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Based on review of staffing schedules and matrix, medical records and interviews, it was determined the facility failed to ensure sufficient numbers of staff were available to meet the needs of the patients who were on the ICT (Intensive Care Telemetry) Unit between 4/5/13 and 4/7/13. This negatively affected Patient Identifiers (PI) # 3, 6, 2, and 1 and had the potential to negatively affect all patients served by this facility.

Findings include:

1. PI # 3 was admitted to the facility on the ICT Unit on 4/3/13 and discharged 4/9/13 with diagnoses including Osteomyelitis Right Distal Tibia, Abscess/Osteomyelitis Right Distal Fibula.

The patient under went an Incision and Drainage of the right distal tibia and lateral fibula on 4/4/13, with cultures which revealed MRSA (Methicillin Resistant Staphylococcus Aureus).

Review of the 24 Hour Flow Sheet dated 4/5/13 at 08:00 revealed the patient was complaining of pain at a 10 on a scale of 0 to 10 ( 0 being no pain and 10 being the greatest pain). The patient received Percocet 10 mg (milligrams) by mouth and Dilaudid 1 mg intravenously (IV).

Review of the 24 Hour Flow Sheet dated 4/5/13 at 10:00 revealed the patient's pain was not controlled. The patient received Dilaudid 1 mg IV.

Review of the 24 Hour Flow Sheet dated 4/5/13 at 12:00 revealed the pain continued and the nurse notified the physician and administered Toradol 30 mg IV at 12:30 per physician's order for a one time dose.

Review of the physician's orders dated 4/5/13 at 12:45 revealed orders for the staff to contact anesthesia for PCA (patient-controlled analgesia) pump for pain control.

Review of the 24 Hour Flow Sheet dated 4/5/13 at 14:00 revealed documentation the patient was still in pain and waiting on anesthesia for pain control.

Review of the 24 Hour Flow Sheet dated 4/5/13 at 16:00 revealed documentation the patient continued to be in pain.

Review of the physician's orders dated 4/5/13 at 16:40 revealed documentation the patient was to receive the PCA pump with Morphine 1.2 mg every 6 minutes with a total of 30 mg in 4 hours. The breakthrough pain was to be treated with Lortab 5 mg every 3 - 4 hours for complaints of pain.


Review of the Patient Controlled Analgesia Flow Sheet dated 4/5/13 revealed the PCA pump began 4/5/13 at 17:20 which was 4 hours and 35 minutes after the original order at 12:40 PM.


Review of the Medication Administration Record revealed the patient received Dilaudid 1 mg IV at 12:47 and 14:57. The patient received Percocet 10 mg at 11:53 and 16:03.

Review of the Medication Administration Record dated 4/5/13 (24 hour period) revealed the patient received 6 doses of Dilaudid 1 mg IV and 4 doses of percocet 10 mg.

Review of the Medication Administration Record dated 4/6/13 (24 hour period) revealed the patient only received 3 doses of Dilaudid 1 mg IV (decrease by 1/2), 3 doses of Lortab 5 mg, and 2 doses of Percocet 10 mg (decrease by 3/4).

Review of the physician's orders dated 4/4/13 revealed Zofran 4 mg/2 ml (milliliter) vial IV every 6 hours as a first choice for nausea and vomiting. Promethazine (Phenergan) 25 mg/ml in 50 ml 0.9 % (percent) sodium chloride IV every 6 hours as 2nd choice for nausea and vomiting.

Review of the 24 Hour Flow Sheet dated 4/6/13 at 10:00 revealed the patient received Zofran for nausea.

Review of the 24 Hour Flow Sheet dated 4/6/13 at 12:00 revealed the patient continued to complain of nausea and the staff contacted the pharmacy for the Phenergan.

Review of the 24 Hour Flow Sheet dated 4/6/13 at 14:00 revealed documentation the staff was still waiting for the Phenergan.

Review of the 24 Hour Flow Sheet dated 4/6/13 at 15:30 revealed documentation the patient received the Phenergan which was 3 and 1/2 hours after documentation the pharmacy was contacted.

The surveyor submitted a question to Employee Identifer # 1, the Chief Nursing Officer on 4/25/13 concerning the time frame on the phenergan for 4/6/13. EI # 1 submitted a sheet which states the Phenergan was ordered at 15:56 and administered 16:18.

Review of the Medication Summary revealed documentation the Phenergan was administered at 16:18.

Review of the 24 Hour Flow Sheet dated 4/7/13 revealed no documentation of the meals served and % of consumption, no documentation of a date, completed activities such as personal care for nights and evenings.

An interview with EI # 1was conducted on 4/25/13 at 11:20 AM who verified the above.


2. PI # 6 was admitted to the facility on the ICT Unit on 4/3/13 with diagnoses including Congestive Heart Failure, Right Bundle Branch Block, Diabetes Mellitus, and Coronary Artery Disease.

Review of the physician orders dated 4/3/13 revealed orders for the staff to weigh the patient now and daily.

Review of the physician's order dated 4/6/13 at 12:00 revealed the following Correctional Dose of Insulin with regular insulin with blood sugar check at 07:00, 11:00, 16:00, and 21:00:
AC (after meals) HS (hours of sleep)
141 - 199 AC = 1 unit (U) - HS = 0 U
200 - 249 AC = 2 U - HS = 0 U
250 - 299 AC = 3 U - HS = 2 U
300 - 349 AC = 4 U - HS = 2 U
> 350 AC = 5 U - HS = 3 U

Review of the Vital Signs/I & O (intake and output) revealed no documentation of a weight for 4/3/13, 4/4/13, 4/5/13, and 4/7/13.

