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Based on record review, staff interview and document review it was determined the facility failed to implement a plan of correction to address problem identified following an adverse patient event.

Findings include:

Patient #1's medical record revealed the patient had fallen on 4/23/12. The fall was unwitnessed and the patient did not notify the staff immediately after he fell. The patient was assessed by the nurse and a physician Neurological assessment was normal as were the vital signs at 7:50 a.m. At 4:00 p.m. the patient demonstrated a change in neurological status. A CT scan of the brain revealed a subdural hematoma. Surgery was performed to evacuate the hematoma.

Interview with the Risk Manager on 4/11/12 revealed that the event had been reviewed and analyzed by a multidisciplinary team. One of the concerns was that the patient's activity order was bed rest, with a bedside commode or chair. The medical record revealed the patient had been permitted to ambulate in his room, without confirming it was permitted by the physician There was no action plan developed to address that issue.

The nurse manger for the unit where the patient had been located was interviewed on 4/16/12 at approximately 9:00 a.m. She indicated that she was looking at random charts to check on correct implementation of activity orders, but had no documentation of the activity.

Based on record review, staff interview, policy review, patient observation and document review, it was determined the facility failed to:

1. Provide staffing levels according to facility's approved staffing plan to ensure appropriate nursing care is provided. refer to A0392.

2. Ensure appropriate nursing care related to fall prevention, use of restraint, skin assessment and skin impairment prevention, complying with physician ordered fluid restrictions, assessment of nutritional status, and assistance with meeting hygiene needs to met the needs of the patients. Refer to A0395.

3. Ensure medications were administered according to physician orders. Refer to A0405.

5. Ensure blood transfusions are administered according to facility policy and procedure. Refer to A0409.

The cumulative effect of these systemic failures resulted in the determination that the Condition of Participation for Nursing Services 42 CFR 482.23 is out of compliance.

Based on record review, staff interview and staffing documentation it was determined the facility failed to ensure sufficient level of nursing personnel to provide appropriate nursing care to 3 (#2, #9, #11) of 13 sampled patients. This practice does not ensure safe and effective nursing care is delivered to all patients.

Findings include:

1. Review of the facility's 2012 Nursing Staffing plan and the actual staffing on the units and selected random dates revealed the facility was not providing the required staffing. The staffing provided for 9 nursing units was reviewed. Staffing was found to be non-compliant with the plan as follows:

1. Unit 2 main:-
4/2/12-one less nurse than required on the day shift
4/3/12-one less nurse than required on the day shift, one less nurse on night shift
4/4/12-one less nurse than required on the day shift, one less nurse on night shift
4/5/12-one less nurse than required on the day shift, one less nurse on night shift
4/6/12-one less nurse than required on day shift
4/10/12-one less nurse than required on day shift
4/11/12-one less nurse than required on day shift
4/12/12-one less nurse than required on day shift

2. Unit 2 Radial North:
4/1/12-one less nurse than required on the day shift,one less nurse on night shift
4/2/12-one less patient care specialist (PCS) on the day shift, one less nurse on night shift
4/3/12-one less nurse than required on night shift
4/5/12-one less nurse than required on the day shift, one less nurse on night shift
4/6/12-one less nurse than required on the day shift
4/9/12-one less nurse than required on the day shift, one less nurse on night shift
4/10/12-one less nurse than required on the day shift, one less nurse on night shift
4/12/12-0.65 less PCS than required on day shift

3. Unit 4 North Tower
4/1/12-one less nurse than required on the night shift
4/2/12-one less nurse than required on day shift, one less nurse on night shift
4/3/12-one less nurse than required on day shift, 2 less nurses on night shift
4/4/12-one less nurse and one less PCS on day shift, 1 less nurse on night shift
4/5/12-one less nurse than required on day shift, one less nurse on night shift
4/6/12-1.5 less nurse and 1 less PCS on day shift, one less nurse on night shift
4/7/12-one less nurse than required one day shift,
4/8/12-one less PCS and 0.5 nurse than required on day shift, one nurse on night shift
4/9/12-one less nurse than required on day shift, one nurse less on night shift
4/10/12-one less nurse than required on day shift, one less nurse on night shift
4/12/12-one less PCS than required on day shift
1/24/12-one less PCS than required on night shift
1/25/12-one less nurse than required on night shift
1/26/12-one less nurse and one less PCS than required on night shift
1/27/12-one less nurse and 0.5 less PCS than required on night shift
1/28/12-one less nurse than required on night shift


