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Based on interview, record review, and document review, the facility failed to ensure adequate Nursing Services (Tags A385, A398 and A404), and failed to maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program (Tag A263).

The facility failed to comply with Federal Standards listed under the condition of Participation for Governing Body as evidenced by:

The failure to ensure hospital and contracted agency nursing staff from a contracted agency were trained adequately (TAG A398).

The facility failed to ensure an effective quality assessment and performance improvement (QAPI) program was maintained in order to assess, identify, and monitor actions following an adverse patient event. The facility failed to ensure a systematic monitoring and tracking system was put into place and reviewed by the QAPI program for the licensed hospital nurses and agency nurses to be trained regarding the new policies and procedures of weight measurements (TAG A-263).

The cumulative effect of these systematic practices resulted in the failure of the facility to deliver statutory-mandated care to patients.

Findings include:

Patient #10 was admitted 5/28/10, with tachycardia. Based on clinical record review, Patient #10 sustained a chest wall hematoma following a supratherapeutic dosage of Levonex on 5/29/10 and 5/30/10.

Based on policy review and interview, the facility updated the policy regarding weight measurement as of October 2010, revised as follows (Note: significant changes in Section III and Section IV (E)):

Policy dated 8/20/10:

"II. PURPOSE: To determine the appropriate weight of a patient in order to accurately calculate weight based medication dosages, fluid status, and nutritional monitoring. III. A. All patients will be weighed upon admission with an actual scale and the actual weight documented in kilograms. B. Nursery will document weight in grams. (Department exception OB/GYN (Obstetrics/Gynecology) where patients will be weighed according to physician order) IV. PROCEDURE: A. Upon admission an actual patient weight, not estimated or stated, will be obtained and documented in Opus on the clinical profile. B. All weights will be documented in kilograms. C. In addition to the admission weight, the patient's weight will be obtained prior to initiation of a weight based medication and as ordered by the physician. D. Critical Care patients will be weighed daily and weight documented on the flow sheet. E. For patients who have a 5% variance in weight, the new weight will be documented on the Clinical profile and pharmacy notified."

Policy dated 10/25/10:

"III. POLICY: A. All patients who are admitted to the inpatient areas will be weighed upon admission with an actual scale and the actual weight documented in kilograms. B. ER (Emergency Room) and OPS (Outpatient Services) will use "stated" weight unless weight based medications are ordered. C. Nursery will document weight in grams. D. OB/GYN patients will be weighted according to physician order unless weight based medications are ordered for administration. PROCEDURE: A. Upon admission to an inpatient unit an actual patient weight, not estimated or stated, will be obtained and documented in Opus on the clinical profile. B. All weights will be documented in kilograms. C. In addition to the admission weight, the patient's weight will be obtained prior to initiation of a weight based medication and as ordered by the physician. D. Critical Care patients will be weighted daily and weight documented on the flow sheet. E. For patients who have a 5% variance in weight, the new weight will be documented in the patient chart and the current weight may be considered for weight based medication dosages."

On 12/21/10, it was verified by interview with Employee #1, Employee #2, and Employee #3 that a new policy, dated 10/25/10, had become effective and that they needed to train their nursing staff in the October 2010 policy.

It was verified by interview on 12/20/10 and 12/21/10, with Employee #1 that the facility did not provide training to contracted agency nursing staff regarding the documentation of weights to be measured in kilograms (kg) rather than in pounds.

It was verified by interview on 12/20/10 and 12/21/10, by Employee #1 and Employee #2 there was no system in place to collect the information that the nurses from each nursing department had completed the in-servicing regarding weights. Employee #1 indicated that each separate department was responsible to maintain their own sign-in in-servicing sheets and there was no monitoring by the Chief Nursing Officer (CNO) and Employee #1.

On 12/21/10, several hours after request by the surveyor, Employee #1 was able to gather the documented sign-in sheets signed by the nurses that they had received the in-servicing. The following units lacked documentation of 15 nurses' signatures indicating that they had received the in-servicing:

ICU: Four (4) of 60 nurses
IMC: One (1) of 54 nurses
Med Surg 2nd Floor: Four (4) of 38 nurses
Med Surg 4th Floor: Six (6) of 32 nurses

The facility's internal investigation and analysis was completed in June 2010, with an anticipated completion date for risk reduction strategies of August 2010. There was no follow up by the QAPI program to ensure the completion of the risk reduction strategies identified, including educating staff of the new weights measurement policy.

