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Based upon observation, record review and interview, the governing body failed to:



A.) ensure the patients were safe from falls, report out of range blood pressures and critical glucose values, document safety measures while sleeping in day area and at nurses station, and implement nursing interventions to prevent falls in 2 (#3 and 16) out of 5 (#2, 3, 7, 16, and 8) patients reviewed. The facility failed to follow their own policy requiring staff to visually observe patients every 15 minutes for location, activity, behavior and unsafe activities in 3 (patients #1, #6 and #18) of 5 (patients #1, #6, #8, #17, #18) records reviewed.

Refer to Tag A0144


B.) properly assess patients with elevated blood pressures and blood sugars, nursing interventions, and document notification of critical lab values in 3(#3, 7, and 16) of 5(#3, 7, 8, 16 and 17) patients reviewed. The facility failed to ensure all patients received a complete nursing physical and psychological assessment every 12 hours in 2 (patients #8 and #18) of 5 (patients #1, #6, #8, #17, #18) records reviewed.

Refer to Tag A0395

Based upon observation, record review and interview, the facility failed to:



A.) ensure the patients were safe from falls, report out of range blood pressures and critical glucose values, document safety measures while sleeping in day area and at nurses station, and implement nursing interventions to prevent falls in 2 (#3 and 16) out of 5 (#2, 3, 7, 16, and 8) patients reviewed. The facility failed to follow their own policy requiring staff to visually observe patients every 15 minutes for location, activity, behavior and unsafe activities in 3 (patients #1, #6 and #18) of 5 (patients #1, #6, #8, #17, #18) records reviewed.

Refer to Tag A0144

Based on chart reviews, interview, and policy and procedure review, the facility failed to ensure the patients were safe from falls, report out of range blood pressures and critical glucose values, document safety measures while sleeping in day area and at nurses station, and implement nursing interventions to prevent falls in 2 (#3 and 16) out of 5 (#2, 3, 7, 16, and 8) patients reviewed. The facility failed to follow their own policy requiring staff to visually observe patients every 15 minutes for location, activity, behavior and unsafe activities in 3 (patients #1, #6 and #18) of 5 (patients #1, #6, #8, #17, #18) records reviewed.

1.) Review of patient #3's chart revealed the patient was admitted to the facility on 12-4-15 at 5:15PM. Patient #3 was admitted with a diagnosis of Neurocognitive Disorder with Behavioral Disturbances, involuntarily, on an Emergency Police Officers Warrant (EPOW). Patient #3 has had a negative psychiatric history. No psychotropic medications have ever been taken by patient #3.

Review of patient #3's daily nurse's notes revealed the patient was on fall precautions at high risk with a bed alarm on. Review of the Multi-Disciplinary Note dated 12/9/15 at 11:15AM stated, "Pt. rolled out of bed landing on the floor. Pt fell approx. 2 feet. Pt denied LOC or any pain or injuries. Pt had no visible injuries. Full body assess was performed, v/s taken, MSC-good no deformities, outward rotation, or shortening of the leg. Family, DR., and DON notified. Mats put on both sides of bed. Fall packet completed. Patient now sleeping and stable." There was no documentation of bed alarm.

According to the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health, blood pressure for adults is
Normal BP <120/<80 mmHg
Heart Rate: Female: 55-95 bpm
Respiration Rate: 12-18 breaths per minute

Review of patient #3's chart revealed a Neuro Flow sheet was started on patient #3 after the fall at 11:15PM. The following vital signs were taken as follows;
1.) 11:15PM- Review of the vital signs revealed the blood pressure was elevated at 162/107 and her heart rate was elevated at 120. Patient #3 has a history of atrial fibrillation and has a defibrillator.
2.) 11:30PM- blank on vital signs.
3.) 11:45PM- Blood pressure 150/90 and heart rate 110.
4.) 12:15AM- Blood pressure 163/85 and heart rate 60.

