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Based on interview, record review, and review of e-mails, personnel files, and facility policy it was determined the facility failed to ensure the Chief Executive Officer (CEO) effectively managed the facility. Review of the facility's Bylaws, revised 01/12/15, revealed the President/CEO should act as the duly authorized representative of the Board of Directors, who is charged with carrying out all policies established by the Board of Directors. The President/CEO's responsibilities included selection, employment, control, and discharge of employees; overseeing development and maintenance of personnel policies and practices; and cooperating with the medical staff and all those concerned with rendering professional services to ensure appropriate medical care was rendered to patients. However, although the CEO was aware medical providers and staff were concerned with the care RN #1 provided to patients and was concerned that the care RN #1 provided was "dangerous," the CEO took no action to ensure the health and safety of patients while the RN continued to provide patient care.

In addition, the CEO failed to ensure there was an effective system for investigating employee behavior/practices and ensuring staff had guidelines/standards for imposing disciplinary action when counseling/corrective action was warranted. Furthermore, the CEO failed to ensure established policies and procedures were followed when allegations of neglect were reported (refer to A0057, A0115, A0145, A0385, A0397, and A0405).

Based on interview, record review, and review of e-mails, personnel files, and facility policy it was determined the facility failed to ensure the Chief Executive Officer (CEO) effectively managed the facility. Although the CEO was aware medical providers and staff were concerned with the care Registered Nurse (RN) #1 provided to patients and were concerned that RN #1 was "dangerous," the CEO took no action to ensure RN #1's care was not negatively affecting the health and safety of patients.

The findings include:

Review of the facility's Bylaws, revised 01/12/15, revealed the Board of Directors meet as a committee at least four (4) times per year. Special meetings of the board may be called by or occur at the direction of the President/CEO, or by three (3) members of the board. The Bylaws state that the President/CEO shall act as the duly authorized representative of the Board of Directors, who is charged with carrying out all policies established by the Board of Directors. The President/CEO's responsibilities include selection, employment, control, and discharge of employees. The President/CEO oversees development and maintenance of personnel policies and practices for the corporation in harmony with the guidelines and policies established by the Board of Directors. Additionally, the President/CEO is also responsible for cooperation with the medical staff and all those concerned with rendering professional services to ensure appropriate medical care was rendered to patients.

Review of the Employee Handbook revealed the facility could take disciplinary action at their discretion for violations of facility policies, rules, and procedures, which included sleeping while on duty and failure to fulfill job requirements. Further review revealed the facility handbook listed six different courses of disciplinary action, which included verbal warning, written reprimand, imposed probation, disciplinary suspension, decision-making leave, and termination. However, there was no guideline, standard, or internal policy that directed which level of disciplinary action should be imposed when counseling/corrective action was warranted.

Interview with the Risk Manager and Medical Surgical Team Leader on 06/18/15 at 4:00 PM revealed even though incidents involving patient safety were required to generate an incident report and be investigated, incidents involving employee behavior did not generate an incident report and therefore, were not investigated, tracked, or trended, for patterns.

A review of the facility's Abuse and Neglect policy dated 02/10/14 revealed upon receiving a report of neglect, the facility was required to investigate the incident in accordance with policy and procedures and shall begin immediately upon the report of suspected neglect. The policy stated administrative staff would immediately remove the alleged perpetrator from work until the investigation is completed.

Review of RN #1's personnel file revealed the facility initially assigned RN #1 to care for patients in the Emergency Department (ED) after being hired on 07/14/14. Review of performance evaluations conducted by the ED Team Leader on 08/06/14, revealed RN #1 was identified to be in need of improvement in multiple areas of clinical practice. However, on 08/28/15, the ED Team Leader identified that RN #1 had failed to make satisfactory progress towards the identified needs, and determined that RN #1 lacked basic medical/surgical skills. On 08/31/14, RN #1 was transferred to the Medical/Surgical Unit on the night shift, and was to be provided an additional ninety (90) days in orientation. However, review of RN #1's schedule from 09/01/15 through 10/31/15 revealed she was only provided forty-five (45) days in orientation.

Review of a Human Resources Status Change Report dated 08/31/14, revealed RN #1 was transferred to the Medical Surgical Unit on 08/31/14, and was placed on the 7AM to 7PM shift. From January 2015 through June 2015, numerous reports were made to Hospital Administration regarding RN #1's lack of skills necessary for conducting basic nursing tasks, and numerous corrective actions were documented in her employee file. However, none of the corrective actions in the employee's file or the written communications detailing the actions of RN #1 was ever investigated to determine the root cause of the problems.

