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Based on clinical record reviews, review of hospital policies and procedures, observations, and staff interviews, it was determined that the hospital failed to ensure:

(C241) The hospital's Governing Body:

1. Failed to ensure for 1 of 1 patient who received nutrition and hydration through a gastrostomy tube, that the physician provided complete diet orders that included the amount of feeding and method (bolus versus continuous via pump) as well as orders for the amount of water the patient required throughout the day. (Patient #6) This deficient practice posed the potential risk of the patient not receiving the amount of calories and fluid to meet her needs.

2. Failed to ensure the Insulin Order Set developed and approved by the medical staff contained accurate wording for the administration of insulin. The Insulin Order Set was implemented with inaccurate wording. This deficient practice posed the risk of patients receiving the wrong dose of insulin.

3. Failed to ensure physician's identified and directed the care of a vascular foot ulcer on Patient #1 and a pressure ulcer on Patient #7.

4. Failed to ensure an Emergency Department (ED) physician directed the transfer of a psychiatric patient to the appropriate specialized level of care. (Patient #14)

The cumulative effect of these systemic problems resulted in the Critical Access Hospital's inability to ensure the Organizational Structure and the delivery of care directed by their Physician staff was maintained to ensure quality health care in a safe environment.

Based on review of clinical records and staff interviews, it was determined the hospital's Governing Body:

1. Failed to ensure for 1 of 1 patient who received nutrition and hydration through a gastrostomy tube, that the physician provided complete diet orders that included the amount of feeding and method (bolus versus continuous via pump) as well as orders for the amount of water the patient required throughout the day. (Patient #6) This deficient practice posed the potential risk of the patient not receiving the amount of calories and fluid to meet her needs.

2. Failed to ensure the Insulin Order Set developed and approved by the medical staff contained accurate wording for the administration of insulin. The Insulin Order Set was implemented with inaccurate wording. This deficient practice posed the risk of patients receiving the wrong dose of insulin.

3. Failed to ensure physician's identified and directed the care of a vascular foot ulcer on Patient #1 and a pressure ulcer on Patient #7.

4. Failed to ensure an Emergency Department (ED) physician directed the transfer of a psychiatric patient to the appropriate specialized level of care. (Patient #14)

Findings include:

1. Patient #6 was an inpatient at the time of the survey. The physician documented in the History and Physical that the patient had a gastrostomy tube for feedings. The physician's diet order dated 01/19/2017, was for Ensure five times a day "as patient tolerates." The order did not include the following elements: the amount of Ensure to be administered; the route (through the gastrostomy tube versus orally); the method (bolus versus continuous via a pump); whether or not to check for residual prior to each feeding and parameters for holding feedings. There was also no order as to how much water and flushes the patient should have throughout the day.

A copy of the Dietitian Evaluation and Treatment Consult dated 12/21/2016, from the acute care hospital where the patient was an inpatient prior to this admission revealed the patient had been transferred there from Copper Queen due to severe hypernatremia because of Limited free water intake the prior week. Cross reference to Tag C294 for more details.

Interviews with the nursing staff on 01/25/2017, revealed the patient's family member was administering a majority of the tube feedings and water, and there were times when the family member "held" the feedings. The amount of feeding and water being administered by the family member was not being recorded in the clinical record.

2. The surveyor was provided with a copy of the hospital's current "Insulin Order Set" approved by the Medical Staff and the Governing Body and implemented in September/October 2016. The "Meal-Time Insulin" section included the following options from which the physician was to choose:

-Lispro insulin: 3 units subcutaneous three times a day at the end of each meal...Nursing to reduce dose "to" 1 unit for each meal if <50% meal consumed.
-Lispro insulin: 4 units subcutaneous three times a day at the end of each meal...Nursing to reduce dose "to" 2 units for each meal if <50% meal consumed.
-Lispro insulin: 5 units subcutaneous three times a day at the end of each meal...Nursing to reduce dose "to" 2 units for each meal if <50% meal consumed.

The Nurse Manager of the medical/surgical unit stated during an interview on 01/26/2017, that dosages were reduced "by" the unit specified rather than "to" the unit specified as documented in the protocol. The CNO acknowledged that there was an error in the wording and that the Insulin Order Set needed to go back to the Medical Staff for clarification and revision, if necessary.