Review of the Medication Summary for 4/7/13 revealed no documentation of a blood sugar at 07:00 and 16:00.

Review of the 24 Hour Flow Sheet dated 4/5/13, 4/6/13 and 4/7/13 revealed no documentation of the meals served and % of consumption.

An interview was conducted with EI # 1 on 4/25/13 at 11:00 AM. EI # 1 verified the above.

3. PI # 2 was admitted to the facility on the ICT Unit on 3/31/13 with diagnoses including Decompensated Liver Cirrhosis, With Ascites and Esophageal Varices, Alcohol, Depression and Anxiety.

Review of the 24 Hour Flow Sheet dated 4/6/13 revealed documentation of an assessment at 00:00 (midnight). The next documentation of an assessment was on 4/7/13 at 08:00.

Review of the 24 Hour Flow Sheet dated 4/7/13 revealed no documentation of a date, completed activities such as personal care for nights and evenings, meals served and % of consumption.

An interview was conducted with EI # 1 on 4/25/13 at 10:50 AM who verified the above and stated there was an agency nurse who worked 4/7/13 and did not document according to the facility's form.

4. PI # 1 was admitted to the facility on the ICT Unit on 3/31/13 with diagnoses including Sepsis With Peridontals Abscess/Infection, Anterior Mandibular Cellulitis and Ludwig Pain.

Review of the 24 Hour Flow Sheet dated 4/5/13, 4/6/13 and 4/7/13 revealed no documentation of the meals served and % of consumption.

An interview was conducted with EI # 1 on 4/25/13 at 10:550 AM who verified the above.

An interview was conducted with EI # 1 on 4/25/13 at 10:00 AM. The surveyor requested the total census for the ICT Unit for 4/5/13, 4/6/13, and 4/7/13.

EI # 1 submitted the following census numbers:

4/5/13 - AM 47 patients - PM 40 patients
4/6/13 - AM 44 patients - PM 41 patients
4/7/13 - AM 43 patients - PM 45 patients

EI # 1 submitted a ICT Staffing Grid to show the number of staff verse the census as follows:

AM

43 = total staff 15
44 = total staff 15
45 = total staff 16
46 = total staff 16
47 = total staff 16

PM

40 = total staff = 14
41 = total staff = 14
42 = total staff = 14
43 = total staff = 15
44 = total staff = 15
45 = total staff = 16


Review of the staffing schedule of the staff who actually worked revealed the following:

AM

4/5/13 AM = 12 staff (4 staff members less than matrix)
4/6/13 AM = 10 staff (5 staff members less than matrix)
4/7/13 AM = 9 staff (6 staff members less than matrix)

PM

4/5/13 AM = 7 staff (7 staff members less than matrix)
4/6/13 AM = 10 staff (4 staff members less than matrix)
4/7/13 AM = 9 staff (7 staff members less than matrix)

An interview was conducted with EI # 1 on 4/25/13 at 10:00 AM who verified the above staffing.

Based on review of medical records and interviews with staff, it was determined the nursing staff failed to:

1. Follow the physician's orders for blood glucose checks

2. Follow the physician's orders for insulin administration

3. Ensure patients were provided with adequate pain control.

4. Ensure patients were provided with adequate control of nausea and vomiting.

This negatively affected Patient Identifiers (PI) # 3, 6, 5,and 4 and had the potential to negatively affect all patients being served by this facility.

Findings include:

1. PI # 3 was admitted to the facility on the ICT (Intensive Care Telemetry) Unit on 4/3/13 and discharged 4/9/13 with diagnoses including Osteomyelitis Right Distal Tibia, Abscess/Osteomyelitis Right Distal Fibula.

The patient under went an Incision and Drainage of the right distal tibia and lateral fibula on 4/4/13, with cultures indicating MRSA (Methicillin Resistant Staphylococcus Aureus).

Review of the 24 Hour Flow Sheet dated 4/5/13 at 08:00 revealed the patient was complaining of pain at a 10 on a scale of 0 to 10 ( 0 being no pain and 10 being the greatest pain). The patient received Percocet 10 mg by mouth and Dilaudid 1 mg intravenously (IV).

Review of the 24 Hour Flow Sheet dated 4/5/13 at 10:00 revealed the patient's pain was not controlled. The patient received Dilaudid 1 mg IV.

Review of the 24 Hour Flow Sheet dated 4/5/13 at 12:00 revealed the pain continued and the nurse notified the physician. and administered Toradol 30 mg iv at 12:30 per physician's order for a one time dose.

Review of the physician's orders dated 4/5/13 at 12:45 revealed orders for the staff to contact anesthesia for PCA (patient-controlled analgesia) pump for pain control.

Review of the 24 Hour Flow Sheet dated 4/5/13 at 14:00 revealed documentation the patient was still in pain and waiting on anesthesia for pain control.

Review of the 24 Hour Flow Sheet dated 4/5/13 at 16:00 revealed documentation the patient continued to be in pain.

