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Based on interviews and record reviews the facility failed to ensure vital signs (VS) were documented accurately in 3 out of 15 medical records reviewed (Patients #1, #6, and #15). Further, patient weights were not obtained as ordered in 4 out of 15 records reviewed (Patients #4, #7, #10, and #13) and physician orders were not completed as ordered in 1 out of 15 records reviewed (Patient #9).

This failure created the potential for patient's medical needs to not be met.

FINDINGS

REFERENCE

According to General Consideration for Admission, Discharge, Care and Documentation Sheet:

ICU (Intensive Care Unit) - General Care and Documentation requirements
Vital signs at a minimum of every 2 hours and more frequently as indicated based upon patient stability, titration and response to drips and treatments.

HOU (High Observation Unit) - General Care and Documentation requirements
Vital signs at a minimum of every 4 hours and more frequently as indicated based upon patient stability, titration and response to drips and treatments.

Med/Surg - General Care and Documentation requirements
Vital signs at a minimum of every 8 hours and more frequently as indicated based upon patient stability, titration and response to drips and treatments.

1. The facility failed to ensure the Certified Nursing Assistant (CNA) collected and documented an accurate set of VS.

a) Review of the record for Patient #6 revealed the patient was admitted to the Intensive Care Unit (ICU) on 01/07/17 requiring treatment for a non-healing wound and a history of heart and respiratory disease. According to the facility's requirements, the patient required a complete set of VS every two hours. Review of the Vital Signs Record showed multiple dates, during the patient's 32-day stay, where vital signs were not completed or documented. For example;

01/18/17 from 9:00 a.m. to 8:00 p.m. there was no VS documentation for 13 hours
01/15/17 from 12:00 p.m. to 9:00 p.m. there was no VS documentation for 9 hours
02/07/17 from 1:00 p.m. to 8:00 p.m. there was no VS documentation for 7 hours
01/27/17 from 2:00 p.m. to 8:00 p.m. there was no VS documentation for 6 hours
02/04/17 from 4:00 p.m. to 8:00 p.m. there was no VS documentation for 4 hours

On 6 separate days, there were 9 occasions of 3-hour time frames where no VS were documented.

On 01/17/17 from 9:00 a.m. to 5:00 p.m. there was no temperature documented for 9 hours
On 02/05/17 from 5:00 p.m. to 8:00 p.m. there was only a temperature documented for 3 hours

b) Review of the medical record of Patient #15 revealed the patient was admitted to the High Observation Unit (HOU) on 01/28/17 for wound care and a history of heart and kidney disease. According to the facility's requirements, Patient #15 should have had a complete set of VS taken every 4 hours. Review of the Vital Signs Records showed multiple dates, during the patient's 18-day admission, where vital signs were not completed or documented . For example;

One occurrence with 18 hours of no VS documented
One occurrence with 24 hours of no VS documented

Two occurrences with 9 hours of no VS documented
Three occurrences with 8 hours of no VS documented

Four occurrences with 12 hours of no VS documented
Four occurrences of VS taken no time documented

Six occurrences with 6 hours of no VS documented

During the review of Patient #15's medical record on 02/15/17, the Director of Quality (DOQ #2) was present. S/he stated the primary nurse was caring for Patient #15 at the Med/Surg level of care and not the physician ordered HOU level of care. There was no physician's order present in the medical record to decrease the level of care for Patient #15.

d) Review of the record for Patient #1 revealed the patient was admitted on ICU status on 11/29/16 with a spinal injury and a history of A-V Block (heart disease) and Obstructive Sleep Apnea (respiratory disease). The patient had a change to Med/Surg status on 12/02/16 which required a complete set of VS every 8 hours. Review of the Vital Signs Records showed multiple dates, after the change to Med/Surg status where vital signs were not completed or documented . For example;

One occurrence of 12 hours no VS documented
Two occurrences of 10 hours no VS documented

In addition, on 12/05/16 a dot had been used as documentation in the temperature column for Patient #1. The dot did not accurately indicate what the specific temperature reading was. This practice was observed in multiple medical records reviewed.

e) On 02/14/17 at 11:18 a.m., an interview was conducted with CNA #21 who stated VS were to be collected and documented every 2 hours for an ICU patient. Additionally s/he reported when a patient was on HOU status VS were completed every 4 hours.

f) On 02/15/17 at 2:48 p.m., an interview was conducted with CNA #15 who reported using a dot instead of a number to document a temperature was not the expected practice in the facility. S/he further stated the number was preferred as the dot could be misinterpreted.