4. Unit 4 South Tower
4/1/12-one less nurse than required on day shift, one less nurse on night shift
4/2/12-one less nurse than required on day shift, one less nurse on night shift
4/3/12-0.5 less nurse and 1 PCS than required on day shift
4/4/12-one less PCS than required on day shift, one less nurse on night shift
4/5/12-one less PCS than required on day shift, one less nurse on night shift
4/6/12-one less nurse than required on day shift, 1.65. less PCS on night shift
4/7/12-one less nurse on night shift
4/8/12-two less nurses than required on day shift, one less nurse on night shift
4/9/12-one less PCS on than required on day shift
4/10/12-one less nurse than required on day shift, one less nurse on night shift
4/12/12-one less PCS than required on day shift
1/24/12-one less PCS than required on night shift
1/26/12-one less PCS than required on night shift
1/27/12-one less nurse that required and one less PCS on night shift
1/28/12-one less nurse than required one night shift

5. Unit PCU A
4/3/12-one less nurse and 1.5 less PCS on day shift, one less nurse on night shift
4/4/12-one less nurse than required on day shift, one less nurse on night shift
4/5/12-2 less nurses than required on night shift
4/6/12-1 less nurse and 0.65 less PCS than required on day shift, one less nurse on night shift
4/7/12-two less nurses than required on night shift
4/8/12-two less nurses than required on day shift, two less nurses than required on night shift
4/9/12-one less nurse than required on day shift, one less nurse on night shift
4/10/12-one less nurse than required on day shift, one less nurse on night shift

6. Unit PCU B
4/1/12-one less nurse than required on day shift, one less nurse on night shift
4/2/12-one less nurse than required on day shift, one less nurse on night shift
4/3/12-one less nurse and 0.5 PCS than required on day shift, one less nurse on night shift
4/4/12-one less nurse than required on day shift, one less nurse on night shift
4/5/12-one less nurse than required on day shift, one less nurse on night shift
4/6/12-one less nurse than required on day shift, one less nurse on night shift
4/7/12-one less nurse than required on day shift, one less nurse on night shift
4/8/12-one less nurse than required on day shift, one less nurse on night shift
4/9/12-one less nurse than required on day shift, one less nurse on night shift
4/10/12-one less nurse than required on day shift, one less nurse on night shift
4/12/12-one less nurse than required on day shift

7.Unit-Cardiac
4/1/12-one nurse less than required on day shift, one less nurse on night shift
4/2/12-0.5 nurse on day shift, 2 less PCS on night shift
4/3/12-3 less nurses on day shift
4/4/12-one less nurse on day shift
4/5/12-one less nurse on day shift, one less nurse on night shift
4/6/12-two less nurses on day shift, one less nurse on night shift
4/7/12-one less nurse on night shift
4/8/12-one less nurse on day shift, one less nurse on night shift
4/9/12-0.65 less PCS on day shift
4/10.12-one less nurse on night shift, one less nurse on night shift

8. Unit-2 North Tower
4/1/12-one less nurse on day shift, one less nurse on night shift
4/2/12-one less nurse on day shift, one less nurse on night shift
4/3/12-three less nurses on day shift, one less nurse on night shift
4/4/12-one less nurse on night shift
4/5/12-one less nurse on day shift, one less nurse on night shift
4/6/12-one less nurse on day shift, one less nurse on night shift
4/7/12-one less nurse on night shift
4/8/12-one less nurse and one less PCS on day shift, one less nurse on night shift
4/9/12-one less nurse on day shift
4/10/12-0.5 nurse on day shift, one less nurse on night shift

9. Patient #11's medical record revealed there was no skin assessment and no fall risk assessment on 4/11/12. Review of actual staffing revealed there was one less nurse than required on the day shift on the PCU B unit, which was the unit where the patient was located.

