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Based on policies and procedures review, the North Carolina Board of Nursing's "Delegation and Assignment of Nursing Activities Position Statement for RN (Registered Nurse) and LPN (Licensed Practical Nurse) Practice" review, facility job descriptions review, medical record review, facility internal document review, physician interview, and staff interview, the facility failed to ensure RN supervision of care by failing to provide oversight of LPN administration of sedating medications in 1 of 1 sampled patient with a fall (Patient #15); failing to provide medication administration parameters in 3 of 3 sampled patients administered medications that were ordered by physician with administration parameters (Patient's #15,#12,#21); and failed to prevent a patient fall during levels of observation monitoring in 1 of 2 sampled patients documented as high risk fall patients in close observation or 1:1 monitoring (Patient #12).

Findings included:

1. Review on 5/10/2018 of the North Carolina Board of Nursing's "Delegation and Assignment of Nursing Activities Position Statement for RN and LPN Practice" revealed RN Role in Assignment and Delegation: "Maintains overall accountability for the coordination and delivery of nursing care to the individual client." LPN Role in Assignment revealed "Evaluates the effectiveness of the care provided, both the performance of the care and the client's response, and proposes interventions for the nursing plan of care for review by the RN."

Review on 05/10/2018 of the facility's "Position Summary for a Registered Nurse (RN)" (Date Approved: 07/31/2015) revealed "Nursing Services: Monitors the work of assigned licensed and non-licensed personnel."

Review on 05/10/2018 of the facility's "LPN (Licensed Practical Nurse) Position Summary" (Date Approved: 07/31/2015) revealed "Nursing Services: 1. Consults, follows and documents with sufficient detail nursing care according to facility policy and procedures. 5. Administers medications, observes compliance/safe administration."

A closed medical record review for Patient #15 revealed the 89-year-old male was an patient at the facility with a diagnosis of "IVC (Involuntary Committed) change in behavior, Dementia/Alzheimer's." Review of the MAR (Medication Administration Record) revealed Patient #15 was administered Tramadol 50mg (milligrams) Tablet (PRN Pain Medication), Lorazepam 1mg Tablet (PRN Anti-anxiety medication), and Hydroxyzine 50mg Capsule (PRN Anti-anxiety medication) on 04/20/2018 at 2000 by LPN (Licensed Practical Nurse) #1. Further review of the MAR's section for "Nurse's Medication Notes" revealed no documentation for the reason the medications were administered or the results and response of the medications after administered. Documentation of the "Health Pre-Incident Review Report" on 04/20/2018 at 0120 from RN #2 revealed "Patient was asleep in chair in milieu (dayroom). Patient awakened and got out of chair and proceeded to ambulate (walk). Patient lost his balance and fell on sacrum (buttocks area) No injuries noted. VS (Vital Signs) 118/65, 76, 16, Saturation 97% RA (room air). No complaints of pain." Further review of the "Health Pre-Incident Review Report" revealed under "Falls/Slips: Observed box checked" and "Pre-Incident Mental Status: Confused and Sleeping box checked." No documentation was found in the medical record for oversight by RN #2 for the medication administration of sedating medications by LPN #1. The review of the medical records revealed no RN documentation of monitoring the work of assigned licensed personnel.

Interview on 05/10/2018 at 0933 with RN #2 revealed Patient #15 on the night of 04/20/2018 was sitting in the day room, as she was sitting at the desk. The interview revealed that she did not monitor the medications administered on 04/20/2018 by LPN #1. The interview further revealed that Patient #15 was asleep in the chair and suddenly awakened. The interview revealed the patient was observed to standup and "he was sleepy and shoes got stuck to floor" before he was reported to have stumbled with a fall to the floor. Interview revealed patient #15 was assessed for injuries, no injuries noted. The interview revealed the RN was not aware of the supervision for LPNs working on the units.

