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Based on policy review, record review and staff interview it was determined the Registered Nurse failed to ensure catheter care was provided according to policy for two (#5, #8) of eight patients sampled, failed to follow policy and procedure related to pressure ulcers care for one (#5) of eight patients sampled, failed to follow facility policy for a patient experiencing pain for one (#5) of eight patients sampled and failed to assess the nutritional intake of one (#5) of eight patients sampled. . This practice does not ensure patient goals are met and may lead to a prolonged hospital stay.

Findings include:

1. Review of the policy # 10-5-012 Suprapubic Catheter Replacement Procedure/Care revealed that suprapubic care should be performed daily at the time of bath and as needed. The policy stated the cleansing procedure is documented in the nurses' notes.

Record review for patient #5 revealed the suprapubic catheter care was not performed on 4/22/12, 4/25/12, and 4/29/12 through discharge on 5/1/12 discharge.

2. Patient #8's urinary catheter care was not performed on 6/2/12, 6/3/12, 6/4/12 and 6/5/12.

Interview with the RN charge nurse on 6/6/12 at 2:30 p.m. confirmed the above findings.

3. Review of the Wound Care Reports and the nursing assessment for patient #5, dated 4/21/12, revealed the patient was admitted with a Stage I deep tissue wound on the left buttock. Review of the Nursing Notes and Clinical Progress notes revealed no wound documentation on 4/22/12, 4/24/12 and 4/25/12.

Review of the policy #10-8-016 Pressure Ulcer/Wound Prevention and Treatment stated the nurse was responsible for documenting wound observation each shift or with each dressing change. The policy indicated that interventions include to turn and reposition the patient every 2 hours while in bed. Review of the turning and repositioning documentation revealed the patient's position was:
? 4/24/12 at 7:00 p.m. sitting in bed, left side
? 4/24/12 at 9:00 p.m. sitting in bed, left side
? 4/24/12 at 11:00 p.m. sitting in bed, left side
There was no evidence of the
patient being turned or
repositioned from 7:00 p.m. on 4/24/12 until 4/25/12 at 1:00 a.m.
? 4/25/12 at 1:00 p.m. supine
? 4/25/12 at 3:00 p.m. supine
The patient remained in the
supine position until 5:00 p.m.
Documentation between 4/26/12 and 4/28/12, revealed repositioning was only performed at the following times:
? 4/26/12 at 07:00 a.m.
? 4/26/12 at 3:00 p.m.
? 4/27/12 at 6:00 p.m.
? 4/28/12 at 8:00 a.m.

Interview with Nurse Manager of the ICU on 6/6/12 at 3:45 p.m. confirmed the above findings in the record.

4. Review of policy # 6-018, "Care of the Patient With Pain", stated interventions include: administering analgesics in a timely manner as to prevent severe pain from reoccurring.

Review of patient #5's medical record revealed on 4/22/12 the patient's pain goal was a 3. Review of the Medication Administration Record (MAR) revealed on 4/22/12 at 7:00 a.m. an order for Dilaudid 2 milligrams (mg) every 2 hours as needed for pain. Review of the pain assessments for patient #5 on 4/22/12 revealed that at:
? 8:00 p.m. the pain score was assessed as 8 and the patient was medicated at 8:14 p.m.
? 9:00 p.m. the pain was reassessed as 8
? 11:00 p.m. the pain score was assessed as 8.
Review of the MAR revealed the patient was not medicated for pain until 4/23/12 at 2:15 a.m.

Interview with the ICU Manager on 6/6/12 at 4:00 p.m. confirmed the findings above.

5. Patient #5's record review revealed a nutrition consult was performed on 4/21/12 and a heart healthy diet was ordered. Review of the nutrition notes dated 4/23/12 revealed a nutritional goal of oral intake 75% or greater of most meals or supplements. Nutrition documentation dated 4/26/12 included to monitor oral intake. Review of nursing notes revealed no documentation of percent of meals consumed from 4/23/12 at 7:00 p.m. to 4/25/12 at 9:00 a.m.
Interview with the ICU Nurse Manager on 6/6/12 at 4:00 p.m. confirmed findings

Based on record review and staff interview it was determined that the facility failed to administer medications according to the physicians orders for one (#5) of eight patients sampled. This does not ensure the physician ordered plan of care is followed.

Findings include:

Patient #5's physician order dated 4/24/2012 at 9:32 p.m. ordered Enalapril 1.25 milligrams (mg) intravenous (IV) every 6 hours as needed for a systolic blood pressure greater than 170. Review of the vital sign record revealed the following blood pressures:
? 4/25/12 at 12:00 a.m.-187/94
? 4/25/12 at 2:00 a.m.- 175/87
? 4/25/12 at 3:00 a.m.- 171/88
? 4/25/12 at 10:00 a.m.- 174/77
? 4/25/12 at 7:00 p.m.- 184/85
Review of the Medication Administration Record (MAR) revealed the Enalapril was not administered as ordered for a systolic blood pressures greater than 170.

Interview with the Nurse Manager of the Intensive Care Unit (ICU) on 6/6/12 at 3:40 p.m. confirmed the findings.

Physician orders revealed Triamcinolone topical 1 application to mouth three times daily was ordered on 4/21/12 at 2:00 p.m. Review of the MAR revealed the Triamcinolone was not administered on 4/22/12 at 2:00 p.m. and 10:00 p.m. On 4/24/12 at 1:00 p.m. the dose was not administered.

Interview with the ICU Nurse Manager on 6/6/12 at 4:00 p.m. confirmed the above findings.

Review of the "Medication Administration and Verification Procedure" policy # 6-008 dated 2/12 revealed that medications ordered three times daily are given at 9:00 a.m., 1:00 p.m. and 6:00 p.m.

Review of physician orders dated 4/20/12 at 2:18 p.m. revealed an order for Dilaudid 1 milligram (mg) every 4 hours for pain as needed. Review of the MAR and physician order revealed Dilaudid 2 mg every 2 hours as needed for pain was ordered on 4/22/12 at 7:00 a.m.

Review of the MAR revealed Dilaudid 1 mg was administered as follows:
4/22/12 at 3:34 p.m. for a pain score of 8 on a level of 0-10 with ten being the worst pain.
4/22/12 at 8:14 p.m. for a pain score of 8
4/24/12 at 2:15 a.m. for a pain score of 7
Interview with the Nurse Manager of the ICU on 6/6/12 at 3:45 p.m. confirmed the above findings.