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Based on interview, record review, and review of the facility's Job Description for the Nursing Technician (NT), it was determined the facility failed to ensure daily personal hygiene was performed for three (3) of twelve (12) sampled patients (Patients #3, #6, and #12).

The findings include:

Review of the facility's Job Description for a Nursing Technician, revised 06/24/14, revealed the Nursing Technician was to work under close direction of the Registered Nurse (RN). Per the Job Description, the Nursing Technician was responsible for patients daily hygiene needs and for providing safe, quality care to patients. Further review revealed the Nursing Technician's Job Description included documentation of the care performed.

1. Review of Patient #3's medical record revealed the facility admitted the patient on 01/08/15, with a diagnosis of Shortness of Air, and discharged him/her in stable condition on 01/17/15. Further review revealed no documented evidence Patient #3 was provided daily hygiene or refused daily hygiene for the following dates: 01/09/15, 01/11/15, 01/13/15, 01/14/15, 01/15/15 and 01/16/15.

2. Review of Patient #6's medical record revealed the facility admitted the patient on 03/20/15, with diagnoses which included Acute and Chronic Renal Failure, Coronary Artery Disease, Chronic Congestive Heart Failure, Insulin Dependent Diabetes Mellitus and Dehydration. Continued review revealed Patient #6 was noted to have expired on 03/29/15 at 9:17 PM. Further review revealed no documented evidence Patient #6 was provided daily hygiene or refused daily hygiene for the following dates: 03/24/15, 03/28/15 and 03/29/15.

3. Review of Patient #12's medical record revealed the facility admitted the patient on 04/25/15, with diagnoses which included Right Lower Extremity Cellulitis, Insulin Dependent Diabetes Mellitus and Chronic Kidney Disease. Further review revealed no documented evidence Patient #12 was provided daily hygiene or refused daily hygiene on 04/26/15 and 04/28/15.

Interview with NT #2, on 04/28/15 at 11:40 AM, revealed one (1) of her duties was to assist patients with personal hygiene and give bed baths if needed on a daily basis. She revealed there had been a log started after 04/01/15 for NT's to list what had been done for patients which included personal hygiene. Per NT #2, she was supposed to document when personal hygiene was performed for her patients by the amount of assistance the patient required. Further interview revealed she was also to document if the patient refused care and add an explanatory note.

Interview with the Clinical Manager (CM), on 04/30/15 at 2:40 PM, revealed her expectation was for every patient to receive an assisted bath everyday if they desired, and if they were independent to receive a towel and wash cloth to take a shower. She revealed she thought there was an issue of documentation of patient refusals, and not of a patient wanting a bath and not getting one. The CM stated she expected the NT's to document patient care or refusal of care because it was part of the facility's nursing standard of care for baths to be given daily unless the patient refused.

Interview with the Chief Nursing Officer (CNO), on 04/30/15 at 4:15 PM, revealed her expectation was for patients to be bathed daily or at least have the NT offer a bath, with the patient having the right to refuse a bath. Per interview, there should have been documentation if patients refused the bath or if the bath/shower had been given. She stated if there was a refusal of care by a patient, it needed to be further explained in a note. The CNO revealed all nurses, at orientation, were told it was a global nursing standard of care for daily personal hygiene, or bathing, pull to every area's work list.

Based on interview and record review, it was determined the facility failed to ensure Physician's Orders were followed for one (1) of twelve (12) patients (Patient #6).

The findings include:

Interview with the Chief Nursing Officer (CNO), on 04/30/15 at 4:15 PM, revealed the facility might have a facility policy on nurses following Physician's Orders; however, it could not be located. Per interview, following Physician's Orders was not included in the job description for the Registered Nurse (RN).

Review of Patient #6's medical record revealed the facility admitted the patient on 03/20/15, with diagnoses which included Chronic Congestive Heart Failure, Acute and Chronic Renal Failure, Coronary Artery Disease, Insulin Dependent Diabetes Mellitus and Dehydration. Record review revealed a Physician's Order, dated 03/20/15 at 1:33 AM, to notify the Physician for a systolic blood pressure (B/P) of less than 90 mmHg (millimeters of mercury-the units used to measure blood pressure).

