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Based on record review and staff interview it was determined that the facility failed to ensure the nursing staff complied with the plan of care for one (#3) of five patients selected for review.


Findings include:

Patient #3 was admitted to the facility on 2/12/11 with the chief complaint of severe back pain. The physician noted, in the History and Physical, that the patient had thoracic spinal fractures with neuralgia. Review of the physician's orders revealed that nursing staff were to perform neurological assessments twice every shift at the time of admission. Review of the medical record on 2/15/11 revealed that the neurological assessments were performed once per shift.

Interview with a staff nurse on 2/15/11 at approximately 10:00 a.m. confirmed the assessments were being performed only once each shift.

Based on record review and staff interview, it was determined that the facility failed to administer medication as ordered for one (#5) of five sampled patients. This practice may result in failure to achieve therapeutic goals.



Findings include:

Patient #5 was admitted to the facility on 11/11/10 with the chief complaint of chest pain and shortness of breath. The physician documented, in the History and Physical, the patient had a history of hypertension and cardiomyopathy. Review of the physician orders revealed the physician wrote an order for Coreg 3.125 twice daily on 11/11/10. Review of the Medication Administration Record revealed no evidence that the medication had been administered and no explanation as to why.

During an interview on 2/15/11 at approximately 9:30 a.m., the Director of Nursing confirmed there was no evidence that the medication had been administered.