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Based on document review and interview, it was determined that the Hospital failed to have an organized nursing service to provide appropriate nursing services that include: nursing evaluation, care planning, and adherence to blood transfusion policy. As a result, it was determined that the Condition of Participation for Nursing Services 482.23 was not in compliance.

Findings include:

1. The Hospital failed to ensure nursing assessment and/or reassessments were conducted and documented, as required. See A-0395.

2. The Hospital failed to ensure that the nursing care plan was developed and updated to address the patients' need. See A-0396.

3. The Hospital failed to ensure evaluations were conducted after medication administration, as required. See A-0405.

4. The Hospital failed to ensure blood was transfused according to policy. See A-0409.

Based on document review and interview, it was determined that for 1 of 1 patient's (Pt. #1) clinical record reviewed with allergic reaction, the Hospital failed to ensure nursing assessment and/or reassessments were conducted and documented, as required.

Findings include:

1. On 12/4/18 at approximately 1:30 PM, the Hospital's policy titled, "Patient Assessment and Reassessment" (revised 11/17) was reviewed and included, "... B. The patient's need for nursing care will be re-assessed by an RN at the start of the shift in which they are assigned and more frequently as patient's condition warrants... Patient Assessment and Reassessment... Inpatient Units... Assessment Criteria...Vital Signs... Allergies... as patient condition warrants... Physical Assessment... as patient condition warrants..."

2. On 12/4/18 at approximately 3:30 PM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 68 year old female admitted to the Hospital on 8/17/18 with a diagnosis of endometrial cancer (cancer that begins in the lining of the uterus), and had a Total Hysterecectomy (surgical removal of the uterus) and Salpingo-Oopherectomy (removal of fallopian tube and ovary). The following were noted:

- Pt. #1's Nursing Assessment by E #1 (Registered Nurse) dated 8/17/18 at 8:00 PM included, "First Shift ... Level of consciousness: Lethargic (sluggish), oriented x 3 (oriented to name/person/place) ... Respiratory Pattern: Regular, unlabored ..." E #1's assessment documentation did not indicate that Pt. #1 was having signs of allergic reaction.

- Pt. #1's clinical record included a physician's telephone order entered by E #1 from MD #4 (Surgeon), dated 8/17/18 at 9:00 PM for Benadryl (medication for allergy) 25 mg intravenously 2 times a day as needed for allergy symptoms. The Progress Notes of E #1 dated 8/17/18 included, " ... Paged (MD #4) regarding possible allergic reaction to IV (intravenous antibiotics) ... (antibiotic) canceled and Benadryl ordered ..." However, there was no nursing reassessment to describe Pt. #1's allergic reaction when MD #4 was paged.

- The clinical record indicated that on 8/17/18 at 11:00 PM, E #1 documented, " ...Patient (Pt. #1) assessed by resident (MD #1/Resident Physician) at family's request ... Doctor notified ... was advised to recheck. Will continue to monitor ..." At 11:45 PM, a physician's order for epinephrine (medication used for severe allergic reaction) 0.3 mg (milligrams) intramuscular injection was acknowledged by E #1. The clinical record did not include a nursing reassessment of Pt. #1's allergic reaction when MD #1 was paged and when Pt. #1 was assessed by MD #1.

- The Physician's Progress Notes of MD #1 (Resident Physician) dated 8/18/18 at 4:40 AM included, " ... Earlier in the evening, (Pt. #1's) nurse (E #1) requested that I (MD #1) see this (patient/Pt. #1) for concern of eye swelling/lip swelling. (Pt. #1) had a hysterectomy earlier in the day ... had received Ancef (antibiotic)... When I was called to assess (Pt. #1) for the first time, (Pt. #1) had chemosis (swelling of [conjunctiva/mucous membrane that covers the front of the eye]) with concern for angioedema (swelling beneath the skin) given family's concern for facial swelling..."

3. On 12/5/18 at approximately 12:25 PM and on 12/6/18 at approximately 10:10 AM, interviews were conducted with E #1 (Registered Nurse). E #1 stated, " ... I work from 7:00 PM to 7:00 AM ... When I came in ...After finishing the change of shift report, I came back to finish my assessment ... Daughter was concerned about mom tearing on eyes ... lips were swollen ... Husband arrived ... Do not remember time ... I (E #1) came in to explain what was happening and what the physician (MD #4) had ordered ... Husband stated patient needs to see a doctor... I (E #1) said that I (E #1) will page the resident (MD #1) ... (MD #1) assessed the patient ... told me patient having allergic reaction ... ordered epi (epinephrine) ... I (E #1) left the room to see another patient ... Daughter called PCT (Patient Care Technician/E #8) ... E #8 told me to see the patient (Pt. #1) ... had low O2 sat (oxygen saturation)... RRT (Rapid Response Team) was called ..." During the interviews, E #1 said, " ... I was not able to document the vital signs ... I should have documented my assessments ..."

4. On 12/6/18 at approximately 10:45 AM, findings were discussed with E #7 (Unit Manager, 2 Medical Surgical). E #7 confirmed that there was no nursing documentation regarding assessments or reassessments of Pt. #1's allergic reaction. E #7 said, "Should have been documented whenever changes were noted... We have opportunities for improvement."

Based on document review and interview, it was determined that for 1 of 4 (Pt. #2) clinical records reviewed with blood transfusion, the Hospital failed to ensure that the nursing care plan was developed and updated to address the patients' need.

Findings include:

1. On 12/4/18 at approximately 11:00 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was a 56 year old female admitted to the Hospital on 11/30/18 with diagnoses of pancreatic cancer, persistent GI (gastrointestinal) bleed, and chronic anemia due to GI bleeding. However, Pt. #2's nursing care plan has not been updated to include persistent bleeding as a problem.