3. Nursing documentation dated 1/21/2017 at 11:30 p.m. revealed Patient #7 had a pressure ulcer located: "...bilateral posterior coccyx". The nurse documented the pressure ulcer was "3" in length and "3.5" in width with the area surrounding the wound red and nonblanchable (the specific unit of measurement was not recorded, i.e., inches versus centimeters).

The following physician documentation was in the Admission History and Physical dated 01/22/2017 at 1:13 p.m.: "Review of Systems...Integumentary: No rash, pruritus, abrasions...." The patient was discharged home on 01/23/2017, without any documentation that the patient and the responsible family member received education or instructions for the care and treatment of the pressure sore.

The CNO acknowledged the above during an interview on 01/25/2017.

4. Patient #14 was taken to the hospital's ED in August 2016 with suicidal ideation. The patient originally presented to the hospital's clinic in Douglas, Arizona where a Crisis Risk Assessment was performed by a contracted mental health provider. The Mental Health Crisis Specialist documented the patient was a danger to self with plan and intent to harm herself. The recommendation was for medical clearance and then transfer to a "level 1 inpatient facility." The patient arrived at Copper Queen at 3:40 p.m. by Emergency Medical Services. The ED physician medically cleared the patient for psychiatric referral. Documentation on the Transfer Summary revealed the patient was transferred to an inpatient sub-acute behavioral health facility at 9:50 p.m., however, the documentation did not specify the location of the inpatient behavioral health facility. The behavioral health provider had inpatient units in Yuma, Arizona and in Apache Junction, Arizona. There was no documentation of a physician reassessment of the patient during the six hour period the patient was in the ED. There was no physician's order for the transfer. A nurse signed the section on the Transfer Summary for the certifying physician's signature.

The Manager of the ED acknowledged the above during a telephone interview on 02/02/2017.

Based on review of hospital policies and procedures, review of clinical records, and staff interviews, it was determined the hospital failed to ensure:

C-271) Patient Care Policies

There were written policies and procedures developed, documented and implemented that covered the scope of services provided including Telemetry, Wound Care, Medication Administration, and Enteral Feedings. Clinical record reviews revealed nursing care and services were provided without documented and approved policies. The deficient practice posed the risk of care provided not in accordance with acceptable standards of practice and approved by the Medical Staff and Governing Body

(C-277) Patient Care Policies

All medication errors were reported and documented following the hospital's policies and procedures. This deficient practice poses the risk of harm to patients if medication errors are not identified and addressed.
For 2 of 12 records reviewed for medication administration in the total sample of 19, the hospital failed to ensure medication errors were documented and reported. (Patients #1, and #5). This deficient practice poses the risk of harm to patients if medication errors are not identified and addressed.

C-271: Patient Care Policies

There were no written policies and procedures developed, documented and implemented that covered the scope of services provided including Telemetry, Wound Care, Medication Administration, and Enteral Feedings. Clinical record reviews revealed nursing care and services were provided without documented and approved policies.
The deficient practice posed the risk care provided not in accordance with acceptable standards of practice and approved by the Medical Staff and Governing Body

C-277: Patient Care Policies

All medication errors were not reported and documented following the hospital's policies and procedures. This deficient practice poses the risk of harm to patients if medication errors are not identified and addressed.

C-294: Nursing Services

The hospital:

1. Failed to ensure for 1 of 1 patient receiving nutrition and fluids through a PEG tube in the total sample of 19 that the registered nurses RN's): clarified a physician's order to include the amount of feedings and fluids the patient was to receive per day; failed to ensure the RN's administered the feedings and fluids; failed to ensure the amounts of nutrition and hydration were consistently recorded in the patient's clinical record. (Patient #6) This deficient practice posed the risk of the patient receiving too much or too little nutrition and fluids without the knowledge of licensed nurses.

2. Failed to ensure for 5 of 5 patients with skin breakdown in the total sample of 19, that wound care was provided and documented following hospital policies and procedures. (Patients #1, #6, #7, #9, and #13) This deficient practice posed the risk of the worsening of wounds without appropriate treatment.

3. Failed to ensure for 2 of 19 patients, there were sufficient numbers of nursing staff to meet the needs of each patient including timely administration of medications and nursing assessments. (Patients #5, #7)

4. Failed to ensure for 2 of 5 patient records reviewed for documentation of weights in the sample of 19, that physician orders for daily weights were followed and/or weight discrepancies documented were addressed. (Patient #6 and #9)

5. Failed to ensure for 3 of 3 patients on telemetry monitoring, there were policies and procedures developed, documented and implemented to ensure that the RN's were adequately trained and oriented and clinical skills evaluated and validated prior to assigning them to patient care. (Patients #1, #2, and #3) This deficient practice posed the risk of patient care being provided by staff without appropriate training developed and approved by the hospital.

