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Based on review of the Acuity Sheet, Acuity Sheet instructions, and interview, it was determined the facility failed to ensure a Registered Nurse assigned the nursing care of each patient in that the Acuity Sheet and the Acuity Sheet instructions did not match, and failed to ensure the Acuity Sheet was completed for 20 (05/01/19 - 05/03/19, 05/06/19, 05/08/19 - 05/13/19, 05/16/19, 05/18/19, 05/22/19, 05/24/19, 05/25/19, 05/27/19, 05/30/19, 05/31/19, and 06/03/19) of 35 (05/01/19 through 06/04/19) days. Failure to ensure the Acuity Sheet and Acuity Sheet instructions matched, and failure to complete the Acuity Sheet for each day, had the potential for insufficient staffing. The failed practice had the potential to affect any inpatient. Findings follow:

A. Review of the Acuity Sheets, received from the Safety Compliance Officer on 06/05/19, showed the following instructions:" ... 4) Round down if .5 or less, round up if .6 or more. 7 P to 7A shift requires a minimum of 3. 5) Total staff needed included ER (Emergency Room) nurse on 7P shift only ..."

B. Review of the Acuity Sheet Instructions, received from the Safety Compliance Officer on 06/05/19, showed the following on the front of the sheet: " ... The ER nurse is not included in the total for either shift. 7P to 7A shift (nights) requires a minimum staff of 3 - 2 nurses and 1 CNA (certified nurse aide)." The back side of the Acuity Sheet Instructions showed the following:
CHARGE NURSES SHOULD COMPLETE THE FOLLOWING:
"... Complete the Acuity sheet for the next shift before 1630/0430 (4:30PM/4:30AM). ... Mark staff as on-call/low census on the Acuity Sheet and the schedule. Complete the Assignment portion of the Acuity Sheet for your shift. Everyone is responsible for completing the above tasks."

C. During an interview with the ER Director and the OR (Operating Room) Director at 11:43 AM on 06/07/19, the ER Director stated the current practice was the ER nurse was not counted on the 7A to 7P shift, and the minimum requirement of three staff on 7P to 7A listed on the Acuity Sheet instructions was wrong. The ER Director stated the Acuity Sheets were to be completed with patient name and staff assignments. The OR Director stated she had never been told the acuity of each individual patient had to be listed.

D. Review of the Acuity Sheets for 05/01/19 through 06/04/19 showed 20 days of 35 days without patient and staff assignments listed: 05/01/19 - 05/03/19, 05/06/19, 05/08/19 - 05/13/19, 05/16/19, 05/18/19, 05/22/19, 05/24/19, 05/25/19, 05/27/19, 05/30/19, 05/31/19, and 06/03/19. The findings in A, B, C and D were confirmed during an interview with the ER Director at 11:45 AM on 06/07/19.

Based on clinical record review and interview, it was determined a registered nurse (RN) failed to supervise and evaluate the nursing care in that four (#2, #13, #19 and #20) of twenty (#1-20) clinical records did not contain evidence patient care was rendered as directed by physician's orders. Review of the clinical records showed no evidence antibiotics were administered, ambulation occurred, orthostatic blood pressures were obtained and documented prior to ambulation, and vital signs were checked and documented every four hours. Failure of a RN to evaluate, supervise, and manage patient care to ensure physician's orders were followed had the potential for adverse events to occur leading to prolonged hospitalization. The failed practice did not ensure vital information was available for the provider to make informed decisions and receive care needed to ensure a timely discharge. The failed practice had the likelihood to affect Patients #13, #19, and #20. Findings follow:

A. Review of Patient #2's clinical record showed physician orders for Augmentin (antibiotic) 500 /125 milligrams that was ordered one time per day. Review of the clinical record with the Emergency Room (ER) Director showed no evidence the Augmentin was administered one time per day for five (05/16/19, 05/19/19, 05/25/19, 06/01/19 and 06/02/19) of 34 (05/02/19-06/06/19) days as ordered by the physician. The findings were verified by the ED Director on 06/06/19 at 4:47 PM.

