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Based on review of the medical record, staff interview and review of facility policy and procedures it was determined the facility failed to ensure a registered nurse supervised and evaluated the nursing care for two (#1 & #4) of eleven patients sampled.

Findings included:

1. Review of the medical record for patient #1 revealed the patient was admitted to the facility on 3/7/2016. Review of the nursing admission assessment dated 3/7/2016 at 5:00 p.m. revealed the patient had a history of type II Diabetes and hypertension.

A nutritional screening was completed by the RN (Registered Nurse) at the time of the admission assessment that revealed a score of zero. Review of the RN documentation revealed the patient was ordered a NCS (No Concentrated Sweets) diet. An NCS diet eliminates all sources of simple carbohydrates and refined sugars from a regular diet.

Review of the nutritional screening revealed a point system used to evaluate the need for a nutritional consult. The form stated if a score of 5 or more was accumulated the nurse was to inform the physician so that a nutritional consult can be ordered. Review of the screening tools revealed the patient should have scored 5 points for having a history of Diabetes Mellitus, type II; 5 points for the appearance of being overweight (patient was noted to be 5' 7" and weighed 236 pounds at the time of admission); 3 points for having a therapeutic diet order; 2 points for a history of hypertension; and 3 points for chemical/alcohol dependency/substance abuse (patient was noted to have a long history of drug abuse at the time of admission). The total score was 18. This score met the criteria to inform the physician so a nutritional consult could be ordered. Review of the record revealed there was no nutritional consult ordered and the dietician did not assess the patient at any time during the admission.

2. Review of medical record for patient #1 revealed on 3/7/2016 the physician ordered nursing to monitor the patient's blood glucose AC/HS (before meals and at the hour of sleep). Review of the nursing documentation revealed nursing failed to monitor the patient's blood glucose on two occasions: on 3/8/2016 at the hour of sleep and on 3/9/2016 before lunch. Review of the record revealed no nursing documentation for not monitoring the patient's blood glucose on 3/8 or 3/9.

3. Review of the medical record for patient #1 revealed a nursing admission assessment was completed on 3/7/2016 at 5:00 p.m. Review of the RN (Registered Nurse) admission skin assessment revealed the patient's skin was normal for ethnicity with a few scars noted and documented.

Review of the physician progress note dated 3/10/2016 at 9:50 a.m. stated the patient had a boil on her leg since yesterday. The physician described it as an abscess to the right groin, closed with no drainage. He noted the patient had a history of these before that required I&D (Incision & Drainage).

Review of the physician orders dated 3/10/2016 at 12:21 p.m. revealed the physician ordered warm compress to the abscess to the right groin twice daily and once the abscess started draining to apply bactroban ointment to the open area twice daily and keep covered with a Band-Aid.

Review of the MAR revealed on 3/10/2016 at 9:00 p.m. the RN documented a warm compress was provided and bactroban ointment was applied. Review of the nursing documentation revealed no nursing assessment of the abscess or a description of the right groin area.

Based on review of the nursing documentation it could not be determined if the area had opened up and started to drain and if a Band-Aid was applied.

An interview was conducted with the CNO (Chief Nursing Officer) on 4/21/2016 at approximately 3:45 p.m. at which time she reviewed the medical record and confirmed the above findings.

4. Review of the medical record for patient #4 revealed the patient was admitted on 4/12/2016. Review of the nursing documentation revealed on 4/15/2016 and 4/16/2016 there was no nursing assessment of the patient.

Review of the facility policy, "Initial Nursing Assessment & Reassessment", last revised 5/2014, under the section titled pain management, stated to administer and monitor pharmacological agents as ordered in the medical plan; and base adjustments in dose and frequency on reassessment of pain relief and the physician's orders.

Review of the facility policy, "Medication Administration: General Guidelines", last reviewed 10/2015, stated when administering PRN (as needed) medication, documentation on the PRN flow sheet will include medication given, reason, instructions to the patient, and patient response.

Review of the MAR (Medication Administration Record) for patient #4 revealed the patient was administered Xanax 1 mg by mouth on 4/15/2016 at 6:35 a.m., 4/17/2016 at 12:40 p.m. and 7:30 p.m. The patient was administered Flexeril 10 mg by mouth on 4/14/2016 at 3:20 p.m. and on 4/17/2016 at 8:50 p.m. The patient was administered Zofran 4 mg by mouth on 4/16/2016 at 10:30 a.m. and 4/17/2016 at 8:50 p.m.

Review of the patient flow sheets for 4/14/2016, 4/15/2016, 4/16/2017 and 4/17/2016 revealed no documentation of the reason the prn medication was administered, instructions to the patient, patient response to the medication or if the patient's pain improved.

An interview was conducted with the CNO on 4/22/2016 at approximately 1:15 p.m. at which time she reviewed the medical record and confirmed the above findings.

Based on review of the medical record, staff interview and review of facility policy and procedures it was determined the facility failed to ensure the nursing staff kept the nursing care plan current for each patient for two (#1, #4) of eleven patients sampled.