6. Failed to ensure for 1 of 4 diabetic patients receiving insulin in the total sample of 19 that physician's orders for hypoglycemia were followed and documented. (Patient #13)

C-297: Nursing Services

The hospital failed to ensure all medications were administered to patients following physician orders. This deficient practice poses the potential risk of harm to patients if medications are not administered as directed by the physicians.

The cumulative effect of these systemic problems resulted in the Critical Access Hospital's inability to ensure the provision of quality health care in a safe environment.

Based on clinical record reviews, review of hospital policies and procedures, observations, and staff interviews, it was determined that the hospital failed to ensure that written policies and procedures were developed, documented and implemented that covered the scope of services provided including Telemetry, Wound Care, Medication Administration, and Enteral Feedings. The deficient practice posed the risk of care provided not in accordance with acceptable standards of practice and approved by the Medical Staff and Governing Body

Findings include:

Cross reference Tag C-294 where the hospital:

1. Failed to ensure for 1 of 1 patient receiving nutrition and fluids through a PEG tube in the total sample of 19 that the registered nurses RN's): clarified a physician's order to include the amount of feedings and fluids the patient was to receive per day; failed to ensure the RN's administered the feedings and fluids; failed to ensure the amounts of nutrition and hydration were consistently recorded in the patient's clinical record. (Patient #6) This deficient practice posed the risk of the patient receiving too much or too little nutrition and fluids without the knowledge of licensed nurses.

2. Failed to ensure for 5 of 5 patients with skin breakdown in the total sample of 19, that wound care was provided and documented following hospital policies and procedures. (Patients #1, #6, #7, #9, and #13) This deficient practice posed the risk of the worsening of wounds without appropriate treatment.

3. Failed to ensure for 2 of 19 patients, there were sufficient numbers of nursing staff to meet the needs of each patient including timely administration of medications and nursing assessments. (Patients #5, #7)

4. Failed to ensure for 2 of 5 patient records reviewed for documentation of weights in the sample of 19, that physician orders for daily weights were followed and/or weight discrepancies documented were addressed. (Patient #6 and #9)

5. Failed to ensure for 3 of 3 patients on telemetry monitoring, there were policies and procedures developed, documented and implemented to ensure that the RN's were adequately trained and oriented and clinical skills evaluated and validated prior to assigning them to patient care. (Patients #1, #2, and #3) This deficient practice posed the risk of patient care being provided by staff without appropriate training developed and approved by the hospital.

6. Failed to ensure for 1 of 4 diabetic patients receiving insulin in the total sample of 19 that physician's orders for hypoglycemia were followed and documented. (Patient #13)

Cross reference tag C-297 where 5 of 12 records reviewed for medication administration in the total sample of 19, the hospital failed to ensure all medications were administered to patients following physician orders. This deficient practice poses the potential risk of harm to patients if medications are not administered as directed by the physicians. (Patients #3, #5, #13, #16, and #18.)

Documentation in clinical records revealed patients were admitted who required telemetry monitoring, wound care, medication administration, and/or enteral (tube) feedings. Documentation of the nursing care provided was inconsistent and/or missing.

Nursing staff and members of the hospital leadership acknowledged during confidential interviews conducted, that there were no policies and procedures developed and implemented for patients requiring telemetry monitoring, wound care and/or tube feedings. The hospital's policy and procedure for Medication Administration did not include the hospital's practice of medication administration times and identification of time-critical medications.

Based on review of hospital policies and procedures, review of clinical records, and staff interviews, it was determined for 2 of 12 records reviewed for medication administration in the total sample of 19, the hospital failed to ensure medication errors were documented and reported. (Patients #1, and #5). This deficient practice poses the risk of harm to patients if medication errors are not identified and addressed.

Findings include:

The Department of Pharmacy policy and procedure titled "Medication Deviations (Errors)" included: "If a medication deviation is made, it is to be immediately reported to the charge nurse...The pharmacy manager will be responsible for trending the gathered data on medication deviations so as to focus on areas of improvement...The wrong drug, the wrong dose, the wrong medication, the wrong patient, the wrong route of administration, or the wrong administration times are the major causes of deviation...The RN or LPN is to make out a Medication Variance Report if a deviation is made. In order for Medication Variance Reports to be useful, personnel should be conscientious about reporting all deviations in writing as well as verbally. The report must document the remediation and any patient care follow up. This is focused on identifying system changes and is therefore non-punitive...The director of pharmacy and the assistant director of patient care services should receive a copy of all medication deviation reports."

