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Based on policy and procedure review, crash cart check document review and interview, it was determined the Registered Nurse failed to check the crash cart daily. Failure to check the crash cart daily had the potential for staff to be unaware of non-working equipment in the event of a patient cardiac or other emergency. The failed practice likelihood to affect all in-patients on 12/31/15. Findings follow:

A. Review of the policy and procedure titled "Crash Cart" received from the Nurse Manager at 0815 on 12/31/15 revealed the following under "POLICY: The crash carts are to be checked and documented daily by the Registered Nurse (RN). ..."

B. Review of the crash cart check documents from September 2, 2015, through December 30, 2015 revealed the crash cart was not checked per policy on the following days: Nine (09/06/15, 09/11/15, 09/12/15, 09/15/15, 09/16/15, 09/18/15 through 09/20/15, and 09/30/15) of 30 days in September; six (10/05/15, 10/15/15, 10/16/15, 10/19/15, 10/21/151 and 10/22/15) of 31 days in October; three (11/04/15, 11/06/15 and 11/14/15) of 30 days in November; and two (12/23/15 and 12/24/15) of 30 (12/01/15 through 12/30/15) days of December.

C. During an interview with the Nurse Manager at 1200 on 12/31/15 he verified the findings in A and B.



Based on policy and procedure review, clinical record review and interview, it was determined the Facility failed to meet the needs of eight (#2, #4-10) of ten (#1-10) patients in that intake and output (I & O), IV (intravenous) assessments, CBGs (capillary blood glucose) and daily weights were not performed as ordered. The failed practices did not ensure accurate assessments were performed for the determination of medications and amounts, fluids, and IV site condition as well as contributing to the potential of prolonging patient discharge. The failed practice affected Patient #2 and Patients #4-10. Findings follow:

A. Review of the policy and procedure titled "Charting Guidelines" received from the Nurse Manager at 1020 on 12/30/15 revealed the following under "POLICY: ... #30. Chart actual intake, output and vital signs in appropriate places. ...#40. Chart CBG results on Diabetic Flow sheet and MAR (medication administration record)."

B. Review of the policy and procedure titled "Checking IV Sites" received from the Nurse Manager at 1105 on 12/30/15 revealed the following under "POLICY: It is the policy of MERCY HOSPITAL WALDRON that all IV sites will be checked by a Registered Nurse or Licensed Practical Nurse at least twice per shift for signs of phlebitis, infiltration, or infection and documented in patient's medical record." Under "DOCUMENTATION: IV site checks are to be charted at least twice a shift. Pediatric IV sites should be checked and charted on hourly."

B. Review of Patient #2's clinical record revealed an admission date of 12/28/15 and orders for I & O and notify MD (Medical Doctor) if urine output was less than 240 mls (milliliters) in 8 hours. Review of the clinical record revealed no documentation of I & O from admission to time of clinical record review. Review of the clinical record revealed Patient #2 had IV access and did not have twice per shift assessments of the IV site on 12/29/15 am and pm (ante-meridian and post-meridian) shifts. The findings were verified by the Nurse Manager at 1334 on 12/30/15.

C. Review of Patient #4's clinical record revealed an admission date of 12/26/15 and orders for CBGs ac and hs (before meals and hour of sleep), and Lantus Insulin 15 U (units) SQ (subcutaneously) daily before breakfast. Review of the clinical record revealed no documentation a CBG was performed prior to breakfast and lunch on 12/28/15 and no documentation the Lantus Insulin was given on 12/28/15 through 12/30/15. There was no documentation the physician was called on 12/28/15 or 12/30/15 regarding the withheld Lantus Insulin. Review of the clinical record revealed Patient #4 had IV access and did not have twice per shift assessments on 12/17/15 am and pm shifts, 12/28/15 pm shift and 12/29/15 am and pm shifts. The findings were verified by the Nurse Manager at 1421 on 12/30/15.

D. Review of Patient #5's clinical record revealed an admission date of 11/16/15 and orders for CBGs ac and hs, daily weights, and I & O every four hours. Review of the clinical record revealed documentation of the CBG result at noon on 11/18/15 but documentation revealed 8 U Novolog Insulin was given. There was no documentation of daily weights and every four hour I & O on 11/17/15 and 11/18/15. The findings were verified by the Nurse Manager at 1550 on 12/30/15.

E. Review of Patient #6's clinical record revealed an admission date of 11/29/15 and orders for CBGs ac and hs. Review of the clinical record revealed no documentation a CBG was performed prior to supper on 12/1/15. Review of the clinical record revealed Patient #6 had IV access and did not have twice per shift assessments of the IV site on 11/29/15 and 11/30/15 pm shifts, 12/01/15 am and pm shifts. The findings were verified by the Nurse Manager at 0952 on 12/31/15.

