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Based on review of policy and procedures, clinical records and interview, it was determined the Facility failed to: assure patients (#5, #14 and #15) received sliding scale insulin according to physician orders; obtain an order to place an Influenza A positive patient (#4) in isolation; re-evaluate medication administered as needed for pain or temperature for patients (#1 and #4) and failed to assure enteral tube feeding was administered per physician order (patient #7). The Facility did not assure patient care needs were met in that care was not received according to physician orders and failed to evaluate the nursing care provided. The failed practices affected patients #1, #4, #5, #7, #14 and #15 and had the potential to affect all patients admitted to the Facility. The findings were:
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A. Clinical record review on 01/20-01/22/15 revealed Patient #5, #14 and #15 did not receive insulin as per physician ordered sliding scale.

1) Patient #5 was admitted 01/12/15. Physician order on 01/14/15 at 1600 for bedside glucose testing ac (before meals) and hs (hour of sleep). Hypoglycemic protocol ordered for blood glucose less than 60. No corrective insulin for blood glucose 60-140. Humulin Regular Insulin 3-14 units subcutaneously (sub q) ordered for sliding scale based on results of blood glucose testing: 141-180, 3 units; 181-210, 4 units; 211-250, 7 units; 251-290, 8 units; 291-350, 9 units; 351-400, 10 units;401-450, 14 units and results greater than 450, call physician.

a) On 01/15/15 at 1229 the blood glucose was 282. The clinical record lacked documentation of insulin administration for the blood glucose of 282 at 1229. Review of the physician order revealed the patient should have received 8 units of Humulin Regular Insulin.

b) On 01/15/15 at 1646 the blood glucose was 321. Review of the Medication Administration record revealed 10 units of Humulin Regular Insulin was administered sub q into the left arm. Review of the physician order revealed the patient should have received 9 units of Humulin Regular Insulin.

c) On 01/16/15 at 0518 the blood glucose was 165. The clinical record lacked documentation of insulin administration for the blood glucose of 165 at 0518. Review of the physician order revealed the patient should have received 3 units of Humulin Regular Insulin.

d) On 01/16/15 at 2133 the blood glucose was 168. The clinical record lacked documentation of insulin administration for the blood glucose of 168 at 2133. Review of the physician order revealed the patient should have received 3 units of Humulin Regular Insulin. Comment/reason not administered stated "patient/family refused" and "Didn't eat much for dinner. Not hungry for snack at this time". There was no notation that the physician was advised of the patient/family medication refusal.

e) On 01/17/15 at 0548 the blood glucose was 184. The clinical record lacked documentation of insulin administration for the blood glucose of 184 at 0548. Review of the physician order revealed the patient should have received 4 units of Human Regular Insulin.

f) On 01/18/15 at 0608 the blood glucose was 146. The clinical record lacked documentation of insulin administration for the blood glucose of 146 at 0608. Review of the physician's order revealed the patient should have received 3 units of Human Regular Insulin.

g) On 01/18/15 at 1156 the blood glucose was 247. On 01/18/15 at 1209 the Medication Administration Record listed left arm, but no insulin amount was documented. According to the Insulin sliding scale order the patient should have received 7 units of Human Regular Insulin.

h) The blood glucose results, times and medication administration were verified at the time of clinical record review for Patient #5 on 01/20/15 by Registered Nurse (RN) #4 and completed at 1530.

2) Patient #14 was admitted on 01/15/15. Clinical record review revealed a physician's order on 01/15/15 at 1709 for bedside glucose testing ac (before meals) and hs (hour of sleep). Hypoglycemic protocol ordered for blood glucose less than 60. No corrective insulin for blood glucose 60-140. Humulin Regular Insulin 3-14 units subcutaneously (sub q) ordered for sliding scale based on results of blood glucose testing: 141-180, 3 units; 181-210, 4 units; 211-250, 7 units; 251-290, 8 units; 291-350, 9 units; 351-400, 10 units; 401-450, 14 units and results greater than 450, call physician.

a) On 01/15/15 at 2043 the blood glucose was 149. According to the sliding scale, Patient #14 should have received 3 units of Humulin Regular Insulin subcutaneously (sub q). Documentation on the Medication Administration Record (MAR) revealed at 2100 on 01/15/15 the patient was not administered any insulin and "Patient/family refused" was documented as the reason. The clinical record lacked documentation the physician was notified.

b) On 01/21/15 at 2120 the blood glucose was 168. According to the sliding scale, Patient #14 should have received 3 units of Humulin Regular Insulin sub q. Documentation on the MAR revealed at 2154 on 01/21/15 the patient was not administered any insulin and "Patient/family refused" was documented as the reason. The clinical record lacked documentation the physician was notified.

c) On 01/22/15 at 0534 the blood glucose was 157. According to the sliding scale, Patient #14 should have received 3 units of Humulin Regular Insulin sub q. Documentation on the MAR revealed the patient was not administered any insulin.

d) The clinical record review results related to insulin administration and blood glucose results for Patient #14 were confirmed by RN #1 on 01/22/15 at 0900.

