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Based on the manner and degree of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES, was out of compliance.

A-0395 RN SUPERVISION OF NURSING CARE A registered nurse must supervise and evaluate the nursing care for each patient. Based on record review and interviews, the facility failed to ensure a registered nurse (RN) reviewed and evaluated nursing care provided by a licensed practical nurse (LPN) in three of three medical records. Specifically, patient assessments and care planning performed by LPNs were not supervised, analyzed or reviewed by a registered nurse (Patient #1, Patient #2 and Patient #3).

A-0396 The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs. The nursing care plan may be part of an interdisciplinary care plan. Based on interviews and document review, the facility failed to perform patient services in accordance with the plan of care. Specifically, the facility failed to provide assistance required for activities of daily living (ADLs) according to the patient's plan of care. This failure was identified in four of five medical records reviewed. (Patient #1, #2, #3 and #5)

A-0405 (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient's care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. Based on observations, interviews and document review, the facility failed to administer medications in accordance with standard of practice and facility policy. Specifically, the facility failed to ensure the nursing staff completed the two patient identifier process prior to administering medications. The failure was identified in two of two medication administration observations. (Patient #4 and #5)

Based on record review and interviews, the facility failed to ensure a registered nurse (RN) reviewed and evaluated nursing care provided by a licensed practical nurse (LPN) in three of three medical records. Specifically, patient assessments and care planning performed by LPNs were not supervised, analyzed or reviewed by a registered nurse (Patient #1, Patient #2 and Patient #3).

Findings include:

Facility policy:

The Care Planning policy dated 3/21 read, RNs were to generate the plan of care for each patient. LPNs assigned to patient care were responsible for monitoring and updating, each patient's plan of care. All updates and revisions of the patient care plan provided by LPNs must be supervised by an RN. Any deviation or change in care provided to patients required RN review during each shift and as needed. Data collected by the LPN will be analyzed by an RN to identify and evaluate the care needs for the patient.

The Assessment and Reassessment policy dated 3/21 read, RNs were to perform the complete physical assessment for the patient. The physical assessment will be analyzed by the RN to formulate an individualized plan of care for each patient. Each patient was to have a head to toe physical assessment and continual re-assessments performed and reviewed by an RN. Collection of physical assessment data may be delegated to an LPN, however an RN must confirm and review all data and information collected by the LPN.

1. The facility failed to ensure physical assessment data and care plan updates performed by LPNs were supervised by an RN.

a. According to the facility policy, RNs were to develop the plan of care for each patient. LPNs could update and revise the patient care plan under direct supervision of an RN. Additionally, physical assessment data collected by LPNs must be reviewed and analyzed by an RN.

b. A review of patient records revealed from 11/1/20 to 5/21/21 patient records lacked RN supervision and co-signatures for patient assessment data and care plan updates performed by LPNs. Examples include:

i. Record review of Patient #1 revealed the patient was diagnosed with an acute stroke with left middle cerebral artery (MCA) intracranial hemorrhage (ruptured blood vessel) and stayed at the facility from 12/15/20 until 1/7/21 (a total of 23 days). Review revealed LPNs performed 27 care plan updates and 31 physical assessments which were not supervised or co-signed by an RN.

ii. Record review of Patient #2 revealed the patient was diagnosed with bilateral acute and subacute infarct (area of dead tissue with no blood supply) with left-sided hemiparesis (paralysis of one side of the body) and stayed at the facility from 12/18/20 until 1/5/21 (a total of 18 days). Review revealed LPNs performed 29 care plan updates and 32 physical assessments which were not supervised or co-signed by an RN.

iii. Record review of Patient #3 revealed the patient was diagnosed with neurological deficits secondary to bilateral subdural hematomas and left posterior cerebral artery (PCA) infarction and stayed at the facility from 2/27/21 until 3/12/21 (a total of 18 days). Review revealed LPNs performed 13 care plan updates and 11 physical assessments which were not supervised or co-signed by an RN.

