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Based on clinical record, policy, and procedure review and staff interview it was determined that the Registered Nurse failed to supervise and evaluate care related to implementing physician orders, assessments, and adhering to facility policy for skin care for 1 (#1) of 3 sampled patients. This practice does not ensure patient needs are met.

Findings include:

1. Patient #1 's physician order dated 5/3/11 at 6:24 p.m. instructed for a sputum culture to be obtained. Review of laboratory results revealed no evidence of the culture being obtained.

Interview with the Chief Clinical Officer (CCO) on 5/10/11 at approximately 3:10 p.m. confirmed the sputum culture had not been obtained as ordered by the physician.

2. Review of policy and procedure "Assessment/Reassessment" #H-PC 04-009 last revised 11/10 noted that patients are reassessed by nursing each shift and that a Registered Nurse (RN) assesses the patients at a minimum of every twenty four hours.

Patient #1 was assessed by a Licensed Practical Nurse (LPN) on 5/6/11 at midnight, 8:00 a.m. and 8:25 p.m. The patient was assessed by a RN on 5/5/11 at 9:00 p.m. The patient had not been assessed by a RN for approximately twenty nine hours. The RN assessment showed the patient conversed on the ventilator and was oriented. There was no evidence of new concerns or distress. The LPN assessment on 5/6/11 at 8:07 a.m. revealed the patient was alert, breathing was unlabored. and heart sounds were normal. The LPN assessment at 5/6/11 at 8:19 p.m. revealed the presence of rhonchi and no other change. The LPN assessment on 5/7/11 at midnight revealed a cardiac assessment was done with no change. RN documentation on 5/7/11 at 2:20 a.m. revealed the patient was noted to have a low heart rate on the telemetry monitor and subsequently expired.

Interview with the Chief Clinical Officer (CCO) on 5/10/11 at approximately 1:18 p.m. confirmed the patient was not assessed per policy by a RN.

3. Review of policy and procedure "Prevention of Skin Breakdown" #H-WC 01-001 last revised 11/09 indicated patients that are unable turn themselves , the staff was to turn the patient every two hours.

Patient #1 was admitted to the facility with diagnoses that included ventilator dependent and quadriplegia following a traumatic spinal cord injury. Review of random days from admission on 2/25/11 to discharge on 5/7/11 revealed no documentation that the patient was turned every two hours. Review of nursing documentation dated 5/6/11 revealed the patient was turned to the left at 11:54 a.m. Documentation at 4:42 p.m. revealed the patient was turned to the left. There was no documentation the patient was turned at 2:00 p.m. Nursing documentation at 8:39 p.m. showed the patient was turned to the left. There was no documentation of the patient being turned at 6:00 p.m. At 10:00 p.m. the patient was turned to the left, the same position. Review of nursing documentation dated 5/5/11 revealed the patient was turned to the left at 5:34 a.m. Nursing documentation at 10:04 a.m. showed the patient was turned to the left, the same position and no other evidence of the patient beng turned. The documentation noted at noon the patient was turned to the right. The patient was turned to the left at 6:01 p.m. There was no other documentation of the patient being turned. Review of nursing documentation dated 4/20/11 revealed the patient was turned to the left at 1:49 p.m. There was no evidence of the patient being turned again until 8:11 p.m. Review of nursing documentation dated 3/29/11 revealed the patient was turned to the left at 6:46 a.m., to the left at 8:00 a.m., and the right at 10:00 a.m. The patient was on the left side for approximately three hours. Review of nursing documentation dated 3/2/11 revealed the patient was turned right at 2:02 a.m. and not turned until 6:29 a.m.

Interview with the Chief Clinical Officer (CCO) on 5/10/11 at approximately 1:18 p.m. confirmed the documentation did not show evidence of the patient being tuned very two hours according to facility policy.

Based on clinical record review and staff interview it was determined that the nursing staff did not administer medication as ordered by the physician for 1 (#1) of 3 records reviewed. This practice does not ensure safe and effective medication therapy.

Findings include:

1. Patient #1's Registered Nurse documentation dated 5/7/11 at 2:20 a.m. revealed the patient became bradycardiac and was administered Atropine. Review of physician orders and physician progress notes did not reveal evidence of an order or that the patient had received Atropine.


Patient #1's Medication Administration Record (MAR) dated 5/3/11 revealed the patient was to receive Methadone 5 milligrams (mg) every six hours via feeding tube at midnight, 6:00 a.m., noon, and 6:00 p.m. The review showed the Methadone was administered at midnight, 6:00 a.m., 1:24 p.m. and 5:25 p.m.

Review of policy and procedure "Administration of Medications" #H-MM 50-001 last revised 11/09 indicated medications will be administered within thirty minutes before or after the scheduled does.

Interview with the Chief Clinical Officer (CCO) on 5/10/11 at approximately 3:10 p.m. confirmed the lack of physician order for the Atropine and that the Methadone was not administered per policy.