Continued review of RN#1's personnel file revealed Facility Administration was aware that medical providers and peers had reported concerns with RN #1 to Facility Administration on several occasions including making five (5) allegations of neglect. The allegations included sleeping while caring for patients, the RN's actions placing patients in imminent danger, leaving a patient's room during an emergency situation, and having to be redirected to return to the floor to care for patients to which she was assigned, failing to act on a critical laboratory report, and failing to administer a patient medication. However, the facility failed to recognize the reported incidents as allegations of potential neglect and therefore failed to follow their own established policies and procedures to ensure patients were protected from neglect.

Review of a Counseling and Corrective Action Documentation form revealed RN #1 continued to provide patient care until 06/05/15, when the RN was terminated for obtaining medication from the trash to reuse and not satisfactorily completing prior action plans.

Interview with the Medical/Surgical Team Leader on 06/18/15 at 4:00 PM revealed when it was determined an employee required disciplinary action she used her "best judgment" to determine action plans because there was no written criteria to follow.

Interview with the CEO on 06/17/15 at 6:25 PM revealed she was aware of all the incidents involving RN #1. The CEO stated she was concerned about the RN's behavior and she was always concerned with patient safety. The facility changed the RN's unit and shift assignments and provided additional training; however, the CEO stated she was aware of no patient harm related to RN #1's behavior, and therefore RN #1 was never removed from patient care.

Based on interview, record review, and review of e-mail correspondence, personnel files, and facility policy it was determined the facility failed to ensure that patients were free from neglect. The facility hired Registered Nurse (RN) #1 on 07/14/14 for the Emergency Department (ED). However, a review of the Performance Improvement Action Plan dated 08/28/14, revealed RN #1's orientation was terminated in the ED because the RN's "basic medical/surgical skills tend to be rusty if not lacking." However, RN #1 was transferred to the Medical/Surgical Unit and began work on that unit on 08/31/14. While on the Medical/Surgical Unit, staff reported five (5) allegations of neglect involving RN #1. The allegations included sleeping at the nurses' station; Hospitalist #1 voiced a concern that RN #1's lack of nursing judgment and skill placed patients in imminent danger, the RN did not know how to respond during an emergency situation, and the RN had to be directed to return to a patient care unit to provide care to patients to which she was assigned; a nurse peer reported RN #1 failed to respond to a patient's critically low blood sugar; and RN #1 failed to administer Insulin medication to Patient #9. However, the facility continued to place patients in the care of RN #1. On 06/02-03/15, at approximately 10:02 PM, RN #1 attempted to obtain an IV medication from the trash and administer it to Patient #3, until stopped by another nurse. However, the facility permitted RN #1 to continue to care for Patient #3 and four (4) additional patients. A short time later (exact time unknown), the medical provider caring for Patient #3 approached the House Supervisor and expressed concern about RN #1's "ability to care for the patients she (RN #1) was assigned." The facility continued to permit RN #1 to care for patients, and at approximately 1:40 AM, the provider caring for Patient #3 transferred the patient to the Intensive Care Unit due to the provider's concern that RN #1 was unable to care for Patient #3. However, the facility permitted RN #1 to continue to provide care for four (4) patients until the RN's shift ended on 04/03/15, at 7:00 AM (refer to A0145).

Based on interview, record review, and review of e-mail correspondence, personnel files, and facility policy it was determined the facility failed to ensure patients were free from neglect. Staff interviews, review of e-mail correspondence, and review of the personnel file for Registered Nurse (RN) #1 revealed the facility was aware that medical providers and peers had reported concerns with RN #1 to Facility Administration on several occasions regarding the care provided to patients, including making five (5) allegations of neglect. The allegations included sleeping at the nurses' station; Hospitalist #1 voiced a concern that RN #1's lack of nursing judgment and skill placed patients in imminent danger, the RN did not know how to respond during an emergency situation, and the RN had to be directed to return to a patient care unit to provide care to patients to which she was assigned; a nurse peer reported RN #1 failed to respond to a patient's critically low blood sugar; and RN #1 failed to administer Insulin medication to Patient #9. However, the facility continued to place patients in the care of RN #1. On 06/02-03/15, at approximately 10:02 PM, RN #1 attempted to obtain an IV medication from the trash and administer it to Patient #3, until stopped by another nurse. However, the facility permitted RN #1 to continue to care for Patient #3 and four (4) additional patients. A short time later (exact time unknown), the medical provider caring for Patient #3 approached the House Supervisor and expressed concern about RN #1's "ability to care for the patients she (RN #1) was assigned." The facility continued to permit RN #1 to care for patients, and at approximately 1:40 AM, the provider caring for Patient #3 transferred the patient to the Intensive Care Unit due to the provider's concern that RN #1 was unable to care for Patient #3. However, the facility permitted RN #1 to continue to provide care for four (4) patients until the RN's shift ended on 04/03/15, at 7:00 AM.

