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Based on review of clinical records and interview, it was determined the Facility failed to provide care as ordered by the physician to 9 (#1, #2, #6,#7,#31,#32, #34-#36) of 36 (#1-#36) patients. Failure to provide care as ordered had the likelihood of prolonging the patient's hospitalization and recovery time. The failed practice affected Patients #1, #2, #6,#7, #31,#32, #34-#36. Findings follow:

A. Review of Patient #1's clinical record revealed a physician order for daily weight beginning on 09/17/14. Review of the clinical record revealed no daily weights recorded on 09/20/14, 09/21/14, 09/22/14 and 09/23/14. Findings were verified by the Director of Quality at 1421 on 09/23/14.

B. Review of Patient #2's clinical record revealed a physician order for daily weights beginning on 09/20/14. Review of the clinical record revealed no daily weights recorded on 09/21/14 and 09/22/14. Findings were verified by the Director of Quality at 1455 on 09/23/14.

C. Review of Patient #6's clinical record revealed a physician order for daily weights beginning on 09/19/14. Review of the clinical record revealed no daily weights recorded on 09/20/14 and 09/21/14. Findings verified by the Director of Quality at 0855 on 09/24/14.

D. Review of Patient #7's clinical record revealed a physician order for daily weights beginning on 09/17/14. Review of the clinical record revealed no daily weights recorded on 09/18/14, 09/20/14 and 09/22/14. Findings verified by the Director of Quality at 0845 on 09/24/14.

E. Review of the clinical record of Patient #31 revealed physician orders authored by Physician #1, dated and timed 09/21/13 at 2311 for neurological assessments every 4 hours. Review of the nursing notes revealed no neurological assessments from 0800 to 2310 on 09/22/14, 0149 to 1443 on 09/23/14 and from 0200 to 1800 on 09/24/14. The above findings were verified by the Director of Quality at 0805 on 09/25/14.

F. Review of the clinical record of Patient #32 revealed physician orders authored by Physician #2, dated and timed 09/22/14 at 2218 for Glucose Level at bedside QID, AC and bedtime (four times a day before meals and bedtime). Review of the Medication Administration Record (MAR) revealed no blood glucose level on 09/23/14 for bedtime. The above findings were verified by the Director of Quality at 0840 on 09/25/14.

G. Review of the clinical record of Patient #34 revealed physician orders authored by Physician #2, dated and timed 09/17/14 at 0645 as follows, "If CIWA-Ar (Clinical Institute Withdrawal Assessment) after 72 hours of assessment is less than or equal to 7, discontinue. If initial CIWA-Ar score is less than or equal to 7, continue assessment and vital signs every 4 hours. If CIWA-Ar score is ever greater than or equal to 8, initiate assessment and vital signs every hour for 8 hours, then every 2 hours for 8 hours if score decreasing and symptoms improving, then every 4 hours if score decreasing. Notify MD (Medical Doctor) if hourly assessments are needed for more than 8 hours. Notify the MD for any CIWA-Ar score above 25." Review of the Physician Orders dated and timed as above revealed the following: Ativan 1 mg (milligram) IV (intravenous) push hourly PRN (as needed) for CIWA-Ar score of 8-13, Ativan 2 mg IV push hourly PRN for CIWA-Ar score of 14-20, Ativan 2 mg IV push every 30 minutes PRN for CIWA-Ar score of 21 or greater." Review of the MAR revealed from 09/17/14 through 09/23/14 Patient #19 received 17 doses of Ativan 2 mg and 3 doses of Ativan 1 mg and was only scored three times per the CIWA-Ar protocol.

H. Review of the clinical record of Patient #35 revealed physician orders authored by Physician #3, dated and timed 09/21/14 at 2148 for Glucose Level at bedside every six hours. Review of the nursing notes revealed three Glucose Levels were not performed on 09/22/14, three were not performed on 09/23/14 and four were not performed on 09/24/14.

