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Based on record review and staff interview, the facility failed to ensure a registered nurse evaluated the nursing care for three of ten patients reviewed (Patient #6, #1 and #8). This could affect all patients receiving services from this facility. The facility census was 603.

Findings include:

1. Review of the facility Procedure for Advanced Care Units, titled Guidelines for Advanced Care Units, effective date 09/01/19 revealed in Assessment, number 12 spinal, vascular, neurologic assessment frequencies were to be completed by provider (physician) order.

Review of the medical record for Patient #6 revealed the patient was admitted to the hospital on 10/03/2020 to the emergency department after being flown by emergency services helicopter transport from another hospital. The patient had diagnoses including traumatic epidural hematoma with loss of consciousness as a result of a motor vehicle collision, facial lacerations, facial abrasions, left eye abrasion, left occipital fracture, bilateral rib fractures, right lung contusion and right pneumothorax, nasal fracture, sternal fracture, and a left lower extremity injury with right ankle fracture. The patient was evaluated in the emergency department on 10/03/2020 and transferred to the medical-surgical intensive care unit (MICU) that same day and remained there until 10/09/2020. Review of the medical record nursing notes revealed the patient transferred to a trauma step-down unit, ME 4, on 10/09/2020 with oversight by the trauma management team with consultations from neurosurgery and orthopedics specialists.

Review of physician's orders dated 10/09/2020 revealed neurological assessments (neuro checks) were to be completed every two hours. Review of the nursing assessment documentation for neuro checks for 10/09/2020 revealed documentation was completed at 11:00 PM. Review of documentation for 10/10/2020 revealed neuro checks were completed at 2:00 AM, 4:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:17 PM, and 6:00 PM. There was no documentation neuro checks were completed from 6:00 PM on 10/10/2020 to 10/11/2020 at 8:00 AM, even though they were ordered every two hours. Review of nursing notes revealed documentation explaining the lack of the neuro checks for that time frame related to maximizing patient rest. Interview with Staff I on 11/03/2020 at 2:40 PM confirmed that the nursing documentation explaining the lack of neuro check completion for that time frame was the only documentation present in the record regarding the lack of neuro check documentation.

Review of neuro check documentation dated 10/11/2020 for day shift revealed checks were completed at 8:00 AM, 10:00 AM and 12:00 PM, then not again until 9:00 PM that evening. Review of physician orders dated 10/11/2020 at 5:51 PM revealed an order for a change in frequency of neuro checks from every two hours to every four hours. However, there were no nursing notes describing the reason for lack of documentation of neuro checks from 12:00 PM to 5:51 PM on 10/11/2020 when the frequency was still ordered for every two hours.

Review of the neuro check documentation for 10/11/2020, post order change for frequency at 5:51 PM, revealed neuro checks were completed at 9:00 PM, then 10/12/2020 at 1:00 AM, 3:00 AM, 5:00 AM, and then there was a gap until 4:00 PM and then another gap until 9:08 PM. Review of the neuro check documentation dated 10/13/2020 revealed checks were completed at 12:15 AM, 8:44 PM and 11:29 PM. Review of those dates and times revealed gaps of time for ordered checks for the night shift and day shift on 10/13/2020 from 12:15 AM through 8:44 PM without documentation explaining the missing assessment data.

Review of neuro check documentation dated 10/14/2020 revealed checks were completed at 8:00 AM and 8:49 PM, then 10/15/2020 at 12:49 AM, 4:58 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 9:06 PM. Review of nursing documentation revealed a note dated 10/15/2020 at the time of the 4:58 AM neuro check that the patient and family were refusing the neuro check at that time. Review of the neuro check documentation dated 10/16/2020 revealed checks were completed at 12:13 AM, 8:40 AM and 12:00 PM. The patient was then discharged at 3:30 PM on that date. Interview with Staff I on 11/03/2020 at 2:40 PM confirmed that the nursing documentation for the ordered neuro checks did not explain the gaps in frequency.