F. Review of Patient #7's clinical record revealed an admission date of 12/01/15 and orders for I & O every 8 hours. Review of the clinical record revealed the I & Os were not documented every 8 hours. Review of the clinical record revealed Patient #7 had IV access and did not have twice per shift assessments of the IV site on 12/01/15 and 12/02/15 pm shifts. The findings were verified by the Nurse Manager at 1015 on12/31/15.

G. Review of Patient #8's clinical record revealed an admission date of 11/16/15 and orders for I & O every 8 hours. Review of the clinical record revealed the I & Os were not documented every 8 hours. Review of the clinical record revealed Patient #8 had IV access and did not have twice per shift assessments of the IV site on 11/16/15 pm shift. The findings were verified by the Nurse Manager at 1030 on 12/31/15.

H. Review of Patient #9's clinical record revealed an admission date of 11/23/15 and orders for daily weights beginning on 11/25/15. Review of the clinical record revealed no documented daily weights for 11/25/15, 11/26/15 and 11/27/15. Patient #9 had IV access and did not have twice per shift assessments of the IV site on 11/24/15 am and pm shifts, 11/25/15 pm shift and 11/26/15 am and pm shifts. The findings were verified by the Nurse Manager at 1045 on 12/31/15.

I. Review of Patient #10's clinical record revealed an admission date of 11/27/15 and orders for I & Os every 8 hours and notify MD if urine output was less than 240 mls per 8 hours. Review of the clinical record revealed the I & Os were not documented every eight hours. Patient #10 had IV access and did not have twice per shift assessments of the IV site on the 11/27/15 pm shift. The findings were verified by the Nurse Manager at 1104 12/31/15.

Based on policy and procedure review, clinical record review and interview, it was determined the Facility failed to follow its policy and procedure in that a Registered Nurse (RN) failed to assess three ( #4, 6 and #9) of ten (#1-10) patients every shift. The failed practice did not ensure the patient's health status/condition, needs and problems were identified and care planned accordingly. The failed practice affected Patients #4, #6 and #9. Findings follow:

A. Review of the policy and procedure titled "Charting Guidelines" received from the Nurse Manager at 1020 on 12/30/15 revealed the following under "POLICY: ... #4. A Registered Nurse will observe each patient at least once per shift and the observation shall be documented in the patient's medical record."
B. Review of the clinical record for Patient #4 revealed no documentation of a RN assessment on the day (7 am - 7 pm) (ante-meridian and post-meridian) shift on 12/27/15.
C. Review of the clinical record for Patient #6 revealed no documentation of a RN assessment on the night (7 pm -7 am) shift on 11/30/15.
D. Review of the clinical record for Patient #9 revealed no documentation of a RN assessment on the night shift on 11/24/15 and again on 11/25/15.
E. During an interview with the Nurse Manager at 1045 on 12/31/15 he verified the findings in A, B, C and D.

Based on clinical record review, policy and procedure review, and interview, it was determined the Facility failed to ensure a current and comprehensive nursing care plan was developed and implemented based on the patient's needs for three (#4, #6 and #8) ten (#1-10) patients. Failure to develop and maintain a current and comprehensive plan of care did not ensure the patients received optimum care to progress and be discharged. The failed practice affected Patient #4, #6 and #8. Findings follow:

A. Review of Patient #4's clinical record revealed admitting diagnoses of Chronic Renal Failure, Severe Thrush, Pacemaker insertion 10 days prior and not eating or drinking. Review of the nursing care plan revealed no interventions or goals geared towards any of the above diagnoses.
B. Review of Patient #6's clinical record revealed admitting diagnoses of Abdominal Pain, Diabetes Mellitus, Shortness of Breath, C-difficile and the resulting isolation. Review of the nursing care plan revealed no interventions or goals geared towards any of the above diagnoses.
C. Review of Patient #8's clinical record revealed admitting diagnoses of Cancer, Pain and Constipation. Review of the nursing care plan revealed no interventions or goals geared towards the Constipation diagnosis.
D. Review of the policy and procedure titled "Charting Guidelines" received from the Nurse Manager at 1020 on 12/30/15 revealed the following under "POLICY: ... #21. A written Care Plan must be developed for each patient. This is to be initiated at time of admission by the Registered Nurse. ... #38. Review Care Plan daily and update as needed."
E. During an interview with the Nurse Manager at 1030 on 12/31/15 he verified the findings in A, B, C and D.