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Based on record review and staff interview it was determined that the Registered Nurse failed to supervise and evaluate care related to the implementation of physician orders for 13 (#1, #2, #3, #6, #7, #8, #9, #10, #11, #12, #14, #15, #16) of 19 sampled patients. This practice does not ensure patient treatments are provided.

Findings include:

1. Patient #8 was admitted to the facility on 3/12/11 with the diagnosis of renal failure. Review of consulting nephrologist orders revealed an order for daily weights on 3/13/11. Review of nursing documentation revealed the daily weight was not recorded from 3/16/11 through 3/21/11 and on 3/23/11 and 3/24/11.

The Director of Quality confirmed the lack of documentation during an interview on 5/17/11 at approximately 11:00 a.m.

2. Patient #15 was admitted to the facility on 5/16/11 with the diagnosis of Ischemic Stroke. A review of the physician orders dated 5/16/11 at 2:50 p.m. revealed to lavage the right ear. Review of a progress note dated 5/17/11 at 10:30 a.m. noted "floor staff did not lavage ear as ordered".

An interview was conducted on 5/17/11 at approximately 11:30 a.m. with unit charge nurse during the review of the clinical record. When questioned why the lavage had not been done, the charge nurse stated the order needed to be clarified as to what solution to use. There was no documentation in the clinical record stating why the lavage was not done or that the physician had been notified to clarify the order.

3. Patient #1 was admitted to the facility with mild diverticulitis and renal insufficiency. Physician's order instructed for an ANCA test to be done. Review of the medical record revealed an ANNA was performed instead of the ANCA that was ordered.

4. Patient #2 was admitted to the facility on 12/30/10 with the diagnosis of patent foramen ovale. Review of physician orders showed an order for a random urinary sodium to be done on 1/4/11. Review of laboratory results revealed no evidence that the test had been conformed.

5. Patient #3 was admitted to the facility on 1/4/11 with the diagnosis of chronic renal insufficiency. Review of physician orders revealed an order for a urinalysis with microscopic examination and an ionized calcium on 1/22/11. Review of laboratory results revealed no evidence the test had been performed.

6. Patient #6 was admitted to the facility on 1/31/11 with the diagnosis of acute renal insufficiency. Review of the medical record revealed an order for ionized calcium on 2/1/11. Review of the laboratory results revealed no evidence the test was performed.

7. Patient #7 was admitted to the facility with the diagnosis of hematuria. Review of physician orders revealed an order for a urinalysis with microscopic examination and a random urinary sodium and creatinine. Review of the laboratory results revealed that the tests had not been performed.

8. Patient #9 was admitted to the facility on 3/9/11 with the diagnosis of alcohol abuse and chronic obstructive pulmonary disease. Review of physician orders instructed to repeat the urinalysis with a random urinary sodium, creatinine and potassium. Review of the laboratory results revealed there was no evidence that the tests had been performed.

9. Patient #10 was admitted to the facility on 3/18/11. Review of physician orders dated 3/22/11 at 8:30 p.m. instructed for a potasium and magnesium tonight. Review of the laboratory result revealed the potassium and magnesium were not done on 3/22/11 as ordered.

10. Patient #11 was admitted to the facility on 3/29/11 with the diagnosis of renal insufficiency. Review of physician orders revealed to obtain a repeat urinalysis with microscopic examination on 4/4/11. Review of laboratory results revealed no evidence the test had been performed.

11. Patient #12 was admitted to the facility on 3/11/11. Review of physician orders revealed an order for a random urinary sodium and creatinine on 3/19/11 at 9:00 p.m. Review of the laboratory results revealed no evidence that the test had been performed.

12. Patient #14 was admitted to the facility on 5/10/11. Review of physician orders dated 5/10/11 instructed to obtain a urinalysis with culture and sensitivity on 5/10/11. Review of the laboratory results revealed no evidence that the test was completed.

13. Patient #16's past medical history included dialysis and end-stage renal disease. Physician's orders dated 5/15/11 at 4:15 p.m. revealed an order for daily weights, serum phosphorus on blood already in lab (2nd order, initially ordered on 5/14/11), and an ionized calcium. Review of the nursing documentation revealed the daily weights were started on 5/17/11, 2 days after the order was written. Review of physician's orders for 5/14/11 revealed the order for a serum phosphorous was not written.

An interview with the nurse involved was conducted on 5/17/11 at approximately 4:30 p.m. The nurse stated he had received a telephone order from the physician for the serum phosphorous, but was busy and failed to write the order.

A review of the laboratory results was conducted on 5/17/11 by the Quality Manager for the ionized calcium results. The Quality Manager was unable to locate the results of the ionized calcium. An interview was conducted on 5/17/11 at approximately 2:00 p.m. with the Charge Nurse, after thorough review of the clinical record, the findings were confirmed

14. During interview on 5/17/11 at approximately 6:00 p.m., the Director of Quality Management confirmed no evidence could be found related to the the above findings.

Based on record review and staff interview it was determined that the facility failed to ensure medication was administered as ordered by the physician for 1 (#4) of 19 sampled patients. This practice does not provide for effective medication therapy.

Findings include:

1. Patient #4 was admitted to the facility on 1/18/11 with the diagnosis of acute renal insufficiency. Review of physician orders revealed an order for Decadron 10 milligrams intravenously prior to the administration of Ferrlecit. Review of the Medication Administration Record revealed the medication was not administered.