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Based on nursing and administrative staff interview, and medical record review, the hospital failed to ensure nursing care was supervised by a Registered Nurse (RN) for seven of 15 sampled patients (Patients 1, 6, 7, 8, 9, 13, and 15) when:

1. Physicians treatment orders were not followed for one patient (Patient 13) with documented wounds.

2. The RN failed to evaluate significant weight changes for two patients (Patients 13 and 15).

3. Patient 6 did not have post-operative vital signs (temperature, pulse, respirations, and blood pressure) for a period of approximately one hour immediately following return to the patient care unit.

4. Patients 6 and 7 did not have repositioning documented every two hours to prevent skin breakdown.

5. Patient 1 had a physicians order for sequential compression devices (SCDs-stocking with alternating pressure to prevent blood clots) that was contraindicated. The RN implemented a physicians order for an alternate method of preventing blood clots, but failed to obtain a discontinue order for the SCDs.

Failure to effectively follow and document physicians' orders and evaluate changes in patient conditions may further compromise medical status.

Findings:

1. Patient 13's record was reviewed. Patient 13 was an 84 year old male admitted with symptoms including persistent diarrhea, incontinence, weakness and diagnoses including acute kidney injury with dehydration. The patient also reported weight loss of 20 pounds during the previous three months. Patient 13's history and physical, dated 5/26/17, noted skin issues on his buttocks as well as right and left hips. The comprehensive nursing admission assessment, dated 5/28/17, noted the presence of pressure ulcers on the coccyx (tailbone) and right hip.

(A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear, National Pressure Ulcer Advisory Panel-NPUAP.)

A physician's order for the coccyx pressure ulcer treatment, dated 5/18/17, was reviewed and was for the application of a barrier cream once each shift and after each incontinence episode.

Review of nursing flow sheet, from 5/28-5/30/17, noted a total of 21 incontinent episodes, 10 of which were stool and 11 of which were urine.

Review of nursing flow sheets for the same time period revealed that application of the barrier cream was not documented for all episodes of incontinence, rather was documented for 12 of 21 episodes.

In a concurrent interview with RN 2 on 5/31/17 at 8:45 am, she acknowledged the missed opportunities for treatment. She also stated nursing staff would be expected to document all provided treatment.

2a. The clinical record for Patient 13 was reviewed. Patient 13's admission weight was documented on 5/27/17 as 103 pounds. Daily weights, dated 5/28 and 5/29/17, were documented as 106 and 143 pounds respectively, a fluctuation of 37 pounds. All of Patient 13's weights were documented as using a bed scale. There was no nursing evaluation of the significant change.

2b. Patient 15's record was reviewed. Patient 15 was admitted with diagnoses including delirium and fever. A nursing admission assessment, dated 5/25/17, noted that the patient was not at nutritional risk. The assessment also documented a height of 5 feet 2 inches and a weight of 127 pounds. The weight was taken using a bed scale. A follow up weight using a standing scale was documented as 145 pounds, a variance of 18 pounds or 14 percent. There was no documented evaluation/analysis of the potential reason for the significant weight fluctuation.

In an interview on 5/31/17 at 11:20 am, RN 2 stated the standard of practice for nursing staff, when using a bed scale, would be to remove all items from the bed with the exception of the pillow and sheet prior to recording weight.

In an interview on 5/31/17 at 11:40 am, Administrative Staff 3 stated the hospital had two types of beds with bed scale capacity. While each of the beds had an acceptable level of variability, the range was no greater than 5 percent. The recorded weight variance for Patient 13 was 35 percent.

In an interview on 5/31/17 at 1:35 pm with Administrative Staff 4, she stated the hospital did not have a policy for assessing weight changes or a reweigh policy when there were significant weight fluctuations.



