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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). This failure affected 2 of 3 sampled patients (Patients #2 and #5), as evidenced by failure to document the provision of tracheostomy care.

The findings included:

Facility policy "Tracheostomy Care Pediatric and Neonatal", last approved 10/2018, documents, "To establish guidelines to the care of pediatric and or neonatal patients with tracheostomies. Tracheotomy site care is to be completed once per shift and as needed. Documentation of the site cleansing, skin condition and changing of ties shall take place in the patients electronic medical record (EMR). Tracheostomy tubes will be changed routinely as indicated and documentation of tracheostomy change shall take place in the patients EMR."

1. Clinical record review conducted on 04/02/19 thru 04/03/19 revealed Patient #2 was admitted to the facility on 11/02/18 due to trauma. The record indicates the patient was placed on a ventilator and underwent a tracheostomy on 11/14/18.

Review of the electronic record failed to provide evidence the nursing or respiratory care staff consistently performed tracheostomy care every shift. The record had no documentation of tracheostomy care provided to the patient from 11/22/18 through 11/24/18.

Interview with the Director of Patient Safety, who navigated the electronic record, on 04/02/19 at approximately 2:28 PM revealed that after the nurse manager review of the record to ensure accuracy of the findings, the documentation of the provision of tracheostomy care is sporadic. The Director confirmed there is no evidence the staff provided tracheostomy care from 11/22/18 through 11/24/18.

2. Clinical record review conducted on 04/03/19 revealed Patient #5 was admitted to the facility on 03/08/19. The record indicates the patient was admitted with a tracheostomy.

Review of the electronic record failed to provide evidence the nursing or respiratory care staff consistently performed tracheostomy care every shift. The record had no documentation of tracheostomy care provided to the patient every shift on 03/31/19 and 04/01/19.

Interview with the Director of Patient Safety, who navigated the electronic record, on 04/03/19 at approximately 10:42 AM, confirmed there is no evidence the staff provided tracheostomy care every shift on two of the four days reviewed.

Based on policy review, clinical record review and interview, it was determined, the facility failed to ensure quality of nursing care was provided to each patient is in accordance with established standards of practice of nursing care, Chapter 464.003(5) for 1 of 1 sampled patients (Patient #4). This failure is evident by failure to assess and reassess patient's condition during blood transfusions as specified in facility policy for Blood Product Administration.

The findings included:

Facility policy titled "Transfusion Blood Product Components", last approved 01/2019 documents, "Monitor and record vital signs 15 minutes post initiation of transfusion and then every hour. Any change in the condition of the patient may signal the development of a transfusion complication. Upon completion of the transfusion, take and record post transfusion vital signs and then one-half hour later take another set of vital signs before the procedure is considered completed."

Clinical record review conducted on 04/02/19 revealed Patient #4 was prescribed a blood transfusion, one unit of red blood cells on 03/28/19.

The record indicates the blood transfusion was initiated on 03/28/19 at 12:20 PM.

Review of the Nurses Notes, Nursing Shift Assessments and Assessment and Reassessment documentation, and blood administration record failed to provide evidence a complete set of vital signs was obtained every hour during the transfusion and thirty minutes after the completion of the blood transfusion.

Interview with the Director of Patient Safety conducted on 04/02/19 at 2:59 PM confirmed there is no evidence the nursing staff completed the hourly reassessment, including vital signs. Also, there is no evidence the nurse monitored the patient's vital signs one-half hour post transfusion as mandated by the facility policies and procedures.

Interview with the Director of Patient Safety, the Director of Education and the Manager of Informatics conducted on 04/03/19 at 11:34 AM revealed the nursing staff was instructed not to conduct hourly reassessments during blood transfusions, due to a recommendation from the accreditation survey. The staff was asked to provide a revised policy or evidence of minutes discussing the change in practice and revision of policy to validate the information provided. The Director of Patient was not able to locate the required documentation. The staff was asked if the facility has a process for policy revision, approval and dissemination to the staff, to ensure the nursing care provided is governed by policy. The educator stated the facility uses Lippincott as best practice and was not able to elaborate on the fact the nursing staff was educated on a change in protocol without validation the policy review and approval process was completed. The Director of Patient Safety stated the policy is currently under revision.