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Based on observation, interview, and record review the facility failed to follow the nursing care plan for fluid restriction and daily weights as evidenced on 3 (#25, #26, and #27) of 32 Sampled Patients.

The findings include:
1) On 5/8/2012 at 3:30pm, an observation of Patient #25 revealed that he was in his room at the bedside sitting in a wheel chair with family at the bedside. Observation of his room revealed a white paper posted to the wall outside the bathroom which was labeled, " Fluid Restrictions Guide; Daily Allowance for Nursing; Daily Allowance for Dietary. "
Review of Patient #25 ' s medical record revealed that he was admitted to the facility on 4/26/2012. His diagnoses (including but not limited to): diabetes, hypertension, coronary arterial bypass graft surgery, acute liver shock, acute renal failure with dialysis Monday-Wednesday-Friday. He was admitted into the facility and placed on a fluid overload protocol. he also had a dietary recommendation as well as a physician ' s order for fluid restriction of 1200 milliliters per day. According to the nursing documentation in the medical record, there was no assessment of a daily weight on 5/5/2012. There was no record of nursing documentation noting why he was not weighed this day.
On 5/8/2012 at 12:30pm, interview with the Director of Nursing (DON) confirms the above discrepancies in fluid intake and the weights. She confirmed that this was not the policy and procedure for patients on fluid restrictions and patients on the fluid overload prevention protocol.
2) On 5/8/2012 at 2:45pm, an observation of Patient #26 revealed that he was in his room sitting in a wheel chair with a foley catheter draining yellow, clear urine. Observation of his room revealed a white paper posted to the wall outside the bathroom which was labeled, " Fluid Restrictions Guide; Daily Allowance for Nursing; Daily Allowance for Dietary. "
Review of Patient #26 ' s medical record revealed that he was admitted to the facility on 5/4/2012. His diagnoses (including but not limited to): pulmonary congestion, chronic obstructive pulmonary disease, hypertension, myocardial infarction, diabetes, and coronary arterial disease. He was admitted into the facility and placed on the fluid overload protocol. He also had a dietary recommendation as well as a physician ' s order for fluid restriction of 1200 milliliters per day. According to nursing documentation, on 5/7/2012 he had a total fluid intake of 1530 milliliters in a 24 hour period. There was no nursing documentation of justification, assessment, nor and notes that the medical doctor was contacted. There is no documentation of Patient #26 ' s daily weights between 5/5/2012 and 5/6/2012, . There was no record of nursing documentation noting why the daily weights were not recorded.
3) On 5/8/2012 at 3:15pm, an observation of Patient #27 revealed that he was in his room at the bedside sitting in a wheel chair. Observation of his room revealed a white paper posted to the wall outside the bathroom which was labeled, " Fluid Restrictions Guide; Daily Allowance for Nursing; Daily Allowance for Dietary. "
Review of Patient #27 ' s medical record revealed that he was admitted to the facility on 5/4/2012. His diagnoses (including but not limited to): acute myocardial infarction, end-stage renal disease with dialysis on Monday-Wednesday-Friday, congestive heart failure, and hypertension. He was admitted and placed on the facility ' s fluid overload protocol. He also had a dietary recommendation as well as a physician ' s order for fluid restriction of 1200 milliliters per day. According to nursing documentation, on 5/6/2012 he had a total fluid intake of 1500 milliliters in a 24 hour period. There was no nursing documentation of justification, assessment, or contacting the medical doctor. Between 5/7/2012 and 5/8/2012, the patient ' s weights were 206 pound and 210 pounds, respectively. This 4 pound difference exceeds the amount identified in the fluid overload prevention protocol, and warranted a call to the physician. There is no record of the nursing staff making a call to the physician about the weight increase.

Based on record review and interview, the facility failed to ensure that drugs are administered as ordered by the physician as evidenced in 1of 32 Sampled Patients (SP#30).

The findings include:

Clinical record review of SP#30 revealed the patient was admitted on 04-22-2012 for rehabilitation procedures. Review of the Reconciliation of Medications form for SP#30 showed the patient was taking at home Cozaar 100 mgs (milligrams) x 2 tablets (tabs) po (per oral) daily. Review of the physician's order dated 04-22-2012 at 09:00 pm showed the patient was to continue Cozaar 100 mgs ( 2 tablets( 200mg) po daily while admitted at the facility.

Review of the MAR (Medication Administration Record) showed on 04-22-2012 the order was "Cozaar 100 mg tab oral (2 tablets) oral daily " . This order was discontinued on the MAR on 05-03-2012. On 05-03-2012, the entry on the MAR stated "Cozaar 100 mg tab oral daily".
Review of the physicians' orders from 04-22-2012 to 05-09-2012 showed there were no orders written for Cozaar to be decreased from 200 mg to 100 mg daily.

On 05-09-2012 at 09:45 am, interview with the Pharmacy Consultant. The Pharmacy Consultant confirmed SP#30 was to receive Cozaar 200 mg po daily since admission. During the interview, the Pharmacy Consultant reviewed SP#30's bingo card. Based on the remaining tablets on the bingo card, the Pharmacy Consultant confirmed that SP#30 had not been receiving the ordered dose of Cozaar. At 09:49 am, the Pharmacy Consultant contacted the Pharmacy services who provided the bingo card and confirmed that the current bingo card is the only one that has been provided to the facility. Per the Pharmacy Consultant, Pharmacy was not aware of the dosage changes entered by the nurse. Pharmacy is not directly integrated and if there are order changes, the nurse has to fax the changes to pharmacy for the pharmacy staff to become aware of the changes.

Interview with the Director of Nursing (D.O.N.) and Pharmacy Consultant conducted on 05-09-2012 at 10:00 am confirmed there was a medication error. Interview with the D.O.N. and the physician for SP#30 conducted on 05-09-2012 at 10:12 am. The physician confirmed that the patient was to receive Cozaar 200 mg po daily instead of 100 mg po daily. The physician further questioned why the order was changed by the nurse. The D.O.N. stated that she had spoken to the nurse who made the order changes but the "nurse was unable to remember".
Interview with the Informatics Nurse and Risk Manager conducted on 05-09-2012 from 02:05 pm to 03:26 pm revealed the Informatics Nurse had interviewed the nurse who made the changes and the nurse was attempting to add " blood pressure parameters " but in the process the nurse inadvertently changed the previously ordered medication.

Review of the facility's policy on Medication Administration General Guidelines showed that "prior to administration, the medication and dosage schedule on the patient's MAR is compared with the medication label. If the label and the MAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule".

Review of the Blood pressure record showed no adverse effect related to failure to receive the correct dose of cozaar as ordered by the physician.