Review of the physician's orders dated 4/5/13 at 16:40 revealed documentation the patient was to receive the PCA pump with Morphine 1.2 mg (milligrams) every 6 minutes with a total of 30 mg in 4 hours. The breakthrough pain was to be treated with Lortab 5 mg every 3 - 4 hours for complaints of pain.


Review Patient Controlled Analgesia Flow Sheet revealed the PCA pump began 4/5/13 at 17:20 which was 4 hours and 35 minutes after the original order at 12:40 PM.


Review of the Medication Administration Record revealed the patient received Dilaudid 1 mg IV at 12:47 and 14:57. The patient received Percocet 10 mg at 11:53 and 16:03.

Review of the Medication Administration Record dated 4/5/13 (24 hour period) revealed the patient received 6 doses of Dilaudid 1 mg IV and 4 doses of percocet 10 mg.

Review of the Medication Administration Record dated 4/6/13 (24 hour period) revealed the patient only received 3 doses of Dilaudid 1 mg IV ( decrease by 1/2), 3 doses of Lortab 5 mg, and 2 doses of percocet 10 mg (decrease by 3/4).

Review of the physician's orders dated 4/4/13 revealed Zofran 4 mg/2 ml (milliliter) vial IV every 6 hours as a first choice for nausea and vomiting. Promethazine (Phenergan) 25 mg/ml in 50 ml 0.9% sodium chloride IV every 6 hours as 2nd choice for nausea and vomiting.

Review of the 24 Hour Flow Sheet dated 4/6/13 at 10:00 revealed the patient received Zofran for nausea.

Review of the 24 Hour Flow Sheet dated 4/6/13 at 12:00 revealed the patient continued to complain of nausea and the staff contacted the pharmacy for the Phenergan.

Review of the 24 Hour Flow Sheet dated 4/6/13 at 14:00 revealed documentation the staff was still waiting for the Phenergan.

Review of the 24 Hour Flow Sheet dated 4/6/13 at 15:30 revealed documentation the patient received the Phenergan which was 3 and 1/2 hours after documentation the pharmacy was contacted.

The surveyor submitted a question to Employee Identifer (EI) # 1, the Chief Nursing Officer on 4/25/13 concerning the time frame on the Phenergan for 4/6/13. EI # 1 submitted a sheet which states the Phenergan was ordered at 15:56 and administered 16:18.

Review of the Medication Summary revealed documentation the Phenergan was administered at 16:18.

Review of the 24 Hour Flow Sheet dated 4/7/13 revealed no documentation of the meals served and % of consumption, no documentation of a date, completed activities such as personal care for nights and evenings.

An interview with EI # 1 was conducted on 4/25/13 at 11:20 AM who verified the above.

2. PI # 6 was admitted to the facility on the ICT Unit on 4/3/13 with diagnoses including Congestive Heart Failure, Right Bundle Branch Block, Diabetes Mellitus, and Coronary Artery Disease and discharged 4/24/13.

Review of the physician orders dated 4/3/13 revealed orders for the staff to weigh the patient now and daily.

Review of the Vital Signs/I & O (intake and output) revealed no documentation of a weight for 4/3/13, 4/4/13, 4/5/13, 4/7/13, 4/8/13, 4/9/13, 4/16/13, 4/17/13, 4/18/13, 4/19/13, 4/21/13, 4/22/13, 4/23/13, and 4/24/13.

Review of the physician's order dated 4/6/13 at 12:00 revealed the following Correctional Dose of Insulin with regular insulin with blood sugar check at 07:00, 11:00, 16:00, and 21:00:
AC (after meals) HS (hours of sleep)
141 - 199 AC = 1 unit (U) - HS = 0 U
200 - 249 AC = 2 U - HS = 0 U
250 - 299 AC = 3 U - HS = 2 U
300 - 349 AC = 4 U - HS = 2 U
> 350 AC = 5 U - HS = 3 U


Review of the Medication Summary for 4/7/13 revealed no doumentation of a blood glucose at 07:00, and 16:00.

Review of the Medication Summary for 4/14/13 at 22:47 (HS) revealed doumentation the patients blood glucose was 213. The nurse documented administering 2 U of insulin when none should have been given according to the physician's orders.

Review of the Medication Summary for 4/15/13 at 00:58 (HS) revealed doumentation the patients blood glucose was 221. The nurse documented administering 2 U of insulin when none should have been given according to the physician's orders.

Review of the Medication Summary for 4/16/13 at 07:00 revealed doumentation the patients blood glucose was 274. The nurse did not document administering insulin when 3 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/19/13 at 16:32 revealed doumentation the patients blood glucose was 291. The nurse did not document administering insulin when 3 U should have been given according to the physician's orders.


Review of the Medication Summary for 4/20/13 at 21:00 (HS) revealed doumentation the patients blood glucose was 283. The nurse did not document administering insulin when 2 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/21/13 at 21:33 (HS) revealed doumentation the patients blood glucose was 268. The nurse did document administering 3 U insulin when 2 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/24/13 at 07:00 revealed doumentation the patients blood glucose was 194. The nurse did document administering 3 U insulin when 1 U should have been given according to the physician's orders.


An interview was conducted with EI # 1 on 4/25/13 at 11:00 AM. EI # 1 verified the above.

3. PI # 5 was admitted to the facility on 4/4/13 with diagnoses including Congestive Heart Failure, Insulin-Dependent Diabetes, and Chronic Kidney Disease stage 3 and remained a current patient on 4/25/13.


