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Based on review of the clinical record, review of facility policies, and interviews, the facility failed to provide documentation of ongoing nursing assessments for seven of ten patients, Patients #1, #2, #3, #5, #7, #8, and #10 who reported medical complaints and/or symptoms that required the attention of a physician and/or failed to follow physician orders for monitoring the vital signs of one of two patients, Patient #1, who was currently undergoing chemotherapy treatment. The findings include:

1. Patient #1 was admitted to the facility on 4/1/80 with diagnoses that included Schizophrenia and BiPolar Disease. Physician progress notes dated 2/14/10 at 11:00 AM identified that at the request of the nursing staff, Patient #1 was evaluated for "swelling of the patient's right forehead." The progress notes failed to reflect that an assessment was conducted by the nursing staff. The physician progress note dated 2/15/10 at 10:35 AM identified that Patient #1 had swelling over the left eyebrow and diffuse swelling over the forehead. Although initially no treatment was prescribed, on 2/23/10, the physician progress note recommended warm soaks to the site as needed. The progress notes lacked documentation to reflect if Patient #1 received the warm soaks and/or that an assessment to identify improvement or worsening of the swelling was conducted. On 2/26/10, physician progress notes identified no significant improvement of Patient #1's forehead swelling and subsequently, a Computerized Tomography Scan (CT Scan) and skull x-ray was ordered. Both diagnostic tests failed to identify the cause of the swelling. A physician progress note dated 3/16/10 described a "bony growth" at the left forehead that measured 6.0 centimeters (cm.) by 6.0 cm., identified that Patient #1 complained of a headache and occasional "double vision," and that the physician would attempt to move up a surgical consult already scheduled for 3/26/10. On 3/18/10, the physician progress note identified that Patient #1 was complaining of pain on the left forehead, that the soft tissue density had enlarged and was now 10.0 cm. by 8.0 cm. over the left eye with positive edema of the left eyelid and identified a new area of swelling on the scalp that measured 5.0 cm. by 4.0 cm. Review of the nursing notes dated 2/14/10 through 3/18/10 lacked documentation to reflect that nursing staff provided ongoing assessments of Patient #1's diffuse swelling over the forehead and eyelid and/or assessed the size and/or growth of the swelling and/or assessed the patient for any additional symptoms.

2. Patient #2 was admitted to the facility on 8/15/86 with diagnoses that included schizoaffective disorder. The clinical record identified that Patient #2 was examined by the physician on 6/14/10 for complaints of cold symptoms and was treated with the medication, Claritin. The 6/14/10 progress note identified that the physician observed wax in Patient #2's ear canal and prescribed Debrox eardrops. Nursing notes dated 6/19 and 6/20/10 identified that Patient #2 refused the Debrox eardrops on both days. Facility documentation identified that on 6/17/10, Patient #2 was placed on the physician's medical list after the patient complained of right ear pain. The progress notes lacked documentation of an assessment by nursing staff of the level of Patient #2's pain or an assessment of other signs and symptoms. The physician subsequently reordered Debrox eardrops for Patient #2 and on 7/6/10, physician progress notes identified that the patient's ears were flushed by the physician resulting in removal of a large amount of ear wax. Review of the nursing notes dated 6/17/10 through 7/6/10 lacked documentation to reflect that nursing staff provided ongoing assessments of Patient #2's pain and/or improvement of pain the patient previously reported.

3. Patient #3 was admitted to the facility on 2/27/10 with diagnoses that included schizoaffective disorder. Facility documentation identified that on 6/15/10, Patient #3 was placed on the physician's medical list after the patient complained of a sore throat. Physician telephone orders were obtained and directed the administration of Diabetic Tussin elixir, fifteen cubic centimeters (cc.) every six hours as needed for cough for four days. Patient #3 was examined by the physician on 6/17/10 and identified to have congestion in the throat. The physician progress notes identified that Patient #3 was advised to gargle with warm salt water as needed and directed that the patient be observed. Interview with RN #4 on 7/27/10 at 8:25 AM identified that if a patient complained of a sore throat, the nurse would be expected to assess the patient's temperature and vital signs and subsequently have the patient evaluated by the medical physician. RN #4 stated that he/she might not always document that information gathered through the assessment in the clinical record. Review of the nursing notes dated 6/17/10 through 7/27/10 lacked documentation to reflect that nursing staff provided ongoing assessments of Patient #3's sore throat complaints and/or assessments of interventions prescribed by the physician.