The findings include:

Review of the facility's policy, "Abuse and Neglect," dated 02/10/14, revealed facility staff was required to immediately report any suspicion of neglect to his/her supervisor, the Director of Nursing (DON) or the Administrator on call, and the immediate safety of the patient must be determined. The policy stated that the alleged associate suspected of the neglect would be removed from work until an investigation had been completed. The policy stated the investigation would be initiated immediately upon the report of the suspected neglect.

The facility hired RN #1 on 07/14/14, and she began working in the Emergency Department (ED) on 07/16/14. Review of a work performance evaluation dated 08/06/14, revealed RN #1 was unfamiliar with cardiac monitoring and had scored 43 percent (43%) on a pre-employment Dysrhythmia Test, which was determined to be unsatisfactory. The evaluation also identified that RN #1 "needs improvement" in ongoing competency in assessment, planning, and evaluating patient care; implementing professional standards of care for all patients; and demonstrating the ability to adequately prioritize patient care. Review of a subsequent Performance Improvement Action Plan dated 08/28/14, revealed RN #1 had not made satisfactory progress toward the identified needs, and the RN's orientation in the ED was terminated "immediately." The plan stated that RN #1's "basic medical/surgical skills tend to be rusty if not lacking," and that those skills were utilized to "build on" in the ED. The plan stated that RN #1 would be transferred to the Medical/Surgical Unit and would receive ninety (90) days of orientation.

Review of RN #1's employee file revealed RN #1 was transferred to the Medical Surgical Unit on 08/31/14, and placed on the night shift working 7PM until 7AM. Review of a Counseling and Corrective Action Documentation form dated 10/14/14, revealed on 10/12/14, RN #1 was observed to be sleeping on duty at the nurses' station.

Review of an e-mail dated 01/15/15 from Hospitalist #1 to the Chief Clinical Officer (CCO) revealed the provider voiced concerns with RN #1's "basic nursing skills." Further review of an e-mail from Hospitalist #1 to the CCO on 03/14/15, revealed the Hospitalist opened the communication by posing the question to the CCO, "Is it going to take a patient death under (RN #1's) care before she is disallowed to care for patients here?" The e-mail to the CCO reiterated the provider's concern that RN #1 "does not have basic nursing skills." The communication detailed specific events that occurred involving medications being administered to a patient being cared for by RN #1. The provider stated in the e-mail that RN #1 "is dangerous and cannot provide basic nursing skills. She (RN #1) has no nursing judgment and it is creating a tense environment because I do not want her to care for anyone with any intensity." The communication ended with the provider stating, "Please intervene before we have a sentinel event."

Review of a Memorandum written by the Unit Manager (undated) revealed on 03/15/15, RN #1's peer reported a concern that RN #1 had received a call from the lab regarding a patient's "critical glucose" level. However, the peer reported that RN #1's priority was not to treat the patient, and was concerned with RN #1's "questions on what to do for it [the critical glucose level]."

Review of an e-mail communication dated 03/24/15, from Hospitalist #1 to the CCO revealed that on 03/23/15, the provider was called to a patient who was in cardiac arrest and was being cared for by RN #1. The provider stated upon entering the room and asking RN #1 to provide basic information concerning the patient, RN #1 was "unable to respond" when the provider asked for the patient's name and clinical information. The provider stated RN #1 was "not able to function during the code," and after assisting with transfer and accompanying the patient to the Intensive Care Unit, RN #1 "had to be told to return to her patients on the floor."

