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Based on observation, six patient record reviews, and interview of the Director of Clinical Services and Director of Quality Management; nursing services was not provided within acceptable standards of practice, consistent with medical orders, or current to patient's condition. The nursing plan of care was incomplete for monitoring and interventions for patients fluid balance status and bowel movement functioning. The Condition of Participation of Nursing Services is Not Met.
Findings include:

1. Three of six patient medical records(#2, 3,5), reviewed did not reflect adequate monitoring of fluid balance of acutely ill ventilator, or respiratory insufficiency patients. Nursing care plans did not addresss goals for fluid intake, monitoring approaches, interventions, or reporting to the physician.
Patient #2, was admitted to the hospital on 1/28/10, with diagnosis of ventilator dependence and congestive heart failure. Two of the four days of this patient's hospital stay the intake exceeded the output by 1,545 cc and 1,940 cc, without nursing intervention.
Patient #3, was admitted to the facility on 2/19/2010 and discharged to an acute care hospital on 2/27/2010. Diagnosis included, Chronic Obstructive Pulmonary Disease, Adbominal Metstases, and Ascites. Intake and Output records reviewed for 2/24/2010 Intake 2664 and Output 1300, +1350 without further explanation; 2/25/2010 Intake 3100 and Output 1800, +1300, without further explanation. On 2/26/2010 the Intake was documented as 2516 and output 850, +1666, without further explanation or reporting to the physician.
Patient #5, was admitted to the facility on 5/24/2010, with quadraplegia and vent dependency. Intake and Output record for 5/26/2010, was observed to be incompletely documented and not in accord with the physician's order. The physician's order for intake was; Jevity 50cc/hour enteral, water flush every hour 25cc, IV Doribax in 100 mililiters (ml) every eight hours, and Fluconazole 100miligram every 24 hours at 100 ml per hour. The total input count for the 24 hour period reflected only 730 cc total, without further explanantion or report to the physician.
2. Three of six patient medical records reviewed (#2, 3, 5), did not contain nursing assessment, monitoring, or interventions for patient bowel movement functioning.
Patient #2, was admitted on 1/28/2010 and coded and passed away on 2/1/2010. The nursing patient record and plan of care for 1/28, 1/29, 1/30, and 1/31, was absent for patient bowel movement. The plan of care did not contain nursing interventions for patient bowel functioning.
Patient #3, was admitted to the facility on 2/19/2010, and transferred to an acute care hospital on 2/27/2010. Nursing patient care record and plan of care did not contain a nursing assessment or intervention on 2/25, 2/26 and 2/27, for patient bowel movement status.
Patient #5, was admitted on 5/24/2010 and remains in the facility. Nursing patient care record and plan of care did not document a bowel movement for this patient on 5/24, 5/25, 5/26, 5/27. A review of the physicians orders and medication administration sheets reflect a order to give Bisacodyl 10 milligram, 1 suppository daily as needed. There was no documentation of administration of the medication, 5/24-5/27, for constipation. No further nursing assessments or interventions for patient bowel functioning was documented.
3. Interview of the Director of Clinical Services and Director of Quality Management was conducted on 5/28/2010, at approximately 11:15. A review of the patient medical records with lack of documentation of fluid balance and bowel monitoring was discussed with the directors. Additional information was requested which would suport nursing monitoring or inteventions for these three patients. No additional information was available. The Director of Quality Management did state that additional training would be offered annually on fluid balance by a Registered Dietician.

Based on observation, interview, and six patient record reviews; the hospital did not report a death associated with the use of a restraint.

Findings Include:

1. One of six, patient medical records reviewed, #2, was placed in bilateral wrist restraints due to aggitation and to prevent removing tubes. Nurse notes and Plan of Care record, for 2/1/2010, record that the patient was placed in bilateral wrist restraints at 1200. Direct patient observations were documented to have occurred at 12, 13, 14, 15, 16, 17, and 18 hours. Nurses Progress Notes document on 2/1/2010, at 1715, the nurse entered the patient's room to draw blood and found the patient unresponsive and called code. The code was documented as concluded at 1820, as the patient continued to be unresponsive with no pulse or blood pressure. The hospital did call 911 and sent the patient to an acute care hospital emergency department and pronounced.
2. Interview was conducted of the hospital Director of Quality Management and Director of Clinical Services, on 5/28/2010, at approximately, 11:00am. The Director of Quality Management stated that she/he was not aware that patient #2, was restrained at the time they coded. The medical record was reviewed with the managers where documentation of the restraints was evident.
3. A review of the hospital, Restraints and Seclusion Policy and Procedure, revised July 2009, states that the hospital will report to CMS in accord with the CMS-COP, and document in the patient's medical record the date and time the death was reported.

Based on observation, inteview and patient medical record reviews; one of six, nursing assessment and care plan was not documented consistently or timely for the patient's condition.
Findings Include:

1. Patient #2, was admitted on 1/28/2010, and coded on 2/1/2010, at 1715 and transferred to an acute care hospital emergency department at 1820. A review of the nurse note documentation for 2/1/2010, for 1800 hour is inconsistent with the patient's condition. Documentation which is initialed by a Registered Nurse as performed at 1800, include: Offer food/fluids every 2 hours; Offer urinal/bedpan every 2 hours; provide comfort measures every 2 hours, and Reposition.

2. Interview of the Director of Clinical Services and Director of Quality Management, was coducted on 5/28/10, at approximately 11:00. Nursing note inconsistencies with the code blue sheet for patient #2, was reviewed with them. No additional information was available for review.