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Based on staff interviews and medical record review the facility failed for 2 of 5 patients, (Patient #1 and Patient #2), to ensure the patients' right to receive care and services in a safe setting.

Findings:

1. Review of the medical record for patient #1 revealed that the patient had the admitting diagnosis of Schizophrenia Paranoid type, Asthma, Emphysema, Benign Prostatic Hyperplasia (BPH), Parkinson's, Gastroesophageal Reflux Disease (GERD), and chronic pain. Review of the admission physician orders dated 08/14/2011 at 2101 that included Flovent inhaler 2 puffs 2 times daily, ProAir 2 puff 2 times daily, and 2 liter oxygen at night. A second admission order written on 08/14/2011 at 2120 revealed a physician order for Albuterol Nebulizer Treatments 0.083% every 4 hours PRN (As Needed).

Review of the History and Physical for patient #1 written on 08/15/2010 by the medical doctor revealed under ASSESSMENT 1. Asthma 2. Chronic Obstructive Pulmonary Disease. Under RECOMMENDATIONS AND Plan: "I am going to start this patient on Flomax 0.4 mg [milligrams] twice daily, Mobic 15 mg q. d. [every day], Zantac 150 mg twice daily, Flovent two puff daily, ProAir two puffs daily and O2 [oxygen] two liters at night. We will leave the remainder of his medications up to Psychiatry and will continue to monitor."

Review of the Medication Administration Record, (MAR), revealed the following medications added to the MAR on 08/15/2011, Flovent Inhaler 2 puff 2 times daily. The MAR revealed that the Flovent was scheduled for 8:00 AM and 5:00 PM. Review of the MAR revealed that the Flovent was not administered on 08/15/2011, but was started on the 16th and all ordered doses were received by the patient.
Review of the medical record revealed that ProAir 2 puff 2 times daily was added on 08/15/2011 and scheduled for 8:00 AM only; the MAR did not reveal a second administration time that would coincide with the medication being ordered twice daily. Review of the MAR revealed that the patient did not receive any doses on 08/15/2011 and on one dose on 08/16 at 8:00 AM and one does on 08/172011 at 8:00 AM. The MAR did not reveal that the patient receive any does at 5:00 PM on either 08/16/2011 or 08/17. The MAR revealed that the patient did not receive any doses on 08/18/2011 resulting in a total of 6 of 8 doses that were not administered to the patient.

Review of the MAR revealed that an order for Oxygen 2 liter at night was added on 08/15/2011. The section of the MAR that is used for scheduling time was left blank and written across the sections for documenting administration was FYI, (for your information). The medical record did not reveal that the patient had received any oxygen during his entire admission. Review of the medical record did not reveal that the patient ' s need for supplemental oxygen was ever assessed or that oxygen saturation levels were every measured. The medical record did not reveal why the MAR was completed with FYI indicating if the patient received 2 liter of oxygen at night. Review of the medical record did not reveal that the admitting nurse or any other nurse who were responsible for the patient's made any attempts to make to obtain an oxygen concentrator or assess if the lack of supplemental oxygen at night was a factor in the patient requesting PRN breathing treatments. Review MAR revealed under PRN Medications an order for Albuterol 0.83% Nebulizer treatment every 4 hours as need. Review of the MAR revealed that on patient had between 08/14/2011 and 08/18 requested a total of 8 rescue treatments. Review of the medical record revealed that the facility's nurses failed to document any assessments of the patient before, during or after 8 treatments were requested and provided to the patient.

Interview with the Assistant Administrator/Risk Manager on 01/18/2011 at 10:30 AM revealed that at the time of admission the patient's nurse stated that all the oxygen concentrators were in use.

Review of the medical record for patient #1 revealed that the patient was found unresponsive on 08/19/2011 at 5:30 AM; Cardiopulmonary Resuscitation (CPR) was started and maintained until Emergency Medical Services (EMS) personnel pronounced the patient had expired. Review of the Autopsy Report dated 08/19/2011 at 1:00 PM revealed that the cause of death was atherosclerotic cardiovascular disease with chronic obstructive pulmonary disease as a contributing cause.

