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Based on clinical record review and staff interview it was determined that the Registered Nurse failed to supervise and evaluate the care related to assessments for 1 (#1) of 13 patients sampled. This practice could result in a delay in treatment and/or discharge.

Findings include:

1. Patient #1's nursing note dated 7/7/10 at 8:00 a.m. revealed an assessment was completed with a possible discharge home that day. A second entry completed at 11:00 a.m., indicated the patient was discharged home. The patient's vital signs documented at 8:00 a.m. revealed a blood pressure of 163/112. There was no documentation from nursing concerning the elevated blood pressure, that the blood pressure was rechecked, or whether the physician was contacted prior to the patient being discharged. A review of the Patient daily Care Record used for documenting the patient's assessment by nursing for 7/7/10 was blank.

2. Patient #1 Nursing discharge instructions dated 7/7/10 at 11:50 a.m. revealed the patient was discharged home on a Cardiac diet. Review of the physician's orders for discharge on 7/7/10 at 11:00a.m. revealed no orders for a discharge diet. Review of physicain orders revealed the physician had ordered a low sodium diet on 7/1/10 and then changed that diet to a low vitamin K diet on 7/5/10.

Review of nursing discharge instructions revealed the patient was discharged home with food/drug interaction information given for daily medications. There were no medications listed on the instruction sheet. The patient was also discharged home on Coumadin but according to the nursing discharge instruction sheet the Coumadin pack was not marked as given to patient.

3. Patient #1's Patient Daily Care Record page#5 of 6, revealed the section for screenings was not completed for the following days 7/4/10, 7/5/10 and 7/7/10. Physician order dated for 7/2/10 instructed to provide the patient with educational material about Coumadin and dietary instruction in regard to treatment. A review of the nursing documentation for dates 7/1/10, 7/2/10, 7/3/10, 7/4/10, 7/5/10, and 7/6/10 did not reveal any documentation from nursing concerning Coumadin and/or dietary instructions. A review of the physician's progress notes revealed an entry by the dietician on 7/6/10 for a limited dietary consultation.

Based on review of clinical record review and facility documents and interviews it was determined the facility failed to ensure that the nursing staff developed and kept current a nursing care plan for six (#1, #2, #5, #9, #10, #12) of 13 records reviewed. This practice does not ensure patient goals are achieved.

Findings include:

1. During lunch observation on 08/16/10 at 11:35 a.m. patient #9 had a lunch tray which included an iceberg lettuce salad with grilled chicken. The patient was prescribed Coumadin. On the overbed table the patient had a handout titled "If You Take Coumadin". The handout's most recent revision date was 2004. Patient #9 stated the nurse gave that to him/her about hour ago and instructed the patient not eat the lettuce salad due to the Coumadin therapy. The salad did not contain a high Vitamin K food (Vitamin K can decrease the blood thinning effects of warfarin).

2. Observation at 11:39 a.m. on 08/16/10 showed patient #12 had a lunch tray and a handout titled "If You Take Coumadin" on the overbed table. Patient #12 was also prescribed Coumadin and stated that the nurse provided that handout ten minutes ago.

3. Patient #9's and #12's physician orders noted the patients were being discharged. The Interdisciplinary Patient Education Record form in the record was not checked that the patient was given the "Coumadin pack" for discharge, but instead the Food and Drug interaction information was given for Coumadin.
Interview with the Education Director revealed that the hospital has educational materials that can be printed from the patient education software. The Education Director printed a sample of the educational materials for the "Coumadin pack" as indicated. The information was different and more current than the handouts that patients #9 and #12 had received. The handouts printed from the education software were personalized with the hospital logo and could be customized for the patient.

4. Patient #10's physician orders indicated the patient was on Coumadin and was in the process of being discharged. The Interdisciplinary Patient Education Record form was checked that the patient was given the "Coumadin pack" for discharge. The Unit Manager was asked which written patient education materials were given to the patient. The Unit Manager went to look for a copy of the handout and produced a handout of drug information from the drug manufacturer from 2005.