There was no nursing documentation found until 12/10/15 at 1:15AM. The nurse documented, "Continuing vital sign checks d/t fall earlier. Pt was agitated, crying d/t VS checks. BP was difficult to obtain, multiple attempts made. Final BP- 157/118, HR- 65, R 14, T- 97.7 O2 sat -99%. Pt laid back down and went back to sleep." There was no documentation that the physician was notified of the patients' hypertension. There was no documented evidence in the nurse's notes or physician progress notes that the physician was aware of the elevated blood pressure and heart rate.

There was no nursing documentation until three hours later at 4:00AM. The nurse documented Pt. became extremely anxious and agitated with vs. She was crying loudly and wailing. MHT unable to assess BP and HR. BP- 153/82 HR- 72. Assessed pt. and respirations 16, even, unlabored, no cyanosis noted. Skin is warm and dry afebrile. Since vs agitate pt. too much at this time, directed MHT to skip 5:15AM vs will continue to check on pt." There was no documentation of any nursing interventions to help the distressed patient.

Review of the Vital Signs and I&O sheet revealed the patient's blood pressure was taken on the "day" shift at 148/111. There is no documented nurse's response to the elevated blood pressure, no documentation found that the physician was notified. There was no documented time when the blood pressure was taken. Review of the 7:00PM-7:00AM daily nurse's note stated patients BP was 148/11 "retake" 142/86. There is no documentation of when that VS was retaken.

Review of the MHT "Close Observation Check Sheet " revealed patient #3 was in room until 4:00AM on 12/10/15. At 4:14AM Patient #3 was in the dayroom sleeping. The nurse documented the patient had bed alarms on and mats by her bed but the patient was not in a bed according to the MHT notes. The MHT notes revealed patient #3 was not in a bed to rest until 8:30PM on 12/11/15 a total of 40 hours. There was no documentation of any nursing interventions, or attempts to allow patient to rest in a bed. There was no documentation that MD was made aware that patient had not been in a bed for 40 hours.

Review of the incident reports from October -December 2015 revealed there was no follow-up on the reports by the DPN or Patient Safety Officer.

Interview with DPN on 12/16/15 revealed she had not addressed any of the incident reports from falls for October- December. The DPN reported she has not had time.

2.) Review of patient #16 revealed the patient was admitted to the facility on 11/11/15 at 7:30PM. Patient was admitted on an Emergency Police Officers Warrent (EPOW) and arrived to the facility by ambulance. Patient #16 was admitted with a diagnosis of Neurocognitive Disorder with Behavioral Disturbance and Delusional Disorder.

Review of the Multi-Disciplinary Notes dated 11/18/15 at 12:00AM revealed patient #16 was having chest pain. The nurse documented, "Patient yelling out and complaining of chest pain. When asked where he's hurting he placed his hand over his left chest. Head of bed is already elevated. When asked what his pain fells like, he replied the pain feels heavy. Vital signs taken; T- 97.4 P- 90, (pacemaker in place), R-18, unlabored BP-158/80, O2 sat- 100% Finger stick blood sugar 228. Skin pink, warm to touch, and dry. MD notified and given report on patients' condition. The patient does not appear to be in any distress. Orders received and carried out CMMS mobile x-ray notified of order."

Review of a telephone physician orders dated 11/18/15 at 12:15AM stated, "Do EKG; notify me of results if any changes noted in comparison of previous EKG." The order was not documented aa a "STAT" order. There was no specifics in who was to read the EKG.

Review of the nurses notes date 11/18/15 at 1:35AM stated, "Staff from CMMS came and did EKG. Results of EKG called to MD. MD said to observe the patient and notify him if further complaints are voiced. Patient denies having chest pain at this time. He is awake and has disconnected the alarm pad on his bed. Alarm reconnected. Patient repositioned and made comfortable."

There was no further documentation of observation or care to patient #16 until 11/18/15 at 7:00AM, a 5 ½ hour time span.

