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Based on policy reviews, clinical record reviews and interviews it was determined the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5) for 3 of 6 sampled patients (Patient #3, #5, and #6) as evidenced by failure to accurately assessed skin conditions and wounds and failure to follow physician orders for medication administration as specified in the facility policies and procedures.

The findings included:

1) Facility policy titled "Medication ordering and Administration" dated 10/2016 documents "Only medications needed to treat the patient are ordered. There is a diagnosis, condition, or indication for each medication ordered if not apparent. All "as needed" or PRN orders must be quantified. The intended indication must be stated. PRN orders with stated indication for use will be profiled and documented in the Medication Administration Record (MAR) as directed by the provider. Medications are to be documented on the patients' medication administration record (eMAR)."

1a) Clinical record review conducted on 10/26/2016 revealed Patient #3 was admitted to the facility on 10/18/2016. Physician's Order dated 10/20/2016 documents Lopressor 2.5 mg intravenously every six hours as needed for heart rate above 110. The record indicates Patient #3 met the parameter for medication administration on the following dates: 10/20/2016 at 4:25 PM with heart rate 111; 10/21/2016 heart rate 114; 10/21/2016 heart rate 116; 10/21/2016 heart rate 113; 10/22/2016 heart rate 111 and on 10/23/2016 heart rate 115. Further review of the medication administration record and nurses' notes failed to provide evidence the medication was administered as ordered or an explanation as to why the doses were held.

Interview with the Quality Coordinator on 10/26/2016 at 11:01 AM, who navigated the electronic record, confirmed the Lopressor was not given on the identified dates and times noted above and was not able to locate nursing documentation as to why the medication was not administered as ordered.

1b) Clinical record review of Resident #5 on 10/26/2016 revealed a Physician's Order for Labetalol 10 mg intravenously every four hours as needed for systolic blood pressure greater than 150 dated 08/27/2016. The record indicates Patient #5 had blood pressure reading of 159/103 on 09/20/2016 at 8:08 AM. The record failed to provide evidence the medication was administered or documentation as to the rationale why it was not given.

Interview with The Quality Coordinator conducted on 10/26/2016 at approximately 1:50 PM confirmed the Labetalol was not given.

2) Facility policy titled "Wound Management" dated 08/2016 documents "Purpose to provide a standard of care for the management of wounds healing by secondary intention and to promote healing and reduce further injury to tissue. Wound assessment and documentation: documentation of complete wound assessment, which requires removal of the dressing, will be done on admission, unless contradicted and at least weekly thereafter. Wound measurements are to be done at least weekly. Complete wound assessment includes location, dressing type and status, wound type, wound color, drainage amount, drainage color, wound odor, hardening around wound, presence of black or gray eschar, presence of tunneling, and status of surrounding tissue.

2a) Clinical record review conducted on 10/26/2016 revealed Patient # 5 developed a wound to the sacrum. The record indicates the wound was first identified on 09/08/2016 measuring 3 cm in length, 2 cm in width and zero centimeters in depth. The clinical record failed to provide evidence complete wound assessments were conducted from 09/09/2016 thru 09/20/2016. There is no evidence of weekly measurements or changes in treatment or interventions to manage the progression of the wound. On 09/21/2016, the date scheduled for the patient discharge, the wound was assessed as unstageable, covered with tan slough and measuring 4 cm in length and 2.5 cm in width.

Further review of the record revealed Patient #5 was prescribed Santyl ointment daily to the sacrum wound on 09/21/2016. Discharge instructions dated 09/24/2016 document treatment to the sacrum wound with zinc oxide and Mepilex dressing. The facility failed to update treatment plan on the discharge instructions.

Interview with The Quality Coordinator and The Director of Patient Safety conducted on 10/26/2016 at approximately 1:50 PM revealed a complaint was recorded and investigated by the director of the unit. Patient #5's discharge was held, a plastic surgery consult was obtained and the patient was discharged on 09/24/2016. The Quality Coordinator who was navigating the electronic record confirmed there is no evidence of comprehensive wound assessment including measurements from 09/09/2016 thru 09/21/2016; evidence of changes in treatment to manage the worsening of the wound from 09/11/2016 thru 09/21/2016; or evidence the patient received updated discharge instructions for wound care.


2a) Clinical record review conducted on 10/26/2016 revealed Patient #6 was admitted to the facility on 10/17/2016. Present on admission form dated 10/17/2016 documents the patient had right lateral leg skin breakdown and an ulcer to the right lateral foot. Nursing shift assessments dated 10/17/2016 through 10/25/2016 failed to document complete wound assessments including measurements of the ulcer to the right foot. Treatment orders to the right foot ulcer were obtained two days later, on 10/19/2016 with Santyl ointment.

Further review of the record indicates Patient #6 was discharged home on 10/25/2016; discharge instructions did not address wound care.

Interview with The Quality Coordinator, who navigated the electronic record, on 10/26/2016 at approximately 2:35 PM confirmed the discrepancies on the wound assessment; the lack of wound measurements and evidence of discharge instructions addressing the wound care at home.

Based on policy review, clinical record review and interview it was determined the facility failed to ensure quality of nursing care provided to each patient is in accordance with established standards of practice of nursing care, chapter 464.003(5) for 2 of 2 sampled patients (Patient #9 and Patient #10) as evidenced by failure to monitor vital signs during blood transfusions as specified per facility policy.


The Findings included:

Facility Policy titled Blood Administration and Protocol reviewed 05/2016 documents vital signs will be performed as listed below and PRN during blood transfusions.

a. 15 minutes after start of transfusion. (temperature, pulse, blood pressure, respirations and pulse oximetry reading.)
b. Full set of vitals at the completion of the transfusion (temperature, pulse, blood pressure, respirations and pulse oximetry reading.)

Clinical record review conducted on 10/27/2016 revealed the following:
Transfusion Record for Patient #9 documents blood transfusion was administered on 10/20/2016. Further review of the record failed to provide evidence a complete set of vital signs was completed fifteen minutes after the initiation of the blood transfusion.

Transfusion Record for Patient #10 documents blood transfusion was administered on 10/20/2016. Further review of the record failed to provide evidence a complete set of vital signs was completed fifteen minutes after the initiation of the blood transfusion.

Interview with The Quality Coordinator, who was navigating the electronic record, on 10/27/2016 at approximately 10:22 AM confirmed there is no evidence Patients #9 and #10 were reassessed as per policy fifteen minutes after the initiation of the blood transfusions.