10. Review of the medical record of patient #9 revealed she was located on the 2 South Tower unit. Review of the History and Physical revealed the patient was admitted with congestive heart failure and shortness of breath Review of the physician orders revealed on 4/7/12, the physician wrote an order for an infusion of 3% sodium chloride solution to be given over 12 hours, to be followed with an extra dose of Lasix 40 milligrams. Review of the Medication Administration Record revealed the nursing staff failed to administer the extra dose, which was due the morning of 4/8/12. Review of staffing for the unit revealed that the unit had 2 nurses less than the staffing plan required.

11. Patient #12 was located on the 2 Main unit. Review of the physician's orders revealed that the patient was ordered nothing by mouth on 4/10/12. The physician wrote an order on 4/11/12 to give the patient clear liquid diet until 9 a.m. on 4/12/12. Review of nursing documentation revealed no evidence the patient had received the ordered diet on 4/11/12. The staffing plan was not met.

The clinical manager confirmed the finding on 4/12/12 at approximately 10:30 a.m. Review of staffing on the unit revealed there was 1 less nurse than required by the staffing plan.

12. Patient #2 was a patient on 4 North Tower unit. On 1/26/12, 1/27/12 and 1/28/12 there was lack of accurate and complete skin assessments, lack of documentation of repositioning and lack of documentation of meeting of hygiene needs. The staffing plan was not met.

13. Patient #6 was a patient on 4 North Tower. There was no documentation of repositioning on 4/12/12. The patient was admitted with a left hip fracture. The staffing plan was not met.

14. Patient #4 was a patient on 2 Radial North unit. On 4/4/12-4/12/12 the staff failed to document a nutritional assessment including the meal consumption. The patient had the diagnosis of Type II Diabetes. There was lack of documentation of hygiene needs needs being met during the entire stay. The staffing plan was not met.

15. Patient #5 was admitted to 4 North Tower on 4/9/12. There was no documentation of his hygiene needs being met until 4/11/12. The staffing plan was not met.

Based on record review, policy review and staff interview it was determined the facility failed to ensure a registered nurse supervised and evaluated nursing care related to implementation of physician orders, pain assessment, fall prevention, fluid restrictions, and personal needs were provided to 11 (#1, #2, #3, #4, #5, #6, #9,#10, #11,#12,#13) of 13 sampled patients. This practice does not ensure nursing goals are met and may lead to an increased hospitalization.

Finding include:

1. Patient #1 was admitted to the facility on 3/21/12 with chest pain. Review of physician's orders revealed an order for "bed rest with bedside commode or chair" on 3/21/12. Review of nursing documentation revealed that the patient was ambulating in his room and to the bathroom. There was no order to increase the patient's activity level. There was no documentation that the patient had been instructed that he was to get up to the bedside commode and chair only.

2. The facility's policy "Pain Management" #P1.0, last reviewed 2/12, required that the patient's pain was to be assessed utilizing a pain scale that rates the pain level from 0 (no pain) to 10 (worst pain).

Review of the Medication Administration Record (MAR) for patient #1 revealed the patient was given two Tylenols on 3/23/12 at 12:54 p.m. Review of the pain assessment revealed no documentation of the level of pain described by the patient.

3. The facility's policy "Fall Prevention" #405, last reviewed 3/2009 required that a fall risk assessment was to be completed at the time of admission and once each shift, using the Morse Fall Scale. Patients scoring 0-24 are considered at no risk for falls and basic nursing care interventions are to be implemented. This includes non-skid footwear, increased room lighting, medication review, bed in low position, call light within reach, education of patient, patient's family and visitors. Patients scoring 25-50 are considered to be at low risk for falls. In addition to the basic nursing care interventions, standard fall prevention interventions are to be implemented. This includes increased toileting, observation rounds, application of a yellow wrist armband and application of falling star magnet to the door frame of the patient's room. Patients who score over 50 will have high risk fall prevention interventions implemented in addition to the basic nursing care interventions and standard fall prevention interventions. This includes moving the patient to a room closer to the nurses' station and use of bed alarms. The policy also required that the staff notify the family of the fall.

