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Based on policy review, clinical record review and interviews the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care for 1 of 10 sampled patients (Patient #4) as evidenced by failure to accurately assessed skin conditions and provide appropriate interventions after a change in assessment.


The findings include:

Facility policy titled Oral Care for Independent and Functionally Dependent Patients with effective date September 2012 documents Each shift, (every 12 hours), patient's oral status will be evaluated. Patient's lips, tongue, mucous membranes, gums teeth/dentures and saliva will be checked for appropriate cleanliness, color and moisture. Depending on patient's functional abilities, oral care will be provided. Provide lip moisturizer and apply as needed. Charge Nurse will be notified of any abnormalities immediately after assessment.

Clinical record review conducted on 08/18/14 revealed Patient # 4 was admitted to the facility on 07/26/13. Nursing Shift Assessments dated 07/27/13 (PM); 07/30/13 (PM); 07/31/13 (PM); 08/01/13 (PM) and 08/02/13 (PM) failed to document a Head, Eyes, Ears Nose and Throat Assessments (HEENT). In addition, The HEENT assessment dated 08/03/13 (PM) documents the patient has cracked lips. Further review of the electronic record failed to provide appropriate interventions. Subsequent HEENT assessment dated 08/04/13 at 8:30 AM documents Patient # 4 has cracked dry lips with laceration, tongue red and blistered. No interventions or physician notification were documented on the record in response to the change in condition.

Interview with the Clinical Analyst, who was navigating the record, and the Director of Medical Surgical Services was conducted on 08/19/14 at approximately 12:45 PM. The Director explained the attending nurse can initiate nursing interventions for cracked lips, any other lesions or skin conditions would require physician notification for further treatment. The Analyst was not able to locate documentation of treatment or notification.

Based on policy review, clinical record review and interview the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care for 2 of 2 sampled patients (Patient # 9 and Patient # 10) who received blood or blood products as evidenced by failure to monitor vital signs after blood transfusions as specified per facility policy.


The Findings include:

Facility policy titled " Administration of Blood and Blood Components" documents the following:
"Vital signs must be taken prior to administering blood products, then every 15 minutes x 2, then prn (as needed), upon discontinuing the unit of blood product, and 30 minutes post discontinuation. It is not appropriate to let a patient leave the floor during transfusions unless it is an emergency" .

Clinical record review conducted on 08/19/14 revealed a physician's order dated 08/03/14 for Patient # 9 to transfuse one unit packed red blood cells. The blood transfusion was completed on 08/03/14 at 8 PM. Further review of the record failed to provide evidence of post transfusion assessment upon completion of the transfusion at 8 PM and thirty minutes later.

Clinical record review conducted on 08/19/14 revealed a physician's order dated 08/03/14 for Patient # 10 to transfuse one unit packed red blood cells. The blood transfusion was completed on 08/03/14 at 3 PM. Further review of the record failed to provide evidence of post transfusion assessment upon completion of the transfusion at 3 PM and thirty minutes later.

Interview with the Clinical Analyst who was navigating the electronic record conducted on 08/19/14 at approximately 1 PM confirmed there are no post blood transfusion vital signs recorded for Patient # 9 and # 10 as noted above.