Review of a Counseling and Corrective Action Documentation form for RN #1 dated 03/30/15, revealed on 03/29/15, RN #1 failed to administer insulin to Patient #9. The "employee comments" section of the form revealed RN #1 documented "coverage was one (1) unit." Interview on 06/18/15 at 4:00 PM with the Unit Manager who signed the Counseling and Corrective Action Documentation form, revealed that RN #1 documented on the form that "coverage was one (1) unit," to indicate that it was "no big deal" because the amount of insulin omitted was a small amount.

Review of an e-mail from the House Supervisor to the Unit Manager dated 06/04/15, and review of Patient #3's medical record revealed that during the 7PM to 7AM shift on 06/02-03/15, at approximately 10:02 PM, RN #1 was observed to obtain a discarded Intravenous (IV) medication from the trash and attempt to administer it to Patient #3. A peer who was present in the room stopped RN #1 from administering the medication. After RN #1 was instructed that she could not administer IV medications from a garbage can to a patient, RN #1 located Hospitalist #2 who was caring for Patient #3 and asked the provider about administering the medication to Patient #3 after obtaining it from the garbage can. The e-mail went on to state that Hospitalist #2 (exact time unknown) went to the House Supervisor and expressed concern about RN #1's ability to care for the "patients" she was assigned. The e-mail stated that at approximately 1:40 AM, Hospitalist #2 transferred Patient #3 to the ICU, because RN #1 had called the Hospitalist to report a blood pressure of 52. After the Hospitalist asked RN #1 if that was the systolic or diastolic number, RN #1 "did not know what systolic and diastolic blood pressure was." After Patient #3 was transferred to the ICU, the facility allowed RN #1 to continue to care for the remaining four (4) patients on the Medical/Surgical Unit until the end of RN #1's shift on 06/03/15 at 7:00AM.

Interview with the House Supervisor on 06/16/15 at 4:10 PM, revealed that if she encountered a problem while on duty she was required to report it to the Unit Manager or the Administrator on call for that shift. The House Supervisor stated Human Resources had instructed her that if an employee was "impaired or can't take care of patients" that she (the House Supervisor) could send the employee home. However, the House Supervisor stated she did not believe that RN #1 was "impaired" during the night shift on 06/02-03/15, and "did not feel like I had the authority to send her [RN #1] home." The House Supervisor stated that she did not contact the Unit Manager or the House Supervisor on 06/02-03/15, to report the concerns. The House Supervisor stated that after being sent to the ICU, Patient #3 was "no longer in danger" and that "none of the other patients had anything going on," so she did not feel that their health and safety would be jeopardized by RN #1.

Interviews on 06/18/15, from 11:45 AM until 4:40PM, with the Unit Manager, Risk Manager, and Interim CCO revealed they were aware of the incidents regarding poor care/lack of care that RN #1 provided to patients. The staff stated they permitted RN #1 to continue to provide care for patients and tried to help her after each incident. However, the facility management staff stated they never considered that the incidents involving RN #1 were neglectful.

Based on interview, record review, and review of e-mails, personnel files, and facility policy it was determined the facility failed to provide nursing services to ensure competent staff provided patient care. The facility initially assigned Registered Nurse (RN) #1 to care for patients in the Emergency Department (ED) after being hired on 07/14/14. On 08/28/14, the facility identified that RN #1 was unable to demonstrate the ability to handle more than one (1) or at the most, two (2) patients at a time, and the RN lacked basic medical/surgical skills. On 08/31/14, RN #1 was transferred to the Medical/Surgical Unit on the night shift, and was to be provided an additional ninety (90) days in orientation. However, the facility failed to ensure that RN #1 was provided the additional orientation. Furthermore, providers and peers identified and reported that RN #1 lacked the necessary skills for conducting basic nursing tasks and was described as being dangerous. In addition, RN#1 had numerous corrective actions documented in her employee file, which included the failure to administer Insulin to a patient with a diagnosis of Diabetes; however, the facility continued to allow RN #1 to provide patient care on a routine basis without recognition that the nurse's actions were likely to affect the health and safety of patients (refer to A0397 and A0405).

