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Based on record reviews and interviews, the hospital failed to ensure the requirements of the Condition of Participation for Nursing Services were met as evidenced by failing to ensure the RN supervised and evaluated the nursing care of each patient. The RN failed to implement the patient's plan of care related to furnishing supplements and assessing weight, administering IV fluids, assessing a patient's neurovascular status after a fall, administering medications, and/or assessing patients in a timely manner when there was a change in condition, all as ordered by the physician or in accordance with acceptable standards of practice, for 2 (#1, #2) of 5 patient records reviewed for implementation of the patient's care plan from a sample of 5 patients. Patients #1 and #2 were each transferred to an acute care hospital on 01/14/18 secondary to a change in condition with no documented evidence that these interventions had been implemented. There were two separate periods on 01/14/18 of 2 hours 13 minutes and 37 minutes that Patient #1 was not assessed by a RN after having been assessed to have a blood pressure of 80/46. There were two separate periods on 01/14/18 of 2 hours 30 minutes and 2 hours 43 minutes that Patient #2 was not assessed by a RN after having been assessed to have a change in mental status, a distended firm abdomen, and hypoactive bowel sounds.

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by failing to implement the patient's plan of care related to furnishing supplements and assessing weight, administering IV fluids, assessing a patient's neurovascular status after a fall, administering medications, and/or assessing patients in a timely manner when there was a change in condition, all as ordered by the physician or in accordance with acceptable standards of practice, for 2 (#1, #2) of 5 patient records reviewed for neglect from a sample of 5 patients. Patients #1 and #2 were each transferred to an acute care hospital on 01/14/18 secondary to a change in condition with no documented evidence that these interventions had been implemented. There were two separate periods on 01/14/18 of 2 hours 13 minutes and 37 minutes that Patient #1 was not assessed by a RN after having been assessed to have a blood pressure of 80/46. There were two separate periods on 01/14/18 of 2 hours 30 minutes and 2 hours 43 minutes that Patient #2 was not assessed by a RN after having been assessed to have a change in mental status, a distended firm abdomen, and hypoactive bowel sounds.
Findings:

Review of the policy titled "Provision Of Emergency Services", presented as a current policy by S2DON, revealed any individual whose condition warrants emergency treatment that is beyond the scope of the facility will be stabilized and transferred to a facility that is designed to meet the individual's medical needs. The attending or on-call physician/Licensed Independent Practitioner is notified or any medical and/or psychiatric needs for consultation, direction, and/or transfer order to the emergency department. If the patient is not transferred to the emergency department and his/her condition continues to deteriorate per the RN's clinical assessment, the RN is to update the attending or on-call physician/Licensed Independent Practitioner of the continued decline for further direction or transfer order. If the RN, after speaking with the attending or on-call physician/Licensed Independent Practitioner , while using his/her nursing judgement, determines that the needs of the deteriorating patient have not been met, they are to call the DON, and if not available, the Administrator for further direction. The DON and/or Administrator will call the attending or on-call physician/Licensed Independent Practitioner and/or the Medical Director to discuss the patient's condition. At any time during this process, if the patient's condition continues to deteriorate and is deemed emergent based on the RN's clinical assessment, the RN is to activate the Code Blue Response policy, and 911 is activated.

Review of the Louisiana State Board of Nursing's "Chapter 39. Legal Standards of Nursing Practice" revealed the board recognizes that assessment, planning, intervention, evaluation, teaching, and supervision are the major responsibilities of the RN in the practice of nursing. The plan for nursing care includes documentation that includes written records that attest to the care provided to patients based on assessment data and the patient's response to the intervention. The planning for nursing care is a continuous process of reassessment and modification according to an ongoing assessment of data used to revise diagnoses, outcomes, and the plan of care as needed.

Patient #1
Review of Patient #1's medical record revealed he was admitted on 01/01/18 with a diagnosis of Dementia with behavioral changes.