The facility's internal investigation and analysis indicated Important Dates: 6/18/10 - First RCA meeting; 6/23/10 - Risk Reduction Strategies discussion meeting.

The internal investigation and analysis completed by the facility stated as follows:
"...Cause #1: Inconsistent process for recording and entering weights by the ED (Emergency Department) staff. Risk Reduction Strategy #1: Develop and implement a standardized process for taking and recording weights. Actions Taken: Implement a hospital standard that all weights be recorded in Kilograms. This includes "stated" weights that are written in the ED. Educate the staff to this new standard. Status: Complete. Date of Completion: August 2010. Measures of Effectiveness: (blank)."

"...Cause #2: Inconsistent process for taking admission and daily weights on IMC (Intermediate Medical Care). Risk Reduction Strategy #2: Implement one standardized policy for taking and recording daily and admission weights on the nursing units. Actions Taken: Eliminate the current IMC and ICU (Intensive Care Unit) specific policy on daily weights. Develop one policy for patient weights which can be hospital specific, yet include daily weight standards for each nursing unit. Educate the staff to this new policy. Status: Complete. Date of Completion: August 2010."

"...Cause #3: Lack of one, correct location for the recording of weights. Risk Reduction Strategy #3: Direct all staff to enter admission and daily weights into one, correct location. Actions Taken: Develop a policy and educate staff that all weights are to be entered into the Clinical Profile section of the Opus Documentation system. Status: Complete. Date of Completion: August 2010. Measures of Effectiveness: (blank)."

"...Cause #4: Failure of Staff to utilize clinical judgement when administering injectable weight based medication. Risk Reduction Strategy #4: Provide feedback and corrective action to involved staff. Actions Taken: Department managers to coordinate with HR (Human Resources) and provide the appropriate level of counseling to the involved staff members. Status: Complete. Date of Completion: (blank). Measures of Effectiveness: (blank)."

It was verified by interview with Employee #2 that the facility's internal investigation and analysis was not reviewed and followed up on during the QAPI Meetings, and that the effective measures identified (education of staff, and counseling to involved staff members) were not taken.

There was no specific documented evidence the facility reviewed, monitored, and tracked that the actions and effective measures identified in the facility's internal investigation and analysis (incorrect medication administration based on pounds versus kilograms) were followed through.

On 12/20/10 at approximately 10:00 AM, it was verified by interview with Employee #2 that there was no specific policy regarding medication errors and how the facility takes action toward the offending nurse following identification of a medication error. Upon questioning whether the facility verbally counseled or take any disciplinary action toward the nurse, Employee #2 stated, "No, due to the fact that it (the medication error) was not malicious." It was further verified with Employee #2 that the incident by the licensed nurse was not reported to the Board of Nursing (BON). Employee #1 and Employee #2 indicated there was no policy regarding under which conditions the facility reports incidents/errors of a licensed nurse to the BON.

Review of the employee's file revealed there was no documented evidence regarding the medication error and that there were no counseling or disciplinary actions taken.

On 12/20/10 and 12/21/10, the following information was verified by interview with Employee #3 in regard to the Governing Body ("The Board"):

The Board did not review the monitoring of the facility's internal investigation and analysis.

On 12/21/10 at 10:30 AM, it was verified by interview with Employee #3 that direct communication with the Governing Body Board was available in between the scheduled quarterly meetings via telephone, electronic mail, and telephone conferencing. However upon further interviewing on 12/21/10 in the afternoon, regarding why the Governing Body was not apprised of the monitoring and tracking status following Patient #1's adverse event identified in the facility's internal investigation and analysis dated June 2010, Employee #3 stated, "There were no issues that have come up since then that needed to be discussed with the Governing Body." Upon interviewing whether there was a means to communicate with the Governing Body prior to the next scheduled meeting, Employee #3 stated, "No, not if it wasn't significant." Employee #3 further indicated there was no policy and procedure regarding when and under what conditions an issue would be considered significant for the Governing body to be notified in-between scheduled meetings.

