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Based on record review and patient interviews the facility failed to ensure for one of five (#1) patients', plan of care was updated to reflect the care needs.

Findings

Review of the medical record for patient #1 revealed that the patient presented to the Emergency Room on 09/22/2011. The medical record revealed that the patient was admitted to the facility at 1239 (12:39 PM) and was assigned a room on the 2nd floor.
A nursing admission assessment was documented at 1441 (2:41 PM) that included a pain assessment. The pain assessment revealed that the patient was experiencing pain in her left foot at a level of 4 on a 0 to 5 scale with zero being no pain. The care plan revealed that the patient took Lortab at home to control the pain.

Review of the pain management care plan developed during the assessment revealed that for the rest of the admission that a 0 to 10 pain scale will be used to evaluate pain every 4 hours.

Review of the medical record revealed a physician admission order dated 09/22/2011 (not timed by the physician) which included Motrin 400 milligrams (mg) every 8 hours as needed (PRN) for moderate pain and Lortab 5/500 mg every 6 hours PRN for severe pain.

Review of the order revealed the unit clerk signed the order at 1400 (2:00 PM) and the nurse signed the order at 1430 (2:30 PM).

Review of the nursing assessments revealed that on 9/22/11 at 2100 (9:00 PM) the patient reported a pain level of 5 or moderate pain. On 09/23/2011 at 0450 (4:50 AM) the patient reported a pain level of 5 or moderate pain, the next 2 scheduled pain assessment was not completed, the pain level at 1650 (4:50 PM) reported as a pain level of 5 or moderate pain and again at 2000 (8:00 PM) the patient reported a pain level of 5 or moderate pain. Review of the record or 09/24/2011 revealed that the 0000 (midnight) pain assessment was not performed and at 0400 (4:00 AM) the patient reported a pain level of 5 or moderate pain the next 2 scheduled pain assessments were not documented, at 1429 (2:49 PM) the patient reported a pain level of 5 or moderate pain, the next pain assessment was missed and at 2345 (11:45 PM) the patient reported a pain level of 5 or moderate pain.

Review of the patient Medication Administration Record, (MAR) revealed that Motrin was never administered or offered to the patient and that Lortab was only provided on 2 times, on 09/22/2100 at 2100 (9:00 PM) and on 09/23 at 1050 (10:50 AM).

The medical record did not reveal why the pain medication was not provided as ordered or why the nursing failed to perform pain assessments as outlined in the Plan of Care. The medical record revealed that at the end of each nursing shift the nurse electronically attaches and signs the following statement.

2. Review of the medical record for patient #1 revealed an intravenous (IV) Assessment dated 09/22/2011 at 1530 (3:30 PM) that stated, "IV Type/Location: #22 Left Antecubital, Date Inserted: 09/22/2011, Dressing Change Date: 09/26/201, IV Site WDP: Y, Site Condition: (Not Completed)".
Review of the IV Assessment dated 09/22/2011 at 1621 (4:21 PM) revealed, "IV Type/Location: #22 Left Antecubital, Date Inserted: 09/22/2011, Dressing Change Date: 09/26/201, IV Site WDP: Y, Site Condition: (Not Completed)."
Review of the IV Assessment dated 09/22/2011 at 2030 revealed, "IV Type/Location: #22 Left Antecubital, Date Inserted: 09/22/2011, Dressing Change Date: 09/26/201, IV Site WDP: Y, Site Condition: (Not Completed)."
Review of the IV Assessment dated 09/23/2011 at 0000 revealed "IV Type/Location: #22 Right Forearm, Date Inserted: 09/23/2011, Dressing Change Date: 09/26/201, IV Site WDP: Y, Site Condition: (Not Completed)."
Review of the medical record, (Nursing notes or nursing assessment) for patient #1 did not reveal the reason for changing the IV from the left antecubital to the right forearm or that if the patient had experienced any events related to the IV.