Review of the physician progress note revealed the physician saw patient #16 on 11/18/15 at 6:00AM. MD wrote, "CP unclear no EKG changes. BS 100's-200's."

Review of the nurses notes dated 11/18/15 at 9:06PM revealed the nurse documented, "Blood sugar taken at 9:00PM- 416, MD notified pt. asymptomatic ate bread, cookies, and baked chips for supper. No orders received will retake blood sugar in two hours, and at scheduled time 0600. Will monitor for s/sx of hyper/hypoglycemia."

Review of the admission physician orders revealed patient #16 was to be on a low NA (sodium) and LCS (low concentrated sweets). Nursing failed to adhere to the patients ordered diet.

Review of patient #16's chart revealed there was no nursing documentation found of patient assessment or recheck of patient #16's blood sugar until 6:00AM on 11/19/2015 a 9 hour delay.

Review of the nurse's notes on 11/19/15 at 8:45PM stated, "Blood sugar check results of 506 assessment done on pt. Pt. has no shaking. Skin warm and dry. Temp 98.2, HR 98, B/P 143/78, O2 sat 99%. BS recheck at 9:25PM results of 247 pt. asymptomatic. Will continue to monitor for s/s of hypoglycemia."

There was no documentation of nurse notifying MD of a 506 blood sugar or a nursing intervention. There was no found documentation of a glucometer error. The test sheet from the glucometer shows the glucometer was checked without failure.

An interview was conducted with DPN on 12/16/15 and staff #1 confirmed the findings above. The DPN reported that she had been trying to audit the charts and had the staff nurses auditing the charts. DPN confirmed nursing had not reported the elevated blood sugars to her.




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3.) A review of patient #1's record revealed a "Multi-Disciplinary Note" with the following documentation: "12/10/15 1120 (11:20 a.m.) NSG #1 Staff was making rounds and noticed patient getting out of bed. Staff entered the room and attempted to assist patient and he began calling her names. Staff asked patient if she could change his soiled clothes and again he began to call her out of her name and swung to hit her. Staff exited the room to get other staff to help patient in fear that he would fall ....12/10/15 1145 (11:45 a.m.) NSG #1 Patient continue calling staff names and trying to hit kick and spit on them. He hit one staff and kicked another ...."

A review of patient #1's record revealed a "Close Observation Check Sheet" dated 12/10/15. The MHT (Mental Health Tech) documented patient #1's location and activity from 8:00 a.m. until 12:00 p.m. as "in room sleeping". The documentation by the MHT contradicted the documentation by the nursing staff for this time period.

A review of patient #1's record revealed a "Multi-Disciplinary Note" with the following nursing documentation: "12/11/15 2030 (8:30 p.m.) NSG #1 Patient continue to be aggressive. Hitting staff. Calling staff out of their names. Attempted to distract patient by offering activities, snacks but patient refused and slapped staff. Patient calling staff 'black niggers'. Threatening to kill all black employees and workers. Patient sitting in dayroom being aggressive. Continue to monitor."

A review of patient #1's record revealed a "Close Observation Check Sheet" dated 12/11/15. The MHT (Mental Health Tech) documented patient #1's location and activity from 7:15 p.m. until 11:00 p.m. as "in room". The documentation by the MHT contradicted the documentation by the nursing staff for this time period.

A review of patient #1's record revealed a "Multi-Disciplinary Note" with the following nursing documentation: "12/12/15 2130 (9:30 p.m.) NSG #1 Patient is going door to door trying to get out 'I just got a page from my company. How do I get to the parking lot'. Pt is walking in the hallway. 'I need to use the phone, the shipment is coming in and I need to be there'. Pt (patient) returned to his room."

A review of patient #1's record revealed a "Close Observation Check Sheet" dated 12/12/15. The MHT (Mental Health Tech) documented patient #1's location and activity from 9:30 p.m. until 10:30 p.m. as "in dining room". The documentation by the MHT contradicted the documentation by the nursing staff for this time period.