4. Patient #5 was admitted to the facility on 10/22/09 with diagnoses that included impulse control disorder. Facility documentation identified that on 6/22/10, Patient #5 was placed on the physician's medical list after the patient reported that he/she believed that he/she had contracted "pink eye." Physician orders directed that administration of "Refresh" eye drops to both eyes every four hours as needed for thirty days. Review of the nursing notes dated 6/22/10 through 7/27/10 lacked a description of the condition of Patient #5's eyes at the time of the complaint and/or documentation to reflect that nursing staff provided ongoing assessments of Patient #5's complaints related to his/her eyes and/or assessments of interventions prescribed by the physician.

5. Patient #7 was admitted to the facility on 10/19/84 with diagnoses that included Schizophrenia. Facility documentation identified that on 7/23/10, Patient #7 was placed on the physician's medical list for an observation of a "right shin open area." Review of the clinical record lacked documentation to reflect an observation and/or nursing assessment of the area on 7/23/10. Physician progress notes dated 7/23/10 identified that the physician examined the patient right shin area, directed the application of Hydrocortisone cream to the area at 8:00 AM and 8:00 PM, and requested that the area be observed. Review of the clinical record dated 7/23/10 to 7/27/10 lacked documentation to reflect that nursing staff provided ongoing assessments of Patient #7's right shin area. On 7/27/10 at 10:30 AM, Patient #7's right shin area was observed with two oval shaped open areas that measured approximately 1.5 cm. each on the lateral sides of the tibia. Interview with RN #2 at the time of the observation identified that he/she was unable to identify if the area had improved or deteriorated with the current treatment as the clinical record lacked documentation of a baseline description. In addition, RN #2 stated that she had not observed the area at the 8:00 AM application of the Hydrocortisone cream as prescribed as he/she had allowed Patient #7 to apply the medicated ointment himself/herself.

6. Patient #8 was admitted to the facility on 12/6/93 with diagnoses that included Schizophrenia. Facility documentation identified that on 7/9/10, Patient #8 was placed on the physician's medical list for a report by the patient of a "groin rash." Review of the clinical record lacked documentation to reflect an observation and/or nursing assessment of the area on 7/9/10. Physician orders dated 7/9/10 directed the application of Hydrocortisone cream to the area at 8:00 AM and 8:00 PM for two weeks, and requested that the area be observed. Review of the clinical record dated 7/9/10 to 7/14/10 lacked documentation to reflect that nursing staff provided ongoing assessments of Patient #8's groin area. Facility documentation identified that on 7/14/10, Patient #8 was again placed on the physician's medical list for a "groin rash." The physician again directed the application of Hydrocortisone cream to the area at 8:00 AM and 8:00 PM for thirty days, and requested that the area be observed. Review of the clinical record dated 7/9/10 to 7/27/10 lacked documentation to reflect that nursing staff provided ongoing assessments of Patient #8's groin rash. Interview with RN #2 on 7/27/10 at 10:10 AM identified that he/she was unable to identify if the rash had improved or deteriorated with the current treatment as the clinical record lacked documentation of a baseline description. In addition, RN #2 stated that he/she had not observed the area at the 8:00 AM application of the Hydrocortisone cream as prescribed as he/she had allowed Patient #8 to apply the medicated ointment himself/herself.

7. Patient #10 was admitted to the facility on 5/15/90 with diagnoses that included Schizophrenia/paranoid type. Facility documentation identified that on 7/1/10, Patient #10 was placed on the physician's medical list for observation of significant swelling of the right knee and complaints of pain at the knee. Review of the clinical record lacked documentation to reflect the observation and/or nursing assessment of Patient #10's right knee and/or the patient's pain level on 7/1/10. Physician progress notes dated 7/1/10 identified that Patient #10 was examined by the physician who ordered the medication, Ibuprofen for pain every six hours as needed and requested an orthopedic consult. Review of the clinical record dated 7/1/10 to 7/27/10 lacked documentation to reflect that nursing staff provided ongoing assessments of Patient #10's right knee and/or the patient's pain level. Patient #10 was subsequently evaluated by an orthopedic surgeon on 7/26/10 who recommended physical therapy for osteoarthritis.

Review of facility policies directed that a Registered Nurse (RN) would provide and document assessment/reassessment findings for medical conditions in the Physical Health Progress Notes upon a significant change in the patient's condition. The policy directed that the RN document nursing interventions and patient response to nursing actions in accordance with professional standards.

8. Patient #1 had diagnoses that included BiPolar Disease and a recent diagnosis (4/10) of Non-Hodgkin's Lymphoma for which the patient was currently undergoing intermittent chemotherapy treatments in the acute care hospital setting. Review of the clinical record identified Patient #1 developed an elevated temperature (101.3 degrees) on 6/7/10 that was identified by staff at the facility during a routine check of the patient's vital signs. Patient #1 was transferred to the acute care hospital on 6/7/10 and subsequently diagnosed with neutropenic fever and acute anemia. Following treatment that included blood transfusions and medications that included Neupogen, Patient #1 was transferred back to the facility on 6/10/10. Physician orders dated 6/10/10 directed that Patient #1's vital signs be assessed every shift with direction to notify the physician if the patient's temperature was greater than 101 degrees. Review of the clinical record and vital sign sheets at the nursing station lacked documentation to reflect that Patient #1's vital signs were consistently monitored in accordance with physician orders. The documentation identified that staff failed to obtain Patient #1's vital signs on twenty-nine shifts from 6/10/10 to 7/7/10. Review of facility policy directed that nursing staff would obtain vital signs as prescribed by the physician.