Interview on 05/10/2018 at 1047 with RN #3 revealed "never been told to supervise them" the LPNs. Interview revealed the only difference in LPN and RN is the LPN is not allowed to do admissions or discharges. Interview further revealed RN #3 brought to nurse manager's attention the overuse of sedatives. Interview also revealed RN #3 has "seen certain nurses give multiple medications at one time" then chart effective/sleeping as the reasoning. Interview also revealed more training and education needed for nurses and new nurses need longer time spent precepting another nurse before being released to care for patients.

Interview on 05/10/20187 at 1202 with the facility's DON (Director of Nursing) revealed "RN supervises LPN notes, patient care, and medication pass." Interview revealed RN should be aware of the medications the LPN is giving. The interview also revealed "we just started using LPNs." Interview revealed RNs are in charge of the unit at all times and that it should be expectation that LPNs are supervised by a RN.

An interview attempted with LPN #1 via telephone on 05/10/2018 at 1012 but there was no answer or return call from the LPN to conduct an interview.

2. a) A closed medical record review for Patient #15 revealed the 89-year-old male was an patient at the facility with a diagnosis of "IVC (Involuntary Committed) change in behavior, Dementia/Alzheimer's." Review of the Physician's Order Sheet dated 04/14/2018 1752 revealed medication orders written as "Zyprexa Zydis 5mg PO q8 PRN agitation >8/10" (atypical antipsychotic medication). The review of the medical record revealed no other information for clarification of "agitation > 8/10" that was written in the physician order. Review of the MAR (Medication Administration Record) for Patient #15 revealed the medication was administered by the facility's nursing staff (Unidentified Nursing Staff) on 04/14/2018 at 2120 and again 04/16/2018 at 0945. The review of the documentation revealed no documentation by the nursing staff that the patient was administered the medications based on agitation greater than 8 of 10.

Interview with MD (Physician) #1 on 05/08/2018 at 1515 revealed that he did write the physician order for "Zyprexa" with an agitation scale on 04/14/2018 while he reviewed the physician orders in the medical record during the interview. The interview revealed the physician was unable to recall any agitation or sedation scale parameters for the facility nursing staff to use when administering PRN (As needed) medications that were ordered with agitation parameters. The interview also revealed that the physician could not describe what ">8/10" parameters for agitation would be in administering medications ordered with those parameters.

Interview on 05/09/2018 at 1553 with RN #1 revealed that she did not know of any agitation scale or guidelines provided by the facility or medical staff to guide the nurses in administering medications ordered by physicians with agitation parameters. The interview with RN #1 revealed, "I have not seen a printed agitation scale, I have had to go on my experience." The interview also revealed RN #1 stated that she learned severe agitation by "just being a nurse." Interview further revealed RN #1 stated that it would be "Helpful if we had something posted in medication room." The interview with RN #1 concluded that it was "pretty much up to the nurse" on which physician ordered PRN anxiety/agitation medications and/or combinations were decided to administer.

Interview on 05/10/2018 at 0933 with RN #2 revealed "Doctor usually orders sedation with agitation scale." The interview revealed RN #2 attempts to administer one sedating medication at a time and then three to four hours later give a different sedating medication if still needed. The interview revealed the agitation scale is not cut and dry, "I would do better with symptoms." The interview also revealed RN #2 "my six might be different than someone else's six." The interview further revealed the RN was not aware of any agitation parameter guidelines provided by the facility or medical staff to help the nursing staff determine how to administer medications ordered with parameters.

Interview on 05/10/2018 at 1047 with RN #3 revealed she was also not aware of any agitation scale or guidelines provided for the nursing staff to use for medications ordered with agitation scale parameters. The RN revealed that PRN medications are written by Doctor, but the orders have no "actual agitation scale" to guide the nursing staff. Interview revealed "Nursing judgment basically" for determining which Doctor ordered PRN anxiety/agitation medications and/or combinations decided to administer.

