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Based on observation, interview and record review the facility failed to ensure nursing assessed and developed a nursing plan of care in 1 of 2 patients reviewed for intravenous (IV) therapy (Patient #14).
This deficient practice had the likelihood to cause harm to all patients receiving intravenous therapy.
Findings include:
Review of a "Nurse's Note" dated 12/15/2013, 6:23 a.m. revealed Patient #14 was a 42 year old female who presented to the emergency room as a walk-in. Patient #14 had a history of bipolar disorder and presented with a diagnosis of a "Septic Joint-Right knee: Cellulitis." According to the "Nurse's Note" Patient #14 received an 18 gauge (IV -intravenous needle) to the right forearm prior to arrival to the emergency room. There was documentation of Patient #14 being awake, alert, oriented and obeys commands. At 7:00 a.m., there was documentation to "maintain field IV. Dressing intact. Good blood return noted. Site clean and dry. Gauge and site: "18 gauge to right FA." There was no documentation of what time the IV was inserted in the field.
Review of the "Medication Administration Record" dated 12/15-17/2013 revealed Patient #14 was receiving the antibiotics Vancomycin and Rocephin IV every 12 hours.
During an observation on 12/17/2013 at 10:50 a.m., Patient #14 was in bed, lethargic and with an IV (heploc) site to the right lower arm which had no time or date of insertion. Coban dressing was wrapped around the right arm above and below the site and was so tight it caused indentions in the arm. The IV site was swollen, red and there was a bag of IV fluids infusing. During an interview Staff #21 confirmed the missing dates, times and the condition of the IV site.
Review of "Nurse's Note" revealed documentation of the IV site on 12/15/2013 at 5:30 p.m. and 12/16/2013 at 8:00 a.m. As of 12/17/2013 at 11:00 a.m. (27 hours later) there was no documentation of an assessment of the IV site.
Review of the policy dated 12/2012 named "Insertion, Discontinuation of and Management of Intravenous Therapy" revealed the following:
"Reassess the infusion rate, drip rate and patient condition frequently during the infusion. Observe for signs of infiltration, redness, swelling or no blood return. Needles should be discontinued upon evidence of edema, redness, phlebitis pain or subcutaneous infiltration.
Assess the venipuncture site for signs of infiltration. Record condition of site and/or surrounding area in the Nurses notes' every shift.
Document date, time, and amount and type of solution, additive, flow rate and insertion site. The Narrative Notes should reflect insertion site, size of needle inserted and site care, any problems encountered with the procedure.
IV catheters inserted under emergency conditions )I.e.: in the field by EMS), must be removed and a new catheter inserted at a different site within 48 hours. If the site cannot be rotated due to lack of another site being available, or some other reason, is to be documentation in the Nurses' Notes."
During an interview on 12/17/2013 at 11:00 a.m., Staff #21 confirmed the missing assessments and not knowing when the initial IV was inserted.

Based on interview and record review the facility failed to ensure verbal orders/order sets were complete and signed off timely by the physician in 3 of 3 sampled patients (#s' 12, 33 and 34).
This deficient practice had the likelihood to cause harm to all patients.
Findings include:

Review of "Admission Orders" revealed Patient #34 was a 64 year old male admitted on 12/08/2013 with diagnoses of dehydration and tachycardia.
Review of physician orders revealed the following verbal orders taken by nursing which had not been signed off by the physician as of 12/18/2013:
12/08/2013 - Two different verbal orders timed for 8:15 p.m.
12/08/2013 - Hypoglycemia order sets which were signed as verbal orders and timed 9:45 p.m.
12/09/2013 - Thromboembolic therapy order sets which were verbal orders and timed 9:45 p.m.
12/09/2013- Two different verbal orders timed 10:40 a.m. and 10:45 a.m..
12/09/2013- Adult Severe Sepsis and Sepsis Shock order sets which included had orders for labs, treatments and medications.
12/10/2013, 12/11/2013. 12/12/2013, 12/13/2013, 12/14/2013, 12/15/2013, 12/16/2013 - Daily Parenteral Nutrition Orders. Nursing continued to administer without getting the physician to sign off.
12/10/2013- Two verbal orders, one without a date and one timed 10:15 p.m.
12/11/2013 - Adult ICU Electrolyte Replacement order sets which included orders for medications.
12/11/2013 - one verbal order timed 9:50 a.m.
12/12/2013- One verbal order timed 5:30 p.m.
12/13/2013- One verbal order timed 12:35 p.m.
12/14/2013- One verbal order timed 10:00 a.m.
12/15/2013- One verbal order timed 4:32 p.m.

Review of a "Transfusion Order Set" dated 12/15/2013 timed 7:15 a.m., revealed Patient #12 was a 71 year old female admitted on 12/14/2013.
According to the "Transfusion Order Set" Patient #12 was to receive 2 units of packed red blood cells. According to instructions on the orders the physician was to indicate the type and amount on the first line and make "x" in one or more of the categories and corresponding justification (s). The only part of the orders completed was the type and amount of blood. There was no justification listed nor was the hemoglobin and hematocrit section completed.
The "Transfusion Order Set" was signed as a verbal order by nursing, but was not signed off by the physician. The orders were incomplete.
There was a thromboembolic therapy order set dated 12/15/2013, 8:10 a.m. which were verbal orders which had not been signed off by the physician.