Based on interview, record review, and document review, the facility failed to meet the Condition of Participation (COP) for Quality Assurance Performance Improvement (QAPI). The facility did not maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program to ensure that oversight was maintained for adequate training for facility staff and contracted agency licensed nursing staff. The facility did not ensure that a comprehensive and ongoing quality assurance and performance improvement program addressed action in response to an adverse patient event. The facility did not ensure an effective quality assessment and performance improvement program was maintained in order to assess, identify, and monitor actions following an adverse patient event. The facility failed to ensure a systematic monitoring and tracking system was put into place and reviewed by the QAPI program for the licensed hospital nurses and agency nurses to be trained regarding the new policies and procedures of weight measurements.

The cumulative effect of these systematic practices resulted in the failure of the facility to deliver statutory-mandated care to patients.

Findings include:

Patient #10 was admitted 5/28/10, with tachycardia. Based on clinical record review, Patient #10 sustained a chest wall hematoma following a supratherapeutic dosage of Levonex on 5/29/10 and 5/30/10.

Based on policy review and interview, the facility updated the policy regarding weight measurement as of October 2010, revised as follows (Note: significant changes in Section III and Section IV (E)):

Policy dated 8/20/10:

"II. PURPOSE: To determine the appropriate weight of a patient in order to accurately calculate weight based medication dosages, fluid status, and nutritional monitoring. III. A. All patients will be weighed upon admission with an actual scale and the actual weight documented in kilograms. B. Nursery will document weight in grams. (Department exception OB/GYN (Obstetrics/Gynecology) where patients will be weighed according to physician order) IV. PROCEDURE: A. Upon admission an actual patient weight, not estimated or stated, will be obtained and documented in Opus on the clinical profile. B. All weights will be documented in kilograms. C. In addition to the admission weight, the patient's weight will be obtained prior to initiation of a weight based medication and as ordered by the physician. D. Critical Care patients will be weighed daily and weight documented on the flow sheet. E. For patients who have a 5% variance in weight, the new weight will be documented on the Clinical profile and pharmacy notified."

Policy dated 10/25/10:

"III. POLICY: A. All patients who are admitted to the inpatient areas will be weighed upon admission with an actual scale and the actual weight documented in kilograms. B. ER (Emergency Room) and OPS (Outpatient Services) will use "stated" weight unless weight based medications are ordered. C. Nursery will document weight in grams. D. OB/GYN patients will be weighted according to physician order unless weight based medications are ordered for administration. PROCEDURE: A. Upon admission to an inpatient unit an actual patient weight, not estimated or stated, will be obtained and documented in Opus on the clinical profile. B. All weights will be documented in kilograms. C. In addition to the admission weight, the patient's weight will be obtained prior to initiation of a weight based medication and as ordered by the physician. D. Critical Care patients will be weighted daily and weight documented on the flow sheet. E. For patients who have a 5% variance in weight, the new weight will be documented in the patient chart and the current weight may be considered for weight based medication dosages."

On 12/21/10, it was verified by interview with Employee #1, Employee #2, and Employee #3 that a new policy, dated 10/25/10, had become effective and that they needed to train their nursing staff in the October 2010 policy.

It was verified by interview on 12/20/10 and 12/21/10, with Employee #1 that the facility did not provide training to contracted agency nursing staff regarding the documentation of weights to be measured in kilograms rather than in pounds.

It was verified by interview on 12/20/10 and 12/21/10, by Employee #1 and Employee #2 there was no system in place to collect the information that the nurses from each nursing department had completed the in-servicing regarding weights. Employee #1 indicated that each separate department was responsible to maintain their own sign-in in-servicing sheets and there was no monitoring by the Chief Nursing Officer and Employee #1.

On 12/21/10, after request by the surveyor, Employee #1 was able to gather the documented sign-in sheets signed by the nurses that they received the in-servicing. The following units lacked documentation of 15 nurses' signatures indicating that they have received the in-servicing:

ICU: Four (4) of 60 nurses
IMC: One (1) of 54 nurses
Med Surg 2nd Floor: Four (4) of 38 nurses
Med Surg 4th Floor: Six (6) of 32 nurses

The facility's internal investigation and analysis was completed in June 2010, with an anticipated completion date for risk reduction strategies of August 2010. There was no follow up by the QAPI program to ensure the completion of the risk reduction strategies, including educating staff of the new weights measurement policy.

The facility's internal investigation and analysis indicated Important Dates: 6/18/10 - First RCA meeting; 6/23/10 - Risk Reduction Strategies discussion meeting.

