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Based on document review and interview, nursing services failed to administer pain medication as scheduled in 1 out of 10 (patient 2) patient medical records reviewed; failed to document the epidural bag ran empty and the total dose amount of medication delivered via a Patient Controlled Epidural Analgesia (PCEA) pump per policy in 1 out of 10 (patient 2) patient medical records reviewed; failed to obtain a provider order for surgical wound dressing change in 1 out of 10 (patient 2) patient medical records reviewed; and failed to document 7 out of 14 daily bed linen changes and 6 out of 14 baths in 1 out of 10 (patient 2) medical records reviewed.

The cumulative effects of these systemic problems resulted in the facility's inability to ensure that quality Nursing Services were provided.

Based on document review and interview, nursing services failed to administer pain medication as scheduled in 1 out of 10 (patient 2) patient medical records reviewed; failed to document the epidural bag ran empty and the total dose amount of medication delivered via a Patient Controlled Epidural Analgesia (PCEA) pump per policy in 1 out of 10 (patient 2) patient medical records reviewed; failed to obtain a provider order for surgical wound dressing change in 1 out of 10 (patient 2) patient medical records reviewed; and failed to document 7 out of 14 daily bed linen changes and 6 out of 14 baths in 1 out of 10 (patient 2) medical records reviewed.

1. Facility policy titled, Medication Administration Times - System, Publication Date: 01/19/2023, indicated under VI. Procedures, F. Time-critical medications should be administered within 30 minutes before or 30 minutes after the scheduled dosing time, for a total window that does not exceed 1 hour.; 1. Time-critical medications are typically those that are entered with interval frequencies six times a day or more frequent (Q4H, Q2H etc.).

2. Facility Policy titled, Epidural and Intrathecal Analgesia: Patient Care and Monitoring, Publication Date: 07/18/2023, indicated under VI. Procedures B. Patient Controlled Epidural Analgesia (PCEA), 4. Total Patient Controlled Epidural Analgesia (PCEA) dose delivered is documented at the end of each RN shift (whether 4 hours, 8 hours, 12 hours, etc.) and with each change of caregiver (transfers to another unit). This Total Drug Delivered is cleared from the pump.

3. Facility document titled, 5 South PCA (Patient Care Assistant) Documentation Responsibilities - Every Shift, indicated under Hygiene, Routine Hygiene: linen changed, CHG treatment, dressing, hair care, eye care, etc. If patient refuses a bath/CHG treatment, document as "refused" & escalate to RN., Q 24 hours.

4. Facility document titled, 4S Support Staff Expectations 2024, indicated every patient should receive a CHG treatment every 24 hours and oral care. These must be documented.

5. Facility document titled, Surgical wound dressing application, Revised May 20, 2024, under Implementation, Verify the practitioner's order for specific wound care medications and instructions.

6. Review of Patient 2's medical record indicated the following:
a. Medical provider ordered Oxycodone 10 mg PO (by mouth) Q (every) 4 hours on 08/28/2024 at 6:00 p.m. The medication administration record indicated the following doses were not administered as ordered: on 08/29/2024 the medical record lacked documentation that the 10:00 a.m. and 2:00 p.m. doses were administered, the 6:17 p.m. dose was administered 12 hours, 19 minutes late; On 08/30/2024, the medical record lacked documentation that the 2:00 a.m. dose was administered, the 4:58 a.m. dose was administered 7 hours, 36 minutes late; the 10:39 a.m. dose was administered 1 hour, 41 minutes late; On 08/31/2024, the 2:28 a.m. dose was administered 1 hour, 4 minutes late and the 6:34 p.m. dose was administered 45 minutes late; On 09/01/2024, the 3:18 a.m. dose was administered 42 minutes late, the 2:59 p.m. dose was administered 1 hour, 6 minutes late; On 09/02/2024, the 3:18 a.m. dose was administered 1 hour, 36 minutes late, the 2:54 p.m. dose was administered 25 minutes late, and the 8:06 p.m. dose was administered 42 minutes late; On 09/03/2024, the 8:50 a.m. dose was administered 33 minutes late; On 09/06/2024, the medical record lacked documentation that the 6:44 a.m. dose was administered; On 09/08/2024, the 8:34 p.m. dose was administered 41 minutes late; On 09/09/2024, the 5:51 a.m. dose was administered 1 hour, 36 minutes late and the 3:07 p.m. dose was administered 19 minutes late; On 09/11/2024, the 11:43 a.m. dose was administered 50 minutes late.
b. Medical record indicated anesthesia placed a fentanyl 100 micrograms (mcg) / 2 ml epidural on 08/29/2024. The Patient Controlled Epidural Analgesia (PCEA) settings were a continuous rate of 8 ml/hour, with a patient-controlled dose of 4 ml every 20 minutes with a lockout of 25 ml/h. Medical record anesthesia note indicated that the patient's epidural bag ran empty on 09/03/2024. MR lacked nursing documentation that the epidural bag ran dry, that anesthesia was notified, and the total amount of medication delivered at the end of the shift on 09/03/2024.
c. Medical record provider notes indicated that the patient was to receive surgical dressing changes every other day and as needed after the 08/30/2024 initial dressing change. Medical record lacked orders for surgical dressing changes.
d. Daily linen changes and CHG/bath treatment were not documented on the following dates:
i. 08/29/2024 lacked linen changes and CHG treatment.
ii. 08/30/2024 lacked linen change.
iii. 08/31/2024, 09/05/2024, 09/06/2024, 09/07/2024 and 09/09/2024 lacked documentation of linen change and CHG/bath treatment.

7. Interview with A3 (Clinical Nurse Specialist) and A5 (Manager of Accreditation and Regulatory Compliance) on 09/26/2024 at approximately 10:30 a.m. confirmed patient 2's medical record lacked the documentation as indicated above.