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Review of the medical record, staff interview and review of facility policy it was determined the facility failed to ensure nursing staff developed and kept current a nursing care plan for each patient for one (#2) of ten patients sampled.

Findings included:

Review of the facility's Plan for the Provision of Patient Care 2016 section (C) Nursing Services stated each patient is assessed by a registered nurse. A plan of care is mutually established based on this assessment. Nursing interventions take place and their effectiveness evaluated.

Review of the medical record for patient #2 revealed the patient was admitted on 1/7/2016. Review of the record revealed the patient had complaints of abdominal pain and required surgery. Review of the nursing documentation and MAR (Medication Administration Record) revealed the patient received pain medication throughout the hospitalization. Review of the discharge information dated 1/10/2016 revealed the patient was provided a prescription for pain medication at discharge.

Review of the patient's individualized plan of care revealed the plan of care was initiated on 1/7/2016. Review of the identified problems revealed pain was not identified as a problem. There was no documentation of the desired outcome or identified patient needs/issues/pertinent information.

Interview with the Chief Quality Officer on 4/6/2016 at approximately 11:30 a.m. confirmed the findings.

Based on medical record review, staff interview and review of policy and procedures it was determined the facility failed to ensure medications were administered according to physician ordered protocol for two (#1, #3) of ten records reviewed.

Findings included:

Review of the facility policy "Administration of Medications: General", last revised 2/2012, stated drugs shall be prepared and administered in accordance with the orders of the prescriber or practitioner responsible for the patient's care and accepted standards of practice.

1. Review of the medical record for patient #1 revealed the patient was admitted to the facility on 1/5/2016. Review of the patient's history revealed the patient had Diabetes. On 1/5/2016 the physician ordered to monitor the patient's blood glucose level before each meal and at the hour of sleep. The order included to administer Regular Insulin per the physician ordered sliding scale protocol.

Review of the nursing documentation revealed on 1/6/2016 at 8:48 p.m. the patient's blood glucose level was 285. Review of the physician ordered sliding scale protocol noted he patient should have received 7 units of Insulin. Review of the MAR (Medication Administration Record) revealed the patient did not receive any insulin. Review of nursing documentation revealed no evidence of why the Insulin was not administered.

On 1/7/2016 at 11:02 a.m. the patient's blood glucose level was 349. Review of the physician ordered sliding scale protocol noted the patient should have received 10 units of Insulin. Review of the MAR revealed the patient did not receive any insulin. Review of the nursing documentation revealed at 11:30 a.m. the nurse documented the patient was administered Insulin according to the sliding scale but the documentation did not reflect the dose of Insulin given.

On 1/7/2016 at 9:30 p.m. the patient's blood glucose level was 268. Review of the physician ordered sliding scale protocol noted the patient should have received 7 units on Insulin. Review of the MAR revealed the patient received 4 units.

On 1/9/2016 the physician ordered to discharge the patient home. Review of the nursing documentation revealed at 11:05 a.m. the patient's blood glucose level was >400. Review of the MAR revealed the patient received 12 units of Insulin. Review of the physician ordered sliding scale protocol revealed for a blood glucose level greater than 349 the patient should receive 12 units of Insulin and the physician should be notified. Review of the nursing documentation revealed the Insulin was administered but there was no documentation the physician was notified. There was no nursing documentation indicating the patient's blood glucose level was reassessed prior to discharge.

Interview with the Medical Unit Director on 4/6/2016 at approximately 5:25 p.m. confirmed the above findings.

2. Review of the medical record for patient #3 revealed the patient was admitted to the facility on 1/9/2016. Review of the patient's history revealed the patient had Diabetes. On 1/9/2016 the physician ordered to monitor the patient's blood glucose level before each meal and at the hour of sleep. The order included to administer Regular Insulin per the physician ordered sliding scale protocol.

Review of the nursing documentation revealed on 1/10/2016 at 8:54 p.m. the patient's blood glucose level was 316. Review of the physician ordered sliding scale protocol noted the patient should have received 4 units of Insulin. Review of the MAR (Medication Administration Record) revealed the patient received 1 unit of Insulin. There was no indication why the patient did not receive 4 units of Insulin per the physician ordered sliding scale protocol.

Review of the nursing documentation revealed on 1/11/2016 at 5:46 p.m. the patient's blood glucose level was 368. Review of the physician ordered sliding scale protocol noted the patient should have received 8 units of Insulin. Review of the MAR revealed the patient did not receive any insulin. Review of nursing documentation revealed nursing documented insulin not given per protocol.

Interview with the Medical Unit Director on 4/6/2016 at approximately 5:15 p.m. confirmed the above findings.