The internal investigation and analysis completed by the facility stated as follows:
"...Cause #1: Inconsistent process for recording and entering weights by the ED (Emergency Department) staff. Risk Reduction Strategy #1: Develop and implement a standardized process for taking and recording weights. Actions Taken: Implement a hospital standard that all weights be recorded in Kilograms. This includes "stated" weights that are written in the ED. Educate the staff to this new standard. Status: Complete. Date of Completion: August 2010. Measures of Effectiveness: (blank)."

"...Cause #2: Inconsistent process for taking admission and daily weights on IMC (Intermediate Medical Care). Risk Reduction Strategy #2: Implement one standardized policy for taking and recording daily and admission weights on the nursing units. Actions Taken: Eliminate the current IMC and ICU (Intensive Care Unit) specific policy on daily weights. Develop one policy for patient weights which can be hospital specific, yet include daily weight standards for each nursing unit. Educate the staff to this new policy. Status: Complete. Date of Completion: August 2010."

"...Cause #3: Lack of one, correct location for the recording of weights. Risk Reduction Strategy #3: Direct all staff to enter admission and daily weights into one, correct location. Actions Taken: Develop a policy and educate staff that all weights are to be entered into the Clinical Profile section of the Opus Documentation system. Status: Complete. Date of Completion: August 2010. Measures of Effectiveness: (blank)."

"...Cause #4: Failure of Staff to utilize clinical judgement when administering injectable weight based medication. Risk Reduction Strategy #4: Provide feedback and corrective action to involved staff. Actions Taken: Department managers to coordinate with HR (Human Resources) and provide the appropriate level of counseling to the involved staff members. Status: Complete. Date of Completion: (blank). Measures of Effectiveness: (blank)."

It was verified by interview with Employee #2 on 12/20/10 and 12/21/10, that the facility's internal investigation and analysis was not reviewed and followed up on during the QAPI Meetings, and that the effective measures identified (education of staff and counseling to involved staff members) were not taken.

There was no specific documented evidence the facility reviewed, monitored, and tracked that the actions and effective measures identified in the facility's internal investigation and analysis were followed through.

On 12/20/10 at approximately 10:00 AM, it was verified by interview with Employee #2 that there was no specific policy regarding medication errors and how the facility takes action toward the offending nurse following identification of the medication error. Upon questioning whether the facility verbally counseled or take any disciplinary action toward the nurse, Employee #2 stated, "No, due to the fact that it (the medication error) was not malicious." It was further verified with Employee #2 that the incident by the licensed nurse was not reported to the Board of Nursing (BON). Employee #1 and Employee #2 indicated there was no policy regarding under which conditions the facility reports incidents/errors of a licensed nurse to the BON.

Review of the employee's file revealed there was no documented evidence regarding the medication error and that there was no counseling or disciplinary action taken.

Based on observation, interview, and document and record review, the facility failed to ensure a registered nurse properly obtained physician orders to administer medications and obtain correct patient weights to calculate weight based medications, and properly train agency staff on changes to the facility's policy as evidenced by: Non-employee licensed nurses who were working in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of the clinical activities of non-employee nursing personnel, which occur within the responsibility of the nursing services (A398). Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient's care as specified under ?482.23(c) (Tag A404).

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver statutorily mandated care to its patients.

Based on interview and document review, the facility failed to ensure non-employee licensed nurses were trained and in-serviced in new hospital policies and procedures regarding patients' weights.

Findings include:

Based on document review and interview, the facility updated the policy regarding weight measurement as of October 2010, revised as follows (Note: significant changes in Section III and Section IV (E)):

Policy dated 8/20/10:

"II. PURPOSE: To determine the appropriate weight of a patient in order to accurately calculate weight based medication dosages, fluid status, and nutritional monitoring. III. A. All patients will be weighed upon admission with an actual scale and the actual weight documented in kilograms. B. Nursery will document weight in grams. (Department exception OB/GYN (Obstetrics/Gynecology) where patients will be weighed according to physician order) IV. PROCEDURE: A. Upon admission an actual patient weight, not estimated or stated, will be obtained and documented in Opus on the clinical profile. B. All weights will be documented in kilograms. C. In addition to the admission weight, the patient's weight will be obtained prior to initiation of a weight based medication and as ordered by the physician. D. Critical Care patients will be weighed daily and weight documented on the flow sheet. E. For patients who have a 5% variance in weight, the new weight will be documented on the Clinical profile and pharmacy notified."