Review of the physician's order dated 4/4/13 revealed the following Correctional Dose of Insulin with Novolog insulin with blood glucose check every 4 hours:

151 - 200 = 2 units (U)
201 - 250 = 4 U
251 - 300 = 6 U
301 - 350 = 8 U
351 - 400 = 10 U
401 - 450 = 12 U
> 450 = 14 U

Review of the Medication Summary for 4/12/13 at 09:19 revealed documentation the patients blood glucose was 191. The nurse did not document administering insulin when 2 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/13/13 at 10:07 revealed documentation the patients blood glucose was 229. The nurse did not document administering insulin when 4 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/13/13 at 14:08 revealed documentation the patients blood glucose was 190. The nurse did not document administering insulin when 2 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/15/13 at 17:55 revealed documentation the patient had been NPO (nothing by mouth) all day . There was no documentation the nurse checked the patient's blood glucose. Review of the 24 Hour Flow Sheet dated 4/15/13 at 14:00 revealed documentation the patient was served a diet and tolerated fair.

Review of the Medication Summary for 4/20/13 at 13:00 revealed documentation the patients blood glucose was 206. The nurse did not document administering insulin when 4 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/21/13 at 17:32 revealed documentation the patients blood glucose was 413. Review of the Medication Summary for 4/21/13 at 21:00 revealed no doumentation the patient's blood glucose was checked. Review of the Medication Summary for 4/22/13 at 00:56 (which was the next blood glucose check) revealed the patient's blood glucose was 316.

Review of the Medication Summary for 4/22/13 at 09:48 revealed documentation the patients blood glucose was 239. The nurse did not document administering insulin when 4 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/22/13 at 20:42 revealed documentation the patients blood glucose was 216. The nurse documented administering 2 U of insulin when 4 U should have been given according to the physician's orders.

An interview was conducted with EI # 2, the Charge Nurse for ICT on 4/25/13 at 12:00. EI # 2 verified the above.

4. PI # 4 was admitted to the facility on 4/6/13 with diagnoses including Right Stump Cellulitis, End Stage Renal Disease with Hemodialysis, and Insulin-Dependent Diabetes and discharged 4/18/13.


Review of the physician's order dated 4/7/13 revealed the following Correctional Dose of Insulin with Novolog insulin with blood glucose check 07:00, 11:00, 16:00, and 21:00:

For Blood Glucoses 0 - 70 give 30 ml (milliliters) orange juice by mouth or 1 ampule D 50 IV. Repeat blood glucose in 15 minutes, if still less then 70, call MD

151 - 200 = 2 units (U)
201 - 250 = 4 U
251 - 300 = 6 U
301 - 350 = 8 U
351 - 400 = 10 U
401 - 450 = 12 U
> 450 = 14 U


Review of the 24 Hour Flow Sheet dated 4/7/13 at 11:00 revealed the patient's blood glucose was 78 and the patient was symptomatic, diaphoretic and sluggish. The nurse gave 400 ml of juice and 1 ampule of Dextrose (D) 50 IV. There was no documentation of a physician's order for the above with a blood glucose at 78. There was no documentation the physician was notified.

Further review of the 24 Hour Flow Sheet dated 4/7/13 at 15:00 revealed the patient was diaphoretic again with a blood glucose of 66. There was no documentation the physician was notified. The nurse gave the patient juice, peanut butter and crackers. There was no documentation of another blood glucose check until 21:33 which read 88.

Review of the Medication Summary for 4/08/13 at 16 revealed documentation the patients blood glucose was 172. The nurse did not document administering insulin when 2 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/09/13 at 15:04 revealed documentation the patients blood glucose was < 60. There was no documentation the physician was notified. The nurse documented administering 1/2 ampule of D 50. There was no documentation of a physician's order for the 1/2 ampule of D 50.

Review of the Medication Summary for 4/11/13 at 07:36 revealed documentation the patients blood glucose was 226. The nurse did not document administering insulin when 4 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/13/13 at 13:42 revealed documentation the patients blood glucose was 196. The nurse did not document administering insulin when 2 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/13/13 at 18:56 revealed documentation the patients blood glucose was 156. The nurse did not document administering insulin when 2 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/15/13 at 09:42 revealed documentation the patients blood glucose was 199. The nurse did not document administering insulin when 2 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/15/13 at 12:56 revealed documentation the patients blood glucose was 178. The nurse did not document administering insulin when 2 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/15/13 at 20:54 revealed documentation the patients blood glucose was > 500. The nurse did not document administering insulin when 12 U should have been given according to the physician's orders. There was no documentation the physician was notified.


Review of the Medication Summary for 4/16/13 at 17:41 revealed documentation the patients blood glucose was 189. The nurse did not document administering insulin when 2 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/17/13 at 18:39 revealed documentation the patients blood glucose was 223. The nurse did not document administering insulin when 4 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/17/13 at 21:07 revealed documentation the patients blood glucose was 185. The nurse did not document administering insulin when 2 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/18/13 at 12:28 revealed documentation the patients blood glucose was 217. The nurse did not document administering insulin when 4 U should have been given according to the physician's orders.

An interview was conducted on 4/25/13 at 11:50 AM with EI # 1. EI # 1 verified the above.

