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Based on policy review, medical record review, staffing schedule review and staff interview, the facility failed to provide adequate staffing to care for patients requiring: medication administration in 1 of 11 sampled geriatric patients (Patient #8); and Registered Nurse supervision of a Licensed Practical Nurse in 2 of 11sampled geriatric patients (Patients #1 and #2) requiring physical assessments.

The findings included:

A. Closed medical record review revealed Patient #8 was a 79-year-old female admitted to the facility's geriatric unit on 11/29/2018 with diagnosis of "...1. Bipolar Disorder..." Review of the Admission orders dated 11/30/2018 at 1129 revealed an order for Spiriva (medication used to provide better breathing for patients with chronic obstructive pulmonary disease)18 milligrams once per day. Review of the Medication Record dated 12/05/2018 and 12/06/2018 revealed Spiriva was not administered to Patient #8. Review of the Nurse's Medication Notes dated 12/05/2018 and 12/06/2018 revealed "Spiriva unavail [sic]-no witness to override."

Interview on 03/13/2019 at 1417 with RN #2 revealed she was the nurse on duty on 12/05/2018 and 12/06/2018 when the Spiriva was not administered to Patient #8. Interview revealed additional nursing staff was not available to override the pyxis within the two-hour time frame they must administer medications. Interview revealed if RN #2 was the only nurse on the unit and needed a witness to override the pyxis then she would request a nurse from another unit come and witness, however sometimes they are not available to come and witness.


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B. Review of policy titled "Levels of Observation" review/revised: (Blank) revealed, "... Falls Precautions ... Fall assessments are completed by RN (Registered Nurse) every shift ... The RN assures levels of observation are placed on the patient's treatment plan and report sheet and notifies the Director of Nursing for adequate staffing ..."

Review of the Staffing Schedule for the facility's geriatric unit revealed a Licensed Practical Nurse (LPN) was scheduled to work on the unit alone on the following date's night shift: 10/25/2018, 10/27/2018, 11/01/2018, 11/03/2018, 11/08/2018, 11/10/2018, 11/15/2018, 11/17/2018, 11/24/2018, 11/29/2018, 12/05/2018, 12/12/2018, 12/18/2018, 12/19/2018, 12/20/2018, 12/21/2018, 12/22/2018, 12/25/2018, 12/26/2018, 12/27/2018, 12/28/2018, 01/19/2019, 01/26/2019, 01/31/2019, 02/07/2019, 02/15/2019, 02/16/2019, 02/21/2019, 02/22/2019, 03/05/2019, 03/06/2019, and 03/08/2019.

1. Closed medical record review revealed Patient #1 was a 70-year-old female admitted to the facility's geriatric unit on 12/19/2018 with diagnoses of "...1. Acute psychotic episode. 2. Rule out schizoaffective disorder. 3. Rule out bipolar I severe with psychotic features. 4. Rule out paranoid schizophrenia ..." Review revealed "Patient Level of Observation" RN assessments were performed by LPN #1 with no RN co-signature on: 12/21/2018 at 0000 and 0400, 12/22/2018 at 0000 and 0400, 12/26/2018 at 0000 and 2000, 12/27/2018 at 0400, 12/28/2018 at 0000, 12/29/2018 at 0400, 12/30/2018 at 0400, and 12/29/2018 at 0000. Review revealed "Assessment of the Patient's Medical Status" assessments were performed by LPN #1 with no RN co-signature on: 12/20/2018 at 1900 and 12/21/2018 at 1900. Review revealed a "Nursing Post Fall Assessment" was performed on 12/21/2018 at 1830 by LPN #1 with no RN co-signature.

Telephone interview was conducted with LPN #1 on 03/14/2019 at 0930. Interview revealed due to staffing shortages, she is frequently assigned to the geriatric unit with no other RN. Interview revealed she has Certified Nursing Assistants with her, but no RN. Interview revealed she initially started employment at the facility with a RN, but she had quit. Interview revealed she frequently is assigned up to 18 patients on the unit and has no choice but to perform assessments and provide patient care with no RN in the unit.

Staff interview was conducted with the Director of Nursing (DON) on 03/14/2019 at 1002. Interview revealed one LPN assigned to the geriatric unit alone is not ideal, but due to staffing issues the facility has not had a choice. Interview revealed the Patient Level of Observation, Assessment of the Patient's Medical Status, and Post Fall Assessments should be performed by a RN, and facility policy was not followed.

2. Closed medical record review revealed Patient #2 was a 73-year-old female admitted to the facility's geriatric unit on 12/19/2018 with diagnoses of "...1. Major Depressive Disorder. 2. Rule out bipolar disorder I versus bipolar disorder II ..." Review revealed "Assessment of the Patient's Medical Status" assessments were performed by LPN #1 with no RN co-signature on: 12/28/2018 at 1900, and 01/03/2019 at 1900. Review revealed a "Morse Fall Score Assessment" was performed by LPN #1 with no RN co-signature on: 12/22/2018 at 1900, 12/28/2018 at 1900, and 01/03/2019 at 1900.

