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Based on record review, document review and interview the facility failed to ensure that Licensed Vocational Nurse (LVN) staff providing patient care were supervised by a Registered Nurse (RN) and the supervision is evidenced in the patient's medical record in 1 (#1) of 1 (#1) records reviewed.

Review of patient #1's record revealed a total of 20 shifts (from 7/13/2015 7:00 p.m. to 7:00 a.m. shift through 7/23/2015 7:00 a.m. to 7:00 p.m. shift) with nursing assessments documented. 10 (7:00 a.m. to 7:00 p.m. shifts on 7/14/2015 through 7/18/2015, and 7/20/2015 through 7/22/2015, 7:00 p.m. to 7:00 a.m. shifts on 7/18/2015 and 7/19/2015) of the 20 shift assessments were documented by LVN staff. 8 (7 a.m. to 7:00 p.m. on 7/14/2015 through 7/18/2015, and 7/21/2015 through 7/22/2015, and 7:00 p.m. to 7:00 a.m. shift on 7/18/2015) of the 10 LVN shift assessments had NO documentation that an RN had reviewed or supervised the LVN's assessment and/or patient care. Further review of the record revealed patient #1's nursing care was provided by LVN staff ONLY from 7/18/2015 at 7:20 a.m. until 7/19/2015 at 7:45 a.m. (24 hours, 25 minutes).

An interview was conducted on 10/15/2015 at approximately 3:00 p.m. with staff #2. While reviewing the record of patient #1, staff #2 was asked to show the surveyor documentation in the patient's record that would provide evidence the care provided by LVNs on the above listed shifts was supervised by an RN. Staff #2 was unable to provide that evidence and stated, "there is an RN assessment on the shift following each LVN shift assessment so, the patient is assessed by an RN every 24 hours." Staff #2 explained that the charge RN for each shift is responsible for supervising the LVN staff but, does not document that information in the patient's record.

Based on document and record review, the facility failed to:

A. ensure the nursing assessment of the care or treatment required to meet the needs of the patient was ongoing throughout the patient's hospital stay and in accordance with accepted standards of nursing practice and the facility's own policy in 1 (#1) of 1 (#1) records reviewed.

Review of patient #1's record revealed an admission date 7/14/2015 through the ER (Emergency Room) with complaints of abdominal pain, nausea and vomiting. An NG (nasogastric) tube was inserted into the patient's right nare (nostril) and proper placement was documented as verified by the ER nurse on 7/14/ 2015 at 12:06 a.m. The ER record stated, "Placement Verification: Auscultation and Return of Gastric Content; Contents: light yellow Drainage Amount: 20 ml (milliliters)".
The record contained electronic physician's order stating: "07/13/2015 22:07 (10:07 p.m.) Insert Nasogastric Tube NG Tube to Low Intermittent Suction. I & O (intake and output) q (every) shift"
The patient was transferred from the ER to the IMC (intermediate care) floor. Admitting diagnosis was small bowel obstruction.

On 7/14/2015 at 1:18 a.m. nursing staff documented an assessment of patient #1. The assessment stated the patient was experiencing diarrhea and vomiting, the NG tube was connected to low intermittent suction and placement was verified by "gastric aspiration". The drainage was described as "green". NO documentation of the amount of gastric contents aspirated or drainage was found.

On 07/14/2015 at 7:21 a.m. nursing staff documented an assessment of patient #1. The assessment stated the NG tube was connected to low intermittent suction, placement was checked and there was a "small amount of yellow drainage in tubing." NO documentation of the method used to check the NG tube placement or the amount of gastric drainage was found.

On 7/14/2015 at 7:55 p.m. nursing staff documented an assessment of patient #1. The assessment stated the NG tube was connected to low intermittent suction and gastric drainage was "green". NO documentation of NG tube placement verification or the amount of gastric drainage was found.

On 7/15/2015 at 3:24 a.m. nursing staff documented the following note:
"NG tube to right nare at low intermittent suction with scant amount of light green contents noted in canister." NO documentation of NG tube placement verification or the amount of gastric drainage was found.

On 7/15/2015 at 6:15 a.m. nursing staff documented the following note:
"less than 50 cc output from NG tube suction". NO documentation of NG tube placement verification was found.

Review of all nursing documentation for 7/15/2015 7:00 a.m. until 5:00 p.m. revealed there was NO documentation present that related to the patient's NG tube or drainage.

Review of the "Intake and Output" documentation had NO recorded output from the NG tube suction until 07/15/2015 17:00 - 17:59 (5:00 - 5:59 p.m.) when 3100 ml (milliliters) of NG tube output was recorded.

Review of the Physician's Progress Notes revealed the following:

On 7/14/2015 at 1:40 p.m. Staff #6 documented: "She was just given some Gastrografin (a contrast medium for the radiological examination of the gastrointestinal tract) and she says she feels more nauseated now than she did earlier."