Dietitian interview on 08/16/10 at 2:10 p.m. revealed that when the dietitian provides counseling on dietary guidelines for coumadin therapy to patients, she provides a handout from the contract food service educational materials dated 2009.
Interview with the Education Director on 08/17/10 at 4:50 p.m. revealed that the hospital has patient education software available for several disease conditions that were available on the hospital intranet which could be printed on demand. The Education Director stated that the other handouts used for patients receiving Coumadin therapy were acceptable to use, even though they were not as current as the patient education available on the hospital intranet. She said that the handout of Coumadin information from the drug manufacturer from 2005 was still used because it had a diary for the patient to record the dosage and lab values.
The Director of Quality and the Risk Manager on 08/17/10 at 5:10 p.m. were informed of the different patient education materials provided to patients, including a hospital pamphlet titled "Possible Food/Drug Interactions" (undated) which included foods that contain Vitamin K to consider for Coumadin. This pamphlet stated "Avoid foods high in Vitamin K" and listed those foods. This pamphlet did not conform to current guidelines to eat a consistent amount of Vitamin K each day. The Director of Quality and Risk Manager agreed that the nurses should be providing the most current information for patients receiving Coumadin.
The Director of Pharmacy on 08/17/10 at 5:27 p.m. during interview indicated patients receiving Coumadin should avoid large fluctuations of Vitamin K intake. He was informed about the information included in the hospital pamphlet titled "Possible Food/Drug Interactions", which was developed by by the Nutritional Services and Pharmacy Departments of the hospital. He stated that that this educational material should be reviewed to ensure it was current with current guidelines.


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5. Patient #1's Plan of Care revealed the plan was initiated on 7/1/10. The patient was discharged home on 7/7/10 but the plan was never resolved. A review of page 3 of 3 revealed the plan was reviewed or revised by the nursing staff but no interventions were documented.

A review of the Interdisciplinary Patient Education Record for patient #1 dated for 7/1/10 under the section for Dietary information/nutritional/oral health, specific content taught by the nurse was a Low Vitamin K diet. A review of the required areas for documenting the instructions was not completed and the patient' s response was left blank.

A review of the Education Interdisciplinary Patient Plan , # 900 A 325, revised 5/10 revealed under policy 2.1, patient/family education will began upon patient's admission and will continue throughout the patient's stay until discharge. A review of section 3.0, Scope: section 3.2 the education provided may include but not limited to: information on Safe and effective use of medication and Nutrition interventions instructions on modified diets. Section 3.3 revealed the education process includes the evaluation of the patient's understanding of the education and training if provided.

6. Patient #2's plan of care initiated on 6/25/10 at 8:00 p.m. revealed none of problems identified were resolved. Review of the Patient Daily Care Record for 6/2610 and 6/27/10 revealed the screenings for functional, social services; wound care, respiratory and nutrition were not completed.
Nursing discharge orders for 6/30/10 at 9:25 a.m. revealed the patient was discharged home on an as tolerated diet. There was no food and drug interaction information given and there was no Coumadin pack given for discharge instructions. A review of the copy of prescriptions given to the patient revealed they were discharged home on Coumadin.

A review of the policy Patient Assessment/Reassessment Plan 2010, no policy #, revised 4/10 revealed for the Progressive Care Unit (PCU), the plan of care is updated every 24 hours by the Registered Nurse based upon patient reassessment and patient need.

A review of the policy Care Plans for Patients, #100.4.2, revised 7/9 revealed all patients admitted to the facility will have a Care Plan initiated by the Registered Nurse (RN). Care is planned and provided in an Interdisciplinary, collaborative manner by qualified individuals upon admission. The Care Plan is reviewed and/or updated by the RN daily. The review of paragraph (8) stated all identified problems/issues on the Care Plan will be dated when implemented and when problems/issues are resolved.

An interview with the Chief Nursing Officer (CNO)and the Director of Clinical Resources on 8/17/10 at approximately 3:00 p.m. revealed that a screening assessment is completed by nursing on a daily basis. The above clinical records were reviewed by the CNO and the Director of Clinical Resources and the findings were confirmed.


7. Patient #5 Plan of Care initiated on 7/20/10 was not resolved by date of discharge of 7/23/10. A review of page 3 of 3 of the plan of care revealed it was not reviewed or revised on 7/21/10 and 7/23/10 by nursing as per the facility policy.

Based on clinical record review, facility policies and staff interviews it was the determined the nursing staff failed to administer medications according to facility policy for one (#5) of 13 records reviewed. This practice has the potential to result in adverse outcomes for the patients.


Findings include:

1. Patient #5's Medication Administration Record (MAR) revealed an entry by nursing at 8:30 p.m. on 7/20/10 for Regular Insulin. The Insulin was given at 9:46 p.m. The MAR for 7/21/10 at 8:30 p.m. revealed the insulin was not given. The medication was given at 9:43 p.m. A review of the MAR for 7/22/10 revealed the insulin was not given at 4:30 p.m., 8:30 p.m., and 11:30 p.m. The insulin was given at 10:14 p.m.
An interview with the Chief Nursing Officer, Chief Operating Officer, Risk Manager and Director of Quality services on 8/17/10 at approximately 3:00 p.m., after a review of the clinical record confirmed the findings.
A review of the SafeScan Medication Bar Coding System policy # 900 A 410, revised 3/22/10, section 4.15.4, Timing alerts, reveals scheduled medications have a lead time of 30 minutes and a lag time of 30 minutes to complete medication administration.