Telephone interview was conducted with LPN #1 on 03/14/2019 at 0930. Interview revealed due to staffing shortages, she is frequently assigned to the geriatric unit with no other RN. Interview revealed she has Certified Nursing Assistants with her, but no RN. Interview revealed she initially started employment at the facility with a RN, but she had quit. Interview revealed she frequently is assigned up to 18 patients on the unit and has no choice but to perform assessments and provide patient care with no RN in the unit.

Staff interview was conducted with the Director of Nursing (DON) on 03/14/2019 at 1002. Interview revealed one LPN assigned to the geriatric unit alone is not ideal, but due to staffing issues the facility has not had a choice. Interview revealed the Assessment of the Patient's Medical Status, and Morse Fall Score Assessments should be performed by a RN, and facility policy was not followed.

Based on medical record review and staff interview, facility staff failed to follow a practitioner's order in 2 of 2 geriatric patients (Patients #1 and #12) requiring daily weight checks.

The findings included:

1. Closed medical record review revealed Patient #1 was a 70-year-old female admitted to the facility's geriatric unit on 12/19/2018 with diagnoses of "...1. Acute psychotic episode. 2. Rule out schizoaffective disorder. 3. Rule out bipolar I severe with psychotic features. 4. Rule out paranoid schizophrenia ..." Patient #1 also had a history of Congestive Heart Failure (a condition in which the heart cannot pump properly, which can cause fluid to build up, detectable by monitoring a patient's weight daily). Review of an order written on 12/20/2018 at 1906 by Physician's Assistant (PA) #1 revealed, "...Daily wt (weight) checks ..." Review revealed a weight of "217.00" was obtained on 12/26/2018 (6 days after the order was written); and "211.04" was obtained on 12/29/2018 (3 days after the previous weight check). Review revealed no evidence of any additional weight checks during the admission. Patient #1 was discharged on 12/31/2018.

Staff interview conducted on 03/13/2019 at 1333 with the Director of Quality revealed there was no evidence any other weight checks were performed on Patient #1. Interview revealed if her weight was checked any more than twice, it should have been documented.

2. Closed medical record review revealed Patient #12 was a 53-year-old female admitted to the facility's geriatric unit on 12/13/2018 with diagnoses of "...1. Homicidal Ideation 2. Psychosis ..." Patient #12 also had a history of Renal Failure (a condition in which the kidneys cease to function, which can cause fluid to build up, detectable by monitoring a patient's weight daily). Review of an order written on 12/14/2018 at 1238 by PA #1 revealed, "...Weigh daily (q [every] am)..." Review revealed a weight of "291.2" was obtained on 12/19/2018 (5 days after the order was written). Review revealed no evidence of any additional weight checks during the admission. Patient #12 was discharged on 12/21/2018.

Staff interview conducted on 03/14/2019 at 1230 with the Director of Quality revealed if daily weights were ordered for Patient #12 they should have been performed and documented.

Based on review of policy and procedure, review of personnel files and staff interview, the facility staff failed to evaluate skill/performance of the contract staff that provided care on the nursing units in 1 of 1 contract staff personnel files reviewed (RN #4).

The findings included:

Review of the hospital policy "New Hire Orientation and On-Boarding", effective 04/01/2016, revealed "Job Specific Orientation Upon completion of the "General Employee Orientation" and satisfactory meeting competency requirements, all employees receive a discipline/job specific orientation with job shadowing opportunities. Job specific competencies are reviewed, verified and documented ... 2. Contracted nursing/clinical personnel will attend general employee orientation as described above and met equivalent requirements to employed counterparts."

Review of contract nurse file (RN#4) revealed no documentation of job specific competencies or orientation. Review revealed the start date of the contract was 11/29/2018.

Interview on 03/14/2019 at 1400 with DON revealed orientation is individualized for contract nurses. Interview confirmed job specific competencies need to be documented and in personnel files.

Interview on 03/14/2019 at 1500 with RN #4 revealed she began her contract at the end of November 2018. Interview confirmed there were no competencies completed during her orientation process or after. Interview revealed she received 2 days of unit based orientation with a LPN.

Based on policy review, medical record review, Pyxis report review, and staff interview, facility nursing staff failed to administer medications in accordance with the orders of a practitioner in 3 of 11 geriatric patients (Patients #1, #11, and #8).

The findings included:

Review of policy titled "Medication Administration - General Guidelines" reviewed/revised 01/23/2018 revealed, "...Medication shall be administered in accordance with orders of the prescribing physician ..."