Findings included:

Review of the facility policy "Initial Nursing Assessment & Reassessment", last revised 5/2014, stated upon completion of the initial nursing assessment, a nursing prioritized initial plan of care will be developed in consultation with the patient/significant other; any change in the patient's condition shall require an immediate reassessment with changes in the plan of care reflecting the change in condition and portions of the initial assessment form include screening information related to other disciplines. Based on the outcome of the screening data, other disciplines will be contacted to perform a more comprehensive assessment of the patient as needed. This data shall be used by the multidisciplinary teams to establish the information necessary to provide the most comprehensive plan of care for the patient.

1. Review of the medical record for patient #1 revealed the patient was admitted on 3/7/2016. Documentation on the intake screening and nursing admission assessment dated 3/7/2016 revealed the patient had a history of hypertension (high blood pressure) and diabetes.

A nutritional screening was completed by the RN (Registered Nurse) at the time of the admission assessment, which revealed a score of zero (0). Review of the nutritional screening revealed a point system was used to evaluate the need for a nutritional consult.

The form stated if a score of 5 or more was accumulated the nurse was to inform the physician so that a nutritional consult can be ordered. Review of the screening tools revealed the patient should have scored 5 points for having a history of Diabetes Mellitus, type II; 5 points for the appearance of being overweight (patient was noted to be 5' 7" and weighed 236 pounds at the time of admission); 3 points for having a therapeutic diet order; 2 points for a history of hypertension and 3 points for chemical/alcohol dependency/substance abuse (patient was noted to have a long history of drug abuse at the time of admission). The total score was 18.

This score met the criteria to inform the physician so that a nutritional consult could be ordered. Review of the record revealed there was no nutritional consult ordered. The dietician did not assess the patient at any time during the admission.

Review of the prioritized initial plan of care, developed by the RN (Registered Nurse) on 3/7/2016, revealed the first prioritized problem was diabetes. The goals identified included the patient would verbalize an understanding of dietary restrictions associated with diabetes; identify medical complications associated with diabetes and demonstrate correct usage of blood sugar monitoring device by discharge.

Review of the medical record revealed the patient had consistently high blood glucose readings, reaching as high as 440, on 3/7/2016, 3/8/2016, 3/9/2016 and 3/10/2016. Review of the record revealed the physician was contacted on 3/7/2016, 3/8/2016 and 3/9/2016 for blood glucose results of >400. On each day the physician ordered insulin coverage outside the insulin sliding scale coverage.

Review of the record revealed the physician changed the standard insulin sliding scale coverage on 3/10/2016 to the customized sliding scale coverage. Review of the patient's plan of care revealed no evidence the plan of care was reviewed and updated to reflect the patient's change in condition.

2. Review of the medical record for patient #4 revealed the patient was admitted on 4/12/2016. Review of the intake screening and nursing admission assessment dated 4/12/2016 revealed the patient had a history that included seizures.

Documentation revealed the patient was on psychotropic medications and anti-seizure medications at home. The patient confirmed she had not taken the medications in a few days and admitted to smoking amphetamines.

Review of the record revealed the RN initiated the initial treatment plan on 4/12/2016 at 8:55 p.m. The RN identified two problems on the treatment plan. The first problem was detox issues and the second problem was risk for seizures. The goal for the identified problems was the patient would be compliant with medication administration. Documentation revealed the patient was placed on suicide and seizure precautions.

Review of the record revealed on 4/13/2016 at 12:50 p.m the patient was noted to be sitting on the patio bench and then was found lying on the ground. The RN assessed the patient. Documentation revealed the patient was transferred to the hospital for further evaluation. Nursing documentation revealed the patient returned to the facility at 5:14 p.m.

Review of the IDT (Interdisciplinary Team) Treatment Plan dated 4/14/2016 at 9:44 a.m. revealed substance abuse and depression were added to the patient's treatment plan. Review of the treatment plan revealed no evidence the identified problem of Risk for Seizures was reassessed or the goal or interventions were changed to reflect the patient's unwitnessed seizure activity on 4/13/2016.

Review of the medical record revealed on 4/14/2016 at 3:20 p.m. the patient was administered physician ordered Flexeril. The Flexeril was prescribed for severe muscle cramps prn (as needed). Review of the MAR (Medication Administration Record) revealed the patient received Flexeril on 4/17/2016 at 8:50 p.m. Review of the nursing notes revealed no description of the signs and symptoms the patient was experiencing that required the administration of the Flexeril and no documentation if the medication was effective.

Review of the MAR revealed the patient received Xanax on 4/15/2016 at 6:35 a., 4/16/2016 at 7:43 p.m., 4/17/2016 at 12:40 p.m. and 7:30 p.m. and 4/18/2016 at 6:00 a.m., 12:00 p.m. and 6:15 p.m. Review of the physician orders revealed the Xanax was prescribed for anxiety prn. Review of the nursing notes revealed no description of the signs and symptoms the patient was experiencing that required the administration of the Xanax and no documentation if the medication was effective.

