone, tendon, or muscle is not exposed ...3. Reposition every 2 hours and document ...6. Patient is to be turned every 1 to 2 hours and must be documented in nurse's notes ...Stage IV: full thickness tissue loss with exposed muscle, tendon, or bone ...3. Reposition every 2 hours and document ...6. Patient is to be turned every 1 to 2 hours and must be documented in nurse's notes ..."

1. Open medical record review on 01/16/2014 of Patient #2 revealed an 88 year old female admitted on 01/11/2014 with a diagnosis of Urinary Tract Infection (UTI) with Sepsis (blood infection), Dementia, and Alzheimer's. Review of the physician's History and Physical (H&P) dated 01/12/2014 revealed "...she appears to be malnourished...she has a skin tear on her right elbow. She has skin breakdown on her left hip and heel and has a necrotic stage IV sacral decubitus that is gangrenous smelling ..."

Review of the Nursing Braden Scale Assessment dated 01/12/2014 at 1942 revealed a Braden Score of 11 (High Risk for Skin Breakdown). Continued review of Braden Score dated 01/13/2014 at 1909 revealed a Braden Score of 9 (High Risk for Skin Breakdown). Continued review of the Braden Score Assessment dated 01/14/2014 at 2045 revealed a Braden Score of 9 (High Risk). Continued review of the Braden Scale Assessment revealed the patients' "Mobility: complete care; Activity: Bedfast; Nutrition: Very Poor; Pressure Reduction Measures: Turn patient every 2 hrs ..."

Review of the Nursing Flow Sheet Adult ADL's (activities of daily living) dated 01/12/2014 at 1322 revealed "Patient Position: turned by staff". Continued review revealed the next documented patient repositioning or turning on 01/14/2014 at 1000 (45 hrs and 22 mins. from last turn). Continued review of documentation at 01/14/2014 at 1849 revealed "patient position: Lying on side". Continued review revealed the next patient turning or repositioning on 01/16/2014 at 0700 (36 hrs and 11 mins from last turn).

Review of the Nurse's Notes on 01/14/2013 at 1849 thrugh 01/16/2014 at 0700 revealed no documentation the patient was turned or repositioned every 2 hours (36 hrs and 11 mins).

Interview on 01/15/2014 at 1405 with the Nursing Unit Director revealed "patients at risk for skin breakdown who have a Braden Score of less than 15 are High Risk for skin breakdown and pressure ulcers. The protocol is to turn and reposition the patients every 2 hours. Yes I would expect the nurse or the CNA (certified nursing assistant) to document the patient was turned ...if it is not documented then I have no way of knowing for sure the turning of the patient was done per the protocol ...I don't know if it was done if it's not documented ...if it's not documented then it's not done..." Interview confirmed the nursing staff failed to document turning of the patient every 2 hrs per the hospital policy for pressure ulcer prevention for a patient at high risk for skin breakdown.

Interview on 01/15/2014 at 1545 with CNA #1 revealed "Patient's at high risk for skin breakdown are to be turned every 2 hrs and we are to document that we turned them in the chart...the only place we (CNA's) would document we turned the patient is on the flow sheet ..." Interview confirmed the nursing staff failed to document turning of the patient every 2 hrs per the hospital policy for pressure ulcer prevention for a patient at high risk for skin breakdown.

Interview on 01/15/2014 at 1605 with RN #7 revealed "skin assessments are done and documented each shift ...any patient at risk for skin breakdown is to be turned frequently at least every 2 hrs and documented in the chart ..." Interview confirmed the nursing staff failed to document turning of the patient every 2 hrs per the hospital policy for pressure ulcer prevention for a patient at high risk for skin breakdown.