1. Closed medical record review revealed Patient #1 was a 70-year-old female admitted to the facility's geriatric unit on 12/19/2018 with diagnoses of "...1. Acute psychotic episode. 2. Rule out schizoaffective disorder. 3. Rule out bipolar I severe with psychotic features. 4. Rule out paranoid schizophrenia ..." Review of an order written on 12/20/2018 at 1906 by Physician's Assistant (PA) #1 revealed, "Tolnaftate (an anti-fungal medication) Spray BID (twice a day) to abd (abdominal) folds rash x (for) 2 wks (weeks) - candidiasis (fungal infection)." Review revealed no evidence the Tolnaftate was administered or not available on 12/21/2018 or 12/22/2018. The medication was documented as "NOT AVAIL (available)" by Registered Nurse (RN) #1 at 0800 on 02/23/2018, 02/24/2018, 02/25/2018. The Tolnaftate spray was initiated on 12/26/2018 at 2000 (6 days and 54 minutes after the order was written), and was administered twice daily until 12/31/2018, when Patient #1 was discharged.

Staff interview conducted with the Director of Pharmacy on 03/13/2019 at 1620 revealed Tolnaftate spray is a bulk product that is "kept in the cabinet," and not stored in the unit Pyxis (a medication storage device). Interview revealed "the cabinet" is in the medication room of the geriatric unit. Due to not being stored in the Pyxis, and the amount of time that had lapsed, the facility's pharmacy would not be able to say if the spray was or was not available, nor why.

Telephone interview was conducted with RN #1 on 03/14/2019 at 0850. RN #1 did not recall the Tolnaftate spray being unavailable for Patient #1. Interview revealed on the weekends sometimes it can be difficult to obtain newly ordered medications because a pharmacist is not on duty.

2. Closed medical record review revealed Patient #11 was an 85-year-old male admitted to the facility's geriatric unit on 12/13/2018 with diagnoses of "...1. Suicidal Ideation. 2. Homicidal Ideation 3. Rule out dementia 4. Rule out delirium ..." Review of an order written on 12/14/2018 at 1117 by PA #2 revealed, "Depakote (a psychiatric medication) Liquid 150 mg (milligrams) po (by mouth) BID ..." Review revealed Depakote Liquid 150 mg was administered BID at 0800 and 2000 daily from 12/15/2018 through 12/18/2018. Review revealed this Depakote order was cancelled by Medical Doctor (MD) #1 on 12/19/2018 at 1640. Simultaneously MD #1 wrote an order for "Depakote ER (Extended Release) 250 mg po TID (three times a day). This order was cancelled by MD #1 on 12/20/2018 at 1822, without being administered. Simultaneously MD #1 wrote an order for "Depakote ER 250 mg po q (every) 1500 (hours) 500mg po qhs (every hour of sleep)..." Review revealed this order was initiated on 12/21/2018 at 2000 and administered until 12/26/2018 at which time it was cancelled; except for 12/25/2018 at 2000 at which time the patient refused. Review revealed the original cancelled Depakote Liquid 150 mg po order was administered concurrently with the third Depakote order at 0800 hours on the dates of 12/20/2018 through 12/24/2018 (5 doses after the order was cancelled) by RN #3.

Staff interview conducted with RN #3 on 03/14/2019 at 1150 revealed he did not recall administering an overdose of Depakote to Patient #11.







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3. Closed medical record review revealed Patient #8 was an 79-year-old female admitted to the facility's geriatric unit on 11/29/2018 with diagnosis of "...1. Bipolar Disorder..." Review of the Admission orders dated 11/30/2018 at 1129 revealed an order for Amiodarone (heart medication used to treat heart rhythm problems) 200 milligrams once per day. Review of the Medication Record dated 11/30/2018, 12/01/2018, 12/02/2018, and 12/03/2018 revealed Amiodarone was not administered to Patient #8. Review of the Nurse's Medication Notes dated 11/30/2018 at 0900 revealed "Amiodarone [sic] ordered." Review of the Nurse's Medication Notes dated 12/01/2018 at 0821 revealed "Amiodarone unavailable in unit." Review of the Medication Record dated 12/02/2018 and 12/03/2018 revealed Amiodarone "N/A (not available)."

Review of the Pyxis Report dated 11/30/2018 at 1416 revealed "Transaction-Load; Med Description-Amiodarone (Cordarone) 200 mg (milligram) tablet; Quantity-5." Review of the Pyxis Report dated 12/03/2018 at 1149 revealed "Transaction-Refill; Med Description-Amiodarone (Cordarone) 200 mg (milligram) tablet; Quantity-25."

Interview on 03/14/2019 at 1122 with the Director of Pharmacy revealed the hospital did not have Amiodarone in stock on 11/30/2018 therefore she requested 5 pills be delivered from their pharmacy supplier. Interview revealed the 5 pills delivered from their pharmacy supplier was placed into the pyxis on 11/30/2018 and available for patient use.

Interview on 03/14/2019 at 1140 with RN (Registered Nurse) #3 revealed he was the RN on duty on 12/01/2018. Interview revealed he was unable to recall the details of the availability of Amiodarone on 12/01/2018.

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