Patient #1

Patient #1 had a physician's order dated 01/23/2017, for furosemide (Lasix) 20 mg by intravenous push every 12 hours. A review of the 01/23/2017, Medication Administration Records (MAR's) revealed the medication was administered at 5:38 a.m.; at 9:05 a.m. (approximately 3.5 hours later); and at 4:50 p.m. (less than 8 hours later). The medication was scheduled to be administered next on 01/24/2017 at 9 a.m. (16 hours later) but was not actually administered until 10:58 a.m., a period of approximately 18 hours between doses.

The Director of Pharmacy and the Chief Nursing Officer acknowledged during an interview on 01/25/2017, that the above administration times did not follow the physician's order for the medication to be given every 12 hours. The Director of Pharmacy acknowledged a Medication Variance Report should have been completed, however, when he followed up with the nursing staff it was reported that the error was not documented following their policies and procedures.

Patient #5

Documentation in the Medication Administration Records (MAR's) for Patient #5 revealed three physician ordered medications scheduled for daily administration at 9 a.m. were administered at 10:30 a.m., one and one-half hours late because of "high census." Cross reference Tag C-294 - Patient #5. A review of the MAR's for Patient #5 revealed the following physician ordered medications were scheduled for daily administration at 9 a.m.: Enoxaparin (anticoagulant) 30 mg subcutaneously; Hydrochlorothiazide (hypertension) 12.5 mg by mouth; and Lisinopril (hypertension) 10 mg by mouth. The medications were administered at 10:30 a.m. The RN documented the reason why the medications were administered late was "high census."

The hospital had no documented policy and procedure for the timing of medication administrations. The Nurse Manager of the medical/surgical unit stated in an interview that it was the practice for medications to be administered no earlier than 1 hour prior to the scheduled time and no later than 1 hour after the scheduled time.

The hospital had no written policy and procedure that addressed administration times and time critical versus non time critical medications. The nursing staff reported during interviews that the practice was for medications to be administered no earlier than one hour prior to or one hour after the scheduled medication time. There was no documentation that a Medication Variance Report was completed. The nursing staff interviewed did not have a clear understanding of the hospital's policy on reporting and documenting the late administration of medications for the purpose of quality improvement.

Based on clinical record reviews and staff interviews, and observation, it was determined the hospital:

1. Failed to ensure for 1 of 1 patient receiving nutrition and fluids through a PEG tube in the total sample of 19 that the registered nurses RN's): clarified a physician's order to include the amount of feedings and fluids the patient was to receive per day; failed to ensure the RN's administered the feedings and fluids; failed to ensure the amounts of nutrition and hydration were consistently recorded in the patient's clinical record. (Patient #6) This deficient practice posed the risk of the patient receiving too much or too little nutrition and fluids without the knowledge of licensed nurses.

2. Failed to ensure for 5 of 5 patients with skin breakdown in the total sample of 19, that wound care was provided and documented following hospital policies and procedures. (Patients #1, #6, #7, #9, and #13) This deficient practice posed the risk of the worsening of wounds without appropriate treatment.

3. Failed to ensure for 2 of 19 patients, there were sufficient numbers of nursing staff to meet the needs of each patient including timely administration of medications and nursing assessments. (Patients #5, #7)

4. Failed to ensure for 2 of 5 patient records reviewed for documentation of weights in the sample of 19, that physician orders for daily weights were followed and/or weight discrepancies documented were addressed. (Patient #6 and #9)

5. Failed to ensure for 3 of 3 patients on telemetry monitoring, there were policies and procedures developed, documented and implemented to ensure that the RN's were adequately trained and oriented and clinical skills evaluated and validated prior to assigning them to patient care. (Patients #1, #2, and #3) This deficient practice posed the risk of patient care being provided by staff without appropriate training developed and approved by the hospital.

6. Failed to ensure for 1 of 4 diabetic patients receiving insulin in the total sample of 19 that physician's orders for hypoglycemia were followed and documented. (Patient #13)

Findings include:

1.

Patient #6.

