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Based on clinical record review, policy and procedure review and interview, it was determined a RN (Registered Nurse) failed to supervise and evaluate the nursing care for 9 (#1-#7, #9-#10) of 10 patients in that patients were not turned per Facility protocol, daily weights were not performed, baths were not performed and supplements were not given as ordered. Failure to ensure nursing care was rendered per protocol and per physician's orders had the potential for development of nosocomial infections, skin breakdown and unknown weight loss/gain. The failed practice affected Patients #1-#7, #9-#10. Findings follow:

A. During an interview with the Medical Surgical Charge Nurse at 0945 on 10/29/15 she stated the Skin Care Prevention Protocol was instituted when a Braden Scale Score reached 18 or less measures were instituted to prevent skin breakdown. Those measures included turning the patient every two hours if unable to turn self, nutritional assessments by Dietary, daily weights and clean and dry skin.

B. Review of the Nursing Policy and Procedure titled "Bed Bath-Complete" received from the Chief Nursing Officer (CNO) at 0800 on 10/28/15 revealed the following under Policy: The patient will obtain a bath daily and as needed, unless refused by the patient and/or family.
... D. Clinical Record
1) Document in Nursing Flow Sheet
2) Document reason when bath refused and notify Charge Nurse
3) Document Skin Assessment

C. Review of the clinical record of Patient #1 revealed a Braden score of 12 on the day shift and 12 on the night shift on 10/27/15. There was no documentation on 10/27/15 Patient #1 was turned every two hours or was able to turn themselves. During an interview with the Director of Education at 1352 on 10/28/15 she verified the above findings.

D. Review of the clinical record of Patient #2 revealed a Braden score of 18 on the night shift on 10/27/15. There was no documentation on 10/27/15 Patient #2 was turned every two hours or was able to turn themselves. During an interview with the Director of Education at 1338 on 10/28/15 she verified the above findings.

E. Review of the clinical record of Patient #3 revealed a Braden score of 14 on the night shift on 10/26/15, 14 on the day shift 10/27/15. There was no documentation on 10/26/15 and day shift on 10/28/15 Patient #3 was turned every two hours or was able to turn themselves. Physician's orders written at 1454 on 10/27/15 revealed orders for Glucerna one can three times a day. Review of the clinical record revealed Patient #3 did not receive the Glucerna on 10/27/15. During an interview with the Director of Education at 1545 on 10/28/15 she verified the above findings.

F. Review of the clinical record of Patient #4 revealed physician orders written at 2102 on 10/23/15 for beside Accucheck every six hours and at 1440 on 10/24/15 for a daily dressing change to a sacral decubitus. Review of the clinical record revealed no documentation the dressing change was performed on 10/27 and no documentation the Accuchek was performed at supper on 10/24/15. Review of the Braden Scores revealed scores 14 or less during the entire admission which meant daily weights should have been obtained by the nursing staff. There was no documentation of weights from 10/24/15 through 10/27/15. During an interview with the Director of Education at 1432 on 10/28/15 she verified the above findings.

G. Review of the clinical record of Patient #5 revealed a Braden score of 18 on both shifts on 10/23/15 and on the day shift on 10/24/15 and 10/27/15. There was no documentation Patient #5 was turned every two hours or was able to turn themselves on those shifts. Review of the clinical record revealed Patient #5 was weighed on 10/23/15 and weighed 90 pounds. There were no other weights documented. During an interview with the Director of Education at 1506 on 10/28/15 she verified the above findings.

H. Review of the clinical record of Patient #6 revealed Braden score of 18 on the day and night shift on 08/20/15, 16 and 12 on 08/31/15 and 13 on the day shift on 09/01/15. Review of the clinical record revealed no documentation Patient #6 was turned every two hours on 08/31/15 and 09/01/15 or that patient was able to turn themselves. Review of the clinical record revealed no documentation Patient #6 received a bath or refused one on 08/30/15. During an interview with the Director of Education at 0957 on 10/28/15 she verified the above findings.

