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Based on record review and interview, the facility failed to ensure the Registered Nurse supervised and evaluated 1 of 4 (Patient #1) patient's care.

Findings:
Review of Patient #1's record revealed that on 1/23/11 at 1:30 PM "patient pulled [trache]out RT replaced with #7." On 1/24/11 at 11:35 PM "patient found with inner cannula dislodged and lying in bed. Oxygen sats 60%. Patient decannulated self in bilateral wrist restraints. Charge nurse & RT called stat. New #7 inserted and patient ambu to 100% oxygenation. Restraints refitted & will monitor closely." According to the 1/24/11, "RHC 24 HOUR PATIENT RECORD & PLAN OF CARE," the patient was seen every two hours from 8:00 AM to 12:00 AM. The patient's vital signs were taken at 1:00 AM, the patient had the G-tube flushed at 2:00 Am and 4:00 AM, The patient's vitals were taken again at 5:00 AM, and another G-tube flush occurred at 6:00 AM. Nursing Notes indicate an entry at 2:30 AM indicating medications provided and 6:00 AM for wound care of the G-tube insertion site. Review of the 1/22/11 "RHC 24 HOUR PATIENT RECORD & PLAN OF CARE", the patient was every two hours from 8 AM to 6 AM the next morning. On 1/31/11 at 11 PM the patient was transferred back to the acute care hospital s/p fall with decannulation of tracheotomy tube and respiratory arrest with code. Review of the "RHC 24 HOUR PATIENT RECORD & PLAN OF CARE," for 01/31/11 revealed the patient's vitals were taken at 8 AM, 12 noon, 6:00 PM, 9:30 PM, 10 PM and 10:30 PM. There is also documentation that the patient's Foley catheter was checked at 1:00 PM, 6:00 PM and 9:00 PM. Patient #1's record failed to indicate what the writer meant on 1/24/11 by "monitor closely".

Interview of the Risk Manager 2/4/11 at 2 PM stated that Patient #1 and Patient #4 have medical restraints. The nurses chart hourly for these patients. During these observations/assessments the nurse assesses for safety, comfort, mobility, skin integrity, food/hydration and toileting. The Certified Nurse Assistants also make rounds during this hour as well. The RM stated that the patients are actually observed more often than hourly. When asked for the CNA documentation it was noted that the CNA rounds are not documented.

Review of the facility's restraint policy and procedure revealed that on page 7 bullet four "2 hours or more often (observations every two hours for medical restraints and every 15 minutes for behavioral restraints)."

On 02/11/2011 at 9:30 AM the facility ' s Risk Manager was asked to provide any documentation of what the facility had done differently, for Patient #1, after the 1/24/11 entry to show the facility was monitoring closely. By noon on 02/14/11, the facility had not provided any documentation.