Review of the medical record of patient #1 revealed that he was assessed as a 45 (low risk) on the Morse scale on 3/21/12. Fall precautions were documented as being in place. Further review of the medical record revealed that the patient reported he had fallen in the bathroom sometime during the 7 p.m.-7 a.m. shift on 3/23/12.

The nurse manger who performed the post fall assessment on 3/23/12 was interviewed on 4/16/12 at approximately 9:00 a.m. She stated that the patient did not have a yellow wrist band or the falling star magnet in place at the time of the fall. She confirmed that the facility's policy regarding fall prevention interventions had not been fully implemented.

There was no documentation that the patient's spouse had been notified of the fall. The Risk Manager confirmed the spouse had not been notified during interview on 4/11/12 at approximately 1:00 p.m.

4. Review of the medical record of patient #10 revealed he was assessed to be a high fall risk on 4/11/12. During patient observation on 4/12/12 at 9:30 a.m. it was noted the patient had no yellow wrist band and no falling star magnet.

The Nursing Director was present at the time of the observation and confirmed failure to have all interventions in place.

5. The facility's policy "Skin Impairment, Prevention and Management", #S2.0, last revised 9/10 required that skin and the patient's risk for skin breakdown be assessed each shift utilizing the Braden scale. The assessment was to be performed at the time of admission and at least once per shift. The policy also required that patients determined to be at risk for skin breakdown are to be repositioned every 2 hours.

Review of the medical record of patient #11 revealed the nursing staff failed to perform a complete skin assessment on 4/6/12 on the night shift, and on both shifts on 4/11/12. In addition, there was no Braden score noted on 4/9/12 during the night shift and the night shift on 4/11/12. Review of nursing documentation revealed that the nursing staff did not reposition the patient as required by the facility's policy on 4/5, 4/6 and 4/7/12

The lack of documentation was confirmed by the nurse manger on 4/12/11 at approximately 11:00 a.m.

6. Review of the medical record of patient #13 revealed the nursing staff failed to document a Braden score on 4/10/12.
This was confirmed by the Quality manager on 4/12/12 at approximately 2:30 p.m.

7. Review of the medical record of patient #2 revealed the documentation of skin assessments were incomplete and inaccurate. The nurse noted on 1/27/12, 1/28/12 and 1/29/12 that the skin was intact with no abnormalities. The patient had a surgical incision on the left hip. There was no documentation of wound or skin assessment on 1/30/12, the day of discharge. A note written by a Physical Therapist on 1/29/12 at 11:27 a.m. indicated " nursing informed about a small blister on the lower right side of the patient's back...". A nursing note dated 1/29/12 at 2:26 p.m. indicated "skin tear approximately 2 millimeters on lower left hip". There was no documentation of this wound in the skin and wound assessment section of the medical record. The nursing staff failed to assess the wound prior to discharge. There was no documentation of the blister identified by the physical therapist on the right side.

The findings were confirmed by the Nursing Director of Medical Surgical on 4/11/12 at 3:30 p.m.

The nursing staff failed to reposition the patient as required by facility policy. The patient was admitted with a fractured left hip with Buck's traction in place. Review of the medical record revealed no evidence the patient was repositioned from the time of admission on 1/26/12 at approximately 5:44 p.m. until 8:00 a.m. on 1/27/12, which was approximately 14 hours. There was no documentation of repositioning from 4:30 p.m. on 1/27/12 until 10:00 a.m. on 1/29/12, a period of approximately 42 hours following hip surgery. Nursing documentation indicated the patient was immobile. The findings were confirmed by the Nursing Director of Medical Surgical on 4/11/12 at 3:30 p.m.

Review of the medical record of patient #2 revealed documentation of meal consumption only twice during her 5 day stay. On 1/28/12 the nurse documented the patient consumed 50% of her breakfast and lunch.