On 7/15/2015 at 1:21 p.m. Staff #6 documented: "The patient is seen at the bedside, appears to be still nauseated. She states she feels very ill."

On 7/15/2015 at 3:43 p.m. Staff #7 documented: "The patient is hospitalized for a partial small bowel obstruction. Today, when she was given contrast and had an x-ray, the NG tube was not in the stomach, and there was a lot of dilatation with a lot of fluid in the stomach and proximal small bowel. We will get the radiologist to try to position the nasogastric tube in the stomach and continue NG suction. May well be that she will come to necessitate a laparotomy and lysis of adhesions to correct whatever problem is causing the small bowel obstruction."

On 7/16/2015 at 8:50 a.m. Staff #7 documented: "The patient has partial bowel obstruction. She looked pretty bad yesterday on x-ray, however her tube had been in her esophagus rather than her stomach and so really had not been decompressing. That was corrected and the x-ray looks much better today."

Review of the Radiology report for 7/15/2015 2:59 p.m. revealed comments by the radiologist that state: "Under fluoroscopy guidance, nasogastric tube is advanced into the stomach."

Patient #1's NG tube was inserted 07/14/2015 at 12:06 a.m. with an aspirated gastric contents output of 20 ml. There was NO other record of drainage amounts suctioned from the tube either by aspiration with a syringe or with machine suction until 7/15/2015 at 6:15 a.m. when nursing staff documented less than 50 cc (cubic centimeter or milliliter) of gastric contents output. On 7/14/2015 at 12:08 p.m. the physician ordered for the patient to be given "Gastrografin via NG tube then clamp tube for 3 hours and then get abdominal x-ray."

For a total of 38 hours and 53 minutes, patient #1's NG tube was not appropriately assessed for placement and drainage content according to standards of nursing practice and the facility's policy.

The nursing staff did not appropriately assess and respond to the patient's condition during the time the NG tube was improperly placed in the patient's esophagus. The patient reported feeling very ill with increased nausea after the Gastrografin was administered and had a low amount (less than 50 ml) of gastric output since admission.

Review of the "Texas Administrative Code, Title 22, Part II, Chapter 217, Rule 217.11, Standards of Nursing Practice" revealed the following information:
"The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted.
(1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall:
(A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice;
(B) Implement measures to promote a safe environment for clients and others;
(C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same;
(D) Accurately and completely report and document:
(i) the client's status including signs and symptoms;
(ii) nursing care rendered;
(iii) physician, dentist or podiatrist orders;
(iv) administration of medications and treatments;
(v) client response(s); and
(vi) contacts with other health care team members concerning significant events regarding client's status; ..."



Review of the facility's policy, "INITIAL PATIENT ASSESSMENT AND REASSESSMENT" revealed the following information:
"POLICY:
Each patient admitted to the hospital shall receive a complete head-to-toe assessment by a Registered Nurse so that a plan of care can be developed to best meet the needs of the patient. The assessment of the care or treatment required to meet the needs of the patient will be ongoing throughout the patient's hospital stay, with the assessment process individualized to meet the needs of the patient population."


B. ensure the nursing care and treatment required to meet the needs of the patient was in accordance with accepted standards of nursing practice and the facility's own policy in 1 (#1) of 1 (#1) records reviewed.

Review of patient #1's record revealed on 7/14/2015 at 12:08 a.m. the physician ordered for the patient to be given "Gastrografin via NG tube then clamp tube for 3 hours and then get abdominal x-ray."

Review of the radiologist's "Final Report Abdomen 1 View" dated 7/14/2015 at 3:50 p.m. revealed the following statement:
"Abdomen film was obtained 3 hours after administration of oral contrast....Contrast material is present in the stomach...."

Review of all staff documentation from the time the order was placed on 7/14/2015 at 12:08 p.m. and the time the abdominal x-ray was completed on 7/14/2015 at 3:50 p.m. revealed there was NO documentation of the Gastrografin administered to the patient or of the NG tube being clamped.

Based on record review the facility failed to ensure nursing staff documented all medications administered to patients in 1 (#1) of 1 (#1) records reviewed.

On 7/14/2015 at 12:08 a.m. the physician ordered for patient #1 to be given "Gastrografin via NG tube then clamp tube for 3 hours and then get abdominal x-ray."

Review of all staff documentation from the time the order was placed on 7/14/2015 at 12:08 p.m. until the time the abdominal x-ray was completed on 7/14/2015 at 3:50 p.m. revealed there was NO documentation of the Gastrografin administered to the patient or of the NG tube being clamped.

Review of the radiologist's "Final Report Abdomen 1 View" dated 7/14/2015 at 3:50 p.m. revealed the following statement:
"Abdomen film was obtained 3 hours after administration of oral contrast....Contrast material is present in the stomach...."