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Based on review of medical records, staff interview and review of policy and procedures it was determined the facility failed to ensure a registered nurse assessed and reassessed patients for pain and changes in condition for two (#5, #6) of eight patients sampled. The Registered Nurse failed to follow the physician ordered plan of care for two (#5, #7) of eight patients sampled. This practice does not ensure patient goals are maintained and may lead to a prolonged hospital stay.

Findings include:

1. Review of the medical record for patient #5 revealed the patient was admitted to the facility on 3/10/2012 with a diagnosis of right sided spontaneous pneumothorax. Review of the physician orders dated 3/10/2012 at 9:30 a.m. revealed an order for oxygen 2 liters via nasal cannula. Review of nursing documentation revealed the patient was on room air at 12:00 p.m., 4:30 p.m. and 7:45 p.m.

Review of physician order on 3/10/2012 at 10:00 p.m. revealed an order that stated to keep the patient on oxygen at 2 liters, humidified, via nasal cannula. Nursing documentation at on 3/10/12 at 10:00 p.m. revealed the oxygen was applied.

Review of nursing documentation on 3/11/2012 at 8:00 a.m. revealed the patient was on room air and remained on room air until 7:30 p.m. on 3/11/2012. At that time the patient was noted to be on oxygen at 2 liters via nasal cannula. On 3/11/2012 at 11:30 p.m. nursing documentation revealed the patient had oxygen at 0.5 liters via nasal cannula. On 3/12/2012 at 8:00 a.m. documentation revealed the patient had oxygen at 2 liters via nasal cannula.

Interview with the CNO (Chief Nursing Officer) on 3/12/2012 at 12:10 p.m. confirmed the oxygen was not administered as ordered by the physician.


2. Patient #5's physician's orders dated 3/10/2012 at 3:00 p.m. revealed an order for Dilaudid 2 mg (milligrams) IV (Intravenous) every 3 hours as needed for pain.

Review of the MAR (Medication Administration Record) dated 3/10/2012 revealed Dilaudid 2 mg was given at 3:50 p.m. Review of the nursing documentation revealed on 3/10/2012 there was no pain assessment or reassessment of the patient's pain level before and after the pain medication.

Review of the MAR (Medication Administration Record) revealed the patient was administered Dilaudid 2 mg IV on 3/11/2012 at 9:53 a.m., 4:36 p.m., and on 3/12/2012 at 12:08 a.m. Review of the nursing documentation on 3/11/2012 and 3/12/2012 revealed no pain assessment or reassessment of the patient's pain level.

Review of the facility's policy, "Pain Management", effective 1/2001, stated the patient's intensity of pain is scored from 0 to 10 on a pain score tool. Re-evaluation occurs within 1/2 to 1 hour following intervention, with documentation of the time; pain score, level of sedation, descriptors and non-verbal signs.

Interview with the CNO on 3/12/2012 at 12:10 p.m. confirmed the findings.

3. Review of the medical record for patient #7 revealed the patient was admitted to the facility on 3/09/2012. Review of the physician orders dated 3/10/2012 at 3:15 a.m. revealed an order for SCD (Sequential Compression Device) while in bed.

Review of the medical record and nursing documentation revealed no indication the SCDs had been initiated and applied as ordered.

Observation of the patient in his room on 3/12/2012 at 2:10 p.m. revealed the patient lying in bed. The SCDs were sitting on a chair located in the patient's room.

On 3/12/2012 at 2:15 p.m. the nurse in charge of the patient was interviewed. The nurse stated the night shift nurse reported the patient was confused and would not leave the SCDs on. When questioned the nurse stated she did not attempt to place the SCDs on the patient. At 2:25 p.m. the charge nurse stated she placed the SCDs on the patient.

An interview with the CNO on 3/12/2012 at 2:10 p.m. confirmed the above findings.

4. Patient #6's physician's H&P (History & Physical) revealed the patient had a history of alcoholism and alcoholic liver disease.

Review of the physician orders on 3/09/2012 at 9:00 a.m. revealed an order for Ativan Withdrawal Protocol. Review of the protocol stated to evaluate the patient using the CIWA (Clinical Institute Withdrawal Assessment) upon admission. If CIWA was less than 8, reassessment should be done every 4 hours. If the score remains less than 8 for 24 hours, then the patient can be assessed per unit routine.