Policy dated 10/25/10:

"III. POLICY: A. All patients who are admitted to the inpatient areas will be weighed upon admission with an actual scale and the actual weight documented in kilograms. B. ER (Emergency Room) and OPS (Outpatient Services) will use "stated" weight unless weight based medications are ordered. C. Nursery will document weight in grams. D. OB/GYN patients will be weighted according to physician order unless weight based medications are ordered for administration. PROCEDURE: A. Upon admission to an inpatient unit an actual patient weight, not estimated or stated, will be obtained and documented in Opus on the clinical profile. B. All weights will be documented in kilograms. C. In addition to the admission weight, the patient's weight will be obtained prior to initiation of a weight based medication and as ordered by the physician. D. Critical Care patients will be weighted daily and weight documented on the flow sheet. E. For patients who have a 5% variance in weight, the new weight will be documented in the patient chart and the current weight may be considered for weight based medication dosages."

On 12/21/10, it was verified by interview with Employee #1, Employee #2, and Employee #3 that a new policy, dated 10/25/10, had become effective and that they needed to train nursing staff in the October 2010 policy.

It was verified by interview on 12/20/10 and 12/21/10, with Employee #1 that the facility did not provide training to contracted agency nursing staff regarding the documentation of weights to be measured in kilograms (kg) rather than in pounds.

Based on interview, record review and document review, the facility nursing staff failed to 1) provide proper care and treatment to a patient and followed physician's orders to ensure a patient received the proper doses of Lovenox (anticoagulant medication) in order to prevent medical complications that resulted in an emergency surgical intervention (Patient #10); and 2) Obtain physician orders for intravenous medications and properly obtain the correct patient weight to calculate weight based intravenous medications (Patient #10, #6, #7, #8, #11).

Findings include:

Patient #10

A Physician Transfer Summary dated 06/14/10, included the following: "The patient is a very debilitated 87 year old female who presented with tachycardia (increased heart rate) and mildly elevated tropins. The patient was seen and evaluated and felt not to be a cardiac catheterization candidate... Patient was noted to be in atrial fibrillation and had an order for 1 mg/kg (milligram per kilogram) of Lovenox BID (twice a day). Unfortunately 1 mg per pound was given and the patient did develop a hematoma under the right pec. The patient was taken for a pericardial window and at the same time the pericardial window was done, an evacuation of the right chest wall hematoma was done. Patient tolerated both procedures well. There were no other complications. The patient has been taken off anticoagulant therapy secondary to the hematoma development..."

On 12/20/10 and 12/21/10, an interview was conducted with Employee #2. Employee #2 confirmed that Patient #10 did receive a total of 5 incorrect dosages on 5/29/10 and 5/30/10, before it was identified.

An Emergency Department Physician Order dated 05/28/10, included the order for Lovenox 1 mg/kg SQ (subcutaneous) BID (twice-a-day).

An Emergency Department Record dated 05/28/10 at 12:40 PM, documented the patient's weight as 90 pounds. Emergency Department Medication Record documented the patient received Lovenox 40 mg SQ on 05/28/10 at 8:05 PM.

An Emergency Department Nursing Note dated 05/28/10 at 11:00 PM, indicated the patient was transferred to the IMC unit bed 243.

A Nursing Clinical Admission Assessment dated 05/29/10 at 12:25 AM documented the patient's admission weight was 90 kilograms.

An undated facility Patient Weight Policy and Procedure documented the following:
Policy:
"All patients admitted to the adult ICU and IMC will be weighed upon admission and daily thereafter.
a. Initial weight is to be recorded in the nursing initial assessment.
b. Daily weight should be obtained between 1900-0700 and recorded on the new days flow sheet."

Medication Administration Records documented the patient was administered Lovenox 90 mg on the following dates and times by nursing staff.
1. 05/29/10 at 10:00 AM, Lovenox 90 mg SQ given. Weight documented as 90.011 kg.
2. 05/29/10 at 10:00 PM, Lovenox 90 mg SQ given. Weight documented as 90.011 kg.
3. 05/30/10 at 10:00 AM, Lovenox 90 mg SQ given. Weight documented as 90.011 kg.
4. 05/30/10 at 10:00 PM, Lovenox 90 mg SQ given. Weight documented as 90.011 kg.
5. 05/31/10 at 10:00 AM, Lovenox 90 mg SQ given. Weight documented as 90.011 kg.