B. Review of Patient #13's clinical record showed orders authored by Physician #1 at 12:48 PM on 05/03/19 for Patient #13 to be ambulated three times per day with assistance and an orthostatic blood pressure to be obtained prior to ambulation. Review of the clinical record showed no evidence orthostatic blood pressures were obtained prior to ambulation on 05/03/19, 05/04/19, 05/05/19, and 05/06/19. Review of the clinical record showed no evidence Patient #13 was ambulated three times a day on 05/06/19. Patient #13 was discharged on 05/07/19. The Medical Records Director verified the above during an interview at 10:31 AM on 06/07/19.

C. Review of Patient #19's clinical record showed orders authored by Physician #1 at 5:00 PM on 03/13/19 for Patient #19 to have vital signs checked every four hours and this was to start at 2:00 AM on 03/14/19. Review of the clinical record also showed orders authored by Physician #1 at 8:15 AM on 03/15/19 for Patient #19 to be ambulated four times per day. This was to start at that time. Review of the Patient vital sign sheet showed no evidence vital signs were checked every four hours as ordered on 03/14/19, 03/15/19, 03/16/19, and 03/17/19. Review of the clinical record showed no evidence Patient #19 was ambulated four times a day. Patient #19 was discharged on 03/18/19. The Safety Compliance Officer verified the above during an interview at 1:49 PM on 06/06/19.

D. Review of Patient #20's clinical record showed orders authored by Physician #1 at 1:38 PM on 03/21/19 to have vital signs checked every four hours and this was to start at 2:00 AM on 03/22/19. Review of the clinical record also showed orders authored by Physician #1 at 8:01 PM on 03/22/29 for Patient #20 to be ambulated four times a day. This was to start at 9:00 PM on 03/22/19. Review of the Patient vital sign sheet showed no evidence vital signs were checked every four hours on 03/22/19, 03/23/19, 03/24/19, and 03/25/19. Review of the clinical record showed no evidence Patient #20 was ambulated four times a day on 03/24/19. Patient #20 was discharged on 03/26/19. The Safety Compliance Officer verified the above findings during an interview at 1:22 PM on 06/06/19.


Based on policy and procedure review, clinical record review, and interview it was determined the facility nursing staff failed to follow policy and procedure in that reassessments of pain levels were not performed for 6 (#1, #6, #8, #14, #16, and #20) of 20 (#1- #20) patients. Failure to reassess the level of pain control/relief had the potential to allow inadequate pain relief and did not ensure staff followed policy. The failed practice had the likelihood to affect Patient #1, #6, #8, #14, #16, and #20. Findings follow:

A. Review of the policy and procedure titled "Pain Management," received from the Safety Compliance Officer on 06/05/19, showed that if medication ordered is not effective, the physician was to be notified for direction in managing the patient's pain; and the effectiveness of the medication was to be recorded by noting the patient's response.

B. Review of Patient #1's clinical record showed physician orders for Norco 10/325 milligrams for pain. Record review with the Emergency Room (ER) Director showed there was no reassessment of pain after Norco was administered 14 (05/26/19 at 4:15 PM, 05/27/19 at 5:13 PM, 05/28/19 at 7:50 PM, 05/29/19 at 4:00 AM and 8:54 PM, 05/30/19 at 3:30 PM, 06/01/19 at 9:05 PM, 06/02/19 at 5:20 PM, 06/02/19 at 7:57 PM, 06/03/19 at 9:10 PM, 06/04/19 at 1:54 PM and 9:00 PM, and 06/05/19 at 5:24 AM) of 16 (05/26/19 - 06/07/19) times to determine if the medication was effective. The findings were verified by the ER Director on 06/06/19 at 3:59 PM.

C. Review of Patient #6's clinical record showed physician orders for Tylenol Extra Strength 500 milligrams every four hours as needed for pain. Record review with the ER Director showed there was no reassessment of pain after Tylenol was administered three of three times (05/19/19 at 5:15 PM, 05/20/19 at 4:46 PM and 05/21/19 at 2:07 PM) to determine if the medication was effective. The findings were verified by the ER Director on 06/07/19 at 9:44 AM.

D. Review of Patient#8's clinical record showed physician orders for Oxycodone Hcl 5 milligrams as needed for pain. Record review with the ER director showed there was no reassessment of pain after Oxycodone was administered four of four times (04/17/19 at 8:20 AM, 04/18/19 at 3:06 PM, 04/23/19 at 10:33 AM and 05/07/19 at 1:33 PM) to determine if the medication was effective. The findings were verified by the ER Director on 06/07/19 at 10:47 AM.