A review of patient #1's record revealed a "Multi-Disciplinary Note" with the following nursing documentation: "12/13/15 2330 (11:30 p.m.) NSG #1 Pt continue to have aggressive behavior. Pacing up and down the halls making racial comments and threating to hit staff. Patient spit on one staff. Redirected patient to his room. Patient layed in floor and started kicking walls and door stating 'this is what I am going to do to all you n----'. Attempted to assist patient from floor and patient became anger stating 'don't touch me. I can lay on the floor if I want to. Get out of my room'. Staff at door monitoring patient."

A review of patient #1's record revealed a "Close Observation Check Sheet" dated 12/13/15. The MHT (Mental Health Tech) documented patient #1's location and activity from 7:15 p.m. until 12:15 a.m. (12/14/2015) as "in room sleeping". The documentation by the MHT contradicted the documentation by the nursing staff for this time period.

4.) A review of patient #6's record revealed a "Multi-Disciplinary Note" with the following nursing documentation: "12/4/15 1415 (2:15 p.m.) NSG #1, #3 Pt ambulating down the hall shuffled gait, drowsy, arousable to verbal stimuli, staff #23 in clinic, received an order to hold 1800 (6:00 p.m.) dose of valium ...".

A review of patient #6's record revealed a "Close Observation Check Sheet" dated 12/4/15. The MHT (Mental Health Tech) documented patient #6's location and activity from 1:45 p.m. until 3:00 p.m. as "in room sleeping". The documentation by the MHT contradicted the documentation by the nursing staff for this time period.

A review of patient #6's record revealed a "Multi-Disciplinary Note" with the following nursing documentation: "12/1/15 9 p.m. NSG #1 Patient came down the hall yelling 'if she doesn't want to shake hands then I don't care, I hate her.' Patient goes back to his room in a fast pace yelling 'this is the fake (patient #6)'. Redirection was provided he went to his room to lay down."

A review of patient #6's record revealed a "Close Observation Check Sheet" dated 12/1/15. The MHT (Mental Health Tech) documented patient #6's location and activity from 9:00 p.m. until 9:45 p.m. as "in room sleeping". The documentation by the MHT contradicted the documentation by the nursing staff for this time period.

5.) A review of patient #18's record revealed a "Multi-Disciplinary Note" with the following nursing documentation: "12/13/15 1800 (6:00 p.m.) NSG #4 Pt sitting in the dining room, calm visiting c (with) peers, alert, no c/o (complaint of) pain. B/P (blood pressure) taken manually 174/86, denies any headache, asymptomatic, given routine metoprolol. Will recheck B/P."
A review of patient #18's record revealed there was NO "Close Observation Check Sheet" for the date of 12/13/15 found.
A review of the facility's policy "TX-SPEC-05: Level of Observations/Monitoring" revealed the following information:

"Observation Levels:

Every 15 minutes - the staff member should visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities....

Close Observation Form:
The staff member utilizes the close observation form to document the location of the patient....

Procedure:
Every 15 Minute Observation:...
Assigned Nursing Staff (MHT):
· Circles/writes the type of specialty observation on the form (fall, suicide, etc.)....
· Physically walks to find each patient on q (every) 15 minute observation....
· Documents the location on the close observation form. Documents the activity when indicated (water offered, etc.)
· Initials the form every 15 minutes.
· Notifies the Charge nurse immediately of any patient who cannot be observed or located."

Based upon observation, record review and interview, the governing body failed to:


A.) properly assess patients with elevated blood pressures and blood sugars, nursing interventions, and document notification of critical lab values in 3(#3, 7, and 16) of 5(#3, 7, 8, 16 and 17) patients reviewed. The facility failed to ensure all patients received a complete nursing physical and psychological assessment every 12 hours in 2 (patients #8 and #18) of 5 (patients #1, #6, #8, #17, #18) records reviewed.