Based on interview, record review, and review of e-mails, personnel files, and facility policy it was determined the facility failed to ensure that the care of each patient was assigned to a qualified and competent staff member. The facility initially assigned Registered Nurse (RN) #1 to care for patients in the Emergency Department (ED) after being hired on 07/14/14, and was identified on 08/28/14, to be unable to demonstrate the ability to handle more than one (1) or at the most, two (2) patients at a time, and lacked basic medical/surgical skills. On 08/31/14, RN #1 was transferred to the Medical/Surgical Unit on the night shift, and was to be provided an additional ninety (90) days in orientation. However, the facility failed to ensure that RN #1 was provided the additional orientation. Although RN #1 was identified by providers and peers to lack the necessary skills for conducting basic nursing tasks, and had numerous corrective actions documented in her employee file, the facility continued to allow RN #1 to provide patient care on a routine basis without recognition that the nurse's actions were likely to affect the health and safety of patients.

The findings include:

Review of the facility's policy/procedure, "Competency of Staff," revised 04/14/14, revealed the job Description/Performance Evaluations served to define minimum competency requirements. The policy stated it would be the responsibility of the Team Leader/Department Manager to monitor the initial and ongoing competency of staff. The policy stated the Team Leader/Department Manager would utilize various sources in the identification of competency including random monitoring, patient complaints, and incident reports. The Team Leader was responsible for reviewing the individual staff competency file during each annual performance review and as issues concerning questionable staff competency arose. The policy stated that if employees were unable to satisfactorily respond to requirements, the Team Leader would develop a plan to restrict clinical assignments until competency was established.

Review of RN #1's employee file revealed the facility hired RN #1 on 07/14/14, and she began working in the facility's ED on 07/16/14. Review of an Initial Hire Performance Evaluation, dated 08/06/14, revealed RN #1 was unfamiliar with cardiac monitoring and had scored 43 percent (43%) on the pre-employment Dysrhythmia Test, which was determined to be unsatisfactory. The evaluation also identified RN #1 needed improvement in the areas of assessments, planning and evaluating patient care, implementing professional standards of care for all patients, and demonstrating the ability to adequately prioritize patient care. Review of the Performance Improvement Action Plan dated 08/06/14, developed for RN #1, revealed the action plan included completing the on-line arrhythmia course by 08/20/14, prior to beginning orientation on the night shift, and utilizing the orientation period to increase her exposure to caring for new types of patients. However, review of a Performance Improvement Action Plan dated 08/28/14, revealed RN #1 had not made satisfactory progress toward the goal of improvement in the identified areas, was unable to demonstrate the ability to handle more than one or two patients at a time, and lacked basic medical/surgical skills. The documented plan to address the identified concerns included stopping orientation in the ER immediately, and transferring RN #1 to the Medical/Surgical Unit. The plan also stated RN #1 would be provided a new ninety (90) day orientation period on the Medical/Surgical Unit.

Review of a Human Resources Status Change report dated 08/31/14, revealed RN #1 was transferred to the Medical/Surgical Unit on 08/31/14, and was scheduled to work the night shift (7PM-7AM). However, review of the Medical/Surgical Nursing Schedule for September and October 2014, revealed RN #1 was only provided forty-five (45) days orientation from 09/01/14 through 10/15/14.

An interview with the Medical/Surgical Team Leader on 06/17/15 at 2:00 PM revealed she was not aware RN #1 was required to receive ninety (90) days of orientation on the Medical/Surgical Unit.

Further review of RN #1's personnel file revealed a Counseling and Corrective Action Documentation form dated 10/14/14, which revealed that on 10/12/14, RN #1 was observed sleeping at the nurses' station. In addition, on 10/13/14, a patient's family member had voiced a complaint that RN #1 "did not have a good bedside manner and was condescending and was not friendly at all." Review of the Future Conduct or Performance Requirement section of the documentation revealed the actions to correct the unsatisfactory performance would be to have adequate rest before each shift, safely care for patients, and that RN #1 would be required to work three shifts during the day shift (7AM-7PM) and be re-evaluated by the Team Leader.

Interview with the Team Leader on 06/18/15, at 3:25 PM revealed that RN #1 was assigned to work the day shift with the Charge Nurse on 10/17/14, 10/21/14, and 10/22/14. The Team Leader stated that the Charge Nurse was required to monitor how RN #1 interacted with others. The Team Leader stated she did not require RN #1 to perform any special skills check or complete any specific action, stating, "My only concern was about her being sleepy." The Team Leader stated she wanted to ensure that RN #1 could stay awake, alert, and function for a twelve (12) hour shift. The Team Leader stated RN #1 displayed no problems during the three days she worked on the day shift, and was returned to the night shift with no specialized supervision or monitoring.