Review of a Nurse's Note documented by RN #2, dated 03/29/15 at 7:05 PM, revealed she went to assess Patient #6, per the family's request, due to the patient having abdominal pain and shortness of breath. Continued review of the Note revealed the patient's blood pressure was 88/53, with no documented evidence of RN #2 having notified the Physician of the systolic B/P of less than 90 mmHg (88), as per the order dated 03/20/15. Review of the Nurse's Note dated 03/29/15 timed 7:30 PM, documented by RN #1, revealed no documented evidence the Physician was notified of the systolic B/P of 88 obtained by RN #2 noted at 7:05 PM. Review of the Nurse's Note dated 03/29/15 at 9:05 PM, documented by RN #2 revealed Patient #6 was in agonal (an abnormal gasping respiration pattern) breathing and was nonresponsive. Further record review revealed Patient #6 was noted to have expired on 03/29/15 at 9:17 PM.

Interview with RN #2, on 04/29/15 at 8:35 AM, revealed she did assess Patient #6 at around 7:00 PM, on 03/29/15, and found the patient's B/P to be 88/53. She stated the patient's B/P was a little low, but the family did not ask her to call the Physician. Per interview, Patient #6 was feeling better and wanted to go to sleep, and she felt the low B/P was volume related. She revealed however, Patient #6 was receiving intravenous fluids. Further interview revealed she knew RN #1 was expecting a call back from the patient's Physician, and she had told RN #1 about her assessment of the patient and about his/her low B/P.

Interview by telephone with RN #1, on 04/29/15 at 9:48 AM, revealed if she had spoken to the Physician on 03/29/15, it would have been about Patient #6 being impacted. Per interview, she could not remember what she had informed the Physician of that far back however.

Interview with the Clinical Manager (CM), on 04/30/15 at 2:40 PM, revealed Patient #6 had an order to notify the Physician if the systolic B/P was less than 90 mmHg; however, it would be difficult for her to say in this case what should have been done. The CM revealed it would be her expectation for Physician's Orders to be carried out by nursing personnel.

Continued interview with the CNO, on 04/30/15 at 4:15 PM, revealed if the Physician had parameters set to be notified about B/P reading, and a BP of 88/53 fell into the range for notification, the Physician should have been notified, as per the order. Per interview, the nurse should document the Physician notification in the patient's medical record. She revealed it was her expectation for nurses to follow Physician's Orders and thoroughly document all Physician notifications. The CNO stated the nurse, as a licensed professional, should know to follow a Physician's appropriately written order. Further interview revealed information on a specific order for notification would go to the patient "work list" which the nurse followed for the entire shift for providing patient care.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure medication for pain was administered as per Physician's Orders for one (1) of twelve (12) patients (Patient #6).

The findings include:

Review of the facility's policy titled, "Pain Management," number PC.082, revised May 2013, revealed pain would be assessed with patient report of pain (new or significant change in). The Policy stated it was the nurse's responsibility to safely and efficiently administer analgesic drugs and to offer pain medications or interventions frequently and/or as ordered rather than wait for a patient to ask for pain relief. Further review revealed pre-emptive management of pain was encouraged.

Review of the facility's policy titled, "Patient Rights," number CSG:QS.004, effective date October 2014, revealed the patient had the right to receive individualized care which fostered the patient's comfort and dignity.

Record review revealed the facility admitted Patient #6 on 03/20/15, with diagnoses which included Dehydration, Insulin Dependent Diabetes Mellitus, Acute and Chronic Renal Failure, Coronary Artery Disease and Chronic Congestive Heart Failure.

Record review revealed, on 03/29/15 at 6:00 PM, Patient #6 was noted to be crying out in pain and was disimpacted (removal of stool from the rectum) with some relief noted. However, even though Patient #6 was crying out in pain and had Tylenol (a non-narcotic pain reliever) ordered every four (4) hours as needed for pain, there was no documented evidence the Tylenol was administered. Record review revealed no documented evidence the nurse attempted to administer the Tylenol on the evening of 03/29/15.