Review of the facility Procedure for Advanced Care Units, titled, Guidelines for Advanced Care Units, effective date 09/01/19 revealed under Intake and Output, number 1, intake and output will be charted every eight hours and as needed.

Review of Patient #6's nutrition documentation revealed there was an initial dietary note dated 10/07/2020 about the patient not taking any nutrition by mouth (NPO) due to his level of consciousness and critical status with mechanical respiration. The patient was transferred to trauma step down, ME 4, on 10/09/2020.

Review of a dietary note dated 10/09/2020 revealed the patient could begin a soft diet to advance as tolerated. A third dietary note dated 10/13/2020 revealed the patient had adequate intake by the dietician's assessment and interview with the patient and his mother who was present. Review of the dietician's documentation revealed the patient was eating full meals from hospital service and his family was providing additional food brought into the facility and protein shakes that the family was providing. Review of the documentation revealed a notation for staff to "please document all meals."

Review of the electronic health record flow sheet for medical nutrition therapy evaluation revealed Patient #6 was NPO until 10/06/2020 when he was offered breakfast but did not eat it. The first meal recorded for the patient was breakfast on 10/09/2020. Review of a nutrition note dated 10/13/2020 revealed the patient was eating full meal trays, food brought in by his family and protein shakes brought by his family. Review of the intake flow record revealed the additional food was not documented.

Review of the intake documentation for meals revealed there was no dinner intake recorded 10/09/2020, no meal intake documentation for any meal recorded on 10/10/2020 or 10/11/2020, no lunch intake on 10/12/2020, no meals documented on 10/13/2020, no breakfast intake on 10/14/2020, no breakfast or dinner intake on 10/15/2020 and on 10/16/2020 the patient was discharged from the facility. The lack of the intake documentation was confirmed with Staff L on 11/05/2020 at 9:09 AM, who said that recording meal intake was nursing staff's responsibility.



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2. Review of the policy and procedure titled, Guidelines for Critical Care Routines and Documentation for the Critical Care Units revealed that head to toe assessments are to be completed on admission and a minimum every four hours unless ordered differently.

Review of the policy and procedure titled, Guidelines for Advance Care Units revealed that a comprehensive head to toe assessment will be completed and documented every four hours, unless ordered otherwise; patient with transfer orders to a lower level of care may have the assessment frequency reduced to the frequency of the accepting unit.

Review of the medical record for Patient #1 on 11/03/2020 with Staff K revealed on 10/24/2020 at 4:00 PM the every four hour head to toe nursing assessment was not completed. This patient's level of care (LOC) was critcal care unit.

This finding was confirmed with Staff K at the time of the review.

3. Review of the medical record for Patient #8 on 11/03/2020 with Staff K revealed that the patient was admitted on 10/23/2020 to SW4 medical surgical ICU and the noon head to toe assessment on 10/26/2020 was not completed. On 10/27/2020 the patient was transferred to ME4 trauma step-down unit and the midnight and 4:00 AM head to toe assessment for 10/30/2020 was not completed. The patient's LOC was advanced care unit.

This finding was confirmed with Staff K at the time of the review.

This deficiency substantiates Substantial Allegation OH00116668.

Based on record review, observation and staff interview, the facility failed to ensure medications were administered in accordance with policies and procedures for one patient observed receiving eye medication (Patient #1). The sample size was ten patients. The facility census was 603.

Findings include:

Review of the policy and procedure titled, Eye Drops: Administering revealed on page 12 of 17 that opthalmic ointment should be delivered by squeezing a thin line of ointment into the subconjunctival space from the inner canthus to the outer canthus.

Observation was made on 11/02/2020 at 2:00 PM of Staff B administering White Petrolatum, an artificial tears eye ointment, to Patient # 1's eyes. Staff B washed her hands with soap and water and put on clean gloves. Staff B pulled the lower lid down for the right eye and applied the eye ointment going from the outer eye towards the inner canthus area of the eye and then applied pressure with gauze. Staff B then repeated the same proceudure with the left eye.

Interview with Staff A on 11/04/2020 at 2:00 PM confirmed the findings.

This deficiency substantiates Substantial Allegation OH00116668.