Continued review of RN #1's personnel file revealed on 03/14/15, a Peer Review form had been completed by a nursing peer, stating that RN #1 had left a Schedule II narcotic in the medication cart and, when discovered by the peer, RN #1 tried to return it to the medication count, but the medication had been partially wasted. The Peer Review form indicated that the Team Leader was notified of the incident, and documented that she talked with RN #1 on the phone regarding the incident, but did not take further action.

Further review of RN #1's personnel file revealed a memorandum (undated) written by the Team Leader. The memorandum stated on 03/14/15, Hospitalist #1 voiced concerns with RN #1's "basic nursing skills," and voiced complaints about RN #1's knowledge of medication and attempting to enter an order into the system, which would have resulted in a patient receiving an incorrect dosage of medication. The Memorandum also detailed a peer reporting that RN #1 had received a phone call from the laboratory reporting a patient's "critical glucose" level, but stated that RN #1's first priority was not to treat the patient's critical glucose level, and voiced concern with the questions RN #1 was asking related to how to address the patient's low glucose level.

Further review of the memorandum and review of an e-mail revealed on 03/24/15, Hospitalist #1 sent an e-mail to the Chief Clinical Officer (CCO), and copied the Team Leader, regarding concerns with RN #1. The documentation revealed on 03/23/15, Hospitalist #1 responded to a "Code Blue" (patient in cardiac/respiratory arrest) for a patient being cared for by RN #1. However, upon entering the room and asking RN #1 to provide basic information regarding the patient, the RN was unable to provide the Hospitalist with any information about the patient. The Hospitalist stated that RN #1 was "not able to function during the code" and after assisting with transfer of the patient to the Intensive Care Unit, "had to be told to return to her patients on the floor."

Review of a Performance Improvement Action Plan dated 03/26/15, completed by the Team Leader, revealed that in response to the incidents listed on the memorandum, RN #1 would be placed on the day shift beginning 04/01/15, and would remain until "further notice" and be assigned to complete "Echelon Courses" (a review of the body systems) in thirty (30) days. The plan stated failure to improve would result in further disciplinary action up to and including termination.

Review of a Counseling and Corrective Action Documentation form dated 03/30/15, revealed a peer had reported that RN #1 had failed to administer Patient #9 insulin at 1:00 AM on 03/29/15. The Conduct and performance review section revealed the action by which the employee could correct the unsatisfactory performance would be to "double check electronic medication administration records and know which patient has insulin and blood glucose checks."

Review of an electronic communication from the developer of the Echelon test to the facility dated 06/04/15, and referencing a conversation on 05/29/15, revealed the test developer was concerned about RN #1 "not passing the test and having the written material at hand." The test developer stated that RN #1 had skipped the introductions of one course and "went straight to the test," stating that this was concerning because "I would want to know that the nurse that was taking care of me knew her stuff."

Interview with the Team Leader on 06/18/15, at 3:25 PM, revealed when RN #1 was assigned to work the day shift during April 2015, the Team Leader assisted RN #1 when the employee voiced questions. The Team Leader stated RN #1 had "done good that month" and had no documented incidents. The Team Leader stated that RN #1 ultimately completed the assigned Echelon course, but only after special arrangements were made. The Team Leader explained that after "failing" the test required upon completing the course, it was discovered that RN #1 had obtained a copy of the test questions, and a specialized test had to be developed to administer to RN #1, which she passed. The Team Leader stated that RN #1 returned to the night shift without specialized supervision or monitoring on 05/01/15.

Review of electronic communication from the House Supervisor to the Team Leader dated 06/04/15, and review of Patient #3's medical record revealed on 06/02/15, at approximately 10:02 PM, RN #1 was observed to remove discarded intravenous medication from the trashcan of Patient #3's room and attempted to administer the medication to Patient #3. However, a peer instructed RN #1 that she could not do that, and notified the House Supervisor. The electronic communication revealed that after being instructed by the peer and House Supervisor that she could not administer discarded medications to patients, RN #1 located Hospitalist #2 who was caring for Patient #3 and asked the provider if the medication removed from the garbage could be administered to Patient #3. The communication stated that Hospitalist #2 located the House Supervisor and expressed concern about RN #1's ability to care for the "patients" she was assigned. However, RN #1 continued to care for patients. At approximately 1:40 AM, Hospitalist #2 contacted the House Supervisor and informed her that Patient #3 was being transferred to the ICU due to RN #1 reporting Patient #3 had a blood pressure of 52. The Hospitalist stated that after asking RN #1 if 52 was referring to the systolic or diastolic blood pressure, RN #1 did not know what the systolic and diastolic blood pressure meant. Although Patient #3 was transferred to the ICU to ensure the patient received adequate nursing care, RN #1 continued to care for the remaining four (4) patients on the Medical/Surgical Unit until the end of the shift at 7:00 AM on 06/03/15.