Review of the patient's Plan of Care did not reveal any updates or references to the change in the IV location.

Review of the medical record revealed a physician order dated 09/22/2011 (not time the order was written) that stated, "Cold Compress to Left Upper Extremity and an order for ultrasound of Right Lower Extremity and Left Upper Extremity to be done today". Review of the physician order revealed that Unit Clerk had signed off on the order the next day on 09/23/2010 at 1502 (3:02 PM) and the Nurse signed the order on 09/23/2011 at 1514.

Review of the medical record did not reveal that the patient had received cold compress therapy on 09/22/2011 and the MAR for 09/23-09/24 the therapy was only noted done without a time documented. The writing of "done" was in the same pen and writing as the nurse documenting on the second shift.

Review of the medical record did not reveal any nursing documentation as why the Cold Compress was ordered or any assessment of the patient's Left Upper Extremity. The medical record did not reveal any Care Plan changes to either the Pain or IV Care Plans.

Review of the medical record did not reveal a report from the Radiologist for the ultrasound of the Left Upper Extremity or any if the procedure was performed or not. Review of the medical record revealed a Physician Progress note dated 09/23/2011, no time noted by physician, revealed "Left upper extremity S/P IV infiltrate".

3. Interview with patient #1 on 10/31/2011 at 8:45 AM revealed that following the dose of Vancomycin on 09/22/2011 at 1700 (5:00 PM) her arm swelled to 3 times its normal size and that the nursing staff did not provide the cold compress or pain medication until the next night.

4. The medical record revealed that at the end of each nursing shift the nurse electronically attaches and signs the following statement. " BY SIGN OFF ON THIS INTERVENTION, THE NURSE VERIFIES THAT THE STANDARD OF CARE FOR PUTNAM COMMUNITY MEDICAL CENTER AND THE CARE AREA STATEMENTS HAVE BEEN ADDRESSED IN THE DOCUMENTATION SCREENS OR NOTES " .

Based on record review and patient interviews the facility failed to ensure for one of five patients (Patient #1), received medications as ordered by the physician.

Findings

1. Review of the medical record revealed a physician admission order dated 09/22/2011 (not timed by the physician) which included Vancomycin 1 gram intravenous (IV) every 12 hours. Vancomycin Trough before 3rd dose. Review of the order revealed the unit clerk signed the order at 1400 (2:00 PM) and the nurse signed the order at 1430 (2:30 PM).

Review of the medication administration record (MAR) revealed that at 1700 (5:00 PM) on 09/22/2011 the first dose Vancomycin was given to the patient. The medical record did not reveal any nursing notes related to the administration of the Vancomycin or the condition of the IV site following the administration of the Vancomycin. Review of the MAR for 09/23/2011 did not reveal that any Vancomycin was administered to the patient. Review of the MAR for 09/24/2011 did not reveal that any Vancomycin was administered to the patient.

Review of the nursing note dated 09/24/2011 at 0420 (4:20 AM) revealed under IV fluids, #1 fluid Vancomycin. No other comments related to Vancomycin were documented by nurse on 09/24/2011. The medical record revealed a physician order dated 09/24/2011 at 1124 (11:24 AM) revealed "Please give Vancomycin at 1300 [1:00 PM] exact". Review of the MAR revealed that the 1300 dose was not given to the patient. Review of the MAR revealed that the next dose of Vancomycin was administered on 09/25/2011 at 1500 (3:00 PM). The Medical record revealed that all other scheduled doses were given as ordered. Review of the medical record did not reveal why the Vancomycin scheduled doses were not given and did not reveal that the physician was made aware that there were doses not administered as ordered.

2. Review of the medical record for patient #1 revealed that the patient presented to the Emergency Room on 09/22/2011. The medical record revealed that the patient was admitted to the facility at 1239 (12:39 PM) and was assigned a room on the 2nd floor.
A nursing admission assessment was documented at 1441 (2:41 PM) that included a pain assessment. The pain assessment revealed that the patient was experiencing pain in her left foot at a level of 4 on a 0 to 5 scale with zero being no pain. The care plan revealed that the patient took Lortab at home to control the pain.