2. Review of the medical record for patient #2 revealed that the patient was admitted to the facility on 01/02/2012 with the following medical conditions Leukocytosis, Hypertension, Chronic Obstructive Pulmonary disease, chronic pain and Hepatitis C. Review of the medical record revealed a physician order for "continuous Oxygen 2 liters daily". Review of the MAR revealed that nursing staff documented that the patient received the oxygen as ordered. Review of the medical record did not reveal that the nursing staff reassessed the patient's oxygen saturation during her admission in the facility. The medical record only revealed that on oxygen saturation was performed on admission.

Review of the facility's Nursing policy and procedure No.: 1100.140.74, last revised date 01/2010 Subject: Oxygen Administration page 2 Section III Monitoring Patient revealed:

A. Monitoring Respiratory Status
1. Nurse will monitor patient's vital sign, hydration status, and observe air exchange during each shift.
2. Assess breath sounds using a stethoscope noting any changes form baseline.
3. Assess skin color and capillary refill of nail beds for good tissue perfusion.
4. Monitor mental status for changes indicating hypoxia: increased confusion, anxiety, and agitation.
5. Nurse ' s assessment and observations and observations will be written in the progress notes.
6. Notify the medical consult physician when there has been a significant change in status in the patient's condition and obtain further physician's orders for any follow-up.
B. Pulse Oximetry
1. Nurses will measure patient's arterial Oxygen saturation using the pulse oximeter. Readings between 95% to 100% are within normal range for adults. Compare reading from baseline to current measurements.

3. Review of the medical record for patient #1 and #2 did not reveal that the patient respiratory status was evaluated and documented all shifts by the nurse or that pulse Oximetry was performed on either patient to insure the patient remained within safe levels of blood oxygen saturation.

4. Review of the facility's Nursing policy and procedure No.: 1100.140.60, last revised 04/2009 Subject: Medication Administration and Records, Number 4. Medication Administration Procedure revealed:
Section e. Stat, Now and Missed Dosed: Number 3 "If a medication dose has been missed for any reason, the nurse shall contact the prescriber"
Section f. MAR: Number 21 "PRN medications do not have designated times written on the MAR since the medication is given only when needed. Documentation of a patient's response to the PRN medication must be documented. When a PRN medication is given, the nurse will record the administration time on the PRN sheet and will record his/her initials directly to the right of the medication time. "

Review of the medical record did not reveal that the missed doses of medication, including that the patient #1 did not receive the 2 liter of oxygen at night were communicated to the patient ' s physician.

Review of the medical records for patient #1 revealed he had received Albuterol 0.83% Nebulizer treatments PRN, (as needed), on 8 occasions during his admission to the facility. Review of the medical record did not reveal that the nurse documented the patient's response to the PRN treatments.

Interview with the nurse of patient #2 on 01/18/2012 at 1:30 PM revealed when asked when is pulse Oximetry performed on patient that are receiving oxygen the nurse stated that oxygen saturation levels are only performed when the patient is in distress or if the physician orders them to be done. When asked if she was aware of Nursing policy and procedure No.: 1100.140.74, last revised date 01/2010 Subject: Oxygen Administration, the nurse stated that she seen it before.


5. Review of the Treatment Care Plan developed on 08/14/2011 for patient #1 revealed a plan for Problem #3 revealed that the patient suffered from COPD and Asthma. Review of the treatment care plan revealed the following nursing assessments to be completed:
1. Assess color, respiratory rate depth, effort, rhythm, and breath sounds every 12 hours.
2. Position to facilitate optimum breathing patterns: Head of Bed elevated 45 degrees.

Review of the medical record for patient #1 did not reveal that any of the Treatment Care plan approaches were performed and documented.

The facility failed to ensure that the nursing services was provided and furnished as per the facility's own policies and procedures. This resulted in the Condition of Nursing Services not to be met.
Findings:
Reference: A 0395: Based on record review and interview, the facility's Registered Nurse failed to supervise and evaluate the nursing care for 2 of 5 patients (#1 & #2) who did not receive medications as ordered or the nursing staff failed to follow the facility's own policies and procedures regarding the administration of oxygen.

