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Based on interview and document review, the facility failed to ensure a registered nurse 1) supervised and evaluated nursing care and 2) adminstered and documented medications within acceptable standard of practice resulting in the potential for unrecognized, unmet patient needs and the potential for harm for all 85 patients currently at the facility. Findings include:

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A-0395 Failure to ensure a registered nurse supervise and evaluates nursing care
A-0405 Failure to administer and document medications within acceptable standards of practice

Based on record review and interview, the facility failed to ensure that a registered nurse supervise and evaluate the nursing care for each patient on an ongoing basis in accordance with accepted standards of Nursing practice and hospital policy for 7 of 8 (#3,4,5,7,8,10, & 11) patients medical records reviewed for daily nursing assessments, resulting in the potential for unmet or unidentified patient care needs for the 85 current inpatient residents.

Findings include:

On 09/03/2020 at 1230 during review of the medical record of patient #5 the nurse failed to sign the 24 hour "Patient Observation Rounds Documentation" sheets for 3 days of a 6 day admission (08/30/2020, 08/31/2020, and 09/03/2020.)

On 09/03/2020 at 1400 during review of the medical record of patient #7 the nurse failed to sign the 24 hour "Patient Observation Rounds Documentation" sheets for 12 days of a 12 day admission (07/25/2020, 07/26/2020, 07/27/2020, 07/28/2020, 07/29/2020, 07/30/2020, 07/31/2020, 08/01/2020, 08/02/2020, 08/03/2020, 08/04/2020, and 08/05/2020.) Further review of the medical record of patient #7 revealed that the "Daily Nursing Assessment" forms had unidentifiable signatures on 2 days of the 12 day admission (07/27/2020, and 07/30/2020.)

On 09/04/2020 at 0800 during review of the medical record of patient #8 the nurse failed to sign the 24 hour "Patient Observation Rounds Documentation" sheets for 3 days of a 6 day admission (07/24/2020, 07/26/2020, and 07/27/2020.) Further review of the medical record of patient #8 revealed that the "Daily Nursing Assessment" forms had unidentifiable signatures on 2 days of the 6 day admission (07/25/2020, and 07/26/2020.)

On 09/04/2020 at 1000 review of the medical record of patient #10 revealed that the "Daily Nursing Assessment" forms had unidentifiable signatures on 2 days of a 10 day admission (07/25/2020, and 07/26/2020.)

On 09/04/2020 at 1130 review of the medical record of patient #11 revealed that the "Daily Nursing Assessment" forms had unidentifiable signatures on 8 days of an 8 day admission (6/30/2020, 07/01/2020, 07/02/2020, 07/03/2020, 07/04/2020, 07/05/2020, 07/06/2020, and 07/07/2020.)

On 09/04/2020 at 1300 staff E stated, "I can see that the Nurses have not signed their name legibly or included their credentials on both the Daily Nursing assessment forms and the Patient observation rounding documents."
On 09/04/2020 at 1400 staff B stated, "Registered Nurses are required to perform patient assessments at least once in a 24 hour period and then document the findings on the Daily Nursing Assessment form, and they must review and sign the Patient Observation rounding documents."

On 09/04/2020 at 0930 the Job description for "Unit Charge Registered Nurse" dated January 2016 was reviewed. Under Essential Job Functions and Responsibilities #7. it states, "The Nurse continually assesses and reassesses the patients medical and psychiatric status and changing needs." and under #13. it states, "Maintains own professionalism and adheres to the determined standards of care and performance."




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On 9/3/2020 at 1400, review of the medical record for Patient #3 revealed the nurse failed to sign the 24-hour "Patient Observation Rounds Documentation" on the following dates and shifts:
-3rd shift on 8/20/2020
-2nd shift on 8/25/2020
-3rd shift on 8/28/2020
-2nd shift on 8/29/2020
-3rd shift on 8/30/2020
-3rd shift on 9/1/2020
-3rd shift on 9/2/2020
-2nd and 3rd shift on 9/3/2020.
Additionally, the "Daily Nursing Assessment" had unidentifiable signatures and/or absent signature titles on the following dates and times:
-8/12/2020 at 1400
-8/14/2020 at 1000
-8/20/2020 missing for both 1st and 2nd shift
-8/21/2020 at 1400
-8/21/2020 at 1630
-8/26/2020 at 2000
-8/27/2020 at 2000
-9/2/2020 missing for both 1st and 2nd shift
-9/3/2020 at 0930
-9/3/2020 at 2140