Documentation in Patient #6's clinical record revealed the patient was totally dependent on others for all activities of daily living including nutrition and hydration and was not able to verbally communicate her needs. The physician documented in the History and Physical that the patient had a gastrostomy tube for feedings. The physician documented in a progress note dated 01/19/2017, that the patient was an inpatient at an acute care hospital in Tucson about two weeks prior to this admission. The patient was treated there for a gastrointestinal (GI) work up related to diarrhea and a GI bleed.

The physician's admission diet order was for Ensure five times a day "as patient tolerates." The order was not complete as it did not include the following elements: the amount of Ensure to be administered; the route (through the gastrostomy tube versus orally); the method (bolus versus continuous via a pump); whether or not to check for residual prior to each feeding and parameters for holding feedings. There was also no order as to how much water and flushes the patient should have throughout the day. There was no documentation that nursing staff questioned the order and requested clarification.

Nursing documentation did not consistently include the time and amounts of Ensure and water the patient was received per day. For example, on 01/20/2017, the nursing documentation revealed the patient did not receive any Ensure except for 60 cc at 7:30 p.m. There was no documentation that the patient received any Ensure on 1/21/2017, and on 1/23/2017 the patient received 60 cc of Ensure at 9:45 a.m. and 60 cc at 2 p.m.

An interview was conducted on 01/25/2017 with an RN on duty. The RN was asked to clarify how much Ensure and water the patient received every day because the physician's order did not include this information. The RN responded that the patient's family member handled the patient's nutrition at home and was administering the tube feedings while in the hospital. The RN was asked if nursing staff was present during the feedings and the response was not always. The RN was asked how the nursing staff knew how much the family member was administering and the answer was that the family member was supposed to let the staff know. The RN also stated that the patient's family member sometimes "held" the tube feedings if the patient had diarrhea. The RN reported that the family member brought in the Ensure rather than having the hospital supply it. The RN obtained one of the bottles of Ensure from the patient's room and according to the label, each bottle contained 247 cc with 250 calories per bottle. The RN acknowledged that there was no documentation in the clinical record of what the patient's caloric and fluids needs were and whether or not the patient was receiving adequate amounts of nutrition and hydration to meet her needs. There was no documentation that a nutritional consult was requested and obtained, and the surveyor was later told that the family member was "working with a dietician" although they had no documentation of that. There was no documentation or physician's order that addressed the family member administering nutrition and hydration during the hospitalization.

A copy of the Dietitian Evaluation and Treatment Consult was requested from and received by the acute care hospital in Tucson. The Registered Dietitian (RD) documented in the report dated 12/21/2016, that the patient had been transferred there from Copper Queen Community Hospital due to "severe hypernatremia...related to inadequate free water flushes prior to admit...." The documentation revealed the patient was being given prune juice via the gastrostomy tube and "limited free water" the week prior to admission. The RD documented the patient's height was 48 inches and weight 36.7 kg (bedscale) at the time of admission. The patient's estimated calorie needs were 1300-1475 kcal per day; protein 55-75 grams per day; and fluids 1500-2250 ml plus 1350 ml per day "to correct free water deficit of 4.1 Liters." The RD also documented consulting with the patient's family member at the bedside who reported the nutritional regimen at that time of Nutren. The Nutren was continued during the hospitalization there.

2. Patient #1

Patient #1 was admitted to the in-patient unit on 01/22/2017. The initial nursing assessment documented at 5:15 p.m. revealed the patient had a pressure sore, however there was no documentation of its specific location, the size, or it's appearance, i.e. presence of drainage, signs of infection, etc. There were no physician's orders for the care and treatment of the sore or for a wound care consult. The RN on duty on 01/23/2017, reported during an interview that there was a Unna boot on the patients lower left leg and received wound care at a wound care center in a nearby city. (An Unna boot is a compressive dressing used to treat ulcers on the lower extremities.) She acknowledged there was no documentation of when the Unna boot had been applied, when it was due to be changed and the status of the wound.

The hospital's Physical Therapist (PT) was then consulted for evaluation and treatment of the wound which was done on 01/24/2017. The PT documented that when she removed the dressings, small gauze squares had been placed over the wound which had dried out and had to be soaked in normal saline in order to remove.