Reference: A 0396: Based on record review and interview the nursing staff failed to develop, keep current and implement care plans for 2 of 5 (#1 & #2) identified patient's needs, as per the facility's own policy and procedures.


Reference : A 0404: Based on staff interviews and medical record review the facility failed for 1 of 5 patients, (Patient #1), to ensure that medications were provided as ordered.

Based on record review and interview, the facility's Registered Nurse failed to supervise and evaluate the nursing care for 2 of 5 patients (#1 & #2) who did not receive medications as ordered or the nursing staff failed to follow the facility's own policies and procedures regarding the administration of oxygen.

Finding:

1. Review of the medical record for patient #1 revealed that the patient had the admitting diagnosis of Schizophrenia Paranoid type, Asthma, Emphysema, Benign Prostatic Hyperplasia (BPH), Parkinson's, Gastroesophageal Reflux Disease (GERD), and chronic pain. Review of the admission physician orders dated 08/14/2011 at 2101 that included Flovent inhaler 2 puffs 2 times daily, ProAir 2 puff 2 times daily, and 2 liter oxygen at night. A second admission order written on 08/14/2011 at 2120 revealed a physician order for Albuterol Nebulizer Treatments 0.083% every 4 hours PRN (As Needed).

Review of the History and Physical for patient #1 written on 08/15/2010 by the medical doctor revealed under ASSESSMENT 1. Asthma 2. Chronic Obstructive Pulmonary Disease. Under RECOMMENDATIONS AND Plan: "I am going to start this patient on Flomax 0.4 mg [milligrams] twice daily, Mobic 15 mg q. d. [every day], Zantac 150 mg twice daily, Flovent two puff daily, ProAir two puffs daily and O2 [oxygen] two liters at night. We will leave the remainder of his medications up to Psychiatry and will continue to monitor."

Review of the Medication Administration Record, (MAR), revealed the following medications added to the MAR on 08/15/2011, Flovent Inhaler 2 puff 2 times daily. The MAR revealed that the Flovent was scheduled for 8:00 AM and 5:00 PM. Review of the MAR revealed that the Flovent was not administered on 08/15/2011, but was started on the 16th and all ordered doses were received by the patient.
Review of the medical record revealed that ProAir 2 puff 2 times daily was added on 08/15/2011 and scheduled for 8:00 AM only; the MAR did not reveal a second administration time that would coincide with the medication being ordered twice daily. Review of the MAR revealed that the patient did not receive any doses on 08/15/2011 and on one dose on 08/16 at 8:00 AM and one does on 08/172011 at 8:00 AM. The MAR did not reveal that the patient receive any does at 5:00 PM on either 08/16/2011 or 08/17. The MAR revealed that the patient did not receive any doses on 08/18/2011 resulting in a total of 6 of 8 doses that were not administered to the patient.

Review of the MAR revealed that an order for Oxygen 2 liter at night was added on 08/15/2011. The section of the MAR that is used for scheduling time was left blank and written across the sections for documenting administration was FYI, (for your information). The medical record did not reveal that the patient had received any oxygen during his entire admission. Review of the medical record did not reveal that the patient ' s need for supplemental oxygen was ever assessed or that oxygen saturation levels were every measured. The medical record did not reveal why the MAR was completed with FYI indicating if the patient received 2 liter of oxygen at night. Review of the medical record did not reveal that the admitting nurse or any other nurse who were responsible for the patient's made any attempts to make to obtain an oxygen concentrator or assess if the lack of supplemental oxygen at night was a factor in the patient requesting PRN breathing treatments. Review MAR revealed under PRN Medications an order for Albuterol 0.83% Nebulizer treatment every 4 hours as need. Review of the MAR revealed that on patient had between 08/14/2011 and 08/18 requested a total of 8 rescue treatments. Review of the medical record revealed that the facility's nurses failed to document any assessments of the patient before, during or after 8 treatments were requested and provided to the patient.