Review of Patient #1's Psychiatric Evaluation conducted on 01/02/18 by S13NP revealed his past medical history included diagnoses of Chronic Kidney Disease Stage III, Anemia, history of Colon Cancer, Hypertension, Gastroesophageal Reflux Disease, Diabtetes Mellitus Type 2, Chronic Kidney Failure, and questionable Urinary Tract Infection.

Review of Patient #1's physician's orders revealed the following orders:
01/03/18 at 6:00 p.m. by S5NP - no sugar added Mighty Shakes TID after meals if consumes < 25% and every HS at 9:00 p.m.; Accuchecks AC and HS, call if blood sugar is < 0 or > 200; daily weight;
01/06/18 at 2:25 p.m. by S5NP - no sugar added Mighty Shakes TID after meals if consumes < 25%; continue one can every HS at 9:00 p.m.; d/c daily weight;
01/11/18 at 11:00 p.m. by S5NP - weigh in a.m. and record result on graphic record; Normal Saline per IV at 100 ml/hr (there was no documented evidence the physician's order included an indication for the IV);
01/13/18 at 9:00 a.m. per S6MD - d/c orders for Normal Saline at 100 ml/hr;
01/14/18 at 7:30 p.m. by S5NP by t.o. - force fluids;
01/14/18 at 9:43 p.m. by S5NP by v.o. - transfer to Hospital B for evaluation and treatment.

Weights:
Review of Patient #1's "Vital Signs and I&O" record revealed no documented evidence of a weight documented on 01/04/18 and 01/05/18 when ordered to be done daily and no documented evidence of a weight with the results documented on the graphic sheet as ordered for 01/12/18.

In an interview on 04/10/18 at 2:00 p.m., S2DON reviewed Patient #1's medical record and confirmed there was no weight documented as ordered on 01/04/18, 01/05/18, and 01/12/18.

No added sugar Mighty Shakes (supplement):
Review of Patient #1's "Vital Signs and I&O" record and his MARs for his hospital stay revealed no documented evidence that no added sugar Mighty Shakes were given as ordered or attempted with Patient #1 refusing the shake when his meal intake was < 25% and/or HS at 9:00 p.m. for the following times:
01/03/18 breakfast, lunch, and supper;
01/04/18 breakfast; HS at 9:00 p.m.
01/05/18 lunch and supper; HS at 9:00 p.m.
01/08/18 lunch and supper;
01/09/18 supper;
01/11/18 lunch and supper;
01/14/18 breakfast and lunch.

In a telephone interview on 04/10/18 at 10:30 a.m., S3RN indicated Patient #1 would often not eat and would refuse the Mighty Shakes when offered. She further indicated it should be documented in his medical record if the shakes were offered, and he refused them.

In an interview on 04/10/18 at 12:30 p.m., S10RN indicated the graphic sheet should reflect that Mighty Shakes were given. When asked if the nurse doesn't document Mighty Shakes on the MAR (surveyor saw Mighty Shakes documented on the MAR with no documented evidence they were given or refused) S10RN indicated "that would be the LPN" who documents on the MAR. After reviewing the chart and the MAR, she confirmed she didn't see documentation that shakes were given or offered and refused on a consistent basis. S10RN indicated she is responsible for the care provided by the LPN but wasn't sure how the LPN documented on the MAR. She further indicated she doesn't review the MARs on the shifts that she works.

In an interview on 04/10/18 at 2:00 p.m., S2DON confirmed Mighty Shakes were not documented as given or offered and refused. She indicated since this was a physician's order, the patient's medical record should include this documentation.

Accuchecks:
Review of Patient #1's MARs revealed Apidra Insulin Sliding Scale orders included the following: CBG < 60, give orange juice with 2 packs of sugar (if NPO, give Glucagon 1 mg IM), recheck CBG in 10 minutes. If still < 60, call MD immediately and give one tube of oral Glucose (if NPO, give Glucagon 1 mg IM). If no response from MD in 10 minutes and CBG still < 60, transfer to emergency room. 61-180= No insulin; 180-250= 3 units; 251-300- 5 units; 301-350= 8 units; 351-400= 10 units; 401-451= 12 units; CBG . 451= 15 units and call MD. If CBG > 451 after 30 minutes, call MD for further orders.

