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Based on clinical record review, review of policy and procedure and staff interview the Hospital failed to ensure the nursing care rendered to Patient #3 was evaluated to ensure provision of Nursing Care in accordance with Nursing Standards and Hospital Policy, and the nursing assessment of Patient #2, post-cardioversion, was conducted in accordance with Hospital policy.

The findings include:

1. Review of the Medication Administration policy revealed, all orders are prescribed by the physician...and the nurse will verify the medication is being administered to the correct patient, at the proper time, in the prescribed dose and by the correct route.
(a) Review of the clinical record for Patient #3 revealed the patient presented to the Emergency Department (ED) on 11/13/2011 at 3:04 AM, and was admitted to the surgical unit at approximately 8:48 AM for continued blood transfusion (started in ED).

Review of physician admitting orders of 6:34 AM obtained by the ED nurse revealed the orders included: Humulin N subq (subcutaneous) 25 units twice a day (bid), and Humulin R 25 units subq at breakfast & dinner times for diabetes, and Lyrica 50mg orally bid (pain medication). Review of the nursing documentation and the Medication Administration Record (MAR) revealed although Lyrica was transcribed correct on the MAR, it is documented to have been given once at 10:00 PM, but there is no evidence the patient was administered a morning dose of the pain medication by the ED nurse, or on the surgical unit. Review of the Patient's pain scale documented by the nurse on 11/13/2012 revealed: 9 AM - on a scale of 1-10, the Patient's pain was 9. At 12 PM, pain at 9 out of 10, and at 2:45 PM: pain at 9 out of 10. The nurse administered a one-time order for Tylenol (ordered at 12:30 PM) at 2:15 PM. Pain level had decreased to 8 on a scale of 1-10.
Further review of the nursing documentation by the ED nurse and the surgical nurse revealed no evidence that Insulin was administered to Patient #3 during the morning hours. The patient's blood sugar level at 4:08 AM is recorded to have been 156 (Normal range: 74 - 118). Review of the MAR revealed the nurse wrote on the MAR, the patient usually takes the Insulin at 6:00 AM. There is no evidence the Insulin was provided in the ED. The clinical record was reviewed with the Clinical Manager of the Ambulatory Care Unit (ACU), the Director of Risk Management, and the Chief Nursing Officer who agreed there is no documentation indicating the patient received the Insulin in the morning, or the pain medication (Lyrica) during the morning hours. Per policy, the facility scheduled 'BID' times are 10:00 AM & 6:00 PM.
(b) Review of the record for Patient #3 who presented to the ED on 11/14/2012 revealed pain medication (Dilaudid) was administered. The nurse did not document the effectiveness of the pain medication. The nurse documented thereafter 'pain decreased' but the physician documented 'pain unchanged'.

2. Clinical record review revealed Patient #2 was admitted on 11/18/11 for an elective Cardioversion procedure; diagnosis Paroxysmal Atrial Fibrillation. The cardioversion procedure was performed at 08:23 on 11/18/11, and the patient ' s cardiac rhythm converted to normal sinus rhythm.

The Hospital policy titled "Elective Cardioversion", revised on 05/2011 requires post procedure assessments to include:
c) Monitor vital signs every 15 minutes x 4, every 30 minutes x 2, and then every 4, hours per unit protocol.
d) Obtain 12 lead ECG.
e) Monitor ECG rhythm for at least 2 hours post procedure.
The patient's vital signs and cardiac rhythm was monitored for only 15 minutes x 1 (08:30, 08:45), and at 08:55; the patient was not monitored per the policy nor was the patient ' s ECG rhythm monitored at least 2 hours per policy post procedure as specified in the hospital policy. The patient was discharged home at 10:03 AM on 11/18/11.
Review of the clinical record for post Cardioversion 12 lead ECG revealed the clinical record did not contain, or indicate that a 12 lead ECG was performed on 11/18/11 after the Cardioversion.

In an interview with the Chief Nursing Officer (CNO) on 01/11/12 at approximately 12:50 PM the CNO stated, the patient did not have an ECG done after the cardioversion procedure was performed. In an interview with a Registered Nurse on 01/11/12 at approximately 2:30 PM, the nurse stated the cardiologist did not write an order for an ECG post cardioversion, therefore the ECG was not done.