Interview with the Assistant Administrator/Risk Manager on 01/18/2011 at 10:30 AM revealed that at the time of admission the patient's nurse stated that all the oxygen concentrators were in use.

Review of the medical record for patient #1 revealed that the patient was found unresponsive on 08/19/2011 at 5:30 AM; Cardiopulmonary Resuscitation (CPR) was started and maintained until Emergency Medical Services (EMS) personnel pronounced the patient had expired. Review of the Autopsy Report dated 08/19/2011 at 1:00 PM revealed that the cause of death was atherosclerotic cardiovascular disease with chronic obstructive pulmonary disease as a contributing cause.

2. Review of the medical record for patient #2 revealed that the patient was admitted to the facility on 01/02/2012 with the following medical conditions Leukocytosis, Hypertension, Chronic Obstructive Pulmonary disease, chronic pain and Hepatitis C. Review of the medical record revealed a physician order for "continuous Oxygen 2 liters daily". Review of the MAR revealed that nursing staff documented that the patient received the oxygen as ordered. Review of the medical record did not reveal that the nursing staff reassessed the patient's oxygen saturation during her admission in the facility. The medical record only revealed that on oxygen saturation was performed on admission.

Review of the facility's Nursing policy and procedure No.: 1100.140.74, last revised date 01/2010 Subject: Oxygen Administration page 2 Section III Monitoring Patient revealed:

A. Monitoring Respiratory Status
1. Nurse will monitor patient's vital sign, hydration status, and observe air exchange during each shift.
2. Assess breath sounds using a stethoscope noting any changes form baseline.
3. Assess skin color and capillary refill of nail beds for good tissue perfusion.
4. Monitor mental status for changes indicating hypoxia: increased confusion, anxiety, and agitation.
5. Nurse ' s assessment and observations and observations will be written in the progress notes.
6. Notify the medical consult physician when there has been a significant change in status in the patient's condition and obtain further physician's orders for any follow-up.
B. Pulse Oximetry
1. Nurses will measure patient's arterial Oxygen saturation using the pulse oximeter. Readings between 95% to 100% are within normal range for adults. Compare reading from baseline to current measurements.

3. Review of the medical record for patient #1 and #2 did not reveal that the patient respiratory status was evaluated and documented all shifts by the nurse or that pulse Oximetry was performed on either patient to insure the patient remained within safe levels of blood oxygen saturation.

4. Review of the facility's Nursing policy and procedure No.: 1100.140.60, last revised 04/2009 Subject: Medication Administration and Records, Number 4. Medication Administration Procedure revealed:
Section e. Stat, Now and Missed Dosed: Number 3 "If a medication dose has been missed for any reason, the nurse shall contact the prescriber"
Section f. MAR: Number 21 "PRN medications do not have designated times written on the MAR since the medication is given only when needed. Documentation of a patient's response to the PRN medication must be documented. When a PRN medication is given, the nurse will record the administration time on the PRN sheet and will record his/her initials directly to the right of the medication time. "

Review of the medical record did not reveal that the missed doses of medication, including that the patient #1 did not receive the 2 liter of oxygen at night were communicated to the patient ' s physician.

Review of the medical records for patient #1 revealed he had received Albuterol 0.83% Nebulizer treatments PRN, (as needed), on 8 occasions during his admission to the facility. Review of the medical record did not reveal that the nurse documented the patient's response to the PRN treatments.

Interview with the nurse of patient #2 on 01/18/2012 at 1:30 PM revealed when asked when is pulse Oximetry performed on patient that are receiving oxygen the nurse stated that oxygen saturation levels are only performed when the patient is in distress or if the physician orders them to be done. When asked if she was aware of Nursing policy and procedure No.: 1100.140.74, last revised date 01/2010 Subject: Oxygen Administration, the nurse stated that she seen it before.


5. Review of the Treatment Care Plan developed on 08/14/2011 for patient #1 revealed a plan for Problem #3 revealed that the patient suffered from COPD and Asthma. Review of the treatment care plan revealed the following nursing assessments to be completed:
1. Assess color, respiratory rate depth, effort, rhythm, and breath sounds every 12 hours.
2. Position to facilitate optimum breathing patterns: Head of Bed elevated 45 degrees.