Review of Patient #1's medical record revealed no documented evidence of a physician's order for sliding scale insulin. The order received was for Accuchecks AC and HS and to call if the blood sugar is < 0 or > 200.

Review of Patient #1's MARs revealed no documented evidence his Accucheck was performed at 9:00 p.m. Further review revealed he received Apidra Insulin without a physician's order on the following days at the respective times:
01/07/18 at 6:30 a.m. and 9:00 p.m.;
01/08/18 at 6:30 a.m. and 4:30 p.m.;
01/09/18 at 6:30 a.m., 11:30 a.m., and 4:30 p.m.;
01/10/14 at 11:30 a.m. and 4:30 p.m.;
01/11/18 at 6:30 a.m. and 4:30 p.m.;
01/12/18 at 11:30 a.m. and 4:30 p.m.;
01/13/18 at 6:30 a.m. and 4:30 p.m.;
01/14/18 at 6:30 a.m. and 11:30 a.m.

In a telephone interview on 04/10/18 at 10:30 a.m., S3RN indicated she doesn't do the Accuchecks and doesn't administer Insulin if indicated. She further indicated the Accuchecks were done by the LPN who was the medication nurse. S3RN confirmed she works the night shift, and the Accuchecks done at 6:30 a.m. and 9:00 p.m. were done on her shift. She indicated she was responsible for the care provided by the LPN and should have co-signed if Insulin was administered, since 2 nurse's signature was required when Insulin was administered.

In an interview on 04/10/18 at 11:20 a.m., S5NP indicated she had noticed confusion in general with the nurses filling out the sliding scale insulin form. She further indicated if Patient #1 wasn't on Insulin and maintained on oral medications, she wouldn't have ordered sliding scale. When informed that Patient #1 had received Insulin in accordance with sliding scale as evidenced in the MAR, she indicated her order did not include sliding scale but to do Accuchecks AC and HS and to call if blood sugar is < 0 or > 200.

In an interview on 04/10/18 at 12:30 p.m., S10RN indicated, after reviewing Patient 31's medical record, there was no physician order for sliding scale Insulin, and Patient #1 received Insulin in accordance with results of Accuchecks. She confirmed the MAR had sliding scale orders listed.

Normal Saline IV at 100 ml/hr:
Review of Patient #1's Multi-Disciplinary Note dated 01/12/18 at 8:35 a.m. revealed S8RN documented she started Patient #1's IV and hung Normal Saline to infuse at 100 ml/hr (9 hours 35 minutes after the order was received). Further review revealed Patient #1 pulled out his IV at 11:30 a.m., and it was restarted by S8RN at 1:00 p.m. with Normal Saline infusing at 100 ml/hr. Further review revealed S9RN documented on 01/12/18 at 8:35 a.m. that she discontinued Patient #1's IV after it was infused. Review of the record revealed the order to discontinue the IV was received on 01/13/18 at 9:00 a.m., 12 hours and 25 minutes after it had been discontinued.

In an interview on 04/10/18 at 11:20 a.m., S5NP indicated if she didn't put a specific number of bags of fluids to be administered, she wanted the fluids to run continuously at 100 ml/hr.

In an interview on 04/10/18 at 12:30 p.m., S10RN indicated she remembered S5NP saying to let the IV run until S6MD d/c'd it.

In an interview on 04/10/18 at 2:00 p.m., S2DON confirmed there was more than a 9 hour delay in the IV being started. She offered no explanation for the delay.