Based on review of staffing schedules and matrix, medical records and interviews, it was determined the facility failed to ensure sufficient numbers of staff were available to meet the needs of the patients who were on the ICT (Intensive Care Telemetry) Unit between 4/5/13 and 4/7/13. This negatively affected Patient Identifiers (PI) # 3, 6, 2, and 1 and had the potential to negatively affect all patients served by this facility.

Findings include:

1. PI # 3 was admitted to the facility on the ICT Unit on 4/3/13 and discharged 4/9/13 with diagnoses including Osteomyelitis Right Distal Tibia, Abscess/Osteomyelitis Right Distal Fibula.

The patient under went an Incision and Drainage of the right distal tibia and lateral fibula on 4/4/13, with cultures which revealed MRSA (Methicillin Resistant Staphylococcus Aureus).

Review of the 24 Hour Flow Sheet dated 4/5/13 at 08:00 revealed the patient was complaining of pain at a 10 on a scale of 0 to 10 ( 0 being no pain and 10 being the greatest pain). The patient received Percocet 10 mg (milligrams) by mouth and Dilaudid 1 mg intravenously (IV).

Review of the 24 Hour Flow Sheet dated 4/5/13 at 10:00 revealed the patient's pain was not controlled. The patient received Dilaudid 1 mg IV.

Review of the 24 Hour Flow Sheet dated 4/5/13 at 12:00 revealed the pain continued and the nurse notified the physician and administered Toradol 30 mg IV at 12:30 per physician's order for a one time dose.

Review of the physician's orders dated 4/5/13 at 12:45 revealed orders for the staff to contact anesthesia for PCA (patient-controlled analgesia) pump for pain control.

Review of the 24 Hour Flow Sheet dated 4/5/13 at 14:00 revealed documentation the patient was still in pain and waiting on anesthesia for pain control.

Review of the 24 Hour Flow Sheet dated 4/5/13 at 16:00 revealed documentation the patient continued to be in pain.

Review of the physician's orders dated 4/5/13 at 16:40 revealed documentation the patient was to receive the PCA pump with Morphine 1.2 mg every 6 minutes with a total of 30 mg in 4 hours. The breakthrough pain was to be treated with Lortab 5 mg every 3 - 4 hours for complaints of pain.


Review of the Patient Controlled Analgesia Flow Sheet dated 4/5/13 revealed the PCA pump began 4/5/13 at 17:20 which was 4 hours and 35 minutes after the original order at 12:40 PM.


Review of the Medication Administration Record revealed the patient received Dilaudid 1 mg IV at 12:47 and 14:57. The patient received Percocet 10 mg at 11:53 and 16:03.

Review of the Medication Administration Record dated 4/5/13 (24 hour period) revealed the patient received 6 doses of Dilaudid 1 mg IV and 4 doses of percocet 10 mg.

Review of the Medication Administration Record dated 4/6/13 (24 hour period) revealed the patient only received 3 doses of Dilaudid 1 mg IV (decrease by 1/2), 3 doses of Lortab 5 mg, and 2 doses of Percocet 10 mg (decrease by 3/4).

Review of the physician's orders dated 4/4/13 revealed Zofran 4 mg/2 ml (milliliter) vial IV every 6 hours as a first choice for nausea and vomiting. Promethazine (Phenergan) 25 mg/ml in 50 ml 0.9 % (percent) sodium chloride IV every 6 hours as 2nd choice for nausea and vomiting.

Review of the 24 Hour Flow Sheet dated 4/6/13 at 10:00 revealed the patient received Zofran for nausea.

Review of the 24 Hour Flow Sheet dated 4/6/13 at 12:00 revealed the patient continued to complain of nausea and the staff contacted the pharmacy for the Phenergan.

Review of the 24 Hour Flow Sheet dated 4/6/13 at 14:00 revealed documentation the staff was still waiting for the Phenergan.

Review of the 24 Hour Flow Sheet dated 4/6/13 at 15:30 revealed documentation the patient received the Phenergan which was 3 and 1/2 hours after documentation the pharmacy was contacted.

The surveyor submitted a question to Employee Identifer # 1, the Chief Nursing Officer on 4/25/13 concerning the time frame on the phenergan for 4/6/13. EI # 1 submitted a sheet which states the Phenergan was ordered at 15:56 and administered 16:18.

Review of the Medication Summary revealed documentation the Phenergan was administered at 16:18.

Review of the 24 Hour Flow Sheet dated 4/7/13 revealed no documentation of the meals served and % of consumption, no documentation of a date, completed activities such as personal care for nights and evenings.

An interview with EI # 1was conducted on 4/25/13 at 11:20 AM who verified the above.


2. PI # 6 was admitted to the facility on the ICT Unit on 4/3/13 with diagnoses including Congestive Heart Failure, Right Bundle Branch Block, Diabetes Mellitus, and Coronary Artery Disease.

Review of the physician orders dated 4/3/13 revealed orders for the staff to weigh the patient now and daily.

Review of the physician's order dated 4/6/13 at 12:00 revealed the following Correctional Dose of Insulin with regular insulin with blood sugar check at 07:00, 11:00, 16:00, and 21:00:
AC (after meals) HS (hours of sleep)
141 - 199 AC = 1 unit (U) - HS = 0 U
200 - 249 AC = 2 U - HS = 0 U
250 - 299 AC = 3 U - HS = 2 U
300 - 349 AC = 4 U - HS = 2 U
> 350 AC = 5 U - HS = 3 U

Review of the Vital Signs/I & O (intake and output) revealed no documentation of a weight for 4/3/13, 4/4/13, 4/5/13, and 4/7/13.

