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Based on interviews and clinical records and policy review it was determined the Registered Nurse failed to supervise and evaluate nursing care related to assessments, coordination of care and providing care in accordance with physician's orders for 4 (#2, #3, #6, #8) of 10 sampled patients out of a census of 58 patients.

Findings include:

1. Patient #2's physician orders dated 6/1/14 at 1:42 a.m. instructed for vital signs every four hours, telemetry and for Carvedilol 12.5 mg (milligrams) orally every 12 hours hold for heart rate less than 60 and/or systolic blood pressure less than 100, Clonidine 0.1 mg orally every 8 hours hold systolic blood pressure less than 100 and Hydralazine 25 mg orally every eight hours hold systolic blood pressure less than 100.

Review of the Medication Administration Record (MAR) dated 6/2/14 revealed the Carvedilol was to be given at 9:00 a.m. and 10:00 p.m. with the noted instructions. Clonidine and Hydralazine was to be given at 6:00 a.m., 2:00 p.m. and 10:00 p.m. with the noted instruction. Review of the MAR, vital sign sheet and nursing documentation dated 6/2/14 revealed no evidence the heart rate and blood pressure were assessed as ordered at 9:00 a.m. and 10:00 p.m. with administration of the Carvedilol. There was no evidence of the blood pressure being assessed as ordered on 6/2/14 at 9:00 a.m., 1:39 p.m. or 10:00 p.m. with the administration of the Clonidine and Hydralazine.

Review of nursing documentation, MAR and vital sign sheet for 6/2/14 revealed the vital signs were assessed at 2:00 a.m., 6:00 a.m. and 10:00 a.m. Registered Nurse documentation dated 6/2/14 at 5:43 p.m. noted the vital signs were not done and were performed by other discipline at 6:00 p.m. There was no evidence of the vital signs being assessed every four hours as ordered after 10:00 a.m. on 6/2/14.

The findings of the failure of the vital signs being performed every four hours and prior to the medication administration were confirmed by the Risk Manager and Director of Education during record review on 7/29/14 at approximately 1:45 p.m.

Physician orders dated 6/1/14 at 1:42 a.m. revealed to keep the oxygenation level at 88-92%. Review of respiratory therapy documentation dated 6/2/14 noted at 7:30 a.m. and 11:20 a.m. the oxygen saturation was 90% on 65% oxygen. At 3:20 p.m. the oxygenation was 90% on 65% oxygen. Respiratory therapy documentation at 8:00 p.m. noted oxygenation at 85% on 90% oxygen. At 9:00 p.m. the oxygen remained at 90%. At 10:00 p.m. the oxygenation was 88% on 90% oxygen. Review of telemetry documentation revealed at 11:10 p.m. the heart rate was 48. There was no evidence the nurse assessed the patient for the decreased oxygenation or decreased heart rate.

Nursing assessment dated 6/2/14 at 9:45 p.m. revealed no change in condition for the increased need in oxygen from the 6/2/14 assessment at 1:41 a.m., approximately 20 hours prior. There was no evidence of an assessment being performed on the 7:00 a.m. to 7:00 p.m. shift on 6/2/14.

The failure of the registered nurse to assess the patient that required the oxygen level to be increased from 65% to 90%, decreased heart rate and perform shift assessment was confirmed by the Risk Manager and Director of Education during record review on 7/29/14 at approximately 1:45 p.m.

2. Patient #3's nursing assessments dated 7/22/14 revealed no nursing assessments was conducted on the 7/22/14 on the 7:00 a.m. to 7:00 p.m. shift.

Interview with the Risk Manager on 7/28/14 at approximately 2:30 p.m. confirmed the findings.

3. Patient #6's Nursing Shift Assessments revealed no evidence of a reassessment on 6/26/14 for the 7:00 a.m.-7:00 p.m. shift, 7/6/14 for the 7:00 p.m.-7:00 a.m. shift and 7/21/14 and 7/22/14 for the 7:00 p.m.-7:00 a.m. shift.

The Chief Clinical Officer (CCO) confirmed the findings at the time of the record review on 7/29/14 at approximately 10:15 a.m.

4. Patient #8's Nursing Shift Assessments revealed no evidence of a nursing reassessment on 6/6/14 for the 7:00 p.m. 7:00 a.m. shift.

The CCO confirmed the findings at the time of the record review on 7/29/14 at approximately 10:15 a.m.

Review of Policy and Procedure "Assessment/Reassessment" #H-PC 04-009 PRO dated 2/14 page two revealed patients are reassessed at a minimum of every 12 hour shift. Interview with the Chief Clinical Officer on 7/29/14 at approximately 11:20 a.m. revealed every 12 shift reassessment can be anytime during the shift not necessarily every 12 hour but that was preferred.