2. On 12/4/18 at approximately 1:30 PM, the Hospital's policy titled, "Interdisciplinary Plan of Care" (revised 8/18) was reviewed and included, "... 1... Upon admission, the registered nurse will assess the patient to determine the appropriate plan of care. The plan of care will focus on the patient's acute condition/problem necessitating the hospital admission... 3. The plan of care will include: a. Problems b. Goals c. Indicators d. Interventions... 7. The problems, goals, indicators, and/or interventions should be added, modified or discontinued based on the continued assessment and/or reassessment..."

3. On 12/6/18 at approximately 11:45 AM, findings were discussed with E #7 (Unit Manager, 2 Medical Surgical). E #7 acknowledged that bleeding problem was not included as part of Pt. #1's care plan.

Based on document review and interview, it was determined that for 1 of 1 patient's (Pt. #1) clinical record reviewed with allergic reaction, the Hospital failed to ensure evaluations were conducted after medication administration, as required.

Findings Include:

1. On 12/6/18 at approximately 12:00 PM, the Hospital's Staff Nurse Job Description (effective 3/17) was reviewed and included, "... Provides direct nursing care in accordance with established policies, procedures... Monitors... patient condition as appropriate..."

2. On 12/6/18 at approximately 12:30 PM, the Hospital's policy titled, "Adverse Drug Reaction Monitoring and Reporting" (revised 6/18) was reviewed and included, "... This program will be ongoing and concurrent during drug therapy and will include suspected adverse drug reactions reported by... nurses..."

3. On 12/6/18 at approximately 12:30 PM, the Hospital's drug reference guide for Epinephrine (medication for severe allergy) was reviewed and included, "... Hypersensitivity reactions... IM (intramuscular) preferred... every 5 to 15 minutes in the absence of clinical improvement... Adverse reactions... chest pain... restlessness... dyspnea (shortness of breath)..."

4. On 12/7/18 at approximately 12:00 PM, the Hospital's drug reference guide for Benadryl (allergy medication) was reviewed and included, "... General Uses: Antihistamine (used as treatment of allergies)...Side Effects... Sedation... drowsiness... dyspnea (shortness of breath)..."

5. On 12/4/18 at approximately 3:30 PM, the clinical record of Pt. #1 was reviewed. Pt. #1 was a 68 year old female admitted to the Hospital on 8/17/18 with a diagnosis of endometrial cancer (cancer that begins in the lining of the uterus), and had a Total Hysterecectomy (surgical removal of the uterus) and Salpingo-Oopherectomy (removal of fallopian tubes and ovaries). The following were noted:

- Pt. #1's clinical record included a physician's telephone order, dated 8/17/18 at 9:00 PM for Benadryl (medication for allergy) 25 mg intravenously 2 times a day as needed for allergy symptoms. The clinical record indicated that Benadryl intravenous injection was given on 8/17/18 at 9:30 PM. However, there was no documentation to re-evaluate efficacy of the medication administered.

- Pt. #1's clinical record indicated that on 8/17/18 at 11:00 PM, E #1 documented, " ...Patient (Pt. #1) assessed by resident (MD #1/Resident Physician)..." At 11:45 PM, a physician's order for epinephrine (medication used for severe allergic reaction) 0.3 mg (milligrams) intramuscular injection was acknowledged by E #1. The clinical record indicated that epinephrine 0.3 mg intramuscular injection was administered by E #1 on 8/18/18 at 12:14 AM. The clinical record lacked nursing re-evaluation of Pt. #1's response to the medication given.

4. On 12/6/18 at approximately 9:11 AM, an interview was conducted with MD #1 (Resident Physician). When asked about drug actions of epinephrine, MD #1 said, "It is given to stop continuation of allergic reaction ... After given, heart rate may rise ... sweating ... Can give the second dose (of epinephrine) within 5 minutes (if symptoms are worsening) ..."

5. On 12/6/18 at approximately 10:45 AM, findings were discussed with E #7 (Unit Manager, 2 Medical Surgical). E #7 confirmed that there was no nursing reevaluation done after administration of Benadryl and Epinephrine. E #7 said, "There should have been a response after medications were administered... We have opportunities for improvement."

Based on document review and interview, it was determined that for 1 of 4 (Pt. #2) clinical records reviewed with blood transfusion, the Hospital failed to ensure blood was transfused according to policy.

Findings include:

1. On 12/4/18 at approximately 11:00 AM, the clinical record of Pt. #2 was reviewed. Pt. #2 was a 56 year old female admitted to the Hospital on 11/30/18 with diagnoses of pancreatic cancer, persistent GI (gastrointestinal) bleed, and chronic anemia due to GI bleeding. The clinical record included a physician's order, dated 12/3/18 at 3:00 PM to transfuse 1 unit pf packed RBC (red blood cells). The clinical record indicated that 1 unit of packed RBC was started on 12/3/18 at 4:43 PM. However, the clinical record lacked documentation of the blood transfusion stop time, volume transfused, or any suspected transfusion reaction.

2. On 12/4/18 at approximately 2:30 PM, the Hospital's policy titled, "Blood Product Administration" (revised 12/17) was reviewed and included, "... II. Procedure... F. The following will be documented... b. The date and time the transfusion was... stopped. c. The volume transfused. d. Any suspected transfusion reaction..."

3. On 12/6/18 at approximately 11:45 AM, blood transfusion documentation findings were discussed with E #7 (Unit Manager, 2 Medical Surgical). E #7 said, "It is missing."