On 9/3/2020 at 1500, review of the medical record for Patient #4 revealed the nurse failed to sign the 24-hour "Patient Observation Rounds Documentation" on the following dates and shifts:
-2nd shift on 8/12/2020
-3rd shift on 8/14/2020
-3rd shift on 8/16/2020
-3rd shift on 8/17/2020
-1st and 3rd shift on 8/20/2020
-2nd and 3rd shift on 8/23/2020
-2nd shift on 8/24/2020
-3rd shift on 8/25/2020
Additionally, the "Daily Nursing Assessment had unidentifiable signatures and/or absent signature titles on the following dates and times:
-8/12/2020 at 2100
-8/13/20 at 1130
-8/19/20 at 1300
-8/20/2020 at 1157
-8/22/2020 at 1430
-8/24/20 at 1113
-8/24/20 at 1740

Based on record review and interview the facility failed ensure medications were administered by authorized individuals in a safe and timely manner to meet the needs of the patient in four of the six medical records reviewed for medication administration (#7,8,10, &11), resulting in the potential for less than optimal outcomes. Findings include:

On 09/03/2020 at 1400 during medical record review for Patient #7 the Nurse Identification, Initial and signatures were missing on 12 of 13 Medication Administration Records dated:
07/25 through 07/27
07/28 through 07/30
07/31 through 08/03
08/04 through 08/05
Medications ordered and not documented as given for Patient #7:
Thorazine 100 mg 2 tablets by mouth give at 0900 and 1800 daily, missing 07/28
Eliquis 5 mg by mouth 2 times per day at 0900 and 1800, missing 07/28

On 09/04/2020 at 0800 during medical record review for Patient #8 the Nurse Identification, Initial and signatures were missing on 7 of 9 Medication Administration Records dated:
07/23
07/24 through 07/27
07/28 through 07/30

On 09/04/2020 at 1400 during medical record review for Patient #10 the Nurse Identification, Initial and signatures were missing on 4 of 6 Medication Administration Records dated:
08/23 through 08/27
08/28 through 09/01
Medications ordered and not documented as given for Patient #10:
Vimpat 250 mg 2 times per day 0900 and 2200, missing 08/25, 08/26, 08/27, 08/28
Seroquel 150 mg by mouth at hour of sleep, missing 08/27 and 08/31
Nicoderm 21 mg daily on 0900 and off 2200, missing 08/24 2200

On 09/04/2020 at 1130 during medical record review for Patient #11 the Nurse Identification, Initial and signatures were missing on 16 of 17 Medication Administration Records dated:
06/29
06/30 through 07/02
07/03 through 07/06
07/07 through 07/08
Medications ordered and not documented as given for Patient #11:
Seroquel 200 mg give at 2200 daily by mouth, missing 07/02
Seroquel 25 mg give at 1200 daily by mouth, missing 07/02
Remeron 15 mg give at 2200 by mouth, missing 07/07

On 09/04/2020 at 1300 staff E stated, "I can see that the some of the Nurses have not signed their name, Some signed their name illegibly, and many are missing their credentials."
On 09/04/2020 at 1400 staff B stated, "Registered Nurses and Licensed Practical Nurses are required to follow Doctors orders for Medication administration unless they document a reason and notify the physician. It is a standard of Practice for the nurse to initial the medication when it is given, then identify their initials with their name and credentials in the key at the bottom of the Medication sheet."

On 09/04/2020 at 0930 the Job description for "Registered Nurse" dated May 2003 was reviewed. Under Essential Job Functions and Responsibilities #8. it states, "Provides Medication administration..." and under #9. it states, "Maintains own professionalism and adheres to the determined standards of care and performance."
On 09/04/2020 at 0940 the Job description for "Licensed Practical Nurse (Inpatient)" dated May 2003 was reviewed. Under Essential Job Functions and Responsibilities #5. it states, "Documents the administration of medications and treatments according to policies and procedures."