E. Review of Patient #14's clinical record showed orders authored by Physician #2 at 5:28 PM on 05/09/19 for Hydrocodone-Acetaminophen 10-325 mg (milligrams) po (by mouth) every 8 hours as needed for pain. Review of the Medication Administration Record showed Patient #14 received nine doses of the Hydrocodone-Acetaminophen: at 8:31 PM on 05/09/19, 6:31 PM on 05/10/19, at 8:56 AM and 4:45 PM on 05/11/19, 6:10 AM and 2:18 PM on 05/13/19, at 3:40 AM and 2213 on 05/12/19, and 12:21 AM on 05/14/19. Review of the clinical record showed only one, the 2:18 PM on 05/13/19 dose, had documentation of assessment of the effectiveness of the pain medication. During an interview with the Medical Record Director at 9:44 AM on 06/07/19, the above findings were verified.

F. Review of Patient #16's clinical record showed orders authored by Physician #3 at 8:06 PM on 05/24/19 for Hydrocodone-Acetaminophen 5-325 mg po every eight hours as needed for pain. Review of the Medication Administration Record showed Patient #16 received six doses of the Hydrocodone-Acetaminophen at 4:30 AM and 5:28 PM on 05/25/19, two doses at 1:30 AM and 11:41 AM on 05/26/19, and 7:33 AM and 10:40 PM on 05/28/19. Review of the clinical record showed only one, the 11:41 AM on 05/28/19 dose, had documentation of the assessment of the effectiveness of the pain medication. During an interview with the Medical Record Director at 9:40 AM on 06/07/19, the above findings were verified.

G. Review of Patient #20's clinical record showed orders authored by Physician #1 at 7:59 AM on 03/22/19 for Oxycodone HCL 5 mg tabs, 10 mg dose, every four hours as needed for moderate pain. Review of the medication administration record showed Patient #20 received nine doses of the Oxycodone HCL at 8:57 AM and 7:40 PM on 03/22/19, 3:50 AM, 10:07 AM, and 8:30 PM on 03/23/19, 8:15 AM, and 7:40 PM on 03/24/19, 6:24 PM on 03/25/19, and 12:15 AM on 03/26/19. Review of the clinical record showed no evidence of an assessment of the effectiveness of the pain medication for any of the administered doses. During an interview with the Safety Compliance Officer at 1:27 PM on 06/06/19, the above findings were verified.

Based on review of personnel files, Swing-Bed policies and interview, it was determined the facility failed to follow their policy in that there was no individual who performed the duties of Activities Director or that met the minimum qualifications for conducting the Swing-bed activities program. Failure to have a qualified professional direct the activities program did not ensure that the individual physical, mental, and psychosocial well-being of each patient would be met. The failed practice affected the 06/06/19 swing-bed census of two patients (#1 and #2); and had the likelihood to affect all patients admitted to the swing-bed program. Findings included:

A. Review of facility policy for swing-beds showed a policy titled "Activities Director," dated 07/05/12 , that the activities director was responsible for evaluation and implementation of appropriate or prescribed activities to each assigned patient in order to restore, reinforce and improve performance of functional skills; and to promote and maintain quality of life for each patient. In addition the Activities Director was responsible for other services such as program development. The basic requirements included the minimum qualification of a qualified therapeutic recreation specialist or an activities professional for other services such as program development. The basic requirements included the minimum qualification of a qualified therapeutic recreation specialist or an activities professional who is licensed or registered by the State and is eligible for certification a therapeutic recreation specialist or as an activities professional.

B. On 06/05/19 at 11:30 AM, the Safety and Compliance Officer stated activities for swing-bed patients were provided by Physical Therapy Assistant (PTA) #1 and staff. On 06/06/19 at 3:25 PM the Chief Nursing Officer (CNO) stated that she was the person responsible for Swing-beds and that PTA #1 was the person who was responsible for activities for Swing-bed patients.

C. PTA #1 was interviewed on 06/06/19 at 8:50 AM and on 06/07/19 at 1:22 PM. At the time of interviews, PTA #1 stated she was a PTA and did not provide activities for patients in Swing-bed status and that all she did was PTA duties. Stated the facility had not had an activity department for "a long time."

