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Based on record review and interview, it was determined that the Chief Nursing Officer (CNO) failed to require that:

1. a registered nurse evaluated a patient's pulse prior to the administration of Atenolol, with a resultant pulse decrease to 42 beats per minute (bpm) in 1 of 1 patients (Patient #3).

2. a registered nurse evaluated the quality of the patient's pureed diet in 1 of 1 patients (Patient #3).

Findings include:

1. Patient #3 was admitted to the Oro Valley Hospital Inpatient Rehabilitation Unit on 12-19-09. The "Reason for Admission" was "Functional Decline."

The medical record revealed that on 12-31-09, that patient had a pulse of 65 at 5:05 A.M., and at 2:35 P.M., the pulse was 77. The record revealed that on 01-01-10, the patient had a pulse of 52 at 3:36 A.M. and at 4:08 A.M.

The Medication Administration Record (MAR) revealed that on 01-01-10 at 9:00 A.M., Patient #3 was administered Atenolol (Antihypertensive) 50 milligrams (mg) at 9:00 A.M. by Registered Nurse #1. The MAR revealed: "Hold for SBP (Systolic Blood Pressure) <140 or HR (heart rate) <60." No pulse was taken prior to administration of the Atenolol. On 01-01-10 at 2:01 P.M., the patient's pulse was 42.

The Nursing Supervisor stated that normally with a pulse of 42, the Rapid Response Team would be called to assess the patient. There was no documentation that the Rapid Response Team was called when Patient #3 had a pulse of 42.

2. No pureed trays were available for observation on the Rehabilitation Unit on 04-14-10 during tour of the unit.

The Rehabilitation Unit Nursing Supervisor acknowledged, during interview conducted on 04-14-10 at 2:40 P.M., that pureed foods received on the unit are often liquefied as opposed to pureed.