Patient #6

Physician documentation in the History and Physical dated 01/18/2017, revealed Patient #6 had a Stage 2 pressure ulcer on the left buttocks and wound care of Mepilex (a foam dressing). The physician ordered an ultrasound of the area which revealed: "There is a 1.7 x 0.8 x 1 cm subcutaneous fluid collection...These findings are highly suspicious for an abscess." There were no physician's order for the care and treatment of the area until 01/25/2017, seven days after admission and after it was called to the attention of the nursing staff by the surveyor.

Nursing documentation of the wound was incomplete and inconsistent. For example, there were no measurements of the wound by nursing staff. The nursing assessment on 01/19/2017 at 8:52 p.m., revealed the area to be Stage 2. On 01/24/2017 at 10:03 p.m., the nurse documented the wound was "unstageable...suspect deep tissue injury evolving."

The surveyor asked the nursing staff on 01/25/2017, when the next dressing change was due for Patient #6 so the surveyor could observe the wound. The RN Nurse Manager reported that the family member did the dressing changes. Verbal consent was obtained from the patient's family member for the surveyor to observe the area with the nursing staff. The patient was laying in bed and was turned by staff to her left side. There was no dressing on and two open distinct and separate open areas (Stage 2's) were observed surrounded by a larger area of intact red skin. The RN asked the family member who was present in the room how often she changed the dressing and the family responded that she changed it whenever it got wet. The family member demonstrated the area of fluid collection underneath the skin. The RN later acknowledged there were two open areas rather than one with no documentation in the clinical record that the nursing staff was aware of two open areas.

Patient #7

Nursing documentation dated 01/21/2017 at 11:30 p.m., revealed Patient #7 had a pressure ulcer located "bilateral posterior coccyx". The nurse documented it was "3" in width and "3.5" in width with the area surrounding the wound red and nonblanchable (the specific unit of measurement was not recorded, i.e., inches versus centimeters). There was no documentation that a physician's order was obtained for the care and treatment of the pressure ulcer. The patient was discharged home on 01/23/2017, in the care of a family member. There was no documentation that the patient's family member was aware of the pressure sore and provided with instructions for care and treatment.

The CNO acknowledged the above findings during interviews.

Patient #9

Nursing documentation dated 01/20/2017 through 01/22/2017, revealed the patient had a "nonblanchable area area to R (right) hip." Nursing documentation dated 0l/23 and 01/24/2017 revealed the patient had a: "stage 1 ulcer L (left) hip." There was no documentation that the area was measured and monitored to ensure the area did not get larger. The surveyor asked an RN on duty on 01/27/2017, to clarify the location of the nonblanchable (Stage 1) area because of the conflicting nursing documentation. The RN went into the patient's room and asked the family member at the bedside where the area was. The family reported it was on the patient's right hip.

Patient #13

Patient #13 presented to the hospital's Emergency Department on 09/17/2016. The nursing assessment documented at 9:08 a.m. revealed the patient had a "diabetic ulcer" on his right inner heel that measured 3.0 cm x 3.0 cm. The physician documented in the History and Physical dated 09/17/2016, that the patient stepped on a foreign body which penetrated through his shoe into his right heel 10 days prior. The physician also documented that the patient was: "...poorly controlled type II diabetic on insulin...." The physician's documentation included: "Right lower extremity has a 2.5 x 3 cm ulcerated lesion on the inside of the right heel...The superficial dead skin was debrided from the wound...He has surrounding erythema extending up the right leg...just below the knee he has redness and swelling spreading distally over the foot."

Nursing documentation including 09/17/2016 at 4:30 p.m.; 09/18/2016 at 9:17 a.m.; 09/19/2016 at 5:30 p.m. revealed the wound was dressed with "adaptic" and gauze bandage. There was no physician's order for the care and treatment of the wound until the day of discharge on 09/22/2016.

The surveyor requested a copy of the hospital's policies and procedures for wound care including preventing, identifying and treating. The Chief Nursing Officer reported she was not able to locate policies and procedures for wound care.

3. The hospital's "Hospital Wide Plan for the Provision of Care" for the acute in-patient care unit included: The unit staffing plan is developed to match patient needs with the nursing staff required to provide care...Each staffing plan is reviewed as warranted by changing patient care needs and identified opportunities for improved service.

The hospital's "Staffing Plan - Patient Care Services/Medical Surgical" included: "The purpose of this policy is to establish a system for measuring the acuity levels of patients on the Medical Surgical Unit and determining the appropriate mix and number of health care professionals needed to safely care for patients...A Registered Nurse shall assess, plan, direct, and evaluate nursing services provided to patients, this will ensure appropriate patient care. nursing assignments will be given according to the acuity of the patients and the abilities of the nursing personnel."