I. Review of the clinical record of Patient #36 revealed physician orders authored by Physician #4, dated and timed 09/24/14 at 2257 as follows: "Ativan, 4 mg, tab, oral hourly PRN for CIWA-Ar score of 21 or greater." Review of the MAR revealed she received a 4 mg tablet at 1000 on 09/25/14 from Licensed Practical Nurse (LPN) and no CIWA-Ar scoring was documented. During an interview with LPN at 1120 on 09/25/14 she was asked what Patient #21's CIWA-Ar score was at 1000. LPN stated she had not scored Patient #36 and had administered the 4mg of Ativan based off of her assessment that Patient #36's level of anxiety was increased.

J. The above findings were verified by the Director of Quality at 1125 on 09/25/14.

Based on clinical record review it was determined the Facility failed to follow policy and procedure in that 5 (#1, #3, #6-#8) of 36 (#1-#36) patients did not receive daily assessments by a Registered Nurse (RN). Failure to ensure the 5 patients were assessed daily by a RN did not ensure the patient's health status/condition, needs and problems were identified and care planned accordingly. The failed practice affected Patients #1, #3, #6-#8 on 09/24/14. Findings follow:

A. Review of Patient #1's clinical record revealed no RN assessment was documented for the day shift on 09/20/14.
B. Review of Patient #3's clinical record revealed no RN assessment was documented for the day shift on 09/22/14.
C. Review of Patient #6's clinical record revealed no RN assessment was documented for the day shift on 09/20/14.
D. Review of Patient #7's clinical record revealed no RN assessment was documented for the day of 09/22/14.
E. Review of Patient #8's clinical record revealed no RN assessment was documented for the day of 09/20/14 and the day of 09/21/14.
F. Review of the policy and procedure titled "Patient Assessment and Re-Assessment", page 4, under the Matrix for Assessment/Reassessment revealed "RN at least every shift".
G. The above findings were verified by the Director of Quality at 1530 on 09/23/14 and again at 0900 on 09/24/14.

Based on clinical record review, it was determined the Facility failed to develop a nursing care plan for 3 (#3, #4 and #6) of 36 (#1-#36) patients and failed to develop a nursing care plan per policy and procedure for one (#7) of one patient. Failure to develop and implement a nursing care plan for each patient did not allow the nursing staff to be aware of patient problems, needs and goals to ensure the patients received the optimum care needed to progress. The failed practice affected Patients #3, #4, #6 and #7 on 09/23/14. Findings follow:

A. Review of the clinical records of Patients #3, #4 and #6 revealed the clinical record did not contain a nursing care plan.

B. Review of the clinical record for Patient #7 revealed he was admitted on 09/17/14 and the nursing care plan was not initiated until 09/23/14, six days after admission.

C. Review of the policy and procedure titled "Interdisciplinary Plan of Care" received from the Chief Quality Officer at 0820 on 09/24/14 revealed the following under PROCEDURE 1. Interdisciplinary plan(s) of care must be initiated within 24 hours of the patient's admission.

D. The findings for Patients #3 and #4 were verified by the Director of Quality at 1500 on 09/23/14 and for Patients #6 and #7 at 0855 on 09/24/14.

Based on clinical record review and interview, it was determined the nursing staff failed to administer medications per physician orders for 7 (#2, #8-#10, #27, #34, and #36) of 36 (#1-#36) patients. Failure to administer medications per physician orders had the likelihood of increasing the patient hospitalization and recovery time. The failed practice affected patients #2, #8-#10, #27, #34, and #36. Findings follow:

A. Review of Patient #2's clinical record revealed orders for Tygacil 50 mg given IV (intravenously) every 12 hours beginning at 0800 on 09/21/14 . Review of the Medication Administration Record (MAR) revealed Patient #2 received doses six hours apart at 1350 and 2035 on 09/21/14 and did not receive the 0800 dose on 09/22/14. Findings were verified by the Director of Quality at 1455 on 09/23/14.