Review of the MAR revealed the patient received Zofran on 4/16/2016 at 10:30 a.m. and 4/17/2016 at 8:50 p.m. Review of the physician orders revealed the Zofran was prescribed for nausea prn. Review of the nursing notes revealed no description of the signs and symptoms the patient was experiencing that required the administration of the Zofran and no documentation if the medication was effective.

Review of the nursing documentation revealed on 4/17/2016 at 8:26 a.m. the patient reported pain in her neck. She stated the pain was the result of tendonitis in her neck and back and this was a chronic issue. The patient reported the pain was a 4/10 on a scale of 1-10 with 10 being the worst possible pain. She stated her acceptable pain level was 4/10.

Review of the nursing documentation revealed on 4/21/2016 the patient sustained another seizure. Documentation revealed the patient was transferred to the hospital for possible loss of consciousness with head trauma and left hip pain. Nursing documentation revealed the patient returned to the facility the same day.

Review of the patient's plan of care revealed no evidence the plan had been reassessed after any of the above changes in the patient's condition.

An interview was conducted with the CNO (Chief Nursing Officer) on 4/22/2016 at approximately 1:15 p.m. at which time she reviewed the record and confirmed the findings.

Based on review of the medical record, staff interview and facility policy and procedures it was determined the facility failed to ensure medications were administered in accordance with the order of the practitioner for one (#1) of eleven patients sampled and failed to ensure the effect of pain medication administered for one (#4) of eleven patients sampled.

Findings included:

1. Review of the medical record for patient #1 revealed the patient was admitted to the facility on 3/7/2016. Documentation on the intake screening and nursing admission assessment revealed the patient had a history of hypertension (high blood pressure) and diabetes.

Review of the patient's home medications revealed the patient was taking three antihypertensive medications to control the hypertension. There were no medications documented for treatment of the patient's diabetes. Documentation revealed the patient reported additional home medications as a skeletal muscle relaxant, Baclofen 10 milligrams (mg) by mouth three times daily and an ophthalmic antibiotic, tobramycin ophthalmic drops 0.3%, one drop each eye four times daily.

Review of the medical record for patient #1 revealed on 3/7/2016 the physician ordered to continue Metoprolol 50 mg (milligrams) by mouth twice daily, Lisinopril 40 mg by mouth twice daily, Baclofen 10 mg by mouth three times daily and Tobramycin ophthalmic drops 0.3%, one (1) drop each eye four times daily.

Review of the MAR (Medication Administration Record) revealed the first dose of the prescribed medications were administered on 3/7/2016 at 9:00 p.m. Review of the MAR dated 3/8/2016 revealed the scheduled dose of Metoprolol, Lisinopril, Baclofen and Tobramycin ophthalmic drops were not administered at 9:00 p.m. There was no nursing documentation providing a reason for not administering the medications as ordered by the practitioner.

Review of the medical record revealed nursing documented on 3/8/2016 at 7:00 p.m. the patient's blood pressure was 170/88. Review of the physician orders revealed on 3/8/2016 at 12:15 p.m. an order for Clonidine 0.1 mg by mouth every 4 hours prn (as needed) was written. Clonidine is used to treat hypertension. The patient reported this was a regular home medication she took twice daily. Review of the MAR revealed the Clonidine was not administered as needed. Review of nursing documentation revealed on 3/9/2016 at 7:00 a.m. the patient's blood pressure remained elevated with a reading of 171/81. There was no documentation to determine the reason for not following the physician orders to administer the medications as prescribed.

An interview was conducted with the CNO (Chief Nursing Officer) on 4/21/2016 at approximately 3:45 p.m. at which time she reviewed the medical record and confirmed the above findings.

2. Review of the medical record for patient #4 revealed the patient was admitted on 4/12/2016.

Review of the record revealed the patient reported home medications that included two medications for seizures. The patient reported she had last taken her home medications two days prior to admission. She also reported she had been smoking amphetamines.

Review of the physician orders dated 4/12/2016 revealed the physician continued her home medications for seizures. The physician also ordered Xanax 1 mg by mouth every 6 hours prn (as needed) for anxiety, Flexeril 10 mg by mouth every 6 hours prn for severe muscle cramps and Zofran 4 mg by mouth every 6 hours prn for nausea.

Review of the MAR revealed the patient was administered Xanax 1 mg by mouth on 4/15/2016 at 6:35 a.m., 4/17/2016 at 12:40 p.m. and 7:30 p.m. The patient was administered Flexeril 10 mg by mouth on 4/14/2016 at 3:20 p.m. and on 4/17/2016 at 8:50 p.m. The patient was administered Zofran 4 mg by mouth on 4/16/2016 at 10:30 a.m. and 4/17/2016 at 8:50 p.m.

Review of the facility policy, "Medication Administration: General Guidelines", last reviewed 10/2015, stated procedure (42.0) when administering PRN medication, documentation on the PRN flow sheet will include medication given, reason, instructions to the patient, and patient response.

Review of the patient flow sheets for 4/14/2016, 4/15/2016, 4/16/2017 and 4/17/2016 revealed no documentation of the reason the prn medication was administered, instructions to the patient or patient response to the medication.