A review of the facility's policies and procedures revealed there were no medication administration parameters found to guide the nursing staff in administering medications ordered with parameters. The review of facility internal documentation also revealed no guidance or direction could be found or produced for medication administration guidelines for medications ordered by physicians with parameters for agitation or sedation.

b) Review on 05/10/2018 of the open medical record for Patient #12 revealed the 80-year-old male was a patient at the facility with a diagnosis of "Dementia with increasingly aggressive/assaultive behaviors." Review of the Physician's Order Sheet dated 04/24/2018 at 1745 revealed an order for "Ativan 2mg (milligrams) PO (by mouth) Q4 (every four hours) PRN (as needed) anxiety >8/10" (Anti-anxiety Medication) and on 04/24/2018 1900 "Zyprexa Zydis 5mg po q6 PRN agitation >8/10." Review of the Physician's Order Sheet dated 05/08/2018 at 1500 also revealed "Seroquel 25mg po q8 prn agitation >8/10" (Anti-psychotic Medication). Review of the MAR for Patient #12 revealed the medication "Ativan" was administered on 04/24/2018 at 1800 and the medication "Zyprexa" was administered on 04/29/2018 at 1540, 04/30/2018 at 1950, and on 05/01/2018 at 1930 all by the facility's nursing staff (Unidentified Nursing Staff). The review of the documentation revealed no documentation by the nursing staff that the patient was administered the medications based on agitation greater than 8 of 10.

Interview with MD #1 on 05/08/2018 at 1515 revealed the physician was unable to recall any agitation or sedation scale parameters for the facility nursing staff to use when administering PRN (As Needed) medications that were ordered with agitation parameters. The interview also revealed that the physician could not describe what ">8/10" parameters for agitation would be in administering medications ordered with those parameters.

Interview on 05/09/2018 at 1553 with RN #1 revealed that she did not know of any agitation scale or guidelines provided by the facility or medical staff to guide the nurses in administering medications ordered by physicians with agitation parameters. The interview with RN #1 revealed, "I have not seen a printed agitation scale, I have had to go on my experience." The interview also revealed RN #1 stated that she learned severe agitation by "just being a nurse." Interview further revealed RN #1 stated that it would be "Helpful if we had something posted in medication room." The interview with RN #1 concluded that it was "pretty much up to the nurse" on which physician ordered PRN anxiety/agitation medications and/or combinations were decided to administer.

Interview on 05/10/2018 at 0933 with RN #2 revealed "Doctor usually orders sedation with agitation scale." The interview revealed RN #2 attempts to administer one sedating medication at a time and then three to four hours later give a different sedating medication if still needed. The interview revealed the agitation scale is not cut and dry, "I would do better with symptoms." The interview also revealed RN #2 "my six might be different than someone else's six." The interview further revealed the RN was not aware of any agitation parameter guidelines provided by the facility or medical staff to help the nursing staff determine how to administer medications ordered with parameters.

Interview on 05/10/2018 at 1047 with RN #3 revealed she was also not aware of any agitation scale or guidelines provided for the nursing staff to use for medications ordered with agitation scale parameters. The RN revealed that PRN medications are written by Doctor, but the orders have no "actual agitation scale" to guide the nursing staff. Interview revealed "Nursing judgment basically" for determining which Doctor ordered PRN anxiety/agitation medications and/or combinations decided to administer.

A review of the facility's policies and procedures revealed there were no medication administration parameters found to guide the nursing staff in administering medications ordered with parameters. The review of facility internal documentation also revealed no guidance or direction could be found or produced for medication administration guidelines for medications ordered by physicians with parameters for agitation or sedation.

c) Review on 05/10/2018 of open medical record for Patient #21 revealed a 75-year-old male was a patient at the facility admitted to the facility on 04/24/2018 who was observed on the facility's acute unit. Review of the Physician's Order Sheet for the patient dated 05/05/2018 1206 revealed order for Zyprexa Zydis 5mg PO q4 hrs PRN for severe >6/10 agitation." Further review of the Physician's Order Sheet dated 05/08/2018 1646 revealed order for "Seroquel 25mg PO q4 PRN agitation >8/10." Review of the MAR (Medication Administration Record) for Patient #21 revealed the medication was administered by the facility's nursing staff (Unidentified Nursing Staff) on 05/05/2018 at 0048. The review of the documentation revealed no documentation by the nursing staff that the patient was administered the medications based on agitation greater than 8 of 10.

