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Based on medical record review, staff interview and review of policy and procedure it was determined the registered nurse failed to supervise and evaluate nursing care related to falls blood glucose monitoring and implementing physician orders for two (#1, #5) of ten patients sampled. This practice does not ensure patient goals are met and may lead to a prolonged hospitalization.

Findings include:

1. Patient #1 was admitted to the facility on 8/23/2012. Documentation revealed the patient had orthopedic surgery of the right ankle. Review of the admitting orders, dated 8/23/2012, stated to have the patient up as tolerated with crutches. Review of the nursing documentation revealed the patient was not assisted out of bed until 8/26/2012.

Review of documentation from another acute care facility revealed the patient was admitted to the facility on 8/30/2012 with a diagnosis of Pulmonary Embolism (PE) and Deep Vein Thrombosis (DVT). Ultrasound of the lower extremities revealed a DVT in one of the paired left peroneal veins. The physician's impression was a "provoked PE" due to a right lower extremity fracture and post-op inactivity.

2. Review of the medical record for patient #1 revealed on 8/24/2012 at 4:25 p.m. a urinary catheter was inserted. Review of the nursing documentation revealed no indication for the insertion of the catheter. Review of the physician orders revealed no evidence of an order to insert the urinary catheter.

3. Review of the medical record for patient #1 revealed a physician's order on 8/25/2012 at 12:30 p.m. to resume NS (Normal Saline) IVF (Intravenous fluids) at 100 ml/h (milliliters/per hour). Review of the MAR (Medication Administration Record) revealed the NS was resumed by nursing on 8/26/2012 at 2:10 a.m. There was no documentation for the delay in resuming the IV fluids.

Interview with the director of PCU (Progressive Care Unit) confirmed the above findings on 3/21/2013 at approximately 1:15 p.m.

4. Patient #5 was admitted to the facility on 3/21/2012. Review of the record revealed the patient was an Insulin Dependent Diabetic. The physician orders dated 3/21/13 ordered to monitor the patient's blood glucose prior to meals and at the hour of sleep.

Review of the blood glucose monitoring revealed on 4/2/2012 at 8:51 a.m. the patient's blood glucose was 44 (70-110). Documentation revealed at 8:54 a.m. the blood glucose was 53. There was no documentation if the patient exhibited any signs or symptoms of hypoglycemia or if the patient was treated. Review of the record revealed no evidence the physician was notified of the patient's blood glucose level.

Review of the facility's policy, "Reporting Critical Test Results/Findings", policy #K.17, states the results will be reported to the Licensed Independent practitioner within 30 minutes. The critical value for blood glucose, as defined by the facility policy, states glucose of <50 mg/dl will be reported.

5. Review of the medical record for patient #5 revealed on 4/3/2012 at 2:50 a.m. the patient was found in his room on the floor. Nursing documentation revealed an assessment was performed by the RN (Registered Nurse). Documentation revealed the patient complained of back/hip pain, no laterality documented. Nursing documented the patient's right shoulder blade had excoriation. Review of the record revealed no evidence the physician was notified of the patient's fall until 9:20 a.m. Review of the record revealed no evidence the patient's family or significant other was notified.

Review of the facility's policy, "Fall Risk Assessment and Prevention", #600-79-085, states the post fall protocol will be implemented after a fall occurs. Nursing intervention is to assess the patient for injuries, vital signs, cardiac rhythm (if applicable), and level of consciousness, orientation and neurological status. The physician will be notified, orders implemented, and family/significant other notified.

Interview with the Director of PCU on 3/21/2013 at approximately 3:00 p.m. confirmed the above findings.

Based on medical record review, staff interview and review of policy and procedures it was determined the facility failed to ensure the availability of appropriate services of home health agencies was presented to the patient for one (#1) of ten patients sampled. This practice does not ensure a safe and effective discharge.

Findings include:

Patient #1 was admitted on 8/23/2012. The patient was discharged on 8/27/2012. Review of the physician's orders, dated 8/27/2012, stated to discharge home with home health care.

Review of the facility policy, "Patient Choice", last reviewed 8/2012, states (III) (A) if post- discharge services are anticipated, or after a physician order is written for post discharge services, the discharge planner will inform the patient that he has the right to select any healthcare provider/supplier; (1) this choice may be limited to the network utilization of their insurance carrier. If this occurs, the discharge planner will inform the patient and or patient representative of their options; (2) the patient/patient representative will be given a "Patient Choice Letter" and, upon request, a Health Care Providers/Suppliers List to review; (C) the choice letter is placed in the patient chart with consents and becomes a permanent part of the medical record.

Review of the record revealed no evidence the patient was informed of his right to select a home healthcare provider. Review of the record revealed no evidence of a patient choice letter.

Interview with the case manager on 3/21/2013 at 1:30 p.m. confirmed the findings.