Based on clinical record review and staff interviews it was determined the facility failed to ensure that all patients orders are signed by a practitioner who is authorized to write orders for 1(#2) of 13 records reviewed. This practice has the potential for patient adverse outcomes and a delay in treatment.

Findings include:

1. Patient #2's physician's order dated 6/28/10 instructed to resume Heparin tomorrow. A review of the physician's orders revealed an order for a heparin drip written by a Registered Nurse and co-signed by a Registered Nurse on 6/28/10 but not signed by a Physician.

A review of the policy, Requirements for medication orders, reference #, L-01, revised 12/09. Under the heading Contents of Drug Orders, written drug orders shall be signed by the prescriber or prescribers responsible for the care of the patient.

An interview with the Chief Nursing Officer, Chief Operating Officer, Risk Manager and Director of Quality services on 8/17/10 at approximately 3:00 p.m., after a review of the clinical record confirmed the findings.

Based on observation, interview and record review, the hospital failed to ensure that three (#9, #10, and #12) of 5 patient's nutritional needs were met who were receiving anticoagulant (Coumadin) therapy.

Findings include:

1. Three patients who were prescribed Coumadin therapy, (#9, #10, and #12), were observed at lunch on 08/16/10 between 11:30 a.m. and 12: 15 p.m. The main menu called for lasagna, green and wax beans with carrots, a dinner roll, and orange fruited gelatin. The alternate for lunch was a grilled chicken salad on iceberg lettuce with vegetable soup. During lunch observation on 08/16/10 at 11:35 a.m., patient #9 had a lunch tray which included a iceberg lettuce salad with grilled chicken. The patient stated the nurse gave a handout titled "If You Take Coumadin" to him/her about hour ago and was told not eat the lettuce salad due to the Coumadin therapy. The salad did not contain a high Vitamin K food (Vitamin K can decrease the blood thinning effects of Coumadin).
On 08/16/10 at 1:42 p.m. the Nutrition Services Supervisor was interviewed about how menus would be modified for limiting high Vitamin K foods for patients receiving Coumadin. She responded that she would make sure they would not get any "green" vegetables, for example the patients would not get the green beans on the menu. The dietitian who was present at the time and corrected her that Vitamin K foods would not be eliminated from the menu, but that the amount was consistent. The Nutrition Services Supervisor was asked if she had any written guidance available to her to follow. The dietician responded that there was information on the hospital intranet and the contract food service website. The Nutrition Service Supervisor stated that she did not have access to this information and had no written guidance.
Dietitian interview on 08/16/10 at 2:10 p.m. revealed that when the dietitian provides counseling on dietary guidelines for coumadin to patients upon physician's order for a consult. She further stated that daily, the Catering Associates (CAs) receive a list of patients receiving anticoagulant therapy and monitor the patient's menu to ensure that the patient consumes a consistent amount of Vitamin K daily.
On 08/17/10 at 11:06 a.m. the dietitian was interviewed again. She indicated that the current menu did not require any modification for limiting the amount of high Vitamin K foods, as the amounts of high and moderately high Vitamin K foods were within recommended guidelines.
Three of three patients (#9, #10, and #12) who were receiving Coumadin were provided different patient education materials by nursing staff about the drug and dietary guidelines, of which some did not reflect the current dietary guidance to eat a consistent amount of Vitamin K each day.
The hospital food service contract Clinical Nutritional Services Policy and Procedure titled: Food-Drug and Herb-Drug Interaction Education, policy #D014 issued originally on May 1995 and recently revised July 2010 indicated the following:
"Dietitian, Pharmacist or Nurse
-Nursing counsels the patient and/or family on potential food-drug-herbal interactions and documents education in the medical record.
-The dietitian will provide further education on anticoagulant therapy when a consult is ordered.
-For patients receiving anticoagulant therapy, education done by nursing includes dietary restrictions, and potential adverse drug reactions and interactions.
Dietitian or Catering Associate
-Reviews daily anticoagulant patient list to ensure that patient's menus follow guidelines.
-Modified the patient meal pattern or diet as needed.
-Ensures that the patient menu follows recommendations for Vitamin K intake follows information outlined in the Contract Food service "Manual of Clinical Nutrition Management 2008". These recommendations include serving no more than 1 serving of foods identified to contain high levels of vitamin K per day and no more than 3 servings of foods identified to contain moderate levels of Vitamin K per day.
-Ensure that patients receiving anticoagulant therapy receive no more than 1 cup of cranberry juice per day."