Interview on 01/16/2013 at 1545 with RN #9, Nursing Leadership, revealed "documentation of turning and repositioning should be on the ADL flow sheet or in the nurses notes ...nursing should document when they turn the patient every 2 hrs ...for this patient (#2) turning or repositioning is not documented every 2 hrs as it should be ...I do not know if the patient (#2) was turned every 2 hrs since it is not documented ..." Interview confirmed the nursing staff failed to document turning of the patient every 2 hrs per the hospital policy for pressure ulcer prevention for a patient at high risk for skin breakdown.

2. Open medical record review on 01/16/2014 of Patient #3 revealed a 62 year old female admitted on 01/06/2014 at 2308 with diagnosis of Respiratory Failure and placed on ventilatory (breathing machine) support. Review of the Physician's H&P dated 01/07/2014 at 0000 revealed "patient continued on mechanical ventilation...Past Medical History: Coronary artery disease, ischemic cardiomyopathy/CHF (congestive heart failure), history of cardiac arrest, chronic anemia (low blood) ... insulin - dependent type 2 diabetes ..."

Review of the Nursing Braden Scale Assessment on 01/08/2014 at 0832 revealed a Braden Score of 13 (High Risk for Skin Breakdown). Continued review of Braden Score dated 01/09/2014 at 0753 revealed a Braden Score of 12 (High Risk for Skin Breakdown). Continued review of the Braden Scale Assessment revealed the patient "Mobility: complete care; Activity: Bedfast; Nutrition: Poor; Pressure Reduction Measures: Turn patient every 2 hrs..."

Review of the Nursing Flow Sheet Adult ADL's (activities of daily living) on 01/07/2014 at 1400 revealed "repositioned by staff". Continued review revealed the next documented position change on 01/08/2014 at 0800 (18 hrs from last turn). Continued review revealed a documented patient turn on 01/08/2014 at 1600. Continued review revealed the next documented turning of the patient on 01/09/2014 at 0806 (16 hrs and 8 mins.)

Interview on 01/15/2014 at 1545 with CNA #1 revealed "Patient's at high risk for skin breakdown are to be turned every 2 hrs and we are to document that we turned them in the chart ...the only place we (CNA ' s) would document we turned the patient is on the flow sheet ..." Interview confirmed the nursing staff failed to document turning of the patient every 2 hrs per the hospital policy for pressure ulcer prevention for a patient at high risk for skin breakdown.

Interview on 01/15/2014 at 1605 with RN #7 revealed "skin assessments are done and documented each shift ...any patient at risk for skin breakdown is to be turned frequently at least every 2 hrs and documented in the chart ..." Interview confirmed the nursing staff failed to document turning of the patient every 2 hrs per the hospital policy for pressure ulcer prevention for a patient at high risk for skin breakdown.

Interview on 01/16/2013 at 1320 with RN #9, Nursing Leadership, revealed "documentation of turning and repositioning should be on the ADL flow sheet or in the nurses notes ...nursing should document when they turn the patient every 2 hrs ...for this patient (#3) turning or repositioning is not documented every 2 hrs as it should be ...I do not know if the patient (#3) was turned every 2 hrs since it is not documented ..." Interview confirmed the nursing staff failed to document turning of the patient every 2 hrs per the hospital policy for pressure ulcer prevention for a patient at high risk for skin breakdown.

3. Closed medical record review on 01/14/2014 at 1500 of Patient #8 revealed a 76 year old male admitted on 04/21/2013 with a diagnosis of Genitourinary Bleeding. Review of the Physician's H&P dictated on 04/21/2013 at 1204 revealed "resident of (Name of Rehabilitation Center) who comes to the Emergency Room (ED) after the nursing staff has noted some blood in the patient's diaper ....The patient has urologic history of stones and a stent apparently recently place ....He has a stage IV sacral decubitus ulcer. Patient is a PEG (percutaneous endoscopic gastrostomy) (feeding tube) tube feeder ...he has a significant Stage IV decubitus ulcer with tunneling ..."