Patient #3

Patient #3 had a physician's order dated 09/17/2016, for the antibiotic Clindamycin 900 mg intravenously every 8 hours. A review of the Medication Administration Records (MAR's) revealed the patient received it on 09/20/2016 at 12:30 a.m. It was not administered again until 10:21 a.m., a period of almost 10 hours. The reason for the late administration was: "Busy with other patients."

Patient #5:

A review of the MAR's for Patient #5 revealed the following physician ordered medications were scheduled for daily administration at 9 a.m.: Enoxaparin (anticoagulant) 30 mg subcutaneously; Hydrochlorothiazide (hypertension) 12.5 mg by mouth; and Lisinopril (hypertension) 10 mg by mouth. The medications were administered at 10:30 a.m. The RN documented the reason why the medications were administered late was "high census."

The hospital had no documented policy and procedure for the timing of medication administrations. The Nurse Manager of the medical/surgical unit stated in an interview that it was the practice for medications to be administered no earlier than 1 hour prior to the scheduled time and no later than 1 hour after the scheduled time.

Patient #7:

Documentation in Patient #7's clinical record revealed he had a Stage 2 pressure ulcer on his coccyx (refer to #2 above). A nursing note dated 01/23/2017 at 11:08 a.m. included: "Pt wife here and insisting that he go home now. Due to pt. load was not able to do assessment...." There was no documentation in the Patient Discharge Instructions that the patient or his responsible family member were provided with education and instructions for the care of the pressure ulcer.

4. Patient #6

Patient #6's weight was recorded on 01/17/2017 to be 23.8 kg (52.47 pounds). The patient's weight recorded on 01/18/2017 was 32 kg (70.5 pounds), an increase of approximately 17.5 pounds within a 24-hour period. There were no documented weights after 01/18/2017.

The surveyor was told by an RN on duty on 01/25/2017, that the patient was not weighed because their Hoyer Lift had broken the day before, 01/24/2017, however, there was no explanation provided as to why there were no weights recorded for 01/19/2017 through 01/23/2017 and no explanation regarding the 17.5 pound weight discrepancy between the weight on 01/17/2017 and 01/18/2017.

Patient #9

Patient #9' documented weight on 01/20/2017 was 74 kg (163 pounds). The documented weight on 01/23/2017 was 84.3 kg (185 pounds), an increase of 22 pounds in a period of 3 days. There was no documentation in the clinical record that the weight discrepancy was identified and addressed.

5. The hospital's policy and procedure titled "Initial Competence Assessment-Patient Care Services" included: "Applicants for a position with the Patient Care areas will meet the following requirements in order to be considered for employment: 1. Identified education requirements; 2. Licensure regulations and requirements; and 3. Competence assessment."

The hospital's policy and procedure titled "Skills Inventory for Clinical Competence" included: "The Clinical Skills Inventory must be initiated with 30-days of the start of staff's unit assignment. It will be completed within a 90-day probationary period...Competency in the skills inventory is updated when any of the following occur: 1. New technology is introduced. 2. performance of skill is limited and competency needs to be verified. 3. Skills needs are identified...The clinical skills inventory is kept in the employees file in HR (Human Resources)...When an acceptable return demonstration is performed, the RN (preceptor) will date and sign for acknowledgement of competence performing the skill."

The surveyor observed a telemetry monitor at the nurses station in the in-patient unit. There were active patient tracings displayed on the monitor at that time. The surveyor asked the Nurse Manager if there was a dedicated Monitor Tech or other qualified person that watched the tracings at all times and she responded there was not. She said they (the RN's on duty) tried to keep an eye on the monitor and that if something went wrong an alarm would go off. The surveyor asked if the staff were trained for telemetry monitoring and the Nurse Manager said some but not all of the nursing staff had ACLS certification (Advanced Cardiac Life Support). There were three patients on the inpatient unit with physician orders for telemetry monitoring at that time: Patients #1, #2, and #3.

A review of Staff #7's personnel record revealed she graduated from nursing school in May 2016 and was issued a license for Registered Nurse in June 2016. The hire date at the hospital was in July 2016. There were no documented validation of competencies in the personnel record.

The in-patient Nurse Manager acknowledged during an interview on 01/27/2017, that there was no documented policy and procedure or protocols for the orientation and competency assessment of newly hired RN's and new graduate RN's.