Refer to Tag A0395

Based on chart reviews, Reviews of Quality Assessment Performance Improvement (QAPI), incident reports, and interviews the facility failed to properly assess patients with elevated blood pressures and blood sugars, nursing interventions, and document notification of critical lab values in 3(#3, 7, and 16) of 5(#3, 7, 8, 16 and 17) patients reviewed. The facility failed to ensure all patients received a complete nursing physical and psychological assessment every 12 hours in 2 (patients #8 and #18) of 5 (patients #1, #6, #8, #17, #18) records reviewed.

1.) Review of patient #7's chart revealed she was a 58 year old admitted to the facility for Major depressive disorder, sever and general anxiety. Review of the Psychiatrist evaluation on 12/10/15 revealed patient #7's chief complaint, "I thought I had a brain tumor, but they feel that it is the Gabapentin that is making me so dizzy."

Review of patient #7's nursing admission notes patient #7 complained of ringing in the ears, blurred vision in her left eye. Review of the Comprehensive Integrated Assessment Intake Screen and Initial Level of Care Determination dated 12/7/15 revealed nurse documentation under Gravely Disabled. The nurse documented, "All of the sudden her ears started ringing last week. Since it has also caused her to feel sick. Unable to walk without holding onto walls, unable to concentrate and care for self for fear this ringing is going to make her die."

Review of the psychiatric evaluation the psychiatrist documented, "Medical History: Hypertension. Medical history is negative and patient #7 has no history of serious illness, injury, operation, or hospitalization. No medications are currently taken."

Review of patient #7's physician progress note dated 12/10/15 at 6:10AM revealed the patients' blood pressure was 96/59. There was no documentation of hypertension, ringing in the ears or dizziness noted on the progress note.

Review of patient #7's Nursing Multi-Disciplinary Note dated 12/10/15 at 8:43AM revealed DPN (Director of Psychiatric Nursing) documented, "BP at 0400 96/59, BP at 0815 145/97 Pt continues to c/o dizziness and ringing in ears. Encouraged pt. to request assistance with ambulation, slowly rise from lying or sitting position. Pt states understanding." There was no documentation found that the physician was notified of the elevated blood pressure, ringing in the ears or dizziness. There was no documentation found of a recheck of the blood pressure, or patient assessment for the 7:00AM-7:00PM shift.

Review of the Daily Nurses Notes for the 7:00PM -7:00AM shift on 12/10/15 revealed a blood pressure at the bottom of the page of 112/72. There was no time documented when this blood pressure was taken. There was a section on the note for the nurse to complete a Cardio/Pulmonary section about blood pressure or edema. This section was left blank. The nurses failed to document any communication to the physician, or assess the patient after elevated blood pressure and active symptoms.


2.) Review of patient #3's chart revealed the patient was admitted to the facility on 12-4-15 at 5:15PM. Patient #3 was admitted with a diagnosis of Neurocognitive Disorder with Behavioral Disturbances, involuntarily, on an Emergency Police Officers Warrant (EPOW). Patient #3 has had a negative psychiatric history. No psychotropic medications have ever been taken by patient #3.

Review of patient #3's daily nurse's notes revealed the patient was on fall precautions at high risk with a bed alarm on. Review of the Multi-Disciplinary Note dated 12/9/15 at 11:15AM stated, "Pt. rolled out of bed landing on the floor. Pt fell approx. 2 feet. Pt denied LOC or any pain or injuries. Pt had no visible injuries. Full body assess was performed, v/s taken, MSC-good no deformities, outward rotation, or shortening of the leg. Family, DR., and DON notified. Mats put on both sides of bed. Fall packet completed. Patient now sleeping and stable." There was no documentation of bed alarm.

According to the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health, blood pressure for adults is
Normal BP <120/<80 mmHg
Heart Rate: Female: 55-95 bpm
Respiration Rate: 12-18 breaths per minute
Blood Sugars- A normal sugar level is less than 100 mg/dL after not eating (fasting) for at least 8 hours. And it's less than 140 mg/dL 2 hours after eating.