g) On 02/15/17 at 3:10 p.m., an interview was conducted with Registered Nurse (RN) #16 who reported when documenting a temperature the number is preferred. S/he additionally stated the use of a dot could be misinterpreted.

h) On 02/15/17 at 2:09 p.m., an interview was conducted with RN #14 who stated s/he would not use a dot to document a temperature as it could be misunderstood. Furthermore, s/he reported staff were not trained to use a dot to record a temperature.

i) On 02/15/17 at 7:39 a.m., an interview was conducted with RN #8 who stated if a patient was on HOU status, VS would need to be obtained and documented every 4 hours. Additionally s/he reported when a patient was on Med/Surg status, VS would be collected and documented 1 time a shift.

j) On 02/14/17 at 10:45 a.m., the Chief Nursing Officer (CNO #1) was interviewed. S/he reported VS were to be collected and documented every 2 hours when a patient was on ICU status.

During a subsequent interview, on 02/15/17 at 3:23 p.m., CNO #1 stated when documenting a temperature a number should be used rather than a dot, as it represented more correctness.

2. The facility failed to ensure the nursing staff provided care as ordered by the physician.

a) Review of the medical record of Patient #9 revealed s/he was admitted on 09/25/16 at a Med/Surg status as an incomplete quadriplegic requiring wound care, and severe protein mal-nutrition as was documented on the Physician progress note on 09/26/16.

On 11/24/16, Physician #12 ordered a urine sodium and urine osmolality test to be collected the same day. The two tests measured electrolyte balance (sodium helps keep the fluid inside and outside of the body cells) and if the kidneys were working correctly. The Physician progress note dated 11/25/17 documented the labs were not obtained and were re-ordered on 11/25/17.

b) On 02/15/17 at 2:09 p.m., an interview was conducted with RN #9 who stated when a physician had written an order the expectation was for the nurse to complete the order.

c) On 02/15/17 at 3:23 p.m., an interview was conducted with CNO #1 who reported when a physician order was written, the expectation was the nurse would follow the order.

d) On 02/15/17 at 1:27 p.m., an interview was conducted with Physician #12 who stated when s/he wrote an order s/he expected the nurse to follow the order.

3. The facility failed to ensure patient weights were obtained in accordance with physician orders.

a) Review of the medical record of Patient #13 revealed s/he was admitted on 02/02/17 for post-operative rehabilitation, wound care and a history of kidney failure requiring dialysis. On 02/08/17, daily weights were ordered.

The daily weights were not documented as ordered. As example, from 02/10/17 to 02/14/17, no weights were documented for 5 days.

b) Review of the medical record was conducted on Patient #7 who was admitted for acute respiratory failure, a history of congestive heart failure (CHF) and cor-pulmonale.

On 02/02/17, the physician ordered daily weights. On 02/03/17, the patient was not weighted. On 02/04/17, the physician again ordered daily weights. On 02/06/17 through 02/08/17, no weights were documented. The physician ordered daily weights on 02/08/17. No weights were documented 02/10/17 through 02/14/17. In a 12 day period of time Patient #7 was weighed 4 times.

c) An interview was conducted with Physician #10 on 02/15/17 at 11:49 a.m. Physician #10 stated, depending on the patients diagnosis a weight may be very important such as CHF and for dialysis patients they tried very hard to get the weight because that was how the amount of fluid removal was calculated.

d) On 02/15/17 at 12:06 p.m., an interview was conducted with RN #11. RN #11 stated weight measurements were obtained because some medication dosages were based on weights. S/he added, in dialysis patients the weight aided in the assessment of accurate fluid removal and for CHF patients, weights helped identify if there was too much fluid in the body which could compromise heart function.

e) Review of the medical record was conducted on Patient #4 who was admitted on 02/04/17 with a stage 4 wound, a history of Diabetes, and hypertension. When s/he was admitted, the admitting orders were for weekly weights.

Starting on 02/05/17 to 02/14/17, for 10 days, there were no documented weights in the medical record.

f) On 02/15/17 at 2:09 p.m., an interview was conducted with RN #14 who reported a physician order was needed for daily weights. S/he stated, for patients receiving some forms of wound care, weights could not be obtained and it was up to the nurse to inform the ordering physician when a weight could not be obtained. RN #14 stated a new order should be obtained to discontinue the daily weights. Furthermore, s/he reported when orders were written by the physician, the expectation was the nurse would follow those orders.

g) On 02/15/17 at 3:23 p.m., an interview was conducted with CNO #1 who reported when a patient had an order for daily weights and was on strict bedrest, the patient should be weighed. Additionally s/he reported an order should be obtained before weighing a patient or discontinuing weights on a patient.