Change in condition resulting in the transfer of Patient #1:
Review of Patient #1's Multi-Disciplinary Note revealed an entry on 01/14/18 at 7:30 p.m. by S7RN of a blood pressure of 82/46, heart rate 93, oxygen saturation 97%, and respiratory rate 17 with even unlabored breathing. Further review revealed the blood pressure was rechecked manually with a result of 80/46 with Patient #1 responding physically to tactile stimuli but not answering questions. S7RN documented she notified S5NP with orders noted to force fluids. S7RN documented she reported to S3RN at 7:00 p.m.

Review of Patient #1's Multi-Disciplinary Note revealed an entry on 01/14/18 at 9:43 p.m. by S3RN that an order was received to transfer Patient #1 to Hospital B for evaluation and treatment related to decreased level of consciousness. Further review revealed documentation included Patient #1 was not responding verbally, mumbling, rambling speech, bilateral breath sounds coarse with rales, blood pressure 86/40, pulse 103, and respirations 22. The family, S2DON, and S4MD were notified of the pending transfer, and the ambulance was notified for transport. Documentation at 10:05 p.m. by S3RN revealed Patient #1 was lifted onto the ambulance stretcher by two emergency medical technicians and transferred to Hospital B.

There was no documented evidence of a RN assessment of Patient #1 for 2 hours 13 minutes (7:30 p.m. to 9:43 p.m.) after he was assessed to have a blood pressure of 80/46 and for 37 minutes (9:43 p.m. to 10:05 p.m.) while awaiting the arrival of the ambulance to transport him to Hospital B.

Review of the "Prehospital Care Report Summary" documented by the ambulance transport company revealed upon arrival at the hospital Patient #1 was found unresponsive slumped to his left side in a geri-chair and was on 4 liters per minute oxygen via cannula. Patient #1 flexed to pain but was otherwise unresponsive. he was breathing spontaneously but crackles heard bilaterally. His CBG was 473, and initial vitals were "extremely low." A 4-lead electrocardiogram showed normal sinus rhythm. Further review revealed the hospital wanted Patient #1 to be taken to Hospital B, but due to his condition, he was taken to the closest facility, Hospital A.

Review of Patient #1's "Emergency Department Physician Medical Record" documented by S14MD at Hospital A revealed the following:
Arrival 01/14/18 at 10:40 p.m. with triage complaint of Altered Mental Status;
Physical Exam: constitutional - not alert and interactive; general appearance is not normal; not awake, alert, and oriented to person, place, and time; appears toxic; Cardiovascular - no murmur, regular rate, regular rhythm, skin is dry; Respiratory - moderate distress, labored respirations, no expiratory wheezing, no inspiratory wheezing, chest rise and fall is unequal bilaterally, no evidence of obstruction, coarse breath sounds; Gastrointestinal - no rebound tenderness noted, not soft, tenderness; Genitourinary - suprapubic tenderness noted; Neurological - unable to assess since the patient is not responding;
Medication, IV Fluid, and Blood Administration Orders: Insulin regular 10 units IV; Vancocin (Vancomycin) 1000 mg IV; Zosyn 3.375 gm IV; Normal Saline 1000 ml at wide open rate to site #1 for hydration; Normal Saline Bolus of 1000 ml to site #2 for hydration; Electrocardiogram; Lab orders for Cardiac panel, Complete Blood Count, Comprehensive Metabolic Panel, Urinalysis with culture if indicated, Serum Acetone, Protime with International Normalized Ratio, Flu A Direct optical, Lactic Acid, Blood Cultures ; Portable chest x-ray; computerized tomography of the brain without contrast; insert an indwelling catheter; CBG; 15 liters oxygen by non-rebreather;
Patient re-evaluation and Observation on 01/15/18 at 12:33 a.m.: patient's blood pressure responded with 2 liters of fluid with a current blood pressure of 98/62; patient's labs point towards Sepsis but the source is unknown; patient is being transported to Hospital B's emergency department.
Differential Diagnosis: Sepsis, Urinary Tract Infection, Influenza Pneumonia, Dementia;
Diagnosis: Sepsis, Hypotension, Hyperglycemia, Acute Renal failure, Leukocytosis.
Disposition: transfer in serious critical condition.