Review of the pain management care plan developed during the assessment revealed that for the rest of the admission that a 0 to 10 pain scale will be used to evaluate pain every 4 hours.

Review of the medical record revealed a physician admission order dated 09/22/2011 (not timed by the physician) which included Motrin 400 milligrams (mg) every 8 hours as needed (PRN) for moderate pain and Lortab 5/500 mg every 6 hours PRN for severe pain.

Review of the order revealed the unit clerk signed the order at 1400 (2:00 PM) and the nurse signed the order at 1430 (2:30 PM).

Review of the nursing assessments revealed that on 9/22/11 at 2100 (9:00 PM) the patient reported a pain level of 5 or moderate pain. On 09/23/2011 at 0450 (4:50 AM) the patient reported a pain level of 5 or moderate pain, the next 2 scheduled pain assessment was not completed, the pain level at 1650 (4:50 PM) reported as a pain level of 5 or moderate pain and again at 2000 (8:00 PM) the patient reported a pain level of 5 or moderate pain. Review of the record or 09/24/2011 revealed that the 0000 (midnight) pain assessment was not performed and at 0400 (4:00 AM) the patient reported a pain level of 5 or moderate pain the next 2 scheduled pain assessments were not documented, at 1429 (2:49 PM) the patient reported a pain level of 5 or moderate pain, the next pain assessment was missed and at 2345 (11:45 PM) the patient reported a pain level of 5 or moderate pain.

Review of the patient Medication Administration Record, (MAR) revealed that Motrin was never administered or offered to the patient and that Lortab was only provided on 2 times, on 09/22/2100 at 2100 (9:00 PM) and on 09/23 at 1050 (10:50 AM).

The medical record did not reveal why the pain medication was not provided as ordered or why the nursing failed to perform pain assessments as outlined in the Plan of Care. The medical record revealed that at the end of each nursing shift the nurse electronically attaches and signs the following statement.

3. Interview on 10/31/2011 at 8:45 AM with patient #1 revealed that patient stated that "They gave me the Vancomycin when they wanted to any when they gave it to me they gave it to fast. The patient also stated that she did not receive pain medication until the next day after why are swelled up."

Based on record review and interview the facility failed for one of five patients (Patient #1), to ensure that the medical record contains nursing assessments that reflect changes in the patient's condition, completed diagnostic reports and patient care plans that reflect the patient's care needs.

Findings:

1. Review of the medical record for patient #1 revealed an intravenous (IV) Assessment dated 09/22/2011 at 1530 (3:30 PM) that stated, "IV Type/Location: #22 Left Antecubital, Date Inserted: 09/22/2011, Dressing Change Date: 09/26/201, IV Site WDP: Y, Site Condition: (Not Completed)".
Review of the IV Assessment dated 09/22/2011 at 1621 (4:21 PM) revealed, "IV Type/Location: #22 Left Antecubital, Date Inserted: 09/22/2011, Dressing Change Date: 09/26/201, IV Site WDP: Y, Site Condition: (Not Completed)."
Review of the IV Assessment dated 09/22/2011 at 2030 revealed, "IV Type/Location: #22 Left Antecubital, Date Inserted: 09/22/2011, Dressing Change Date: 09/26/201, IV Site WDP: Y, Site Condition: (Not Completed)."
Review of the IV Assessment dated 09/23/2011 at 0000 revealed "IV Type/Location: #22 Right Forearm, Date Inserted: 09/23/2011, Dressing Change Date: 09/26/201, IV Site WDP: Y, Site Condition: (Not Completed)."
Review of the medical record, (Nursing notes or nursing assessment) for patient #1 did not reveal the reason for changing the IV from the left antecubital to the right forearm or that if the patient had experienced any events related to the IV.