Review of the medical record for patient #1 did not reveal that any of the Treatment Care plan approaches were performed and documented.

Based on record review and interview the nursing staff failed to develop, keep current and implement care plans for 2 of 5 (#1 & #2) identified patient's needs, as per the facility's own policy and procedures.

Findings:
1. Review of the medical record for patient #1 revealed that the patient had the admitting diagnosis of Schizophrenia Paranoid type, Asthma, Emphysema, Benign Prostatic Hyperplasia (BPH), Parkinson's, Gastroesophageal Reflux Disease (GERD), and chronic pain. Review of the admission physician orders dated 08/14/2011 at 2101 that included Flovent inhaler 2 puffs 2 times daily, ProAir 2 puff 2 times daily, and 2 liter oxygen at night. A second admission order written on 08/14/2011 at 2120 revealed a physician order for Albuterol Nebulizer Treatments 0.083% every 4 hours PRN (As Needed).

Review of the History and Physical for patient #1 written on 08/15/2010 by the medical doctor revealed under ASSESSMENT 1. Asthma 2. Chronic Obstructive Pulmonary Disease. Under RECOMMENDATIONS AND Plan: "I am going to start this patient on Flomax 0.4 mg [milligrams] twice daily, Mobic 15 mg q. d. [every day], Zantac 150 mg twice daily, Flovent two puff daily, ProAir two puffs daily and O2 [oxygen] two liters at night. We will leave the remainder of his medications up to Psychiatry and will continue to monitor."

Review of the Medication Administration Record, (MAR), revealed the following medications added to the MAR on 08/15/2011, Flovent Inhaler 2 puff 2 times daily. The MAR revealed that the Flovent was scheduled for 8:00 AM and 5:00 PM. Review of the MAR revealed that the Flovent was not administered on 08/15/2011, but was started on the 16th and all ordered doses were received by the patient.
Review of the medical record revealed that ProAir 2 puff 2 times daily was added on 08/15/2011 and scheduled for 8:00 AM only; the MAR did not reveal a second administration time that would coincide with the medication being ordered twice daily. Review of the MAR revealed that the patient did not receive any doses on 08/15/2011 and on one dose on 08/16 at 8:00 AM and one does on 08/172011 at 8:00 AM. The MAR did not reveal that the patient receive any does at 5:00 PM on either 08/16/2011 or 08/17. The MAR revealed that the patient did not receive any doses on 08/18/2011 resulting in a total of 6 of 8 doses that were not administered to the patient.

Review of the MAR revealed that an order for Oxygen 2 liter at night was added on 08/15/2011. The section of the MAR that is used for scheduling time was left blank and written across the sections for documenting administration was FYI, (for your information). The medical record did not reveal that the patient had received any oxygen during his entire admission. Review of the medical record did not reveal that the patient ' s need for supplemental oxygen was ever assessed or that oxygen saturation levels were every measured. The medical record did not reveal why the MAR was completed with FYI indicating if the patient received 2 liter of oxygen at night. Review of the medical record did not reveal that the admitting nurse or any other nurse who were responsible for the patient's made any attempts to make to obtain an oxygen concentrator or assess if the lack of supplemental oxygen at night was a factor in the patient requesting PRN breathing treatments. Review MAR revealed under PRN Medications an order for Albuterol 0.83% Nebulizer treatment every 4 hours as need. Review of the MAR revealed that on patient had between 08/14/2011 and 08/18 requested a total of 8 rescue treatments. Review of the medical record revealed that the facility's nurses failed to document any assessments of the patient before, during or after 8 treatments were requested and provided to the patient.

Interview with the Assistant Administrator/Risk Manager on 01/18/2011 at 10:30 AM revealed that at the time of admission the patient's nurse stated that all the oxygen concentrators were in use.