In a telephone interview on 04/10/18 at 10:30 a.m., S3RN indicated she was the RN present when Patient #1 was transferred to the acute care hospital. When asked about a more than 2 hour time span followed by a 37 minute time span with no documentation of RN assessments after Patient #1 was documented as having a blood pressure of 80/46, S3RN indicated she was with the patient but can't say why she didn't document assessments. She further indicated "I have no excuse for not documenting minute-by-minute."

In an interview on 04/10/18 at 11:20 a.m., S5NP indicated she couldn't specifically remember what was reported to her during the call on 01/14/18 at 7:30 p.m.. She further indicated she remembered the night nurse called (call documented at 9:43 p.m.) and said "he didn't look good", so she gave the order to transfer him. She further indicated that evidently from the first call she received from the nurse, she didn't think Patient #1 needed to be transferred, because she gave orders to force fluids.

In an interview on 04/10/18 at 2:00 p.m., S2DON reviewed Patient #1's medical record and confirmed the two time spans with no documentation of RN assessments. She confirmed ongoing RN assessments should have been documented.

Patient #2
Review of Patient #2's medical record revealed he was admitted on 01/04/18 with a diagnosis of Mild Neurocognitive Disorder secondary to Parkinson's dementia with behavioral change and transferred to Hospital B on 01/14/18 where he was admitted with a diagnosis of Acute Renal Failure.

Review of Patient #2's physician orders revealed the following orders:
01/11/18 at 11:55 p.m. by S5NP - consult S6MD during rounds tomorrow regarding change in mental status; defer to primary care physician after discharge for Hematuria and Proteinuria.
01/14/18 at 1:30 p.m. by S5NP - complete blood count and comprehensive metabolic profile in a.m.; encourage fluids; vital signs and oxygen saturation every 6 hours.
01/14/18 at 2:15 p.m. by v.o. from S5NP - cancel above orders; transfer to Hospital B for evaluation.

Review of physician progress notes revealed the following notes:
01/11/18 at 10:00 p.m. by S5NP - confused; 122/62, 74, 18, 97.9; skin warm and dry, good turgor; abdomen soft and positive bowel sounds in 4 quadrants; labs white blood count 5-10, +30 Protein; change in mental status.
01/12/18 (no time documented) by S6MD - lungs are clear; regular heart rate; abdomen soft; recent lab work revealed some mild anemia and thrombocytopenia; reviewed S5NP's most recent progress note and agree with assessment and plan of care; we will continue treatment as we are now doing medically.
01/14/18 at 1:30 p.m. by S5NP - mumbling; 109/64, 78, 17, 97.5; abdomen distended and hypoactive bowel sounds; last bowel movement 01/11/18; assessment and plan: abdomen distended, complete blood count and comprehensive metabolic profile abnormal, increased protein, consult S6MD.

Review of S4MD's progress note dictated on 01/14/18 at 11:39 a.m. revealed "Medicine is going to follow up for his change in his mental status and nurse was complaining about abdominal distention. Medicine is aware of it and they are going to follow up for medical problems."

Review of Patient #2's "Daily Nurse Note" documented by S7RN at 11:30 a.m. on 01/14/18 revealed Patient #2 was lethargic, moaning when asked his name or with verbal and tactile stimuli, had poor intake, and the physician (no name documented) was notified.

Review of Patient #2's Multi-Disciplinary Notes revealed the following entries:
01/14/18 at 9:00 a.m. by S7RN - abdomen distended and firm, hypoactive bowel sounds; S4MD in facility and aware of patient status; awaiting S5NP for further assessment; continue to monitor.
01/14/18 at 2:00 p.m. by S7RN - S4MD, S5NP, and S6MD agree on patient transfer to Hospital B for evaluation; S2DON and family notified.
01/14/18 at 2:13 p.m. by S7RN - ambulance service called for transfer; ambulance arrived at 3:00 p.m.; 137/72, 69, 17, oxygen saturation on room air 97.