This was in direct conflict with the facility policy which stated physical assessment data and care plan updates performed by LPNs must be supervised by an RN.

c. Interviews with staff revealed RN supervision was to occur for all patient assessments and reassessments performed by LPNs.

i. On 5/19/21 at 11:44 a.m., an interview was conducted with RN #2. RN #2 stated she previously worked as an LPN at the facility. RN #2 stated RN supervision of the assessment performed by an LPN occurred to ensure patient assessments were performed and no concerns were present. RN #2 stated every patient assessment performed by an LPN required an RN to co-sign the assessment as verification the assessment had been supervised and reviewed.

ii. On 5/19/21 at 2:12 p.m., an interview was conducted with Nursing Supervisor (Supervisor) #4. Supervisor #4 stated RNs performed comprehensive analysis of patient assessments and re-assessments to determine the efficacy of treatment interventions and care plans. Supervisor #4 stated LPNs collected the subjective patient data which contribute to the nursing assessment performed by the RN. Supervisor #4 stated all patient assessments performed by an LPN were to be supervised by an RN. Supervisor #4 stated during every shift the RN supervisor on shift was to review and co-sign all patient assessments performed by LPNs. Supervisor #4 stated LPNs were supervised by an RN or RN supervisor to ensure patients received complete and comprehensive nursing care.

Supervisor #4 acknowledged the facility had not ensured patient assessments performed by LPNs were supervised and co-signed by an RN.

Based on interviews and document review, the facility failed to perform patient services in accordance with the plan of care. Specifically, the facility failed to provide assistance required for activities of daily living (ADLs) according to the patient's plan of care. This failure was identified in four of five medical records reviewed. (Patient #1, #2, #3 and #5)

Findings include:

Facility policy:

The Care Planning policy dated 3/21, read, care, treatment and services are planned to ensure that they are individualized to the patient's needs. The hospital shall provide an individualized, interdisciplinary plan of care for all patients that are appropriate to the patient's needs, strengths, results of diagnostic testing, limitations and goals. The nursing staff shall develop a plan of care for each patient within 24 hours of admission. Care planning will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals for the patient that are reasonable and measurable. The activities defined in the plan of care shall be planned to occur in the time frame that meets the healthcare needs of the patient. The plan of care shall include the input of other disciplines as appropriate.

1. The facility failed to ensure the patient received the assistance required for activities of daily living (ADLs) and patients did not receive a bath or shower according to the plan of care.

A. Documents were reviewed.

a. According to the Care Planning policy, care plans were individualized to meet the patient's needs. Care plans were developed by nursing within 24 hours of admission and implemented through prescribed treatment plans with input from other disciplines.

b. Patient #1's medical record was reviewed.

i. According to the History and Physical (H&P) dated 12/15/20, Patient #1 had a history of high blood pressure, diabetes and chronic kidney disease. On 12/13/20, Patient #1 presented to another facility with a sudden onset of right-sided weakness, slurred speech and confusion. Patient #1 was diagnosed with intraparenchymal hemorrhage (bleeding in the brain) and was stabilized. Patient #1 was admitted to the facility on 12/15/20 at 5:17 p.m. for continued care and rehabilitation. On 1/7/21 at 8:15 a.m., Patient #1 discharged home with family.

ii. On 12/15/20 at 6:40 p.m., a registered nurse (RN) assigned care plans to Patient #1. Due to neurological and ADL deficits demonstrated by Patient #1, the RN assigned a care plan with the objective for the patient to achieve the highest level of neurological independence in performing ADLs and details regarding the plan of care were in the Occupational Therapy (OT) initial evaluation.

iii. On 12/16/20 at 11:15 a.m., OT #6 evaluated Patient #1. OT #6 documented Patient #1 displayed weakness and decreased balance, safety awareness, coordination, endurance and ability to perform ADLs independently and safely. OT #6 documented Patient #1 performed at least half the effort of washing, rinsing and drying during the shower evaluation. OT #6 documented Patient #1's goal for shower or bathing was supervision or verbal cues. OT #6's treatment plan for Patient #1 included ADL training.

iv. Patient #1 was hospitalized for 23 days. The medical record only showed evidence of five showers performed. The OT treatment notes included documentation of shower training received by Patient #1 on 12/24/20 at 9:21 a.m., 12/30/20 at 7:30 a.m. and 1/5/21 at 8:45 a.m. Certified nursing assistant (CNA) #5 documented Patient #1 received assistance with a shower during her shift on 1/6/21 at 10:32 a.m.

c. Patient #2's medical record was reviewed.