Review of the Medication Summary for 4/7/13 revealed no documentation of a blood sugar at 07:00 and 16:00.

Review of the 24 Hour Flow Sheet dated 4/5/13, 4/6/13 and 4/7/13 revealed no documentation of the meals served and % of consumption.

An interview was conducted with EI # 1 on 4/25/13 at 11:00 AM. EI # 1 verified the above.

3. PI # 2 was admitted to the facility on the ICT Unit on 3/31/13 with diagnoses including Decompensated Liver Cirrhosis, With Ascites and Esophageal Varices, Alcohol, Depression and Anxiety.

Review of the 24 Hour Flow Sheet dated 4/6/13 revealed documentation of an assessment at 00:00 (midnight). The next documentation of an assessment was on 4/7/13 at 08:00.

Review of the 24 Hour Flow Sheet dated 4/7/13 revealed no documentation of a date, completed activities such as personal care for nights and evenings, meals served and % of consumption.

An interview was conducted with EI # 1 on 4/25/13 at 10:50 AM who verified the above and stated there was an agency nurse who worked 4/7/13 and did not document according to the facility's form.

4. PI # 1 was admitted to the facility on the ICT Unit on 3/31/13 with diagnoses including Sepsis With Peridontals Abscess/Infection, Anterior Mandibular Cellulitis and Ludwig Pain.

Review of the 24 Hour Flow Sheet dated 4/5/13, 4/6/13 and 4/7/13 revealed no documentation of the meals served and % of consumption.

An interview was conducted with EI # 1 on 4/25/13 at 10:550 AM who verified the above.

An interview was conducted with EI # 1 on 4/25/13 at 10:00 AM. The surveyor requested the total census for the ICT Unit for 4/5/13, 4/6/13, and 4/7/13.

EI # 1 submitted the following census numbers:

4/5/13 - AM 47 patients - PM 40 patients
4/6/13 - AM 44 patients - PM 41 patients
4/7/13 - AM 43 patients - PM 45 patients

EI # 1 submitted a ICT Staffing Grid to show the number of staff verse the census as follows:

AM

43 = total staff 15
44 = total staff 15
45 = total staff 16
46 = total staff 16
47 = total staff 16

PM

40 = total staff = 14
41 = total staff = 14
42 = total staff = 14
43 = total staff = 15
44 = total staff = 15
45 = total staff = 16


Review of the staffing schedule of the staff who actually worked revealed the following:

AM

4/5/13 AM = 12 staff (4 staff members less than matrix)
4/6/13 AM = 10 staff (5 staff members less than matrix)
4/7/13 AM = 9 staff (6 staff members less than matrix)

PM

4/5/13 AM = 7 staff (7 staff members less than matrix)
4/6/13 AM = 10 staff (4 staff members less than matrix)
4/7/13 AM = 9 staff (7 staff members less than matrix)

An interview was conducted with EI # 1 on 4/25/13 at 10:00 AM who verified the above staffing.

Based on review of medical records and interviews with staff, it was determined the nursing staff failed to:

1. Follow the physician's orders for blood glucose checks

2. Follow the physician's orders for insulin administration

3. Ensure patients were provided with adequate pain control.

4. Ensure patients were provided with adequate control of nausea and vomiting.

This negatively affected Patient Identifiers (PI) # 3, 6, 5,and 4 and had the potential to negatively affect all patients being served by this facility.

Findings include:

1. PI # 3 was admitted to the facility on the ICT (Intensive Care Telemetry) Unit on 4/3/13 and discharged 4/9/13 with diagnoses including Osteomyelitis Right Distal Tibia, Abscess/Osteomyelitis Right Distal Fibula.

The patient under went an Incision and Drainage of the right distal tibia and lateral fibula on 4/4/13, with cultures indicating MRSA (Methicillin Resistant Staphylococcus Aureus).

Review of the 24 Hour Flow Sheet dated 4/5/13 at 08:00 revealed the patient was complaining of pain at a 10 on a scale of 0 to 10 ( 0 being no pain and 10 being the greatest pain). The patient received Percocet 10 mg by mouth and Dilaudid 1 mg intravenously (IV).

Review of the 24 Hour Flow Sheet dated 4/5/13 at 10:00 revealed the patient's pain was not controlled. The patient received Dilaudid 1 mg IV.

Review of the 24 Hour Flow Sheet dated 4/5/13 at 12:00 revealed the pain continued and the nurse notified the physician. and administered Toradol 30 mg iv at 12:30 per physician's order for a one time dose.

Review of the physician's orders dated 4/5/13 at 12:45 revealed orders for the staff to contact anesthesia for PCA (patient-controlled analgesia) pump for pain control.

Review of the 24 Hour Flow Sheet dated 4/5/13 at 14:00 revealed documentation the patient was still in pain and waiting on anesthesia for pain control.

Review of the 24 Hour Flow Sheet dated 4/5/13 at 16:00 revealed documentation the patient continued to be in pain.