Review of the Nursing Braden Scale Assessment dated 04/22/2013 at 1049 revealed a Braden Score of 10 (High Risk for Skin Breakdown). Continued review of Braden Score dated 04/23/2013 at 2000 revealed a Braden Score of 9 (High Risk for Skin Breakdown). Continued review of the Nursing Braden Score Assessment dated 05/06/2013 at 1400 revealed a Braden Score of "12" (high risk for skin breakdown). Continued review revealed on 05/07/2013 at 1107 a documented Braden Score of "10" (high risk). Continued review revealed on 05/08/2013 at 0311 a Braden Score of "10" (high risk).

Review of the Nursing Flow Sheet Adult ADL's (activities of daily living) dated 04/22/2013 at 1000 revealed the patient's activity status "complete care; bedfast" and the patient's position "turned by staff". At 1340 documentation revealed "turned by staff" (3 hrs and 40 mins from last turn). At 1600 documentation revealed the patient's position change "turned by staff". Continued review revealed the next documented time of patient position change/turning on 04/22/2013 at 2000 (4 hrs from last turn). Continued review at 2300 revealed "Complete care" and "turned by staff". Continued review revealed the next documented position change on 04/23/2013 at 0800 (9 hrs since last documented position change/turn). Continued review of documentation on 04/23/2013 at 1000 revealed the patient was turned by the staff. Continued review revealed the next documented position change/turning of the patient at 2000 (10 hrs from last turn).

Review of the Nursing Flow Sheet Adult ADL's (activities of daily living) dated 05/04/2013 at 1337 revealed the patient's position "turned by staff". Continued review of the flow sheet revealed the patient "total care" for his ADL's. Continued review of the flow sheet revealed no documentation the patient was turned or repositioned every 2 hours on 05/05/2013, 05/06/2013, 05/07/2013, or 05/08/2013 (4 days).

Review of the Nurse's Notes on 05/05/2013, 05/06/2013, 05/07/2013, and 05/08/2013 revealed no documentation the patient was turned or repositioned every 2 hours.

Interview 01/14/2013 at 1545 with RN #9, Nursing Leadership, revealed "documentation of turning and repositioning should be on the ADL flow sheet or in the nurses notes ...nursing should document when they turn the patient every 2 hrs ...for this patient (#8) turning or repositioning is not documented every 2 hrs as it should be ...I do not know if the patient (#8) was turned every 2 hrs since it is not documented ..." Interview confirmed the nursing staff failed to document turning of the patient every 2 hrs per the hospital policy for pressure ulcer prevention for a patient at high risk for skin breakdown.

Interview on 01/15/2014 at 1405 with the Nursing Unit Director revealed "patient's at risk for skin breakdown who have a Braden Score of less than 15 are High Risk for skin breakdown and pressure ulcers. The protocol is to turn and reposition the patient's every 2 hours. Yes I would expect the nurse or the CNA (certified nursing assistant) to document the patient was turned ...if it is not documented then I have no way of knowing for sure the turning of the patient was done per the protocol ...I don't know if it was done ...if it's not documented then it's not done ..." Interview confirmed the nursing staff failed to document turning of the patient every 2 hrs per the hospital policy for pressure ulcer prevention for a patient at high risk for skin breakdown.

Interview on 01/15/2013 at 1500 with RN #8 revealed "...I remember caring for this gentlemen (Pt #8), he had a Stage IV pressure ulcer on his coccyx ...we were to turn him every 2 hrs and it should be documented on the flow sheet by the person turning him ...I do not see it documented that he was turned on May 6th or 7th..." Interview confirmed the nursing staff failed to document turning of the patien

Based on review of hospital policy, open and closed medical record review and staff interview the nursing staff failed to monitor the patient's receiving blood for 2 of 3 patients receiving blood (#7 & #9)

Review of the hospital's policy and procedure "TRANSFUSIONS OF BLOOD AND BLOOD COMPONENTS" last revised date of 06/2010 revealed "...8. Blood bag information shall be checked at the patient's bedside by two licensed nurses, RN (registered nurse) and LPN (licensed practical nurse)/RN documented on the transfusion tag record and Nursing Blood Product Transfusion Record. 9. A unit of blood or blood component must be infused within 4 hours of issue from the blood bank...15. For each unit transfused: Vital signs (VS) (Temperature, Blood Pressure, Pulse, and Respirations) must be obtained and recorded on the Nursing Blood Product Transfusion Record immediately before the initiation of the transfusion, 15 minutes after the transfusion started and every hour during the transfusion and 15 minutes after the transfusion has been discontinued..."