Continued review revealed Nurse's Notes dated 03/29/15, documented by RN #1, who was providing care for Patient #6 beginning at 3:00 PM, revealed a Note timed 7:47 PM, which stated the nurse had received an order from the Physician for Ibuprofen (a nonsteroidal pain reliever) every six (6) hours as needed for pain. Record review revealed the Ibuprofen order was verified by a Pharmacist and was ready to give at 8:06 PM. However, there was no documented evidence nurses attempted to administer the Ibuprofen after 8:06 PM, until at 9:05 PM, when RN #2, who had taken over Patient #6's care at 7:00 PM, an attempt to administer the Ibuprofen, was at that time. Per RN #2's 9:05 PM Note, Patient #6 was experiencing agonal (an abnormal gasping respiratory pattern) breathing and was non-responsive. Further record review revealed Patient #6 expired on 03/29/15 at 9:17 PM.

Interview with the Assistant Director of Pharmacy, Clinical Services Manager, on 04/28/15 at 12:10 PM, revealed Tylenol and Ibuprofen (all strengths) were stored on the floors in a dispensing machine format (Pyxis system) for point-of-use to prevent wait time for medication to be delivered from the Pharmacy. He revealed the nurse on 03/29/15, could have accessed medications as soon as the medication order had been verified by a Pharmacist. The Assistant Director stated the order for the Ibuprofen was verified by a Pharmacist at 8:06 PM, but it was not signed out to be given to Patient #6 until 9:10 PM on 03/29/15.

Interview with RN #2, on 04/29/15 at 8:35 AM, revealed she was Patient #6's nurse starting at 7:00 PM, on 03/29/15. She revealed she went in to assess Patient #6, shortly after coming to work on 03/29/15 because Patient #6's granddaughter had come to the nurse's station requesting assistance due to the patient having abdominal pain and shortness of breath. RN #2 stated she repositioned Patient #6 at that time, and gave him/her sips of water. Per interview, Patient #6 stated he/she felt better and wanted to go to sleep. She revealed RN #1 had reported to her she was putting an order for Ibuprofen in the computer, and RN #2 could wait to medicate Patient #6 with the Ibuprofen. Continued interview with RN #2 revealed the only reason she could give as to the approximately one (1) hour delay between verification of the Ibuprofen order and her attempt to give the Ibuprofen to Patient #6, was because she was busy with other patients. She stated Patient #6 had not expressed any additional pain also, and Nursing Technician (NT) #1 who put Patient #6 on a bedpan, had told her, Patient #6 was not in any distress.

Interview by telephone with RN #1, on 04/29/15 at 9:48 AM, revealed she could not remember why she did not give Patient #6 Tylenol after she cried out in pain on 03/29/15 at 6:00 PM. She revealed she should have given the Tylenol, and perhaps she did not realize it was ordered and that was why she called the Physician for the Ibuprofen order.

Interview by telephone with NT #1, on 04/29/15 at 3:49 PM, revealed she had taken care of Patient #6 starting at 7:00 PM on 03/29/15. She revealed at 8:30 PM on 03/29/15, Patient #6 expressed no pain, and she thought the patient needed a drink and needed to have a bowel movement. NT #1 further revealed around 9:00 PM, she put Patient #6 on a bedpan, and she was conversant and did not seem to be in distress.

Interview with the Clinical Manager (CM) of the 4th Floor, on 04/30/15 at 2:40 PM, revealed the only reason she could think of why RN #1 did not give Patient #6 the Tylenol on 03/29/15 at 6:00 PM, when the patient expressed pain, was because RN #1 thought the patient needed something stronger for pain. The CM revealed it would be difficult for her to say, not having been in the situation, if the Tylenol should or should not have been given. Per interview, it was her expectation patients pain would be treated as quickly and as effectively as possible, in conjunction with the Physician's Orders.

Interview with the Chief Nursing Officer (CNO), on 04/30/15 at 4:15 PM, revealed she could not comment on the specifics of Patient #6's episode because the disimpaction did diminish the pain. Per interview, however, her expectation was nurses to do everything possible, within nursing standards of care and Physician's orders, to relieve a patient's pain as quickly and effectively as possible.