Review of the physician's orders dated 4/5/13 at 16:40 revealed documentation the patient was to receive the PCA pump with Morphine 1.2 mg (milligrams) every 6 minutes with a total of 30 mg in 4 hours. The breakthrough pain was to be treated with Lortab 5 mg every 3 - 4 hours for complaints of pain.


Review Patient Controlled Analgesia Flow Sheet revealed the PCA pump began 4/5/13 at 17:20 which was 4 hours and 35 minutes after the original order at 12:40 PM.


Review of the Medication Administration Record revealed the patient received Dilaudid 1 mg IV at 12:47 and 14:57. The patient received Percocet 10 mg at 11:53 and 16:03.

Review of the Medication Administration Record dated 4/5/13 (24 hour period) revealed the patient received 6 doses of Dilaudid 1 mg IV and 4 doses of percocet 10 mg.

Review of the Medication Administration Record dated 4/6/13 (24 hour period) revealed the patient only received 3 doses of Dilaudid 1 mg IV ( decrease by 1/2), 3 doses of Lortab 5 mg, and 2 doses of percocet 10 mg (decrease by 3/4).

Review of the physician's orders dated 4/4/13 revealed Zofran 4 mg/2 ml (milliliter) vial IV every 6 hours as a first choice for nausea and vomiting. Promethazine (Phenergan) 25 mg/ml in 50 ml 0.9% sodium chloride IV every 6 hours as 2nd choice for nausea and vomiting.

Review of the 24 Hour Flow Sheet dated 4/6/13 at 10:00 revealed the patient received Zofran for nausea.

Review of the 24 Hour Flow Sheet dated 4/6/13 at 12:00 revealed the patient continued to complain of nausea and the staff contacted the pharmacy for the Phenergan.

Review of the 24 Hour Flow Sheet dated 4/6/13 at 14:00 revealed documentation the staff was still waiting for the Phenergan.

Review of the 24 Hour Flow Sheet dated 4/6/13 at 15:30 revealed documentation the patient received the Phenergan which was 3 and 1/2 hours after documentation the pharmacy was contacted.

The surveyor submitted a question to Employee Identifer (EI) # 1, the Chief Nursing Officer on 4/25/13 concerning the time frame on the Phenergan for 4/6/13. EI # 1 submitted a sheet which states the Phenergan was ordered at 15:56 and administered 16:18.

Review of the Medication Summary revealed documentation the Phenergan was administered at 16:18.

Review of the 24 Hour Flow Sheet dated 4/7/13 revealed no documentation of the meals served and % of consumption, no documentation of a date, completed activities such as personal care for nights and evenings.

An interview with EI # 1 was conducted on 4/25/13 at 11:20 AM who verified the above.

2. PI # 6 was admitted to the facility on the ICT Unit on 4/3/13 with diagnoses including Congestive Heart Failure, Right Bundle Branch Block, Diabetes Mellitus, and Coronary Artery Disease and discharged 4/24/13.

Review of the physician orders dated 4/3/13 revealed orders for the staff to weigh the patient now and daily.

Review of the Vital Signs/I & O (intake and output) revealed no documentation of a weight for 4/3/13, 4/4/13, 4/5/13, 4/7/13, 4/8/13, 4/9/13, 4/16/13, 4/17/13, 4/18/13, 4/19/13, 4/21/13, 4/22/13, 4/23/13, and 4/24/13.

Review of the physician's order dated 4/6/13 at 12:00 revealed the following Correctional Dose of Insulin with regular insulin with blood sugar check at 07:00, 11:00, 16:00, and 21:00:
AC (after meals) HS (hours of sleep)
141 - 199 AC = 1 unit (U) - HS = 0 U
200 - 249 AC = 2 U - HS = 0 U
250 - 299 AC = 3 U - HS = 2 U
300 - 349 AC = 4 U - HS = 2 U
> 350 AC = 5 U - HS = 3 U


Review of the Medication Summary for 4/7/13 revealed no doumentation of a blood glucose at 07:00, and 16:00.

Review of the Medication Summary for 4/14/13 at 22:47 (HS) revealed doumentation the patients blood glucose was 213. The nurse documented administering 2 U of insulin when none should have been given according to the physician's orders.

Review of the Medication Summary for 4/15/13 at 00:58 (HS) revealed doumentation the patients blood glucose was 221. The nurse documented administering 2 U of insulin when none should have been given according to the physician's orders.

Review of the Medication Summary for 4/16/13 at 07:00 revealed doumentation the patients blood glucose was 274. The nurse did not document administering insulin when 3 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/19/13 at 16:32 revealed doumentation the patients blood glucose was 291. The nurse did not document administering insulin when 3 U should have been given according to the physician's orders.


Review of the Medication Summary for 4/20/13 at 21:00 (HS) revealed doumentation the patients blood glucose was 283. The nurse did not document administering insulin when 2 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/21/13 at 21:33 (HS) revealed doumentation the patients blood glucose was 268. The nurse did document administering 3 U insulin when 2 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/24/13 at 07:00 revealed doumentation the patients blood glucose was 194. The nurse did document administering 3 U insulin when 1 U should have been given according to the physician's orders.


An interview was conducted with EI # 1 on 4/25/13 at 11:00 AM. EI # 1 verified the above.

3. PI # 5 was admitted to the facility on 4/4/13 with diagnoses including Congestive Heart Failure, Insulin-Dependent Diabetes, and Chronic Kidney Disease stage 3 and remained a current patient on 4/25/13.


