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Based on record review and staff interview it was determined the Registered Nurse failed to supervise and evaluate nursing care for 3 (#1, #2, #9) of 32 sampled patients. This practice does not ensure goals of the plan of care are achieved.

Findings include:

1. Patient #1 was admitted on 9/19/11 with the diagnoses that of diabetes and chronic obstructive pulmonary disease (COPD). The physician ordered blood glucose testing to be done before meals and before bedtime. Review of the Diabetic and Insulin Rotation Record revealed the test was not performed on 9/23/11 at noon. Review of the 24 Hour Nursing Flow Sheet revealed the nursing staff failed to document meal consumption for the evening meal on 9/23/11, the evening meal on 9/24/11, the evening meal on 9/25/11 and all three meals on 9/26/11. The review also revealed no skin assessment on 9/22/11 and no documentation of meeting the patient's hygiene needs on 9/23/11.

The Director of Quality Improvement confirmed the finding on 9/28/11 at approximately 10:30 a.m.

2. Patient #2 was admitted on 9/24/11 with the diagnoses of diabetes, COPD, chest pain and hypertension. Review of the 24 hour Nursing Flow Sheet revealed the nursing staff failed to documented meal consumption for the evening meal on 9/27/11. A physician's order was written on 9/25/11 that the patient was not to have anything by mouth after midnight. Review of nursing documentation revealed that the patient was provided breakfast on the morning of 9/26/11. There was no documentation that the physician had given an order to provide the breakfast.

The Director of Quality confirmed the findings on 9/28/11 at approximately 12:20 p.m.

3. Review of patient #9's medical record revealed the patient was admitted on 9/23/11. Review of the physician's orders dated 9/23/11 at 4:30 p.m. revealed an order to weigh the patient daily. Review of the medical record documentation revealed the patient was weighed on 9/27/11 and 9/28/11. There was no documentation the patient was weighed on 9/23-9/26/11.

On 9/28/11 at 2:15 p.m. an interview with the Director of Surgery confirmed the findings.

Based on record review and staff interview it was determined that the facility failed to ensure that medications were administered as ordered by the physician for 2 (#1, #2) of 32 sampled patients. This practice does not ensure safe medication administration.

Findings include:

1. Patient #1's physician order instructed for accuchecks with novolog insulin coverage according to the aggressive protocol on 9/19/11. Review of the Diabetic and Insulin Rotation Record revealed that on 9/19/11 and 9/20/11 the nursing staff documented that the patient was administering herself via her insulin pump. The number of units administered was not documented for any of the doses on 9/19/11 and not until the 9:30 p.m. dose on 9/20/11. There was no order that the patient could administer via her insulin pump until 9/21/11. The patient's blood glucose was 364 on 9/23/11 at 4:30 p.m. The nurse documented the patient administered 15 units. Review of the protocol revealed the patient should have received 16 unit of insulin.

The Director of Quality confirmed the finding during the record review on 9/28/11 at approximately 10:30 a.m.

2. Review of the medical record of patient #2 revealed the physician ordered accuchecks with novolog insulin coverage according to the aggressive protocol on 9/25/11. Review of the Diabetic and Insulin Rotation Record revealed that the patient's blood glucose was 283 at 4:30 p.m. on 9/26/11. The protocol called for 13 units of insulin. There was no documentation that any insulin was administered or the reason for the omission. The physician ordered glyburide 5 milligrams orally twice daily on 9/25/11 at 9 a.m. The medication was no administered until 5:00 p.m. and only once on 9/25/11.

The Director of Quality confirmed the finding on 9/28/11 at approximately 12:30 p.m.

Based on record review and staff interview it was determined the facility failed to ensure a History and Physical (H&P) examination was in the medical record within 24 hours of admission for 2 (#1, #9) of 32 sampled patients. This practice does not ensure significant patient information is available to the patient care team members.

Findings include:

1. Patient #1 was admitted to the facility on 9/19/11. Review of the medical record on 9/28/11 at approximately 10:30 a.m. revealed there was no H&P in the medical record.

The Director of Quality, who was present at the time of the record review, confirmed that there was no H&P for the patient.

2. Patient #9's was admitted to the facility on 9/23/2011. Review of the record revealed there was no H & P located in the record. A note located on a blank physician progress note stated, "please dictate H & P".

On 9/28/2011 at 12:45 p.m. an interview with the Director of Surgery confirmed there was no H & P located on the record. The medical records department was contacted and verified there was no H & P dictated as of the date and time of the findings.

Based on record review, policy review and staff interview it was determined that the facility failed to ensure a discharge summary was dictated as required by facility policy for 2 (#19, #20) of thirty two records reviewed. This practice does not ensure the recapitulation of stay is available.

Findings include:

Review of the facility's Medical Staff Rules and Regulations revealed that a discharge summary must be written or dictated at the time of the patient's discharge.

1. Patient #19 was discharge on 8/16/11. The record review was performed on 9/29/11. There was no discharge summary in the record

2. Patient #20 was discharged on 5/24/11. The discharge summary was dated 6/28/11.

The Chief Nursing Officer confirmed the facility failed to comply with the policy on discharge summary completion during interview on 9/29/11 at approximately 2:30 p.m.

Based on record review and staff interview it was determined the facility failed to ensure reassessment of the discharge plan for 1 (#13) of 32 sampled patients. This practice does not ensure patient's needs are met following discharge.

Findings included:

Patient #13's physician wrote an order that the patient was to be discharged with home health nursing care. The physician also documented in the discharge progress note on 9/7/11 and discharge summary that the patient was discharged with home health care. Review of the case management notes on 9/6/11 revealed that the patient had declined the referral to home health agency. The discharge instructions to the patient indicated the patient was to have home health care. There was no evidence that home health had been arranged by case management or that the physician and nursing staff had been informed hat the patient had declined the home health referral.

The Chief Nursing Officer was interview on 9/28/11 at approximately 3:00 p.m. and confirmed the lack of reassessment and coordination of the discharge plan.