Review of a "Transfusion Order Set" dated 12/15/2013 revealed Patient #33 was a 45 year old female admitted on 11/19/2013 and was ordered 3 units of packed red blood cells on 11/20/2013.
The "Transfusion Order Set" was signed as a verbal order by nursing, but was not signed off by the physician until 12 days later on 12/02/2013.
Review of the "Medical Staff Bylaws and Rules and Regulations" dated 12/17/2012 revealed the following about physician orders:
"Standing Orders may be formulated by a member of the Medical Staff for individual patients. These orders shall be signed by the attending physician and shall be reviewed annually by the attending physician.
All orders for inpatients and outpatients treatment shall be documented. All orders shall be in writing, dated, and timed. Orders shall be considered documented, if identified by the name of the person receiving the order and the name of the practitioner giving the order.
The hospital employee who takes the verbal order will flag the verbal order chart entry for the practitioner' s signature. The goal of the Medical Staff is to have all verbal orders signed within 48 hours or as soon as possible thereafter."
During an interview on 12/18/2013 at 4:55 p.m., Staff #36 confirmed the orders had not been signed off by the physician.

Based on interview and record review the facility failed to ensure blood transfusions were administered per their policy in 3 of 4 patients (#s' 12, 13 and 33) reviewed for blood administration and reactions.
This deficient practice had the likelihood to cause harm to all patients receiving blood transfusions.

Findings include:

Review of a "Transfusion Order Set" dated 12/15/2013 revealed Patient #33 was a 45 year old female admitted on 11/19/2013 and was ordered 3 units of packed red blood cells on 11/20/2013.
Unit #1
*The first set of vital sets was taken on 11/20/2013 at 6:50 p.m. and other set of vital signs were taken at 6:55 p.m., 7:05 p.m., 8:00 p.m. and then the blood was stopped at 8:30 p.m. According to the flow sheet the blood was stopped because of a reaction. Patient #33 had whelps on her neck which spread to the upper and lower extremities. There was no documented time of when the blood was initially hung.
*Unit #2
The first full set of vital signs was taken on 11/21/2013 at 3:05 p.m. Six more sets of vital signs were taken they did not include the temperature, respirations or times. The next full set of vital signs was not taken until over 2 hours later at 5:42 p.m.
*Unit #3
The first full set of vital signs was taken on 11/21/2013 at 7:23 p.m. 10 more sets of vital signs were taken and they did not include the temperature, respirations or times. The blood was stopped over 2.5 hours later at 10:00 p.m. and the temperature and respirations were not taken.


Review of a "Transfusion Order Set" revealed Patient #13 was a 71 year old male admitted on 12/10/2013.
Review of a "Blood and Blood Component Flow Sheet" on Patient #13 revealed the following:
Unit #1
*The first set of vital signs was taken on 12/10/2013 at 11:00 p.m. and two nurses signed the blood was verified on 12/10/2013 at 11:00 p.m. The next set of vital signs was taken on 11:45 p.m. There was no documented time of when the blood was initially hung.
Unit #2
* The first set of vital signs was taken on 12/11/2013 at 2:45 a.m. and two nurses signed the blood was verified on 12/10/2013 at 2:45 a.m. The next set of vital signs was taken at 3:25 a.m. There was no documented time of when the blood was initially hung.

Review of a "Transfusion Order Set" dated 12/15/2013 revealed Patient #12 was a 71 year old female admitted on 12/14/2013.
According to the "Transfusion Order Set" Patient #12 was to receive 2 units of packed red blood cells. According to instructions on the orders the physician was to indicate the type and amount on the first line and make "x" in one or more of the categories and corresponding justification (s). The only part of the orders completed was the type and amount of blood. There was no justification listed nor was the hemoglobin and hematocrit section completed.
Review of a "Blood and Blood Component Flow Sheet" on Patient #12 revealed the following:

Unit #1
*The first set of vital signs was taken on 12/15/2013 at 12:30 p.m.
*Two nurses signed the blood was verified on 12/15/2013 at 12:48 p.m. and 1:00 p.m.
*The next set of vital signs was taken at 1:00 p.m... There was no documented time of when the blood was initially hung.
* The next hourly vital sign was taken over an hour later at 2:30 p.m.

Unit #2
*The first set of vital signs was taken on 12/15/2013 at 3:20 p.m.
*Two nurses signed the blood was verified on 12/15/2013 at 3:25 p.m.
*The next set of vital was taken at 3:45 p.m. There was no documented time of when the blood was initially hung.

Review of the policy dated 11/2012 named "Blood or Blood Component Therapy/Management of Transfusion Reaction" revealed the following:
"Take an record the patient's vital signs, including temperature prior to administration of blood or components, and after the first 50 mls of blood has infused, and then hourly for the duration of the transfusion.
Baseline vital signs are used for later comparisons, to determine possible transfusion reaction.
The most common clinical events accompanying a severe transfusion reaction in order of frequency area:
a. fever, with or without chills
b. lumbar, extremity, or chest pain
c. change of pulse, temperature or blood pressure (hypotension)
d. nausea
e. nausea, flushing of the face
f. dyspnea
g. bleeding"
During an interview on 12/17/2013 at 11:40 a.m., Staff #21 confirmed there was no blood initiation dates on the forms. They were just realizing it was not there.