Review of the physician's order dated 4/4/13 revealed the following Correctional Dose of Insulin with Novolog insulin with blood glucose check every 4 hours:

151 - 200 = 2 units (U)
201 - 250 = 4 U
251 - 300 = 6 U
301 - 350 = 8 U
351 - 400 = 10 U
401 - 450 = 12 U
> 450 = 14 U

Review of the Medication Summary for 4/12/13 at 09:19 revealed documentation the patients blood glucose was 191. The nurse did not document administering insulin when 2 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/13/13 at 10:07 revealed documentation the patients blood glucose was 229. The nurse did not document administering insulin when 4 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/13/13 at 14:08 revealed documentation the patients blood glucose was 190. The nurse did not document administering insulin when 2 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/15/13 at 17:55 revealed documentation the patient had been NPO (nothing by mouth) all day . There was no documentation the nurse checked the patient's blood glucose. Review of the 24 Hour Flow Sheet dated 4/15/13 at 14:00 revealed documentation the patient was served a diet and tolerated fair.

Review of the Medication Summary for 4/20/13 at 13:00 revealed documentation the patients blood glucose was 206. The nurse did not document administering insulin when 4 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/21/13 at 17:32 revealed documentation the patients blood glucose was 413. Review of the Medication Summary for 4/21/13 at 21:00 revealed no doumentation the patient's blood glucose was checked. Review of the Medication Summary for 4/22/13 at 00:56 (which was the next blood glucose check) revealed the patient's blood glucose was 316.

Review of the Medication Summary for 4/22/13 at 09:48 revealed documentation the patients blood glucose was 239. The nurse did not document administering insulin when 4 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/22/13 at 20:42 revealed documentation the patients blood glucose was 216. The nurse documented administering 2 U of insulin when 4 U should have been given according to the physician's orders.

An interview was conducted with EI # 2, the Charge Nurse for ICT on 4/25/13 at 12:00. EI # 2 verified the above.

4. PI # 4 was admitted to the facility on 4/6/13 with diagnoses including Right Stump Cellulitis, End Stage Renal Disease with Hemodialysis, and Insulin-Dependent Diabetes and discharged 4/18/13.


Review of the physician's order dated 4/7/13 revealed the following Correctional Dose of Insulin with Novolog insulin with blood glucose check 07:00, 11:00, 16:00, and 21:00:

For Blood Glucoses 0 - 70 give 30 ml (milliliters) orange juice by mouth or 1 ampule D 50 IV. Repeat blood glucose in 15 minutes, if still less then 70, call MD

151 - 200 = 2 units (U)
201 - 250 = 4 U
251 - 300 = 6 U
301 - 350 = 8 U
351 - 400 = 10 U
401 - 450 = 12 U
> 450 = 14 U


Review of the 24 Hour Flow Sheet dated 4/7/13 at 11:00 revealed the patient's blood glucose was 78 and the patient was symptomatic, diaphoretic and sluggish. The nurse gave 400 ml of juice and 1 ampule of Dextrose (D) 50 IV. There was no documentation of a physician's order for the above with a blood glucose at 78. There was no documentation the physician was notified.

Further review of the 24 Hour Flow Sheet dated 4/7/13 at 15:00 revealed the patient was diaphoretic again with a blood glucose of 66. There was no documentation the physician was notified. The nurse gave the patient juice, peanut butter and crackers. There was no documentation of another blood glucose check until 21:33 which read 88.

Review of the Medication Summary for 4/08/13 at 16 revealed documentation the patients blood glucose was 172. The nurse did not document administering insulin when 2 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/09/13 at 15:04 revealed documentation the patients blood glucose was < 60. There was no documentation the physician was notified. The nurse documented administering 1/2 ampule of D 50. There was no documentation of a physician's order for the 1/2 ampule of D 50.

Review of the Medication Summary for 4/11/13 at 07:36 revealed documentation the patients blood glucose was 226. The nurse did not document administering insulin when 4 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/13/13 at 13:42 revealed documentation the patients blood glucose was 196. The nurse did not document administering insulin when 2 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/13/13 at 18:56 revealed documentation the patients blood glucose was 156. The nurse did not document administering insulin when 2 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/15/13 at 09:42 revealed documentation the patients blood glucose was 199. The nurse did not document administering insulin when 2 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/15/13 at 12:56 revealed documentation the patients blood glucose was 178. The nurse did not document administering insulin when 2 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/15/13 at 20:54 revealed documentation the patients blood glucose was > 500. The nurse did not document administering insulin when 12 U should have been given according to the physician's orders. There was no documentation the physician was notified.


Review of the Medication Summary for 4/16/13 at 17:41 revealed documentation the patients blood glucose was 189. The nurse did not document administering insulin when 2 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/17/13 at 18:39 revealed documentation the patients blood glucose was 223. The nurse did not document administering insulin when 4 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/17/13 at 21:07 revealed documentation the patients blood glucose was 185. The nurse did not document administering insulin when 2 U should have been given according to the physician's orders.

Review of the Medication Summary for 4/18/13 at 12:28 revealed documentation the patients blood glucose was 217. The nurse did not document administering insulin when 4 U should have been given according to the physician's orders.

An interview was conducted on 4/25/13 at 11:50 AM with EI # 1. EI # 1 verified the above.