D. The Swing-bed activity requirements were reviewed on 06/07/19 at 1:32 PM with the administrative staff present (Emergency Room (ER) Director and the Operating Room (OR) Director). The ER Director and OR Director confirmed on 06/07/19 at 1:33 PM that the facility did not have an Activity Director at this time and there had not been an Activity Director for Swing-bed patients for about one year; no assessment of activities was performed or documented and there were no individual or group planned activities for patients admitted to Swing-bed.

E. Clinical record review showed Patient #1 was admitted to Swing-bed status on 05/23/19 at 2:04 PM. The Director of ER confirmed on 06/06/19 at 3:59 PM the clinical record did not include an activities assessment, activities were not addressed on the individual plan of care and there was no evidence activities were provided. Patient #1 was interviewed on 06/06/19 from 9:00 AM to 9:33 AM in the room and stated no one had asked him about activities or taken him for activities. Patient #1 stated that he enjoyed reading and journaling in his notebook.

F. Clinical record review showed Patient #2 was admitted to Swing-bed status on 05/01/19. The Director of ER confirmed on 06/06/19 at 4:15 PM that the clinical record did not include an activities assessment, activities were not addressed on the individual plan of care and there was no evidence activities were provided. Patient #2 was interviewed on 06/06/19 at 8:58 AM and stated he had therapy. Patient #2 stated he did not recall anyone talking to him about activities.

Based on clinical record review, review of swing-bed policies and interviews, it was determined the facility failed to provide an activities assessment or care plan for two of two (#1 and #2) Swing-bed patients. Failure to have a program of activities based on the needs and preferences of each patient did not ensure that the individual physical, mental, and psychosocial well-being of each patient would be met. The failed practice affected Patient #1 and #2 and was likely to affect all patients admitted to Swing-bed status. Findings included:

A. Review of facility policy for swing-beds showed a policy titled "Activities Director," dated 07/05/12, that showed the Activities Director was responsible for evaluation and implementation of appropriate or prescribed activities to each assigned patient in order to restore, reinforce and improve performance of functional skills; and to promote and maintain quality of life for each patient. In addition the Activities Director was responsible for other services such as program development. The basic requirements included the minimum qualification of a qualified therapeutic recreation specialist or an activities professional who is licensed or registered by the State and is eligible for certification a therapeutic recreation specialist or as an activities professional.

B. On 06/05/19 at 11:30 AM, the Safety and Compliance Officer stated activities for swing-bed patients were provided by Physical Therapy Assistant (PTA) #1 and staff. On 06/06/19 at 3:25 PM the Chief Nursing Officer (CNO) stated she was responsible for Swing-beds and that PTA #1 was the person who was responsible for activities.

C. PTA #1 was interviewed on 06/06/19 at 8:50 AM and on 06/07/19 at 1:22 PM. At the time of interviews, PTA #1 stated she was a PTA and did not provide activities for patients in Swing-bed status and that all she did was PTA duties. Stated the facility had not had an activity department for "a long time."

D. The Swing-bed activity requirements were reviewed on 06/07/19 at 1:32 PM with the administrative staff present (Emergency Room (ER) Director and the Operating Room (OR) Director). The ER Director and OR Director confirmed on 06/07/19 at 1:33 PM that the facility did not have an Activity Director at this time and there had not been an Activity Director for Swing-bed patients for about one year; no assessment of activities was performed or documented and there were no individual or group planned activities for patients admitted to Swing-bed.

E. Clinical record review showed Patient #1 was admitted to Swing-bed status on 05/23/19 at 2:04 PM. The Director of ER confirmed on 06/06/19 at 3:59 PM the clinical record did not include an activities assessment, activities were not addressed on the individual plan of care and there was no evidence activities were provided. Patient #1 was interviewed on 06/06/19 from 9:00 AM to 9:33 AM in the room and stated no one had asked him about activities or taken him for activities. Patient #1 stated that he enjoyed reading and to journal in his notebook.

F. Clinical record review showed Patient #2 was admitted to Swing-bed status on 05/01/19. The Director of ER confirmed on 06/06/19 at 4:15 PM that the clinical record did not include an activities assessment, activities were not addressed on the individual plan of care and there was no evidence activities were provided. Patient #2 was interviewed on 06/06/19 at 8:58 AM and stated he had therapy. Patient #2 stated he did not recall anyone talking to him about activities.