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3. On 5/30/17, Patient 6's record was reviewed. Patient 6 was admitted on 5/14/17 with respiratory failure and progressive multiple sclerosis, a debilitating nerve and muscle disease. Patient 6 had a tracheostomy (a tube inserted into the neck and into the lungs to aide mechanical ventilation) procedure on 5/21/17.

Review of the hospital policy titled, "Vital Signs," dated 11/24/2009, indicated that vital signs would be taken post-operatively every 30 minutes for two times, every hour for four times, and then every six hours.

Patient 6's record was reviewed and indicated that no vitals signs were taken for approximately one hour after her procedure was completed.

During a concurrent interview and record review on 5/31/17 at 12:20 pm, Administrative Nurse 8 reviewed Patient 8's record and acknowledged the vital signs policy was not followed.

4. Review of Patient 6's care plan indicated she should have been repositioned every two hours. Patient 6 had one period of time on 5/29/17, from 2 pm to 8 pm (4 hours), in which she was documented as being on her left side.

On 5/31/17, Patient 7's record was reviewed. Patient 7 was admitted on 5/23/17 for sepsis (a life threatening blood infection) and cellulitis of the lower extremities (an infection of skin and tissues). Patient 7's care plan indicated he should be repositioned every two hours. Patient 7 had one period of time on 5/29/17, from 4 am to 8:14 am (4+ hours), in which he was documented as being on his left side.

Review of the hospital policy titled, "Prevention of and Treatment of Impaired Skin Integrity," dated 4/6/17, read, "Provide pressure redistribution by turning approximately every 2 hours ...."

During a concurrent interview and record review on 5/31/17 at 10:55 am, Administrative Staff 9 reviewed Patients 6 and 7's records and acknowledged the policy for repositioning was not followed.

5. On 5/30/17, Patient 1's record was reviewed. Patient 1 was admitted on 5/26/17 with renal (kidney) failure.

Patient 1 had a physician's order for SCDs, dated 5/26/17 at 11:31 pm, but Patient 1's record did not have evidence of SCDs being applied.

During a concurrent interview and record review on 5/30/17 at 1:45 pm, Administrative Nurse 5 reviewed Patient 1's record. She stated SCDs were contraindicated for Patient 1 because of the cellulitis on her legs, and another means of preventing blood clots was instituted. Administrative Nurse 5 acknowledged that nursing staff should have noted that the SCD order was no longer needed and obtained a discontinue order from Patient 1's physician.

Based on interview and record review, the hospital failed to ensure that nursing care plans were kept current for one of 15 sampled patient's post-surgical and urological (related to urination) needs (Patient 3).

This failure had the potential for patient needs to go unmet and cause a deterioration in health status.

Findings:

On 5/30/17, Patient 3's record was reviewed. Patient 3 was admitted on 5/26/17 with sepsis (a life threatening blood infection and a urinary tract infection. On 5/28/17, Patient 1 required a surgical intervention to place a tube (a nephrostomy tube) to relieve a build-up of urine in the kidney caused by a blockage.

Patient 3's care plan was reviewed and did not contain evidence that Patient 3's post-surgical needs and urological needs were added to the care plan.

The hospital's "Documentation: Nursing Process and Multidisciplinary Plan of Care," policy, dated 9/2008, was reviewed and read, "The RN reviews and revises the patient plan of care diagnoses and goals daily."

During a concurrent interview and record review on 5/30/17 at 2:30 pm, Administrative Nurse 5 reviewed Patient 3's record and acknowledged that Patient 3's care plan had not been kept current.

Based on interview and record review, the hospital failed to ensure that two of 15 sampled patients (Patients 8 and 9) had medications for pain given in accordance with the physicians orders.

This failure had the potential for patients to be overmedicated, at risk for narcotic dependency, and could result in a significant change in condition.