Review of a Counseling and Corrective Action Documentation form dated 06/05/15, revealed that RN #1 was terminated on 06/05/15, for obtaining medication from the trash to reuse and not satisfactorily completing prior action plans.

Interview with the Chief Clinical Officer (CCO) on 06/16/15 at 5:15 PM revealed his last day at the facility was 05/12/15. He stated he was aware of all the incidents documented in RN #1's employee file and had received the e-mails from Hospitalist #1 regarding concerns with RN #1's inability to provide safe patient care. He stated he discussed the incidents with the Team Leader, but left actions plans/disciplinary actions up to the Team Leader. He stated he did not conduct any follow-up to ensure the concerns were appropriately addressed and the Team Leader did not "get back" with him to discuss RN #1's progress.

An interview with the Education Coordinator on 06/18/15 at 2:25 PM revealed that once initial orientation was provided to an employee, it was up to the Team Leader to contact her to coordinate further education. The Education Coordinator stated she had arranged the Echelon courses for RN #1 to complete, but had not been contacted to do any other training/in-service education.

An interview with the Team Leader on 06/18/15 at 4:00 PM revealed when it was determined an employee required disciplinary action, she used her "best judgment" to determine action plans because there was no written criteria to follow.

Based on interview, record review, review of facility policies, and review of personnel files, it was determined the facility failed to ensure medications were administered in accordance with physician orders. On 03/29/15, Registered Nurse (RN) #1 failed to administer Patient #9's insulin (insulin injections are used to treat high blood sugar) at 1:00 AM.

The findings include:

Review of the facility's Medication Errors policy dated 04/14/14 revealed the purpose of the policy and procedure was to define a system for identifying, reporting, classifying, reviewing, and preventing medication errors. The policy stated that it is the responsibility of all health care providers in the clinical setting to detect and report medication errors. The policy defined specific types of medication errors, including omitting a medication, which is defined as the failure to administer an ordered dose to a patient. When a medication error occurred, the person who discovered the error was required to complete a "Medication Occurrence Report" or use the electronic "Risk Master" to report the error. The Pharmacy Director and Risk Manager then reviewed the error and action was taken based on the severity of the error.

Review of Patient #9's medical record revealed the facility admitted the patient on 03/20/15 with a diagnosis of Possible Pneumonia. According to the patient's medical record, the patient also had a diagnosis of Diabetes.

Review of Patient #9's physician orders revealed an order dated 03/26/15 to administer Insulin to the patient every four hours. The insulin dose was determined by the patient's blood sugar. According to the physician orders, staff was required to administer one unit of insulin if the patient's blood sugar was 150-199.

Review of Patient #9's Medication Administration Record (MAR) revealed on 03/29/15 at 1:00 AM, the patient had a "Missed dose" of insulin. The MAR revealed RN #1 was the nurse responsible for the patient's insulin.

Review of a Counseling and Corrective Action Documentation form for RN #1 dated 03/30/15, revealed on 03/29/15, RN #1 failed to administer Insulin to Patient #9. The "employee comments" section of the form revealed RN #1 documented "coverage was one (1) unit." Interview on 06/18/15 at 4:00 PM with the Unit Manager who signed the Counseling and Corrective Action Documentation form, revealed that RN #1 documented on the form that "coverage was one (1) unit," to indicate that it was "no big deal" because the amount of insulin omitted was a small amount.

Further review of the Counseling and Corrective Action form revealed the action by which the employee could correct the unsatisfactory performance would be to "double check electronic medication administration records and know which patient has insulin and blood glucose checks."

Interview with the Risk Manager and Medical/Surgical Team Leader on 06/18/15 at 4:00 PM revealed RN #1's peer completed a Hospital Associate Peer Review form when she discovered RN #1's medication error on 03/29/15, and submitted the form to the Medical/Surgical Team Leader who counseled the employee via phone. The Risk Manager and Team Leader had not identified that the facility's procedure for reporting medication errors was not followed and therefore an Incident Report was not generated.