1. Closed medical record review on 01/14/2014 revealed a 68 year old female (Patient #7) admitted to the facility on 01/04/2014 with diagnosis of "rectal bleeding". Review of the Physician's orders revealed an order dated 01/07/2014 at 0820 "transfuse red blood cell product...2 units."

Review of the record revealed two (2) Nursing Blood Product Transfusion Records. Review of the first blood product transfusion record dated 01/07/2014 (the time is left blank) revealed no documented time the blood was initiated or discontinued. Continued review revealed no documented signature for the second RN signature required for verification of blood at the patient's bedside. Continued review revealed no documented patient temperature's at 15 minutes after initiation of the transfusion, 1 hour, 2 hours, 3 hours, or at the 15 minute post infusion time.

Review of the second blood transfusion record dated 01/07/2014 revealed pre-transfusion vital signs at 2000. Continued review revealed no documented time the blood was discontinued. Continued review revealed no documented patient temperatures at 15 minutes after initiation of the blood and 1 hour after initiation of the blood. Continued review revealed no documented stop time and no documented 15 minute post transfusion Vital Signs (Blood pressure, temperature, pulse, or respirations).

Interview on 01/14/2014 at 1400 with an administrative Registered Nurse revealed "the date and time of administration of blood should be included on the blood transfusion record. Vital Signs should include the temperature which is part of the monitoring of the blood administration. There should be two licensed staff signatures on the blood administration record verifying the blood was matched and verified for the correct patient. These two blood administration records are incomplete..." Interview confirmed the nurses failed to follow the hospital policy and procedure for monitoring the patient during the blood transfusion.

Interview on 01/17/2014 at 0800 with the RN #5, the nurse administering the blood, revealed "Vital Signs include the temperature and the temperature should be documented. The date and time the blood is started and stopped should be documented on the blood administration record. Two licensed staff must verify against the patient's armband the blood is the correct blood for the correct patient and then both persons are to sign the blood administration record....the vital signs are incomplete on this record and there is no start or stop time of the transfusion. A second RN did verify the blood with me but she forgot to sign the record." Interview confirmed the nurses failed to follow the hospital policy and procedure for monitoring the patient during the blood transfusion.


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2. Closed medical record review conducted January 14, 2014 through January 17, 2014 revealed patient #9, an 82-year-old presented to the hospital February 27, 2013 with complaints of shortness of breath, leg swelling and a 13-pound weight gain. Further review revealed the patient received an admitting diagnosis of congestive heart failure exacerbation.

Review revealed February 27, 2013; the patient's hemoglobin level was 8.3. Further review revealed February 27, 2013; the physician ordered to transfuse one unit of blood and the patient's spouse consented for the blood transfusion. Further review revealed the patient was transfused one unit of blood.

Review of the blood transfusion documentation revealed pre-transfusion vital signs were documented at 0423. Further review revealed the fifteen minute vital signs, after blood transfusion initiation, were documented at 0514 (51 minutes later). Further review revealed the one hour vital signs were documented at 0615 (one hour and 1 minute later), and the two hour vital signs was documented at 0715 (one hour later). Review revealed the transfusion stopped date and time was blank. Review revealed no vital signs were documented fifteen minutes after the blood transfusion was completed.

Interview conducted January 17, 2014 at 0900 with nursing information technologist confirmed no additional vital signs documentation, during the time of the blood transfusion, was available.

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