Review of the medical record for patient #1 revealed that the patient was found unresponsive on 08/19/2011 at 5:30 AM; Cardiopulmonary Resuscitation (CPR) was started and maintained until Emergency Medical Services (EMS) personnel pronounced the patient had expired. Review of the Autopsy Report dated 08/19/2011 at 1:00 PM revealed that the cause of death was atherosclerotic cardiovascular disease with chronic obstructive pulmonary disease as a contributing cause.

2. Review of the medical record for patient #2 revealed that the patient was admitted to the facility on 01/02/2012 with the following medical conditions Leukocytosis, Hypertension, Chronic Obstructive Pulmonary disease, chronic pain and Hepatitis C. Review of the medical record revealed a physician order for "continuous Oxygen 2 liters daily". Review of the MAR revealed that nursing staff documented that the patient received the oxygen as ordered. Review of the medical record did not reveal that the nursing staff reassessed the patient's oxygen saturation during her admission in the facility. The medical record only revealed that on oxygen saturation was performed on admission.

Review of the facility's Nursing policy and procedure No.: 1100.140.74, last revised date 01/2010 Subject: Oxygen Administration page 2 Section III Monitoring Patient revealed:

A. Monitoring Respiratory Status
1. Nurse will monitor patient's vital sign, hydration status, and observe air exchange during each shift.
2. Assess breath sounds using a stethoscope noting any changes form baseline.
3. Assess skin color and capillary refill of nail beds for good tissue perfusion.
4. Monitor mental status for changes indicating hypoxia: increased confusion, anxiety, and agitation.
5. Nurse ' s assessment and observations and observations will be written in the progress notes.
6. Notify the medical consult physician when there has been a significant change in status in the patient's condition and obtain further physician's orders for any follow-up.
B. Pulse Oximetry
1. Nurses will measure patient's arterial Oxygen saturation using the pulse oximeter. Readings between 95% to 100% are within normal range for adults. Compare reading from baseline to current measurements.

3. Review of the medical record for patient #1 and #2 did not reveal that the patient respiratory status was evaluated and documented all shifts by the nurse or that pulse Oximetry was performed on either patient to insure the patient remained within safe levels of blood oxygen saturation.

4. Review of the facility's Nursing policy and procedure No.: 1100.140.60, last revised 04/2009 Subject: Medication Administration and Records, Number 4. Medication Administration Procedure revealed:
Section e. Stat, Now and Missed Dosed: Number 3 "If a medication dose has been missed for any reason, the nurse shall contact the prescriber"
Section f. MAR: Number 21 "PRN medications do not have designated times written on the MAR since the medication is given only when needed. Documentation of a patient's response to the PRN medication must be documented. When a PRN medication is given, the nurse will record the administration time on the PRN sheet and will record his/her initials directly to the right of the medication time. "

Review of the medical record did not reveal that the missed doses of medication, including that the patient #1 did not receive the 2 liter of oxygen at night were communicated to the patient ' s physician.

Review of the medical records for patient #1 revealed he had received Albuterol 0.83% Nebulizer treatments PRN, (as needed), on 8 occasions during his admission to the facility. Review of the medical record did not reveal that the nurse documented the patient's response to the PRN treatments.

Interview with the nurse of patient #2 on 01/18/2012 at 1:30 PM revealed when asked when is pulse Oximetry performed on patient that are receiving oxygen the nurse stated that oxygen saturation levels are only performed when the patient is in distress or if the physician orders them to be done. When asked if she was aware of Nursing policy and procedure No.: 1100.140.74, last revised date 01/2010 Subject: Oxygen Administration, the nurse stated that she seen it before.


5. Review of the Treatment Care Plan developed on 08/14/2011 for patient #1 revealed a plan for Problem #3 revealed that the patient suffered from COPD and Asthma. Review of the treatment care plan revealed the following nursing assessments to be completed:
1. Assess color, respiratory rate depth, effort, rhythm, and breath sounds every 12 hours.
2. Position to facilitate optimum breathing patterns: Head of Bed elevated 45 degrees.

Review of the medical record for patient #1 did not reveal that any of the Treatment Care plan approaches were performed and documented.

