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Based on record review, policy review and staff interview it was determined the registered nurse failed to assess, plan, intervene, and evaluate nursing care related to skin care and pain management for 4 (#4, #6, #8, #9) of 10 sampled patients. This practice does not ensure patient goals are met and may lead to a prolonged hospital stay.

Findings include:


The facility's policy "Skin Care Protocol", #WC 004 revised 3/12 required patients at risk of pressure ulcer development with a Braden score of 15 or less are to have photos of any alteration of skin integrity are to be taken and placed in the patient's medical record. In addition pressure ulcer prevention measures, including repositioning every two hours are to be initiated.

1. Patient #8 was admitted to the facility on 10/8/12. The initial Braden assessment on 10/8/12 was 15. The nurse documented a skin tear on the right forearm, ecchymosis of the left arm and a pressure ulcer on the left buttock. Review of the medical record revealed no photos were present. The nurse manager who was present during the medical record review on 10/11/12 at approximately 1:00 p.m. reviewed the medical record and checked with other sources confirmed the photos had not been taken.

Review of the nursing documentation for patient #8 revealed the Braden score was 13 on 10/9/12 and 10/10/12. Review of the nursing documentation revealed no evidence the patient was repositioned as required by policy. Impaired skin integrity was not listed as a problem on the plan of care.

2. Patient #9 was admitted to the facility on 10/1/12 for abdominal surgery. Review of the skin assessment section of the medical record revealed the Braden score on admission was 12. Review of the nursing documentation revealed no evidence that the patient was repositioned every two hours as required.

The nurse manager, who was present during the record reviews on 10/11/12 confirmed the above findings.

3. Review of the facility's policy "Pain Assessment and Management", no number, revised 4/12 revealed the staff was to evaluate the intensity of pain by using the Wong Baker scale, which ranks pain level from 0 (no pain) to 10 (worst pain ever). It also required the patient to be reassessed for response to the pain medication given IV within 30 minutes.

Patient #6 was admitted to the facility on 10/7/12 for repair of a hip fracture. Review of the post-operative physician orders revealed orders for Morphine 2 mg IV every 3 hours as needed for mild pain (1-3), Morphine 4 mg IV every 3 hours as needed for moderate pain (4-7) and Morphine 6 mg IV every 3 hours as needed for severe pain (8-10).

Review of the Medication Administration Record (MAR) revealed the patient received Morphine 2 mg IV at 12:03 a.m. on 10/8/12. The nurse documented pain level of 5, which required 4 mgs, not 2. There was no reassessment to determine the effectiveness of the medication. The patient received Morphine 2 mg at 6:14 a.m. on 10/8/12. There was no assessment of the pain level prior to the administration of the medication to determine the accuracy of the dose. There was no reassessment of the pain level following the administration of the medication.

4. Patient #9 was admitted to the facility on 10/1/12 for surgery. The post-operative orders included an order for Morphine 2-5 mg IV every 2 hours as needed. Review of the MAR revealed:
10/1 at 11:50 p.m. 2 mg of Morphine was given with no pain assessment before or after administration
10/3 at 5:46 p.m. 2 mg of Morphine was given with no pain assessment after administration
10/8 at 10:00 a.m. 2 mg of Morphine given with no assessment before or after administration
10/8 at 12:17 a.m. 2 mg of Morphine was given with no assessment after administration
10/9 at 9:37 a.m. 2 mg of Morphine was given with no assessment before or after administration
10/9 at 3:27 p.m. 2 mg of Morphine was given with no assessment before or after administration
10/9 at 5:58 p.m. 2 mg of Morphine was given with no assessment after administration
10/10 at 8:47 a.m., 12:35 p.m. and 4:23 p.m. 4 mg of Morphine was given with no assessment before or after administration
10/11 at 10:23 a.m. 2 mg of Morphine was given with no assessment before or after administration.

5. Patient #4 was admitted on 9/27/2012 for abdominal surgery. The Med/Surg Nursing Flow sheet revealed no documentation of hygiene care provided by the nursing staff or that the patient was independent in her personal hygiene on 10/3, 10/4, 10/5, and 10/6/2012.
An interview and record review was conducted with the Director of Nursing on 10/11/2012 at approximately 2:45 p.m. She confirmed the above findings.

Based on record review and staff interview it was determined the facility failed to ensure medications were administered as ordered by the physician for 1 (#7) of 10 sampled patients. This practice does not ensure safe administration of medication.

Findings include:

Patient #7 was admitted to the facility on 10/8/12 with physician orders for Levoquin 750 milligrams (mg) intravenously (IV) every 24 hours on 10/8/12. A second order was written by the physician changing the order to 750 mg IV every 48 hours on 10/9/12 at 2:40 p.m. Review of the Medication Administration Record revealed the first dose of the medication was given at 11:42 p.m. on 10/8/12. A second dose was administered on 10/9/12 at 9:25 p.m., which was 22 hours after the last administration. The order had been changed to every 48 hours. The nursing manager confirmed the nurse should not have administered the medication on 10/9/12 during interview on 10/11/12 at approximately 2:00 p.m.

Based on record review, policy review and interviews it was determined the facility failed to ensure the nursing staff followed the policy for culturing patients admitted with a known history of Methicillin-Resistant Staphylococcus Aureus (MRSA) infection for one (#3) of ten sampled patients. This practice does not ensure patients are safe from infections.

Findings include:

Patient #3 was admitted on 9/26/2012 for surgery. The Patient History dated 9/26/2012 noted the patient stated he had a previous history of MRSA infection. A review of the record failed to reveal documentation that a screening test for MRSA had been performed at the time of the admission to the facility.

The facility Policy #IC 1.08, MRSA Screening Protocol indicated patients with a stated history of MRSA will have cultures collected on admission to rule out MRSA.

An interview was conducted with Patient #3 on 10/10/2012 at approximately 1:30 p.m. He stated he had been placed on contact precaution isolation on 10/6/2012 due to a MRSA infection in his surgical wound. Patient #3 stated he had MRSA infections in the past and had informed the staff at the time of admission.

An interview with the Director of Infection control was conducted on 10/11/2012 at approximately 10:30 a.m. She stated when a patient had a history of previous MRSA infections, the protocol was for the nursing staff to initiate isolation precautions pending test results, perform a MRSA screening test and inform the physician of positive or negative results.

The Chief Nursing Officer confirmed the MRSA screening test had not been performed as required by policy on 10/11/2012 at approximately 11:00 a.m.