Review of patient #3's chart revealed a Neuro Flow sheet was started on patient #3 after the fall at 11:15PM. The following vital signs were taken as follows;
1.) 11:15PM- Review of the vital signs revealed the blood pressure was elevated at 162/107 and her heart rate was elevated at 120. Patient #3 has a history of atrial fibrillation and has a defibrillator.
2.) 11:30PM- blank on vital signs.
3.) 11:45PM- Blood pressure 150/90 and heart rate 110.
4.) 12:15AM- Blood pressure 163/85 and heart rate 60.

There was no nursing documentation found until 12/10/15 at 1:15AM. The nurse documented, "Continuing vital sign checks d/t fall earlier. Pt was agitated, crying d/t VS checks. BP was difficult to obtain, multiple attempts made. Final BP- 157/118, HR- 65, R 14, T- 97.7 O2 sat -99%. Pt laid back down and went back to sleep." There was no documentation that the physician was notified of the patients' hypertension. There was no documented evidence in the nurse's notes or physician progress notes that the physician was aware of the elevated blood pressure and heart rate.

There was no nursing documentation until three hours later at 4:00AM. The nurse documented Pt. became extremely anxious and agitated with vs. She was crying loudly and wailing. MHT unable to assess BP and HR. BP- 153/82 HR- 72. Assessed pt. and respirations 16, even, unlabored, no cyanosis noted. Skin is warm and dry afebrile. Since vs agitate pt. too much at this time, directed MHT to skip 5:15AM vs will continue to check on pt. " There was no documentation of any nursing interventions to help the distressed patient.

Review of the Vital Signs and I&O sheet revealed the patient's blood pressure was taken on the "day" shift at 148/111. There is no documented nurse's response to the elevated blood pressure, no documentation found that the physician was notified. There was no documented time when the blood pressure was taken. Review of the 7:00PM-7:00AM daily nurse's note stated patients BP was 148/111 "retake" 142/86. There is no documentation of when that VS was retaken.

Review of the MHT "Close Observation Check Sheet" revealed patient #3 was in room until 4:00AM. At 4:14AM Patient #3 was in the dayroom sleeping. Documentation shows patient #3 was not in a bed to rest until 8:30PM on 12/11/15 a total of 40 hours. There is no documentation of any nursing interventions, or attempts to allow patient to rest in a bed. There is no documentation that MD was made aware that patient had not been in a bed for 40 hours. Patient is documented sleeping in the dayroom or at nurse's station.

Review of the incident reports from October- December 2015 revealed there was no follow-up on the reports by the Director of Physiciatric Nursing (DPN) or Patient Safety Officer.

Review of 8 incident reports dated from 10/19/15 - 12/10/15 revealed the report was filled out by the nurse and signed by the DPN. There was no updates or investigations of the incidents by the DPN or Patient Safety Officer. There was no data found of these incident reports reported to QAPI.

Review of the Patient Incident & Occurrence Reporting Policy The QAPI Coordinator or department manager was to;
"Conference with personnel and parties involved.
Cosigns occurrence report and investigation form.
Recommends corrective action and follows up with appropriate department manager for implementation and follow through for immediate safety measures.
Utilizes data for performance improvement activities monthly.
Ensures all incidences minutes are evaluated/ investigated and documented is provided to show follow up and corrective actions."

Interview with DPN on 12/16/15 revealed she had not addressed any of the incident reports from falls from October - December 2015. The DPN reported she has not had time.

Interview with Staff #3 on 12/16/15 revealed this information was not getting to the QAPI process.

3.) Review of patient #16 revealed the patient was admitted to the facility on 11/11/15 at 7:30PM. Patient was admitted on an Emergency Police Officers warrant (EPOW) and arrived to the facility by ambulance. Patient #16 was admitted with a diagnosis of Neurocognitive Disorder with Behavioral Disturbance and Delusional Disorder.