I. Review of the clinical record of Patient #7 revealed a Braden score of 18 on the night shift on 08/29/15, 17 on the day shift, no documentation of the Braden score on the night shift on 08/30/15, 16 on the night shift on 08/31/15, 17 on the day shift and 18 on the night shift on 09/01/15 and 18 on the day shift on 09/02/15. Review of the clinical record revealed no documentation Patient #7 was turned every two hours or was able to turn himself on any of the above shifts. Review of the clinical record revealed no documentation Patient #7 received a bath on 08/29/15, 08/30/15 and 08/31/15. Review of physician orders revealed Ensure 1 can three times a day was ordered at 2200 on 08/28/15. Review of the clinical record revealed Patient #7 received one of three cans on 08/29/15 and two of three cans on 08/30/15. During an interview with the Director of Education at 1043 on 10/28/15 she verified the above findings.

J. Review of the clinical record of Patient #9 revealed a Braden score of 18 on the day shift on 08/26/15, 17 on the day shift on 08/27/15 and 18 on the day shift on 08/28/15. Review of the clinical record revealed no documentation Patient #9 was turned every two hours or was able to turn herself on any of the above shifts. Review of the clinical record revealed no documentation Patient #9 received or refused a bath from 08/25/15 through 08/28/15. During an interview with the CNO at 1150 on 10/28/15 she verified the above findings.

K. Review of Patient #10's clinical record revealed a Braden score of 15 on the day shift and 17 on the night shift on 08/25/15, 14 on both shifts on 08/26/15 and 14 on 08/27/15. Review of the clinical record revealed no documentation Patient #10 was turned every two hours or was able to turn themselves from 0535 to 1747 on 08/26/15 and from 0800 till 1925 on 08/27/15. Review of the clinical record revealed no documentation of weights on 08/26/15 and 08/27/15. During an interview with the Director of Education at 1245 on 10/28/15 she verified the above findings.




2

Based on interview, review of orientation documents, personnel files, policy and procedure and staffing schedules, it was determined the Facility failed to ensure three of three Agency nurses were oriented, trained and skills evaluated according to Facility policy and procedure. Failure to ensure each Agency nurse received orientation, training and skills evaluation did not allow the Facility to ensure each nurse was knowledgeable and skilled to render the necessary care to assigned patients. The failed practice affected Patient #1, #2, #7 and #9. Findings follow:

A. During an interview conducted with RN (Registered Nurse) #1 at 0830 on 10/29/15 he stated he had a couple days of orientation and then had 3-4 days with a preceptor (RN #4).

B. Review of "Education Orientation Sign In August 17, 2015 Agency Nurses" received from the Director of Education at 1215 on 10/29/15 revealed the two day EMR (electronic medical record)/Education Schedule for August 17th and 18th. The topics were policy and procedure, tests, Care learning for the 17th and EMR training, tour of the hospital and finish care learning for the 18th. During an interview with the Director of Education at 1215 on 10/29/15 she verified the above findings.

C. Review of RN #1, #2 and #7's personnel files revealed each attended a two day orientation on 08/17/15 and 08/18/15. During an interview with the Director of Education at 1215 on 10/29/15 she verified the above findings. Review of the personnel files did not reveal a completed skills evaluation/check off form. During an interview with the Director of Education at 1215 on 10/29/15 she verified the above findings.

D. Review of the policy and procedure titled Nursing Orientation received from the Director of Education at 1245 on 10/29/15 revealed the following:
POLICY:
Nursing orientation will be provided for each employee. Each nursing employee will attend Hospital and Nursing Orientation. The nursing employee will be schedule to work a nurse preceptor for 4 to 6 weeks, depending on the nurse's experience and capabilities.
II. The Orientation Skills Checklist:
1. Having this form completed is the responsibility of the new employees. Fill in the date you participated in or watched a procedure being done. The nurse that observed will write her initials also.
2. This form is to be completed by the end of the orientation period and returned to Nursing Administration to be placed in the employee's file.
3. The orientation period will not be considered completed until this checklist is completed, CPR (cardiopulmonary resuscitation) is current, care learning is completed and the Employee Health Exam is completed. It is the responsibility of the nursing employee to get this information to Nursing Administration and to keep it current. ...

E. Review of the staffing scheduled revealed RN #1 was oriented by RN #4 on 08/19/15 and 08/20/15 on the day shift and per the schedule was no longer on orientation on 08/24/15; RN #2 was oriented by RN #5 on 08/20/15 and by RN #6 on 08/21/15 on the night shift and per the schedule was no longer on orientation on 08/22/15. During an interview with the Chief Nursing Officer at 1200 on 10/29/15 she verified the above findings.

F. During an interview with the CNO at 1200 on 10/29/15 she stated Agency nurses were to have the same orientation as employee nurses.