Based on staff interviews and medical record review the facility failed for 1 of 5 patients, (Patient #1), to ensure that medications were provided as ordered.

Findings:

1. Review of the medical record for patient #1 revealed that the patient had the admitting diagnosis of Schizophrenia Paranoid type, Asthma, Emphysema, Benign Prostatic Hyperplasia (BPH), Parkinson's, Gastroesophageal Reflux Disease (GERD), and chronic pain. Review of the admission physician orders dated 08/14/2011 at 2101 that included Flovent inhaler 2 puffs 2 times daily, ProAir 2 puff 2 times daily, and 2 liter oxygen at night. A second admission order written on 08/14/2011 at 2120 revealed a physician order for Albuterol Nebulizer Treatments 0.083% every 4 hours PRN (As Needed).

Review of the History and Physical for patient #1 written on 08/15/2010 by the medical doctor revealed under ASSESSMENT 1. Asthma 2. Chronic Obstructive Pulmonary Disease. Under RECOMMENDATIONS AND Plan: "I am going to start this patient on Flomax 0.4 mg [milligrams] twice daily, Mobic 15 mg q. d. [every day], Zantac 150 mg twice daily, Flovent two puff daily, ProAir two puffs daily and O2 [oxygen] two liters at night. We will leave the remainder of his medications up to Psychiatry and will continue to monitor."

Review of the Medication Administration Record, (MAR), revealed the following medications added to the MAR on 08/15/2011, Flovent Inhaler 2 puff 2 times daily. The MAR revealed that the Flovent was scheduled for 8:00 AM and 5:00 PM. Review of the MAR revealed that the Flovent was not administered on 08/15/2011, but was started on the 16th and all ordered doses were received by the patient.
Review of the medical record revealed that ProAir 2 puff 2 times daily was added on 08/15/2011 and scheduled for 8:00 AM only; the MAR did not reveal a second administration time that would coincide with the medication being ordered twice daily. Review of the MAR revealed that the patient did not receive any doses on 08/15/2011 and on one dose on 08/16 at 8:00 AM and one does on 08/172011 at 8:00 AM. The MAR did not reveal that the patient receive any does at 5:00 PM on either 08/16/2011 or 08/17. The MAR revealed that the patient did not receive any doses on 08/18/2011 resulting in a total of 6 of 8 doses that were not administered to the patient.

Review of the MAR revealed that an order for Oxygen 2 liter at night was added on 08/15/2011. The section of the MAR that is used for scheduling time was left blank and written across the sections for documenting administration was FYI, (for your information). The medical record did not reveal that the patient had received any oxygen during his entire admission. Review of the medical record did not reveal that the patient ' s need for supplemental oxygen was ever assessed or that oxygen saturation levels were every measured. The medical record did not reveal why the MAR was completed with FYI indicating if the patient received 2 liter of oxygen at night. Review of the medical record did not reveal that the admitting nurse or any other nurse who were responsible for the patient's made any attempts to make to obtain an oxygen concentrator or assess if the lack of supplemental oxygen at night was a factor in the patient requesting PRN breathing treatments. Review MAR revealed under PRN Medications an order for Albuterol 0.83% Nebulizer treatment every 4 hours as need. Review of the MAR revealed that on patient had between 08/14/2011 and 08/18 requested a total of 8 rescue treatments. Review of the medical record revealed that the facility's nurses failed to document any assessments of the patient before, during or after 8 treatments were requested and provided to the patient.

Interview with the Assistant Administrator/Risk Manager on 01/18/2011 at 10:30 AM revealed that at the time of admission the patient's nurse stated that all the oxygen concentrators were in use.

Review of the medical record for patient #1 revealed that the patient was found unresponsive on 08/19/2011 at 5:30 AM; Cardiopulmonary Resuscitation (CPR) was started and maintained until Emergency Medical Services (EMS) personnel pronounced the patient had expired. Review of the Autopsy Report dated 08/19/2011 at 1:00 PM revealed that the cause of death was atherosclerotic cardiovascular disease with chronic obstructive pulmonary disease as a contributing cause.