Interview with MD #1 on 05/08/2018 at 1515 revealed the physician was unable to recall any agitation or sedation scale parameters for the facility nursing staff to use when administering PRN (As Needed) medications that were ordered with agitation parameters. The interview also revealed that the physician could not describe what ">8/10" parameters for agitation would be in administering medications ordered with those parameters.

Interview on 05/09/2018 at 1553 with RN #1 revealed that she did not know of any agitation scale or guidelines provided by the facility or medical staff to guide the nurses in administering medications ordered by physicians with agitation parameters. The interview with RN #1 revealed, "I have not seen a printed agitation scale, I have had to go on my experience." The interview also revealed RN #1 stated that she learned severe agitation by "just being a nurse." Interview further revealed RN #1 stated that it would be "Helpful if we had something posted in medication room." The interview with RN #1 concluded that it was "pretty much up to the nurse" on which physician ordered PRN anxiety/agitation medications and/or combinations were decided to administer.

Interview on 05/10/2018 at 0933 with RN #2 revealed "Doctor usually orders sedation with agitation scale." The interview revealed RN #2 attempts to administer one sedating medication at a time and then three to four hours later give a different sedating medication if still needed. The interview revealed the agitation scale is not cut and dry, "I would do better with symptoms." The interview also revealed RN #2 "my six might be different than someone else's six." The interview further revealed the RN was not aware of any agitation parameter guidelines provided by the facility or medical staff to help the nursing staff determine how to administer medications ordered with parameters.

Interview on 05/10/2018 at 1047 with the facility's RN #3 revealed she was also not aware of any agitation scale or guidelines provided for the nursing staff to use for medications ordered with agitation scale parameters. The RN revealed that PRN medications are written by Doctor, but the orders have no "actual agitation scale" to guide the nursing staff. Interview revealed "Nursing judgment basically" for determining which Doctor ordered PRN anxiety/agitation medications and/or combinations decided to administer.

A review of the facility's policies and procedures revealed there were no medication administration parameters found to guide the nursing staff in administering medications ordered with parameters. The review of facility internal documentation also revealed no guidance or direction could be found or produced for medication administration guidelines for medications ordered by physicians with parameters for agitation or sedation.

3. Review on 05/10/2018 of the facility's "Fall Risk Precautions" (Revised: 06/12/2015) revealed "Policy: All patients will be assessed for the potential to fall and will be placed on an appropriate prevention program upon admission. Procedure: Nursing staff will assess and determine risk of adult patients with regard to falls utilizing the Fall Risk Assessment tool. Based on the score on the Fall Risk Assessment, nursing judgment and/or physician input, patients will be placed on Fall Precaution.
Nursing Interventions:

-Instruct patient to wear non-slip footwear,
-Reassess and observe every 2 hours after medication change or as condition worsens,
-Remind patient to call for assistance to go to the bathroom at night,
-Communicate patient's "Fall Risk" during nursing shift report,
-Identify the patient's "Fall Risk" on patient door with a yellow star and a fall label on the patient's chart."

Review on 05/10/2018 of the facility's policy for "Levels of Observation" (Approved: 09/2013) revealed "Purpose: To provide a consistent, therapeutic approach to ensure a safe environment for the patients within the facility." "15 minute Observations: The patient is observed with visual checks every 15 minutes." "Line of Sight (LOS): The patient must be in sight of a staff member at all times and 15-minute checks documented." "One to One Observation (1:1): One-to-one is where a staff member is assigned to a patient to care for them in constant attendance and remain in arm's length at all times."