3) Patient #15 was admitted on 01/20/15. Clinical record review revealed a physician's order on 01/20/15 at 0740 for bedside glucose testing ac (before meals) and hs (hour of sleep). Hypoglycemic protocol ordered for blood glucose less than 60. No corrective insulin for blood glucose 60-140. Humulin Regular Insulin 3-14 units subcutaneously (sub q) ordered for sliding scale based on results of blood glucose testing: 141-180, 3 units; 181-210, 4 units; 211-250, 7 units; 251-290, 8 units; 291-350, 9 units; 351-400, 10 units; 401-450, 14 units and results greater than 450, call physician.

a) On 01/20/15 at 1542 the blood glucose was 169. According to the sliding scale, Patient #15 should have received 3 units of Humulin Regular Insulin sub q. The clinical record lacked documentation the patient received 3 units of Humulin Regular Insulin as ordered by the physician.

b) The clinical record review results related to insulin administration and blood glucose results for Patient #15 were confirmed by RN #1 on 01/22/15 at 1000.

B. Clinical record review on 01/21/15 revealed there was no order for Patient #4 to be placed in isolation after testing positive for Influenza A virus. Patient #4 presented to the Emergency Department on 01/19/15 at 1518 by Ambulance. Triage began at 1523 and was completed at 1527. A rapid influenza A/B antigen test was ordered on 01/19/15 at 1553. The result of the rapid influenza test was positive for the influenza A virus. The results were documented as called to nursing (Named) at 1730 on 01/19/15. Review of the clinical record revealed no evidence isolation precautions were implemented for Patient #4 until a physician order on 01/20/15 at 0713 for "Droplet Isolation".

1) Review of Facility policy III.O.1 "Infection Control Policy/Procedure, section III. Implementation of Transmission-based precautions (airborne, droplet, contact, and special contact)". The section stated "Physician should order isolation precautions when needed; All patients must be assessed on admission for the need for infectious disease precautions".

2) The clinical record findings for Patient #4 were confirmed by RN #3 at 0930 on 01/21/15.

C. Clinical record review revealed re-evaluation of medication administered as needed for pain or temperature was not performed for all Patients (#1 and #4).

1) Clinical record review on 01/20/15 revealed Patient #1 presented to the Emergency Department by private car on 10/30/14 at 1051. A Physician ordered Morphine 2 mg for pain at 1801. No pain assessment or pain medication was administered until 10/30/14 at 2103. The pain score assigned at triage (1101) was an 8. The clinical record review findings for Patient #1 were verified on 01/20/15 at 1310 by RN #5.

2) Clinical record review on 01/21/15 revealed Patient #4 presented to the Emergency Department on 01/19/15 at 1518 by Ambulance. The patient temperature was 101.8 Fahrenheit (F) at 1524. The patient was administered acetaminophen 650 milligrams (mg) on 01/19/15 at 1643. The next temperature, documented at 2152, was 99.5 (F) The clinical record did not include a reevaluation of the temperature recorded for 1524, after the administration of acetaminophen at 1643. RN #3 stated "they should have re-checked it in an hour or so". RN #3 confirmed at 0930 on 01/21/15 that there was no re-assessment of the patient's temperature after administration of the Acetaminophen for Patient #4.

D. Clinical record review revealed enteral tube feeding was not administered per physician order for Patient #7. Patient #7 was admitted to the Facility on 01/15/15 at 2028 via the Emergency Department for cellulitis of the abdominal wall. The patient was initially placed on NPO status. A physician order was noted for "Restart tube feeds" on 01/17/15 at 1651 and "Glucerna 1.5 tube feeding continuous" on 01/17/15 at 1805. The clinical record did not include the rate the tube feeding was to be administered or the amount of flush solution.

1) Nursing documentation reflected Glucerna was administered on 01/17/15 at 2200 and was initiated at 20 ml (milliliters) per hour with 10 ml flush; 01/18/15 at 0400 the tube feeding of Glucerna was administered at 30 ml per hour with 10 ml flush and then 01/19/15 at 0300 Glucerna at 45 ml per hour with 10 ml flush.

2) RN #1 confirmed on 01/21/15 at 1100 that the physician order for tube feeding did not include the rate or flush amounts documented as administered on 01/17/15-01/18/15 for Patient #7.