Review of the patient's Plan of Care did not reveal any updates or references to the change in the IV location.

Review of the medical record revealed a physician order dated 09/22/2011 (not time the order was written) that stated, "Cold Compress to Left Upper Extremity and an order for ultrasound of Right Lower Extremity and Left Upper Extremity to be done today". Review of the physician order revealed that Unit Clerk had signed off on the order the next day on 09/23/2010 at 1502 (3:02 PM) and the Nurse signed the order on 09/23/2011 at 1514.

Review of the medical record did not reveal that the patient had received cold compress therapy on 09/22/2011 and the MAR for 09/23-09/24 the therapy was only noted done without a time documented. The writing of "done" was in the same pen and writing as the nurse documenting on the second shift.

Review of the medical record did not reveal any nursing documentation as why the Cold Compress was ordered or any assessment of the patient's Left Upper Extremity. The medical record did not reveal any Care Plan changes to either the Pain or IV Care Plans.

Review of the medical record did not reveal a report from the Radiologist for the ultrasound of the Left Upper Extremity or any if the procedure was performed or not. Review of the medical record revealed a Physician Progress note dated 09/23/2011, no time noted by physician, revealed "Left upper extremity S/P IV infiltrate".

2. Interview with patient #1 on 10/31/2011 at 8:45 AM revealed that following the dose of Vancomycin on 09/22/2011 at 1700 (5:00 PM) her arm swelled to 3 times its normal size and that the nursing staff did not provide the cold compress or pain medication until the next night.

3. Interview with the Administrator on 10/31/11 at 4:00 PM revealed that the facility should have reassessed patient #1 for a change in condition.

Based on medical record review the facility failed for 2 of 2, (patients #1 and #3), inpatient records to ensure that all physician entries in the medical records are timed at the time of authentication.

Findings:

1. Review of the medical record for patient #1 revealed that six of ten physician progress notes completed on the patient did not include the time the note was written. Review of the medical record for patient #1 revealed that eight of fifteen physician orders did not include the time the physician wrote the order.

2. Review of the medical record for patient #3 revealed that eight of eight physician progress notes completed on the patient did not include the time the note was written.

Based on observation and staff interview the facility failed to ensure that the air conditioning return vents in 7 of 7 ( on the 2nd floor) patients' rooms, patient bath rooms, emergency rooms (ER), and intensive care unit (ICU) were clean and free of dust buildup.

Findings

1. On 10/31/2011 starting at 10:15 AM, a tour of the facility including the 2nd floor Medical/Surgical units, the Emergency Room, (ER), Intensive Care Unit, Pharmacy, and the 1st floor Medical/Surgical units. Observation of the 2nd floor rooms revealed that 7 of 7 rooms inspected revealed that both the main air return vent and the bathroom in all the room had a moderate to heavy accumulation of dust.

2. Observation of the ER during the tour revealed that return air ducts in ER X-ray, room and rooms #1 and #7 had a moderate to heavy accumulation of dust.

3. Observation of the ICU during the tour revealed that return air ducts in rooms ICU 1 and ICU 4 had a moderate to heavy accumulation of dust.

4. Interview with the housekeeper assigned to the 2nd floor on 10/31/11, during the tour of the facility, revealed that the housekeeping staff is responsible for the cleaning of the surface of the grills and that if the dust has accumulated inside the grill openings the maintenance department is notified so they can remove the grills and clean them outside of the facility.

Based on record review and patient interviews the facility failed to ensure for one of five patients (Patient #1), received medications as ordered by the physician.

Findings

1. Review of the medical record revealed a physician admission order dated 09/22/2011 (not timed by the physician) which included Vancomycin 1 gram intravenous (IV) every 12 hours. Vancomycin Trough before 3rd dose. Review of the order revealed the unit clerk signed the order at 1400 (2:00 PM) and the nurse signed the order at 1430 (2:30 PM).