i. According to the H&P dated 12/28/20, Patient #2 had a history of high blood pressure, high cholesterol and chronic alcohol use. On 11/19/20, Patient #2 presented to another facility due to a fall, acute changes in mental status and weakness. Patient #2 was diagnosed with atrial fibrillation and stroke. Patient #2 was admitted to the facility on 12/15/20 at 5:30 p.m. for continued care and rehabilitation. On 1/5/21 at 11:50 a.m., Patient #2 discharged home with family.

ii. On 12/19/20 at 00:23 a.m., a Licensed Practical Nurse (LPN) assigned care plans to Patient #2. Due to neurological and ADL deficits demonstrated by Patient #2, the LPN assigned a care plan with the objective for the patient to achieve the highest level of neurological independence in performing ADLs and details regarding the plan of care were in the Occupational Therapy (OT) initial evaluation.

iii. On 12/19/20 at 1:01 p.m., an occupational therapist evaluated Patient #2 and documented assistance was required during bathing. The OT documented Patient #2 presented with decreased range of motion, strength, balance, memory and insight which impacted independence with ADLs.

iv. Patient #2 was hospitalized for 18 days. The medical record only showed evidence of three showers performed. The OT initial assessment documented the assessment the patient's ability to shower on 12/19/20 at 1:01 p.m. Patient #2 received at shower on 12/20/20 and 12/25/20 according to documentation by nursing.

d. Three additional medical records were reviewed.

i. Patients #3 and #5 were evaluated by an occupational therapist and each required assistance for bathing.

ii. Patient #3 was hospitalized for 12 days and the medical record only showed evidence of one shower performed. One shower refusal by Patient #3 was documented by nursing.

iii. Patient #5 was hospitalized for six days and the medical record only showed evidence of one shower performed.

B. Interviews were conducted.

i. On 5/18/21 at 4:27 p.m., an interview was conducted with OT #6. OT #6 stated patients always received an evaluation of ADLs which included their ability to shower or bathe by occupational therapy the day after admission. OT #6 stated the patient's shower schedule was based on the day of evaluation by an OT. She stated patients were either assigned to receive showers on Mondays, Wednesdays and Fridays or Tuesdays, Thursdays and Saturdays. OT #6 stated the showers would be performed by OT if it was part of the treatment plan to improve the independence of the patients. She stated OT and nursing coordinated to ensure patients received showers on their scheduled days.

ii. On 5/17/21 at 2:25 p.m., an interview was conducted with Registered Nurse (RN) #1. RN #1 stated shower schedules were determined by the admission day of a patient. She stated the day after the patient was admitted was the patient's first shower day. RN #1 stated shower schedules were set to either Monday, Wednesday and Friday or Tuesday, Thursday and Saturday. She stated showers were performed by either nursing or therapy.

iii. On 5/17/21 at 2:38 p.m., an interview was conducted with Certified Nursing Assistant (CNA) #5. CNA #5 stated shower schedules were posted on the board in each patient's room. She stated she also received a report from the CNA from the previous shift if a patient refused a shower and attempted to schedule a shower for the patient during her shift.

iv. On 5/19/21 at 1:04 p.m., an interview was conducted with Nurse Supervisor (Supervisor) #4. Supervisor #4 stated therapy and nursing documented in separate sections of the medical record to indicate patients received assistance for ADLs, such as bathing and dressing. She stated therapy and nursing were able to view documentation done by either discipline.

Supervisor #4 reviewed Patient #1's medical record. Supervisor #4 located documentation in which Patient #1 received five showers during his 23-day hospitalization.

This is in conflict with Patient #1's care plan for ADLs and three times a week shower schedule.

Based on observations, interviews and document review, the facility failed to administer medications in accordance with standard of practice and facility policy. Specifically, the facility failed to ensure the nursing staff completed the two patient identifier process prior to administering medications. The failure was identified in two of two medication administration observations. (Patient #4 and #5)

Findings include:

Facility policies:

The Administration of Medications policy dated 5/21 read, the overview of medication administration includes to follow the seven Rs of administering medications. The seven Rs include the right patient, medication, dose, time, route, documentation and reason. Complete the two patient identifier process. Scan the patient ID bracelet and scan the medication.