8. Patient #6 was admitted to the facility on 4/11/12 at 4:00 p.m. with a fracture of the left hip. Buck's traction was applied. The patient was interviewed on 4/12/12 at 9:50 a.m. She indicated she had not been repositioned since her admission, which was approximately 17 hours. Review of the medical record revealed no evidence the patient had been repositioned.

9. Patient #9 was admitted to the facility on 4/5/12 with the diagnosis of congestive heart failure and shortness of breath. Review of the physician's orders revealed an order for a fluid restriction of 1500 milliliters (ml) per 24 hours. The physician changed the restriction to 1200 ml's on 4/11/12. Review of the intake and output record revealed that the patient received 1304 ml's on the 24 hour period following the order. In addition, during patient observation on 4/12/12 at approximately 11:40 a.m., it was noted the sign indicating the patient was on fluid restrictions indicated that the restriction was 1500 ml's instead of 1200 cc's.

The findings were confirmed by the nurse manger who was present during the record review and patient observation.

10. Review of the medical record of patient #10 revealed he was admitted to the facility on 4/7/12 with the diagnosis of pleural effusion. The physician wrote an order on 4/7/12 to restrict fluid intake to 1200 ml's per day. Review of the intake and output documentation revealed the patient had a total intake of 1310 ml's on 4/10/12 and a total of 1810 ml's on 4/11/12.

The finding was confirmed by the nursing director on 4/12/11 at approximately 9:30 a.m.

11. Review of physician's orders for patient #10 revealed the patient was ordered nothing by mouth on 4/10/12. The physician wrote an order on 4/11/12 to give the patient clear liquid diet until 9 a.m. on 4/12/12. Review of nursing documentation revealed no evidence the patient had received the ordered diet on 4/11/12.

The clinical manager confirmed the finding on 4/12/12 at approximately 10:30 a.m.

12. Review of the medical record for patient #11 revealed he was to receive a cardiac diet. Review of the nutrition documentation revealed that the meal consumption was not documented on 4/9/12, 4/10/12 and 4/11/12.

The finding was confirmed by the nurse manager on 4/12/12 at approximately 11:00 a.m.


13. Review of the medical record for patient #4 revealed he was admitted with the diagnosis of Type II diabetes. The patent was admitted on 4/5/12. The medical record was reviewed on 4/12/12 at 2:40 p.m. There was no documentation of meal consumption for the entire hospital stay.

14. Review of the medical record of patient #12 revealed lack of documentation that the patient's hygiene needs were met. The only documentation regarding meeting hygiene needs was on 1/29/12 when oral care was documented at 10:00 a.m. The patient had an indwelling urinary catheter inserted at the time of her admission on 1/26/2012. Documentation revealed the indwelling catheter care was done at 5:00 p.m. on 1/26/2012. There no documentation that catheter care was performed at any other time.

15. Review of the record of patient #4 was conducted on 4/12/2012 at 2:00 p.m. The documentation revealed the patient was admitted on 4/5/2012 at 10:51 p.m. Review of the medical record revealed no documentation of personal hygiene care.

The finding was confirmed by the staff nurse assigned to the care of the patient on 4/12/2012 at 2:40 p.m.

16. Review of the record of patient #5 was conducted on 4/12/2012 at 10:3 a.m. The documentation revealed the patient was admitted on 4/9/2012 at 11:12 a.m. with a diagnosis of superficial thrombophlebitis of the right lower leg. Review of the record revealed the first documentation of personal hygiene care was documented on 4/11/2012 at 4:00 p.m.

This finding was confirmed by the charge nurse on 4/12/2012 at 11:00 a.m.

17. The facility policy "Restraint Utilization and Documentation" #PC 519, last reviewed 5/10 required that the patient who was in restraints was to be reassessed every 2 hours.

Patient #3 was assessed and placed in soft wrist restraints on 4/9/2012 at 11:00 p.m. He was reassessed on 4/9/2012 at 2:00 a.m. when the restraints were removed. Three hours elapsed between assessments.