Review of the medication administration record (MAR) revealed that at 1700 (5:00 PM) on 09/22/2011 the first dose Vancomycin was given to the patient. The medical record did not reveal any nursing notes related to the administration of the Vancomycin or the condition of the IV site following the administration of the Vancomycin. Review of the MAR for 09/23/2011 did not reveal that any Vancomycin was administered to the patient. Review of the MAR for 09/24/2011 did not reveal that any Vancomycin was administered to the patient.

Review of the nursing note dated 09/24/2011 at 0420 (4:20 AM) revealed under IV fluids, #1 fluid Vancomycin. No other comments related to Vancomycin were documented by nurse on 09/24/2011. The medical record revealed a physician order dated 09/24/2011 at 1124 (11:24 AM) revealed "Please give Vancomycin at 1300 [1:00 PM] exact". Review of the MAR revealed that the 1300 dose was not given to the patient. Review of the MAR revealed that the next dose of Vancomycin was administered on 09/25/2011 at 1500 (3:00 PM). The Medical record revealed that all other scheduled doses were given as ordered. Review of the medical record did not reveal why the Vancomycin scheduled doses were not given and did not reveal that the physician was made aware that there were doses not administered as ordered.

2. Review of the medical record for patient #1 revealed that the patient presented to the Emergency Room on 09/22/2011. The medical record revealed that the patient was admitted to the facility at 1239 (12:39 PM) and was assigned a room on the 2nd floor.
A nursing admission assessment was documented at 1441 (2:41 PM) that included a pain assessment. The pain assessment revealed that the patient was experiencing pain in her left foot at a level of 4 on a 0 to 5 scale with zero being no pain. The care plan revealed that the patient took Lortab at home to control the pain.

Review of the pain management care plan developed during the assessment revealed that for the rest of the admission that a 0 to 10 pain scale will be used to evaluate pain every 4 hours.

Review of the medical record revealed a physician admission order dated 09/22/2011 (not timed by the physician) which included Motrin 400 milligrams (mg) every 8 hours as needed (PRN) for moderate pain and Lortab 5/500 mg every 6 hours PRN for severe pain.

Review of the order revealed the unit clerk signed the order at 1400 (2:00 PM) and the nurse signed the order at 1430 (2:30 PM).

Review of the nursing assessments revealed that on 9/22/11 at 2100 (9:00 PM) the patient reported a pain level of 5 or moderate pain. On 09/23/2011 at 0450 (4:50 AM) the patient reported a pain level of 5 or moderate pain, the next 2 scheduled pain assessment was not completed, the pain level at 1650 (4:50 PM) reported as a pain level of 5 or moderate pain and again at 2000 (8:00 PM) the patient reported a pain level of 5 or moderate pain. Review of the record or 09/24/2011 revealed that the 0000 (midnight) pain assessment was not performed and at 0400 (4:00 AM) the patient reported a pain level of 5 or moderate pain the next 2 scheduled pain assessments were not documented, at 1429 (2:49 PM) the patient reported a pain level of 5 or moderate pain, the next pain assessment was missed and at 2345 (11:45 PM) the patient reported a pain level of 5 or moderate pain.

Review of the patient Medication Administration Record, (MAR) revealed that Motrin was never administered or offered to the patient and that Lortab was only provided on 2 times, on 09/22/2100 at 2100 (9:00 PM) and on 09/23 at 1050 (10:50 AM).

The medical record did not reveal why the pain medication was not provided as ordered or why the nursing failed to perform pain assessments as outlined in the Plan of Care. The medical record revealed that at the end of each nursing shift the nurse electronically attaches and signs the following statement.

3. Interview on 10/31/2011 at 8:45 AM with patient #1 revealed that patient stated that "They gave me the Vancomycin when they wanted to any when they gave it to me they gave it to fast. The patient also stated that she did not receive pain medication until the next day after why are swelled up."