Based on review of the clinical record, review of facility policies, and interviews, the facility failed to develop a comprehensive plan of care for one patient, Patient #1, who required a portacath for chemotherapy delivery. The findings include:

1. Patient #1 had diagnoses that included BiPolar Disease and a recent diagnosis (4/10) of Non-Hodgkin's Lymphoma. During an interview with Patient #1 on 7/7/10 at 9:00, the patient reported that he/she had a catheter placed in his/her chest in order to receive chemotherapy treatments. Review of a fluoroscopy report dated 5/5/10 identified that Patient #1 underwent the portacath insertion on 5/5/10. Review of the clinical record and treatment plan dated 6/2/10 lacked documentation to reflect that a plan of care was developed to address Patient #1's portacath and/or interventions for monitoring of the catheter and site of insertion. Interview with RN #1 on 7/7/10 at 11:40 AM identified that staff at the facility does not provide care to the catheter and therefore, no plan had been put into place for monitoring/assessment of the site between chemotherapy inductions. Review of facility policies directed that the integrated treatment plan is a plan driven by needs identified and provided a detailed set of goals to manage illness and improve the patient's quality of life. The policy directed that the nursing plan of care list key information and services for nursing staff related to the medical care of the patient, list treatment approaches, frequency and focus of interventions in order to provide a clear and concise resource that outlined medical treatment interventions required by the patient.

Based on review of the clinical record, review of facility policies, observation, and interviews, the facility failed to ensure that treatments that included the application of medicated ointments, were provided and/or supervised by nursing personnel.

1. Patient #7 was admitted to the facility on 10/19/84 with diagnoses that included Schizophrenia. Facility documentation identified that on 7/23/10, Patient #7 was placed on the physician's medical list for an observation of a "right shin open area." Physician progress notes dated 7/23/10 identified that the physician examined the patient's right shin area, directed the application of Hydrocortisone cream to the area at 8:00 AM and 8:00 PM, and requested that the area be observed. On 7/27/10 at 10:30 AM, Patient #7 removed two bandaids placed over the right shin that contained a moderately thick amount of a white creamy substance. Patient #7's right shin area was observed with two oval shaped open areas that measured approximately 1.5 cm. each of the lateral sides of the tibia. Interview with Patient #7 at the time of the observation identified that that nursing staff handed him/her a packet of Hydrocortisone cream at each directed time and that he/she applied the medicated ointment and the bandaids himself/herself. Patient #7 stated that he/she was concerned that the area was not healing properly. Interview with RN #2 at the time of the observation identified that he/she had never seen the area before this observation as he/she had allowed Patient #7 to apply the 8:00 AM (7/27/10) application of the Hydrocortisone cream himself/herself. RN #2 stated that facility policy directed that patients were allowed to self-administer medications with permission from a physician. Review of Patient #7's clinical record with RN #2 lacked documentation of a physician's order for self-administration of the prescribed treatment to the patient's right shin open areas.

2. Patient #8 was admitted to the facility on 12/6/93 with diagnoses that included Schizophrenia. Physician orders dated 7/9/10 directed the application of Hydrocortisone cream to the area at 8:00 AM and 8:00 PM for two weeks, and requested that the area be observed. Facility documentation identified that on 7/14/10, Patient #8 was again placed on the physician's medical list for a "groin rash" and that the physician again directed the application of Hydrocortisone cream to the area at 8:00 AM and 8:00 PM for thirty days and again requested that the area be observed. Patient #8 was not available for observation at the time of the survey. Interview with RN #2 on 7/27/10 at 10:10 AM identified that he/she was unable to identify if the rash had improved or deteriorated with the current treatment and that he/she had not observed the area at the 8:00 AM application of the Hydrocortisone cream on 7/27/10. RN #23 stated that he/she had allowed Patient #8 to apply the medicated ointment himself/herself. Review of the clinical record with RN #2 lacked documentation of a physician order to allow Patient #8 to self administer the Hydrocortisone cream to his/her own groin rash.

Facility policy directed that a physician may write an order to self administer an Epipen or inhaler without direct supervision of a nurse under circumstances that included an initial competency assessment, client teaching, and annual assessments thereafter. Supervised self-administration would encompass all other medications and documentation of the process would be included in the clinical record.