Findings:

1. On 5/31/17, Patient 8's record was reviewed. Patient 8 was admitted on 5/28/17 for pain control following a fall.

Patient 8's record contained a physician's order, dated 5/28/17 at 11:41 pm, for Norco 5/325 (a pain medication) one to two tablets every 4 hours as needed for pain scored moderate to severe (4-10 on a scale of 0-10, ten being the worst pain). May repeat one dose after 30 minutes if pain goal not achieved. If two tablets effective, continue with two tablets for subsequent dosing.

Review of Patient 8's medication record indicated that one tablet of Norco was effective for pain control on 5/29/17 at 6:36 am, and again at 4:45 pm. Patient 8's record indicated two tablets were given to Patient 8 on 5/30/17 at 8:47 am by Registered Nurse (RN) 7.

During a concurrent interview and record review on 5/31/17 at 10:45 am, RN 7 recalled administering Patient 8's pain medication and stated she gave two tablets to Patient 8 because his pain was severe (score of 8). RN 7 reviewed the physician's order for Norco and acknowledged that she did not follow the physician's order.

2. On 5/31/17, Patient 9's record was reviewed. Patient 9 was admitted on 5/28/17 for diabetes control. Patient 9's record contained a physician's order, dated 5/28/17 at 5:14 am, for Norco 5/325 one to two tablets every 4 hours as needed for pain scored moderate to severe (4-10 on a scale of 0-10, ten being the worst pain). May repeat one dose after 30 minutes if pain goal not achieved. If two tablets effective, continue with two tablets for subsequent dosing.

Patient 9's record indicated two tablets were given to Patient 8 on 5/28/17 at 1:38 pm by RN 6.

During a concurrent interview and record review on 5/31/17 at 11:40 am, RN 6 recalled administering Patient 8's pain medication and stated he gave two tablets to Patient 8 because his pain was severe (score of 8). RN 6 reviewed the physician's order for Norco and acknowledged that he did not follow the physician's order.

(The California Board of Registered Nursing scope of practice permits under Business and Professions Code Section 2725.3. (a)(1) a RN to administer medication under a physician order but does not permit independent judgement of dosage amounts.)

During an interview on 5/31/17 at 12 pm, Administrative Nurse 5 acknowledged RNs 6 and 7 should have followed physicians orders for pain medication administration and not given two tablets without assessing if one tablet would be effective.

Based on dietary staff observation, interview, and dietary document review, the hospital failed to ensure one dietetic staff member followed manufacturers' guidance when evaluating sanitation effectiveness of mechanical and manual processes.

Failure to ensure staff competency in sanitation processes may result in patient exposure to microorganisms.

Findings:

On 5/30/17 at 11:10 am, the sanitation processes were reviewed with Dietary Staff (DS) 1. In a concurrent interview, the surveyor asked how she ensured the dishwasher was working properly. DS 1 demonstrated that she would check the temperature dials on the Dishmachine. In addition, she would run a paper temperature indicator strip through the Dishmachine. DS 1 also demonstrated that she would compare the color of the temperature strip to a chart on the wall. It was noted that the chart on the wall was not related to the dishwasher test strips, rather was intended for measuring the strength of quaternary ammonia.

In a follow up observation and concurrent interview on 5/30/17 beginning at 11:20 am, DS 1 described the cleaning of patient meal carts utilizing a sanitizing solution. She demonstrated testing the strength of the solution by placing a paper test strip in the solution, moving it through the water, for approximately 3 seconds.

Manufacturers' guidance for the dishwasher strip was reviewed and indicated the Thermocromatic color-change band verified that proper sanitizing temperature of 180 degrees Fahrenheit was reached during dish washing operation (Taylor USA). There was no comparison of color to any particular chart. Review of manufacturers' guidance for the quaternary ammonia revealed that the strip should have been dipped for 10 seconds in the solution without any movement.

In an interview with Dietary Management Staff (DMS) on 5/31/17 at 11:45 am, and concurrent position evaluation review, dated 4/26/17, revealed that DS 1 was oriented and evaluated as competent to these tasks. DMS also stated that standard process for position orientation was to pair up new employees with current employees.