Review of the Multi-Disciplinary Notes dated 11/18/15 at 12:00AM revealed patient #16 was having chest pain. The nurse documented, "Patient yelling out and complaining of chest pain. When asked where he's hurting he placed his hand over his left chest. Head of bed is already elevated. When asked what his pain fells like, he replied the pain feel heavy. Vital signs taken; T- 97.4 P- 90, (pacemaker in place), R-18, unlabored BP-158/80, O2 sat- 100% Finger stick blood sugar 228. Skin pink, warm to touch, and dry. MD notified and given report on patients' condition. The patient does not appear to be in any distress. Orders received and carried out CMMS mobile x-ray notified of order."

Review of a telephone physician orders dated 11/18/15 at 12:15AM stated, "Do EKG; notify me of results if any changes noted in comparison of previous EKG." The order was not documented a "STAT" order. There was no specifics in who was to read the EKG.

Review of the nurses notes date 11/18/15 at 1:35AM stated, "Staff from CMMS came and did EKG. Results of EKG called to MD. MD said to observe the patient and notify him if further complaints are voiced. Patient denies having chest pain at this time. He is awake and has disconnected the alarm pad on his bed. Alarm reconnected. Patient repositioned and made comfortable."

There was no further documentation of observation or care to patient #16 until 11/18/15 at 7:00AM, a 5 ½ hour time span.

Review of the physician progress note revealed the physician saw patient #16 on 11/18/15 at 6:00AM. MD wrote, "CP unclear no EKG changes. BS 100's-200's."

Review of the nurses notes dated 11/18/15 at 9:06PM revealed the nurse documented, "Blood sugar taken at 9:00PM- 416, MD notified pt. - asymptomatic ate bread, cookies, and baked chips for supper. No orders received will retake blood sugar in two hours, and at scheduled time 0600. Will monitor for s/sx of hyper/hypoglycemia."

Review of the admission physician orders revealed patient #16 was to be on a low NA (sodium) and LCS (low concentrated sweets). Nursing failed to adhere to the patients ordered diet.

Review of patient #16's chart revealed there was no nursing documentation found of patient assessment or recheck of patient #16's blood sugar until 6:00AM on 11/19/2015 a 9 hour delay.

Review of the nurse's notes on 11/19/15 at 8:45PM stated, "Blood sugar check results of 506 assessment done on pt. Pt. has no shaking. Skin warm and dry. Temp 98.2, HR 98, B/P 143/78, O2 sat 99%. BS recheck at 9:25PM results of 247 pt. asymptomatic. Will continue to monitor for s/s of hypoglycemia."

There was no documentation of nurse notifying MD of a 506 blood sugar or a nursing intervention. There was no found documentation of a glucometer error. The test sheet from the glucometer shows the glucometer was checked without failure.

An interview was conducted with DPN on 12/16/15 and staff #1 confirmed the findings above. The DPN reported that she had been trying to audit the charts and had the staff nurses auditing the charts. DPN confirmed nursing had not reported the elevated blood sugars to her.


















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Review of patient #8's medical record on 12/15/2015 at 10:00 a.m. revealed there was NO nursing physical or psychological assessment found for the 12 hour period of 7:00 a.m. until 7:00 p.m. on 12/14/2015.

Review of patient #18's medical record on 12/15/2015 at 10:30 a.m. revealed there was NO nursing physical or psychological assessment found for the 12 hour period of 7:00 a.m. until 7:00 p.m. on 12/13/2015.

Review of the facility's policy titled, "NSG-02: Documentation", revealed the following information:
"Policy: Nursing service personnel document on the Daily Nurse's Note and in the integrated progress notes.
Documentation is done on every shift, incorporating the elements of the nursing process and including treatment plan ....
Documentation:
Inpatient:
· RN/LVN documents on the Daily Nurse's Note a minimum of once per shift or at the time any pertinent event occurs."