The findings confirmed by the charge nurse on 4/12/2012 at 11:40 am.

Based on record review, observation and staff interview it was determined the facility failed to ensure medications were administered as ordered by the physician for 3 (#9, #11, #13) of 13 sampled patients. This practices does not ensure the therapeutic goals for medication administration are achieved.

Findings include:

1. Patient #9 was admitted to the facility on 4/6/12 with congestive heart failure and shortness of breath Review of the physician orders revealed an order on 4/6/12 for Lasix 40 milligrams Intravenously (IV) every 8 hours. On 4/10/12 the physician wrote an order for an extra dose of Lasix 40 milligrams to be administered IV following an infusion of 3% sodium chloride solution. Review of the Medication Administration Record (MAR) revealed the extra dose of the Lasix was not administered. There was no documentation as to why the dose was not given.

The finding was confirmed by the nurse manager on 4/12/12 at approximately 11:30 a.m.

Observation on 4/12/12 11:40 am. revealed the patient was asleep in the room. A medicine cup was on the over bed table. There were several unpackaged pills in a medicine cup. The nurse manager removed the cup and stated medications were never to be left at the bedside.

2. Review of the medical record for patient #11 revealed the patient was admitted to the facility with a cardiac arrest and renal insufficiency. Review of physician orders revealed an order for Potassium elixir 40 milliequivalents to be given now on 4/7/12 at 9:00 a.m. Review of the MAR revealed the medication was not administered until 2:00 p.m., five hours after the order was written. There was no documentation regarding the reason for the delay. The patient's Potassium level at 5:00 a.m. on 4/7/12 was 3.3, which is below normal value.

3. Review of the medical record of patient #13 revealed a telephone order for Lasix 80 milligrams IV now written on 4/11/12 at 7:30 p.m. Review of the MAR revealed the medication was not administered until 10:05 p.m., 2 1/2 hours later. There was no explanation in the record for the delay.

The finding was confirmed by the quality manager on 4/12/12 at approximately 2:30 p.m.

Based on record review, policy review and staff interview it was determined the facility failed to ensure blood was administered according to facility policy for 1 (#10) of 13 sampled patients. This practice does not ensure safe administration of blood

Findings include:

The facility's policy "Blood and Blood Component Administration", #456, revised 7/09 required that vital signs be recorded before the transfusion begins, after 15 minutes, at 1 hour and at the end of the transfusion.

Review of the medical record of patient #10 revealed a physician order to transfuse two units of packed red blood cells on 4/11/12 at 7:40 a.m. Review of nursing documentation revealed the first transfusion was initiated at 12:47 p.m. Vital signs were documented at 12:39 p.m. There was no documentation of vital signs during the administration of the first unit The time the first unit was completed was not documented The second unit was started at 3:39 p.m. Vital signs were documented at 3:44 p.m., 3:50 p.m. and 3:58 p.m. There was no further documentation of vital signed during the second transfusion. The completion time for the second unit was not documented.

The nurse manger confirmed the findings on 4/12/12 at approximately 11:00 p.m.

Based on record review and staff interview it was determined the facility failed to reassess the discharge plan prior to discharge to ensure that all discharge needs are met for 1 (# 2) of 13 sampled patients. This practice may lead to a prolonged stay or readmission.

Findings include:

Review of the medical record for patient #2 revealed she was admitted on 1/26/12 with a fractured left hip. An open reduction and internal fixation surgical procedures was performed on 1/27/12. The patient was discharged on 1/30/12. Review of documentation of the physical therapy assessment performed on 1/28/12 at 8:37 a.m. revealed "PT Equipment Anticipated or Recommended: Rolling Walker". Review of the physician's discharge order revealed the box to be checked for rolling walker was not checked. Review of nursing and case management documentation revealed no documentation regarding the need for a rolling walker. There was documentation in the record the patient was ambulating with a walker.

The Nursing Director of Medical Surgical was interviewed on 4/11/12 at 3:30 p.m. She stated that patients with hip fractures are to be discharged with a rolling walker and indicated the nursing staff should have ensured the order from the physician had been obtained.