A Physician Order dated 05/31/10 at 1:50 PM, included the following:
"Regarding enlarged right chest wall. Stat (immediate) chest x-ray."

A Physician Order dated 05/31/10 at 3:00 PM, included the order for a stat (immediate) CT scan of the chest without contrast.

A Physician Order dated 05/31/10 (No time listed), documented to decrease Lovenox to 40 mg SQ every day.

A Physician Order dated 05/31/10 at 5:30 PM, documented to discontinue Lovenox.

A Physician Order dated 05/31/10 at 10:05 PM, included the orders to transfer the patient to the ICU (Intensive care Unit) and transfuse the patient with 2 units of packed red blood cells.

A Facility Operative Report dated 06/01/10, included the following: "The patient had a large right sided chest wall hematoma most likely related to supratheraputic dose of Lovenox. She was emergently brought to the operating room for evacuation of pericardial effusion with the understanding that she is stable and her remaining issues will be addressed as well. There was a large amount of clot evacuated from the hematoma on the right chest wall."

The facility updated the policy regarding weight measurement as of October 2010, revised as follows (Note: significant changes in Section III and Section IV (E)):

Policy dated 8/20/10:

"II. PURPOSE: To determine the appropriate weight of a patient in order to accurately calculate weight based medication dosages, fluid status, and nutritional monitoring. III. A. All patients will be weighed upon admission with an actual scale and the actual weight documented in kilograms. B. Nursery will document weight in grams. (Department exception OB/GYN (Obstetrics/Gynecology) where patients will be weighed according to physician order) IV. PROCEDURE: A. Upon admission an actual patient weight, not estimated or stated, will be obtained and documented in Opus on the clinical profile. B. All weights will be documented in kilograms. C. In addition to the admission weight, the patient's weight will be obtained prior to initiation of a weight based medication and as ordered by the physician. D. Critical Care patients will be weighed daily and weight documented on the flow sheet. E. For patients who have a 5% variance in weight, the new weight will be documented on the Clinical profile and pharmacy notified."

Policy dated 10/25/10:

"III. POLICY: A. All patients who are admitted to the inpatient areas will be weighed upon admission with an actual scale and the actual weight documented in kilograms. B. ER (Emergency Room) and OPS (Outpatient Services) will use "stated" weight unless weight based medications are ordered. C. Nursery will document weight in grams. D. OB/GYN patients will be weighted according to physician order unless weight based medications are ordered for administration. PROCEDURE: A. Upon admission to an inpatient unit an actual patient weight, not estimated or stated, will be obtained and documented in Opus on the clinical profile. B. All weights will be documented in kilograms. C. In addition to the admission weight, the patient's weight will be obtained prior to initiation of a weight based medication and as ordered by the physician. D. Critical Care patients will be weighted daily and weight documented on the flow sheet. E. For patients who have a 5% variance in weight, the new weight will be documented in the patient chart and the current weight may be considered for weight based medication dosages."

On 12/21/2010, in the afternoon, the Intensive Care Unit (ICU) manager, the Intermediate Care (IMC) unit charge nurse, and a IMC staff Registered Nurse (RN) were confused with the facility policy and procedure regarding obtaining a patient's weight to calculate weight based medications. The staff requested guidance from the surveyor to interpret the facility policy regarding which weight to use when calculating weight based medications. (Note: The surveyor did not give any guidance regarding the facility policy.) The surveyor referred the staff to the Director of Nursing for their concerns.

The staff were observed using initial admitting weights when calculating weight based intravenous medications on a daily basis. Some staff were using initial admitting weights even though there was a weight change greater than 5% from the initial weight. Some staff were using daily weights and some used the previous days daily weight to calculate weight based intravenous medications.

On 12/20/2010, the ICU manager indicated the initial admission weight should be used to calculate weight based medications. The manager stated, " The initial admission weight would be the dry weight and should not be changed."

Patient #6

Patient #6 was admitted on 12/15/2010. The initial admitting weight was documented as 238 pounds.

The Admission Assessment Downtime Form, dated 12/15/2010, documented the initial weight was 238 pounds. The weight was not documented in kilograms (kg) on the form. The Adult Critical Care Flow Sheet, dated 12/15/2010, documented Patient #6's weight was 238 pounds even though the form required the weight to be placed in kilograms.