B. Review of Patient #8's clinical record revealed orders for sliding scale insulin based on blood sugar results performed before meals and at bedtime. Review of the sliding scale orders revealed for blood sugars in the 211 to 250 range, Patient #8 should have received 3 units of insulin. Review of the MAR revealed Patient #8 received 4 units of insulin at lunch on 09/21/14. Review of the MAR also revealed no documentation of blood sugar results or insulin given at bedtime on 09/19/14 and 09/20/14. Findings were verified by the Director of Quality at 1009 on 09/24/14.

C. Review of Patient #9's clinical record revealed orders for Dilaudid 0.2 mg for pain score of 4-6 and 0.5 mg for pain score of 7-10. Review of the MAR revealed Patient #9 received 0.4 mg of Dilaudid at 0848, 0853 and 0900 on 08/11/14 by Registered Nurse Findings verified by the Director of Quality at 1030 on 09/23/14.

D. Review of Patient #10's clinical record revealed orders for Zosyn 3.375 milligram (mg) given IV every eight hours beginning 1700 on 08/11/14. Review of the MAR revealed Patient #10 received the second dose 2 hours late and did not receive the third dose at all. Findings verified by the Director of Quality at 1000 on 09/23/14.

E. Review of the clinical record of Patient #27 revealed orders for Lo-Dose Insulin QID (four times per day) per scale. The scale was: 171-210 2 Units, 211 - 250 3 Units, 251 - 290 4 Units, 291 - 330 5 Units, and 331 or greater 6 Units. Review of the Medication Administration Record (MAR) revealed no documentation of the blood glucose results at noon on 09/21/14, blood glucose results of 351 at bedtime on 09/22/14 with 5 Units given instead of 6, blood glucose results at bedtime on 09/23/14 of 183 with no Insulin given and patient should have received 2 Units of Insulin. The above findings were verified by the Director of Quality at 1400 on 09/24/14.

F. Review of the clinical record of Patient #34 revealed physician orders authored by Physician #2, dated and timed 09/17/14 at 0645 as follows, "If CIWA-Ar (Clinical Institute Withdrawal Assessment) after 72 hours of assessment is less than or equal to 7, discontinue. If initial CIWA-Ar score is less than or equal to 7, continue assessment and vital signs every 4 hours. If CIWA-Ar score is ever greater than or equal to 8, initiate assessment and vital signs every hours for 8 hours, then every 2 hours for 8 hours if score decreasing and symptoms improving, then every 4 hours if score decreasing. Notify MD (medical doctor) if hourly assessments are needed for more than 8 hours. Notify the MD for any CIWA-Ar score above 25." Review of the Physician Orders dated and timed as above revealed the following: Ativan 1 mg (milligram) IV (intravenous) push hourly PRN (as needed) for CIWA-Ar score of 8-13, Ativan 2 mg IV push hourly PRN for CIWA-Ar score of 14-20, Ativan 2 mg IV push every 30 minutes PRN for CIWA-Ar score of 21 or greater. " Review of the MAR revealed from 09/17/14 through 09/23/14 Patient #34 received 17 doses of Ativan 2 mg and 3 doses of Ativan 1 mg and was only scored three times per the CIWA-Ar protocol. The above findings were verified by the Director of Quality at 1000 on 09/25/14.

G. Review of the clinical record of Patient #36 revealed physician's orders authored by Physician #4, dated and timed 09/24/14 at 2257 as follows: "Ativan, 4 mg, tab, oral hourly PRN for CIWA-Ar score of 21 or greater." Review of the MAR revealed she received a 4 mg tablet at 1000 on 09/25/14 from Licensed Practical Nurse (LPN) and no CIWA-Ar scoring was documented. During an interview with LPN at 1120 on 09/25/14 she was asked what Patient #36's CIWA-Ar score was at 1000. LPN stated she had not scored Patient #36 and had administered the 4mg of Ativan based off of her assessment that Patient #36's level of anxiety was increased. The above findings were verified by the Director of Quality at 1125 on 09/25/14.