Review of the nursing assessments for 3/09/2012 and 3/10/2012 revealed no evidence the CIWA assessment was completed as required by the facility's protocol and physician order.

Interview with the CNO on 3/12/2012 at 2:45 p.m. confirmed the findings.

Based on medical record review and staff interview it was determined the facility failed to ensure the nursing staff kept current the nursing care plan for one (#4) of eight patients sampled. This does not ensure the appropriate nursing interventions are provided based on the patients needs.

Findings include:

Review of the medical record for patient #4 revealed the patient was admitted to the facility on 3/09/2012 for altered mental status and alcoholic liver disease. The patient's plan of care was initiated on 3/10/2012. Review of the plan of care revealed the plan of care was not reviewed by the nursing staff on 3/11/2012. The plan of care was not reviewed or revised on 3/11/2012 in order to respond to the changes in the patient's health status and movement toward the achievement of the patient's health care goals.

Interview on 3/12/2012 at 11:15 a.m. with the CNO confirmed the patient's plan of care should be reviewed daily and revised as indicated by the nursing assessments and the patient's response to interventions. The CNO confirmed the above findings.

Based on medical record review, staff interview and review of policy and procedures it was determined the facility failed to ensure medications were administered according to physician orders for two (#4, #8) of eight patients sampled. This practice does not provide for safe and effective medication therapy.

Findings include:

1. Review of the medical record for patient #4 revealed the patient was admitted to the facility on 3/09/2012 for altered mental status and alcoholic liver disease. Review of the physician orders revealed an order on 3/10/2012 for Ativan Withdrawal Protocol.

Review of the protocol stated to evaluate the patient using the CIWA (Clinical Institute Withdrawal Assessment) upon admission. If CIWA was less than 8, reassessment should be done every 4 hours. If the score was less than 8, no medication was to be administered.

Review of the MAR (Medication Administration Record) revealed on 3/11/2012 at 8:54 p.m. the patient received Ativan 2 mg (milligrams) by mouth. Review of the patient's CIWA assessment on 3/11/2012 at 8:00 p.m. revealed a score of 1. Based on the facility's protocol the patient did not meet the criteria for administration of the Ativan. The protocol stated Ativan 2 mg for CIWA score of 8 to 15 and reassess in 2 hours. The patient's CIWA score on 3/11/2012 at 10:00 p.m. was 1 as documented by nursing. Nursing failed to follow the medication administration protocol as ordered by the physician.

An interview with the Chief Nursing Officer (CNO) on 3/12/2012 at 11:15 a.m. confirmed the above findings.

2. Review of the medical record for patient #8 revealed the patient was admitted to the facility on 3/06/2012 for orthopedic surgery. Review of the physician orders on 3/06/2012 at 2:20 p.m. revealed an order for accuchecks AC/HS (before meals and at the hour of sleep) with low dose insulin sliding scale protocol.

Review of the accucheck results and MAR revealed on 3/06/12 at 8:44 p.m. the patient's accucheck result was 270 mg/dL, She was administered 4 units of insulin. Review of the low dose insulin sliding scale protocol revealed the patient should have received 6 units of insulin.

On 3/07/12 at 7:14 a.m. the patient's accucheck result was 213 mg/dL. She was administered 2 units of insulin. Review of the low dose insulin sliding scale protocol revealed the patient should have received 4 units of insulin.

On 3/07 at 11:58 a.m. the patient's accucheck result was 232 mg/dL. She was not administer any insulin. Review of the low dose insulin sliding scale protocol revealed the patient should have received 4 units of insulin. Documentation on the MAR stated to "see nursing notes". Review of the nursing notes revealed no indication why the insulin was not administered as required by the physician ordered protocol.

On 3/07 at 4:49 a.m. the patient's accucheck result was 223 mg/dL. The patient was administered 2 units of insulin. Review of the low dose insulin sliding scale protocol revealed the patient should have received 4 units of insulin.

An interview with the CNO on 3/12/2012 at 3:45 p.m. confirmed the above findings.