The High Risk/High Alert Medications policy dated 2/21 read, the medications may be involved in a high percentage of medication errors and/or sentinel events and have a higher risk for abuse, errors or other adverse outcomes. An included table of high risk medications includes all types of insulin and anticoagulants (blood thinners) such as Lovenox. Protocols and precautions are established for the safe and efficient storage, preparation, distribution and administration of each high alert medication. Prior to administration of a high risk medication, two licensed individuals must verify the correct medication, dosage and medication form are being given.

1. The facility failed to ensure nursing staff completed the two patient identifier process prior to administration of high risk medications.

A. According to the Administration of Medications policy, prior to the administration of a medication, the nurse must complete the two patient identifier process prior to scanning the patient identification bracelet and medication.

B. Medication administrations were observed.

a. Patient #4 was admitted to the facility on 5/12/21 due to metabolic encephalopathy (a disorder of the brain which may cause a change in mental status). Patient #4 had a history of diabetes and stroke. Patient #4's medication orders included a sliding scale for insulin to determine how many units of insulin were received before meals based on the blood glucose reading taken by nursing at the bedside.

i. On 5/18/21, Registered Nurse (RN) #3 was observed administering medication to Patient #4.

ii. At 7:52 a.m. in the medication room, RN #3 and Licensed Practical Nurse (LPN) #7 reviewed Patient #4's orders for the insulin and glucose reading of 215. Both nurses confirmed the insulin dose for Patient #4.

iii. At 8:07 a.m., RN #3 entered room 203, accessed Patient #4's medical record, scanned Patient #4's identification bracelet and scanned the medications. At 8:16 a.m., RN #3 reviewed the medications with Patient #4 and administered the insulin by injection to Patient #4's left upper arm.

b. Patient #5 was admitted to the facility on 5/12/21 due to an ankle fracture. Patient #5 had a history of chest pain. Patient #5's medication orders included Lovenox (a blood thinner) for prevention of blood clots due to immobility.

i. On 5/18/21, RN #3 was observed administering medications to Patient #5.

ii. At 8:28 a.m., RN #3 scanned Patient #5's identification bracelet and medications. RN #3 reviewed the medications with Patient #5, then observed Patient #5 take the oral medications. At 8:32 a.m., RN #3 administered Lovenox by injection to Patient #5's abdomen.

Observations of both medication administrations were in conflict with the facility policy which required the nurse to obtain two patient identifiers prior to scanning the identification bracelet.

C. Interviews were conducted.

a. On 5/18/21 at 5:15 p.m., an interview was conducted with RN #3. RN #3 stated prior to administration of medications, the two patient identifier step was required. She stated the two patient identifiers asked were the patient's name and date of birth. RN #3 stated insulin and blood thinners were considered high risk medications. She stated the two patient identifiers were necessary to prevent the administration of a high risk medication to the wrong patient which could cause harm.

b. On 5/19/21 at 1:04 p.m., an interview was conducted with Nursing Supervisor (Supervisor) #4. Supervisor #4 stated the nurses were expected to perform the two patient identifier process prior to scanning the identification bracelet and administering medications. She stated nurses were expected to ask patients two identifiers, such as their name and date of birth. Supervisor #4 stated the patient's response was confirmed with the patient's identification bracelet and medical record. Supervisor #4 stated the two patient identifier process was important to prevent administering the wrong medication to the wrong patient. Supervisor #4 stated it was never acceptable to skip the two patient identifier step. She stated high risk medications, such as insulin, may cause low blood sugar and symptoms such as fatigue, sweating, tremors, seizures or death if administered the wrong patient.

c. On 5/19/21 at 11:45 a.m., an interview was conducted with RN #2. RN #2 stated prior to administering medications to a patient, she asked them their name and date of birth. RN #2 stated she would ensure the identifiers given by the patient matched the scanned identification bracelet and the medical record. RN #2 stated it was expected for nurses to always ask a patient their name and date of birth to help confirm their identity. She stated this was important for the safety of patients particularly when she administered high risk medications such as insulin or blood thinners. RN #2 stated patients were at risk if administered a high risk medication not intended for them. She stated some possible side effects for a patient who received insulin or Lovenox who did not require them included nausea, lethargy, bruising and bleeding. RN #2 stated some patients may require a transfer to another facility if they received a medication intended for another patient.

Interviews revealed the medication administrations were in conflict with the facility policy which required the nurse to obtain two patient identifiers prior to scanning the identification bracelet.