Review on 05/10/2018 of the open medical record for Patient # 12 revealed an 80-year-old male was a patient at the facility with a diagnosis of "Dementia with increasingly aggressive/assaultive behaviors." Review of the "Health Pre-Incident Review Report" revealed on 04/24/2018 at 1745 "Pt.(Patient) fell from wheelchair to floor, observed by MHT (Mental Health Technician) - ___ (Name of MHT). Vitals taken recorded, family notified, assessed pt has skin tear left upper inner arm, cleansed and bandage applied. He continues on 1:1 observation d/t (due to) aggression/irritability." Further review of "Health Pre-Incident Review Report" revealed "Falls/Slips" category: Observed box checked and "other: fall from wheelchair to floor." Review of the "Health Pre-Incident Review Report" revealed on 04/24/2018 at 1915 as "Called to room, noted resident lying on the bed bleeding from left side of head. MHT stated he got out of bed and fell to the floor." Further review of "Health Pre-Incident Review Report" revealed "Falls/Slips" category: Observed box checked. "Treatment or intervention given: ER Hospital/____ (Name of Local Hospital) ER." Review of "Nursing Progress Note" for 04/24/2018 7p-7a, "Precautions: Other 1:1" boxed checked. Review of the "Physician Progress Note" for 04/26/2018 1642 revealed "attempts to walk with poor gait plus fall yesterday. Needs 1:1 all times." Medical record review of the "SOAP Note" dated 04/30/2018 1228 revealed "fall risk. Fell last night." The review of medical records revealed Patient #12 experienced two falls while observed on 04/24/2018 while the patient was documented by the facility staff as being on 1:1 observation status.

Random interview on 05/08/2018 at 1035 was conducted with a facility MHT (#1) during observation of the MHT monitoring a patient (#12) for fall risk. The MHT was observed to be sitting inside of the patient room doorway with the patient in line of site. The interview revealed patient had an unsteady gait and was a fall risk. The observation revealed the MHT was sitting in the edge of the door of the patient's room during the time of the interview.

Interview on 05/08/2018 at 1514 with MD #1 revealed that he had observed falls occurring while a patient would be under 1:1 observation. Further interview revealed MD #1 reported his concerns of patients falls while being under 1:1 observation to administration. Further interview also revealed "Don't understand 1:1 when in bed how they still fall." The interview with the physician revealed concerns for patient's having falls while having staff assigned as 1:1. The interview revealed the physician was in room with a patient on 1:1 along with MHT during a patient fall.

Random interview on 05/09/2018 at 1518 during observation and tour with CNA # 1(Certified Nursing Assistant) revealed once patients enter their room they go from "1:1" to "close obs". "When out of their rooms I would have to be in arms reach the whole time. While they are in room they can be on close obs." Interview revealed CNA #1 defines 1:1 as arms reach and close obs as line of sight. Interview revealed doctors order "usually" written for a patient to be under close obs.

Random interview on 05/09/2018 at 1536 with MHT #2 revealed close observation is being able to see them with eye sight, staying close, and removing obstacles between "me and them", making sure they are safe. 1:1 is one patient to one staff member, always within arm's reach to them. Interview revealed instructed by CNA's "usually" if they are on 1:1.

Interview on 05/09/2018 at 1553 with RN #1 revealed patients have been on close observation before and still fall because "they can trip before they get to them." The interview failed to reveal information for patients falling if on 1:1 observation and within arm's length. Interview also revealed if patients are on "close obs," there are no limit on numbers of patients being observed.

Based on policy and procedure review, facility job descriptions review, the North Carolina Board of Nursing's "Nursing Practice Act" review, medical record review and staff interview, the facility nursing staff failed to document a patient pre-assessment and re-assessment for 2 of 2 sampled patients receiving PRN (As Needed) medications who were documented as high-risk for falls (Patient's #12, #15).

Findings included:

Review on 05/08/2018 of the facility's policy titled "Pharmacy Department" (Revised: 01/23/2018) revealed "Procedure- B. All PRN orders must specify frequency of administration and rationale for medication administration." "7. When PRN medications shall be administered, the following documentation is provided:
a. Date and time of administration, dose, route of administration (if other than oral), and, if applicable, the injection site.
b. Complaints or symptoms for which the medications were given.
c. Results achieved from giving the dose and the time results were noted."

