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Based on observation, interview and record review, it was determined the facility failed to ensure drugs and biological were administered in accordance with the Physician's order for two (2) of thirty (30) sampled patients, (Patients #13 and #4). Patient #13's intravenous (IV) fluid was infused at one hundred and twenty-five (125) milliliters per hour; however, the Physician's order was for one hundred (100) milliliters per hour. Patient #4 was ordered a three (3) percent (%)potassium dialysate bath, but was being dialyzed on a four (4) % potassium dialysate bath.

The findings include:

1. Observation of Patient #13, on 12/12/12 at 9:10 AM, revealed Patient #13 was receiving his/her morning medications. Observation of the pump for the IV fluids was set for the patient to receive one hundred and twenty-five (125) milliliters (mls) of intravenous fluids (IVF) per hour.
Review of the clinical record revealed a Physician's order, dated 12/11/12, for Normal Saline to be administered at one hundred (100) ml per hour.

Interview with Licensed Practical Nurse (LPN) #1, on 12/12/12 at 9:20 PM, revealed she was the staff member assigned to patient #13. She stated the night nurse had changed the IVF at 12:37 AM to the ordered fluids, but had not changed the rate to the ordered rate. She stated she took over the care of Patient #13 at 7:00 AM but had not performed rounds on Patient #13 prior to giving his/her medications.

Interview with the Director of Quality Outcomes, on 12/14/12 at 11:00 AM, revealed the IVF running at the wrong rate was a medication error and an incident report should have been completed. She stated some units did rounds on their patients when they took over their care, but it was a "hit and miss" in the mornings.

Interview with the Charge Nurse, Registered Nurse (RN) #4, on 12/14/12 at 11:40 AM, revealed when the assignment sheet was made and a LPN was given an assignment, an RN was given one room of the LPN's. The RN was responsible for the care plan, flushing the PICC line or Mediport, ensuring wound and dietary were consulted as needed, etc.

2. Observation of Patient #4 during a hemodialysis treatment, on 12/12/12 at 2:20 PM, revealed Patient #4 was lying in bed, remaining time to dialyses was one hour and twenty-two minutes, the ultrafiltration rate was fifty (50) mls, the ultrafiltration goal was eleven hundred (1100) mls and the dialysate flow of potassium two (2) percent and five (5) percent calcium dialysate bath.

Review of the Physician's dialysis orders for 12/12/12 revealed an order for Patient #4 to be administered three (3) percent potassium and two point five (2.5) percent calcium dialysate bath.

Interview with the Hemodialysis Charge Nurse, RN #2, on 12/12/12 at 3:15 PM, revealed Patient #4 had thirty-six (36) minutes left to dialyze and had been running on the wrong bath. She stated she was going to notify the Physician, draw labs and fill out an incident report. She stated the dialysis unit did not have another nurse or technician check the setting on the machine prior to initiating treatment.

Interview with RN #3, on 12/12/12 at 3:30 PM, revealed she had put Patient #4 on the dialysis machine and stated someone had called her away to another patient and she thought she had finished with Patient #4.

Based on record review and interview, it was determined the facility failed to ensure a discharge summary was completed no later than 30 (thirty) days after discharge for 1 (one) out of 36 (thirty-six) sampled patients (#29).

The findings include:

Review of the closed medical record revealed the facility admitted Patient #29, on 10/28/12, with diagnoses of Gastrointestinal Bleeding and Diverticulitis. Further record review revealed Patient #29 was discharged on 10/31/12. Additional record review on 12/14/12 revealed a discharge summary had not been completed, 44 (forty-four) days after discharge.

Interview on 12/14/12 at 11:20 AM with Director of Medical Records confirmed a discharge summary was not completed on Patient #29. The Director explained the facility used electronic charting (Epic) and the system should have sent the discharge summary to the discharging physician to complete. She stated, instead, Epic sent discharge summary to file awaiting for a physician to be assigned. The director further stated all charts are reviewed for completeness when discharged. The Director stated this chart was "missed" but discharge summary had already been sent to the physician to complete.

Based on observation, interview and review of the facility's policy, it was determined the facility failed to ensure safe food handling practices were followed. Dietary staff were observed to take a drink from an open cup while working on the food tray line.

The findings include:

Review of the facility's policy titled "Food Service Department Policy and Procedure; Dietary Employee Health and Practices", revised on 09/21/08, revealed employees should eat, drink, or use tobacco only in designated areas.

Observation, on 12/13/12 at 11:00 AM, revealed Dietary Staff #1 took a drink from a personal cup containing ice while working on the patient tray line.

Interview with Dietary Staff (DS) #1, on 12/13/12 at 2:25 PM, revealed she was not supposed to have a personal drink while working on the patient food tray line. DS #1 stated she had a she was eating ice from and was not in a designated area when she took the last piece of ice into her mouth prior to throwing the cup away. Interview further revealed the staff had "drink stations" where they were allowed personal beverages as long as the cup had a lid.

Interview with the Dietary Manager (DM), on 12/13/12 at 11:05 AM, revealed the employee should not have been drinking from a personal cup while performing duties on the patient tray line. The DM stated the Food Tray Line was not a designated area for personal drinks and staff had "drink stations" or a designated area where the staff could store and consume personal beverages which had a lid.