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Based on medical record review and staff interview, facility staff failed to provide dressing changes as ordered in 1 of 1 patient (Patient #3) requiring dressing changes.

Findings included:

Closed medical record review conducted on 04/23/2019 revealed Patient #3 was a 19-year-old female admitted to the facility on 02/13/2019 with a diagnosis of Opioid Substance abuse requiring detoxification. Review of a History and Physical written on 02/14/2019 at 1422 by Nurse Practitioner #1 revealed, "...Open laceration on Left wrist ..." Review of physician telephone orders taken on 02/13/2019 at 1722, and electronically signed by Physician's Assistant (PA) #1 on 02/14/2019 at 0838 revealed, "...dressing change to l (left) wrist bid (twice daily) ..." Review of Patient #3's Medication Administration Record (MAR) revealed "...Dressing changes to left wrist Non stick (sic) Gauze ... 2o13o19..." Review revealed illegible initials (untimed) marking the dressing changes as done (once daily instead of twice) under the dates of 02/14/2019 and 02/15/2019. Review revealed no evidence any dressing change was provided on 02/16/2019. Review of physician telephone orders taken on 02/17/2019 at 1002, and electronically signed by NP #1 on 02/17/2019 at 1010 revealed, "...Dry dressing daily to left arm ..." Review of Patient #3's MAR revealed, "...Dry Dressing (triangular symbol for 'change') to (symbol for left) wrist Daily 2/17..." Review revealed illegible initials timed for 0900 on 02/17/2019 and 02/19/2019, with no evidence the dressing was changed on 02/18/2019.

The nurse assigned to Patient #3 on 02/14/2019, 02/15/2019, and 02/18/2019 was unavailable for interview.

Interview was conducted with the Director of Nursing on 04/24/2019 at 0912, who advised upon review of Patient #3's MAR that it appeared the initial order to change the dressing twice daily was incorrectly transcribed to the MAR to not specify the dressing needed to be changed twice daily.

Interview conducted with Licensed Practical Nurse (LPN) #2 on 04/24/2019 at 0921 revealed he was assigned to Patient #3 on 02/16/2019. Interview revealed he could not recall whether the dressing was changed on that day and could provide no explanation for the absence of documentation for the procedure.

Interview conducted with NP #1 on 04/24/2019 at 1655 revealed further dressing changes after 02/19/2019 were no longer necessary.

Based on policy review, medical record review, and staff interview, facility staff failed to administer and document medication administrations per facility policy in 3 of 5 patients (Patients #1, #2, and #3) requiring medications.

Review of policy titled, "Medication Administration" revised: 12/1/2017 revealed, "... It is the policy of (Named Facility) to administer medications per medical orders ... All medications shall be documented on the patient's Medication Administration Record ... The nurse who administers the medication must sign their initials in the appropriate box on the font (sic) of the MAR ... Any medication given before or after one hour of the scheduled times, will be considered a medication error..."

Findings included:

1. Closed medical record review conducted on 04/24/2019 revealed Patient (PT) #1 was a 52-year-old male admitted to the facility on 04/13/2019 with a diagnosis of Alcohol Abuse. Review of a medication order written by Medical Doctor (MD) #1 on 04/13/2019 at 2315 revealed, "...Seroquel (a psychiatric medication) 100 mg (milligrams) po (by mouth) qhs (every hour of sleep) ..." Review of PT #1's Medication Administration Record (MAR) revealed no evidence the medication was administered until 04/19/2019. Review revealed no explanation provided why the medication was not administered.

Interview conducted with the Director of Nursing (DON) on 04/24/2019 at 1235 revealed the nurses on duty for the above dates were not available for interview, and no explanation could be provided for the lapse of medication administration.

2. Closed medical record review conducted on 04/24/2019 revealed PT #2 was a 37-year-old female admitted to the facility on 02/14/2019 with a diagnosis of Substance abuse. Review of a telephone medication order written on 02/14/2019 at 2230, and electronically signed by Nurse Practitioner (NP) #1 on 02/15/2019 at 0001 revealed, "...Thiamine (a vitamin) 200 mg PO on admission, then follow standing orders..." Review of PT #2's MAR revealed no evidence the Thiamine 200 mg dose was ever administered.

Interview conducted with the DON on 04/24/2019 at 1235 revealed the nurses on duty for the above dates were not available for interview, and no explanation could be provided for the lapse of medication administration.

3. Closed medical record review conducted on 04/23/2019 revealed Patient #3 was a 19-year-old female admitted to the facility on 02/13/2019 with a diagnosis of Opioid Substance abuse requiring detoxification. Review of a telephone medication order written on 02/13/2019 at 1722, and electronically signed by Physician's Assistant (PA) #1 on 02/14/2019 at 0838 revealed, "...Bactrim (an antibiotic) ds (double strength) po bid (twice daily) x (for) 7 days ..." Review of PT #3's MAR revealed no evidence the Bactrim was administered during the morning administration on 02/17/2019 or the evening administration of 02/19/2019.

Interview conducted with the DON on 04/24/2019 at 1235 revealed the nurses on duty for the above dates were not available for interview, and no explanation could be provided for the lapse of medication administration.

NC00148851