Review of Patient #2's medical record revealed no documented evidence of a RN assessment of Patient #2 who had been assessed as having a change in mental status, distended firm abdomen, and hypoactive bowel sounds for 2 hours 30 minutes (9:00 a.m. to 11:30 a.m.) and for 2 hours 43 minutes from 11:30 a.m. to 2:13 p.m. There was no documented evidence S7RN called S5NP or S6MD to report her findings from her assessment at 9:00 a.m. on 01/14/18, and S5NP did not assess Patient #2 until 1:30 p.m.

In an interview on 04/10/18 at 2:30 p.m., S2DON indicated there should be documented evidence in Patient #2's medical record of ongoing RN assessments during the total of more than 5 hours before Patient #2 was assessed by S5NP. She further indicated S7RN was off and not available to be interviewed.

In a telephone interview on 04/10/18 at 4:15 p.m., S5NP indicated she didn't remember if S7RN called her to report Patient #2's condition on 01/14/18. She further indicated the nurses know she comes to the hospital every day, so they don't always call. She further indicated the nurse is supposed to document if they call her, so if it's not documented that the nurse called, she thinks S7RN knew she (S5NP) was coming in and waited for her to arrive to assess Patient #2.

Based on record reviews and interview, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for each patient as evidenced by failure of the RN to ensure the goals were complete and the care plan was revised with changes in the patient's condition for 5 (#1, #2, #3, #4, #4) of 5 patient records reviewed for revisions to the nursing care plan from a sample of 5 patients. Findings:

Patient #1
Review of Patient #1's nursing care plan revealed it was developed on 01/01/18 and included identified problems of alteration in perception, high risk for falls, and alteration in health maintenance related to medical issues.

Review of Patient #1's medical record revealed he experienced a fall on 01/05/18 and had an IV of Normal Saline initiated at 100 ml/hr on 01/12/18. Further review revealed a physician's order on 01/12/18 at 5:00 p.m. for DNR. Review of Patient #1's nursing care plan revealed no documented evidence that nursing interventions were revised after his fall and nursing interventions were developed for care related to receiving IV fluids and related to his DNR status.

Patient #2
Review of Patient #2's nursing care plan revealed it was developed on 01/04/18 and included identified problems of alteration in thought process, high risk for falls, alteration in health maintenance, and potential for impaired coagulation.

Review of patient #2's medical record revealed an order on 01/09/18 at 7:45 p.m. to encourage fluids and documentation of a change in mental status, proteinuria, and hematuria on 01/11/18. Review of his nursing care plan revealed no documented evidence it was revised when Patient #2's condition changed.

Patient #3
Review of patient #3's nursing care plan revealed it was developed on 03/29/18 and included identified problems of risk for violence, alteration in perception, high risk for falls, and alteration in health maintenance related to medical treatment for fluid retention.

Review of patient #3's physician orders revealed an order on 03/30/18 at 6:00 p.m. to increase Lasix to 40 mg every day secondary to fluid retention. There was no documented evidence his nursing care plan was revised to address the increase in medication related to fluid retention.

Patient #4
Review of Patient #4's nursing care plan revealed it was developed for alteration in health maintenance and risk for infection. Further review revealed goals were incomplete as evidenced by the following statements having blanks that were not filled in: remain free of signs and symptoms of ____ difficulties times ___ consecutive days within 2 weeks; use proper hand hygiene within ___ days.

Review of patient #4's physician orders revealed an order on 04/05/18 at 5:00 p.m. for DNR. There was no documented evidence her nursing care plan was revised to reflect her DNR status.

Patient #5
Review of Patient #5's medical record revealed an order on 03/23/18 for DNR. Review of her nursing care plan revealed no documented evidence the plan was revised to reflect her DNR status.

In an interview on 04/10/18 at 4:50 p.m., S2DON reviewed the above medical records and confirmed the nursing care plans were not revised with changes in the patient's condition.