6. Patient #13

The Insulin Order Set ordered by the physician at the time of admission included hypoglycemic protocols. The protocols included the administration of graham crackers and juice or milk if the patient's blood sugar was between 50-69 and directed a recheck of the blood sugars after 15 minutes. The patient's recorded blood sugar on 09/22/2016 at 6:30 a.m. was "67." There was no documentation that the patient was provided with graham crackers, and juice or milk and that the patient's blood sugar was rechecked in 15 minutes.

Based on review of hospital policies and procedures, review of clinical records, and staff interviews, it was determined for 5 of 12 records reviewed for medication administration in the total sample of 19, the hospital failed to ensure all medications were administered to patients following physician orders. This deficient practice poses the potential risk of harm to patients if medications are not administered as directed by the physicians. (Patients #3, #5, #13, #16, and #18.)

Findings include:

The hospital's Department of Pharmacy "Drug Administration Safety Procedures" included: "The Nurse Should:...2. Read the medicine record carefully, making sure that the entries are identical in all respects to patient charts. 3. Check for Right Drug, Right Patient, Right Time, Right Route, Right Dose."

Another Department of Pharmacy "Drug Administration" policy included: "The dosing times agreed upon in Medical Staff will be used as standard dosing times except when special circumstances require unique dosing frequency."

The hospital was not able to locate or provide a medication administration policy that addressed the timing of medication administration that included time-critical and non-time critical scheduled medications.

Patient #3

Patient #3 had a physician's order dated 09/17/2016, for the antibiotic Clindamycin 900 mg intravenously every 8 hours. A review of the Medication Administration Records (MAR's) revealed the patient received it on 09/20/2016 at 12:30 a.m. It was not administered again until 10:21 a.m., a period of almost 10 hours.

Patient #5:

A review of the MAR's for Patient #5 revealed the following physician ordered medications were scheduled for daily administration at 9 a.m.: Enoxaparin (anticoagulant) 30 mg subcutaneously; Hydrochlorothiazide (hypertension) 12.5 mg by mouth; and Lisinopril (hypertension) 10 mg by mouth. The medications were administered at 10:30 a.m., one and one-half hours late.

Patient #13

Patient #13 had a physician's order dated 09/18/2016, for insulin Lispro 5 units subcutaneously three times a day after meals. A review of the MAR's for 09/19/2016, revealed the patient received 5 units of lispro at 8:34 a.m., however there was no documentation that insulin was administered after lunch or dinner and no documentation as to why.

Patient #16

Patient #16 had a physician's order dated 10/02/2016, for the antibiotic Piperacillin-Tazobactam 4.5 grams to be administered intravenously every 6 hours. A review of the MAR's dated 10/03/2016, revealed it was administered at 1:28 p.m. and then at 5:58 p.m., a period of approximately 4.5 hours. The RN documented the reason for early administration was "Non-Time Critical - Within 2 Hours."

The Pharmacy Director and the Chief Nursing Officer revealed during interviews, the hospital had no policy that supported that reason.

Patient #18

Patient #18 had physician orders dated 01/23/2017 for insulin Lispro 5 units subcutaneously (sq) three times a day with meals. A review of the medication administration records (MAR) revealed the patient was given 9 units (u) of Lispro on 1/23/2017 at 5:46 p.m. The physician increased the Lispro to 13 units three times a day on 01/24/2017, which was given at 9:26 a.m. after breakfast, however, the patient was given 16 units at 1:04 p.m. after lunch. There were other examples of doses of insulin administered without a corresponding physician's order.

The patient's record was reviewed with the Nurse Manager of the inpatient unit on 01/26/2017. The Nurse Manager stated the hospital implemented an Insulin Order Set in September/October 2016 that was carbohydrate based and included blood sugar levels, the diet ordered by the physician and the percentage of each meal consumed. The amount of insulin administered would be adjusted from the physician's order based on the patient's blood sugar levels after each meal and the percentage of each meal. The surveyor asked the Nurse Manager where the Insulin Order Set was located in Patient #18's record, and she was unable to locate it. She stated the physician must have "forgotten" to order it and the nursing staff implemented it anyway. She acknowledged nursing staff were administering insulin doses based on a protocol which had not been ordered.

The Director of the Pharmacy and the CNO acknowledged during interviews that physician's have the option not to order the Insulin Order Set and agreed that it had to be ordered by a physician before implemented by nursing staff.