Note: If Patient #6's initial admitting weight was converted from pounds to kg, the weight would be 108.18 kg.

On 12/21/2010, the Director of Clinical Operations (DCO) confirmed that the nurse who admitted the patient on 12/15/2010, was an agency nurse who may not have received in-service on the policy regarding weights. The DCO indicated the weights should have been documented in kilograms to decrease confusion. There was no documented evidence agency staff were given in-services regarding the policy on weight measurements.

On 12/20/2010, in the afternoon, a Dobutamine intravenous medication was infusing and the patient weight for the day was 112 kg. The weight used to calculate the Dobutamine medication was 109 kg, which was Patient #6's weight on 12/16/2010. The initial admitting weight of 108.18 was not used.

Patient #7

Patient #7 was admitted on 12/14/2010. The initial admitting weight documented on the Adult Critical Care Flow Sheet on 12/14/2010, was 65 kg.

On 12/20/2010, in the afternoon, a Propofol intravenous drip was infusing into Patient #7 at 40 mcg (micrograms)/kg/minute. The calculated weight being used was 66 kg. There was no documented evidence the patient weighed 66 kg. Patient #7's weight on 12/20/2010, was 79.1 kg, which was documented on Patient #7's Adult Critical Care Flow Sheet. There was a greater than 5% difference from 66 kg to 79.1 kg, but the weight used on 12/20/2010, to calculate the weight based medication for Dobutamine was 66 kg.

There was no documented evidence physician orders were written to start the Propofol intravenous medication. On 12/20/2010, the DCO confirmed that there was no physician order to start Propofol and the Propofol drip was started on 12/18/2010.

There was no daily weight documented on Patient #7's Adult Critical Care Flow Sheet for 12/18/2010. Documented on the 12/18/2010 form was the 12/17/2010 weight of 77.6 kg. Patient #7's Adult Critical Care Flow Sheet for 12/19/2010, incorrectly documented the previous days weight, 12/18/2010, as 77.6 kg.

The initial admission weight of 65 kg was not being used on 12/20/2010, to calculate the weight based medication of Propofol. The 12/20/2010 weight of 79.1 kg was a weight difference of 5% from 66 kg, but 79.1 kg was not being used to calculate the Propofol drip on 12/20/2010. When the propofol drip was started on 12/18/2010, there was no daily weight documented on 12/18/2010. There was no documented evidence Patient #7 weighed 66 kg, but 66 kg was being used in the calculation of the propofol drip on 12/20/2010.

Patient #8

Patient #8 was admitted on 12/6/2010. The Patient initial weight was 81 kg

On 12/20/2010, in the afternoon, a Dopamine drip was infusing into Patient #8. When the surveyor asked the staff RN what weight was being used to calculate the Dopamine infusion, the RN obtained the information from the infusion pump. The weight being used was 75 kg. Patient #8's previous days weight on 12/19/2010 was 75 kg. Patient #8's 12/20/2010 weight was 74.4 kg. The RN returned to the patient's room and changed the weight on the infusion pump to 74.4 kg.

Patient #11

Patient #11 was admitted on 12/15/2010.

On 12/22/2010, in the morning, a 5% Dextrose in .45 normal saline solution intravenous (IV) one liter bag was hanging at the patients bedside. The IV bag was not labeled and was not infusing. A Heparin IV solution was being infused. The Heparin IV tubing had a label indicating to change the tubing on 12/21/2010. The peripheral IV site located on the patients left forearm had a dressing covering the site, which was labeled 12/17/2010. The staff RN indicated the IV was stopped last night, confirmed the peripheral catheter IV site should have been changed, and the Heparin IV line should have been changed.

Patient #11's Inpatient Transfer Orders dated 12/20/2010, documented:

" IVF (intravenous fluids) D 5 1/2 (5% Dextrose in .45 normal saline) 85 ml (milliliter)/hr (hour)"

There was no documented evidence to stop the intravenous solution. The unit manager confirmed that there were no physician orders to stop the IV fluids and that a label should be placed whenever an IV bag is spiked and used on a patient.

The facility policy #NU 100.059 on Intravenous Therapy with the last review date of 8/2009, documented: "...IV catheter sites will be changed every 96 hours..."