Review on 05/10/2018 of the North Carolina Board of Nursing's "Nursing Practice Act" revealed:

"§ 90-171.20. Definitions. As used in this Article, unless the context requires otherwise:
(7) The "practice of nursing by a registered nurse" consists of the following components: a. Assessing the patient's physical and mental health, including the patient's reaction to illnesses and treatment regimens.
b. Recording and reporting the results of the nursing assessment... f. Implementing the treatment and pharmaceutical regimen prescribed by any person authorized by State law to prescribe the regimen... h. Reporting and recording the plan for care, nursing care given, and the patient's response to that care." Review of the "Nursing Practice Act" further revealed, "(8) The "practice of nursing by a licensed practical nurse" consists of the following components: a. Participating in the assessment of the patient's physical and mental health, including the patient's reaction to illnesses and treatment regimens... b. Recording and reporting the results of the nursing assessment... e. Reporting and recording the nursing care rendered and the patient's response to that care."

Review on 05/10/2018 of the facility's "Position Summary for a Registered Nurse" (Date Approved: 07/31/2015) revealed "Nursing Services: 5. Administers medications, observes compliance/safe administration, consults pharmacy when indicated and records effectiveness or reactions to psychotropic and other medications."

Review on 05/10/2018 of the facility's "LPN Position Summary" (Date Approved: 07/31/2015) revealed "Nursing Services: 5. Administers medications, observes compliance/safe administration, consults pharmacy when indicated and records effectiveness or reactions to psychotropic and other medications."

1. Review on 05/10/2018 of the open medical record for Patient # 12 revealed an 80-year-old male was a patient at the facility on with a diagnosis of "Dementia with increasingly aggressive/assaultive behaviors." Medical record review of the MAR dated 04/25/2018-05/01/2018 revealed documentation under "Nurse's Medication Notes" section the following PRN medications were administered by the facility's nursing staff:

- "04/25/2018-Tylenol (Pain Medication) given at 2325." (Unidentified Nursing Staff)
- "04/27/2018-Ativan (Anti-Anxiety Medication) given at 1529" (Unidentified Nursing Staff)
- "04/27/2018- Tylenol given at 2140" (Unidentified Nursing Staff)
- "04/28/2018- Ativan given at 1553" (Unidentified Nursing Staff)
- "05/06/2018- Ativan given at 0350" (Unidentified Nursing Staff)

The review of the facility's medical records revealed no pre-assessment and/or post-assessment documentation for the administration of PRN medications.

Interview with the facility's DON on 05/10/2018 at 1202 revealed nurses should always document the reason, time, date and results when giving PRN medications. Interview also revealed that Pain levels, location, medication, and medication results should be documented by the nursing staff after one hour on the back of the MAR. The interview confirmed the medical record finding.

2. Review on 05/08/2018 of the closed medical record for Patient #15 revealed an 89-year-old male was a patient at the facility with a diagnosis of "IVC (Involuntary Committed) change in behavior, Dementia/Alzheimer's." Medical record review of the MAR dated 04/27/2018 revealed documentation under "Nurse's Medication Notes" section the following PRN medications were administered by the facility's nursing staff:

- "04/26/2018- Lorazepam, Hydroxyzine (Anti-Anxiety Medications), and Melatonin (Sleep Medication) given at 2040" (Unidentified Nursing Staff)
- "04/27/2018- Melatonin, Vistaril (Anti-Anxiety Medication), and Tramadol (Pain Medication) given at 2047" (Unidentified Nursing Staff)

The review of the facility's medical records revealed no pre-assessment and/or post-assessment documentation for the administration of PRN medications.

Interview with the facility's DON on 05/10/2018 at 1202 revealed nurses should always document the reason, time, date and results when giving PRN medications. Interview also revealed that Pain levels, location, medication, and medication results should be documented by the nursing staff after one hour on the back of the MAR. The interview confirmed the medical record finding.

NC00138585.