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Based on interview and record review, the hospital failed to ensure that nursing staff were sufficient to meet patients needs for six of 31 sampled patients when:

1. Patients 14, 15, and 16 were not repositioned every two hours.

2. Patients 15 and 16 failed to have personal care such as bathing and linen changes provided.

3. Patient 2's intravenous (IV, tube inserted in the vein to deliver medication and fluids) medication label was not labeled with the patient's name.

4. Patients 3 and 4's IV site was not labeled with the date and time of insertion.

These failures have the potential to result in medication administration errors, nurses not being aware of what medications the patient had received or when the dose was administered, infection, pressure sores developing or worsening, and unstable health conditions.

Findings:

1. On 9/14/16, the hospital's policy titled, "Medical/Surgical Staff Plan," dated 8/2015, read, "1. A Registered Nurse (RN) plans, assesses, supervises, and evaluates the nursing care of each patient. 2. A Registered Nurse makes a patient care assignment by delegating appropriate aspects of nursing care to licensed and ancillary nursing personnel... 4. The patient care assignment is commensurate (based on) with the qualifications of each nursing staff member, the identified needs of the patient, and the prescribed medical regimen."

On 9/13/16 at 3:30 pm, Administrative Nurse (ADM RN) 2 stated that RNs are assigned according to state minimum patient to nurse ratios, 1 nurse to 5 patients for medical surgical nursing units and the hospital will adjust staffing for patients with increased acuity (increased care requirements). The hospital routinely plans to staff these units with Certified Nurse Assistants (CNAs) but there was no State requirement for this type of personnel. ADM RN 2 explained that if CNAs are available they staff three CNAs for day shift (6:45 am to 2:45 pm), two for evening shift (2:45 pm to 10:45 pm), and one for night shift (10:45 pm to 6:45 am). ADM RN 2 further explained that the RN will delegate tasks to the CNAs but the RN is responsible for all the patient care. When asked what happens when there is not enough CNAs for a shift, ADM RN 2 stated the RN must perform all the patient care and if that is not possible, the RN must report this to the Charge Nurse who will problem solve to meet the patients' needs.

Confidential interviews were conducted with six nursing staff, RNs and CNAs, from 8/30 to 9/14/16. The interviews revealed that the hospital did not staff the medical surgical units with the planned CNAs, and the RNs were expected to complete all the duties performed by CNAs such as repositioning, bathing, linen changes, taking vital signs, toileting, and feeding patients in addition to their other duties. RNs expressed that while they did the best they could in the time allotted, they were not able to complete all the duties and confirmed that patients did not get turned or bathed as often as required.

On 9/14/16, the hospital policy, titled, "Wound Care Protocol General Guidelines," dated 7/2016, read, "Adhere to turning, reposition at least every 2 hours. Document on hourly rounding form."

1a. On 7/13/16, Patient 15's record was reviewed. Patient 15 was admitted to the hospital on 7/21/16 with diagnoses that included dry gangrene (dead tissue caused by lack of blood supply) and osteomyelitis (bone infection) of the right leg. Patient 15's record indicated repositioning every two hours as a nursing intervention. Patient 15's record record contained hourly rounding forms that failed to contain evidence of patient repositioning every two hours (or refusals) as follows:

- 7/22/16 9 am to 6 pm (9 hours)
- 7/23/16 7 am to 7 pm (12 hours)
- 7/28/16 11 pm to 7 am (8 hours)
- 7/29/16 12 noon to 7 pm (6 hours)

Staffing records were reviewed for 7/29/16 day shift and indicated that one CNA was present for 28 patients.

1b. On 7/13/16, Patient 16's record was reviewed. Patient 16 was admitted to the hospital on 7/14/16 with diagnoses that included severe pain from breast cancer that had spread to the liver and ribs. Patient 16's care plan listed repositioning every two hours under interventions for skin care. Patient 16's record contained hourly rounding forms completed by RNs for each hour that failed to contain evidence of patient repositioning every two hours (or refusals) as follows:

- 7/16/16 3 pm to 7 pm (4 hours)
- 7/17/16 9 am to 5 pm (9 hours)

Staffing records were reviewed for the above shift and indicated that one CNA was present for 34 patients on 7/16/16 evening shift, and no CNA was present on 7/17/16 day shift for 32 patients.

1c. On 7/13/16, Patient 14's record was reviewed. Patient 14 was admitted to the hospital on 7/6/16 with diagnoses that included sepsis (a life threatening infection which can lead to multiple organ failure) and a history of lung cancer that had spread to the brain, chest, and adrenal gland (regulate hormones). Patient 14's nursing record indicated her skin was fragile and she developed skin tears easily. Patient 14's care plan listed repositioning every two hours under interventions for skin care. Patient 14's record contained hourly rounding forms completed by RNs for each hour that failed to contain evidence of patient repositioning every two hours (or refusals) as follows:

- 7/7/16 8 pm to 7/8/16 at 6 am (10 hours);
- 7/8/16 7 pm to 7/9/16 at 6 am (10 hours);
- 7/9/16 7 am to 7/10/16 at 6 pm (35 hours)
- 7/24/16 7 pm to 11 pm (4 hours)
- 7/26/16 7 am to 6 pm (11 hours)
- 7/27/16 7 am to 2 pm (7 hours)
- 7/28/16 3 pm to 7/29/16 at 6 am (16 hours)

On 9/13/16 at 3:30 pm, ADM RN reviewed the above patient records and acknowledged that repositioning was not documented as required for Patients 14, 15, and 16.

2. On 7/14/16, the hospital policy, titled,"AM, PM, and HS Care," dated 6/2015, read, "AM (morning) care: mouth care, daily hygiene/skin care provided appropriate for patient's condition... New linens offered per patient preference. PM care: Mouth care, daily hygiene/skin care and freshening or straightening of the linens."

2a. Patient 15's record was reviewed. Patient 15's record contained hourly rounding forms that indicated that Patient 15 did not have a "wash up" (bath/shower/sponge bath) documented from admission on 7/21 to 7/30/16 (9 days) with the exception of a documented refusal on 7/23 and 7/24/16, in which a linen change only was documented.

2b. Patient 16's record was reviewed. Patient 16's history and physical indicated she was incontinent of urine. Patient 16's hourly rounding forms indicated that Patient did not have a "wash up" or linen change documented from 7/17 to 7/19/16, (3 days).

On 9/13/16 at 3:30 pm, ADM RN reviewed Patient 15 and 16's records and acknowledged that bathing and linen changes or refusals were not documented for Patients 15 and 16.


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3. On 9/13/16, the hospital's Unit Dose Medication Labeling policy, dated 6/2016, read that unit dose medications (pharmacy prepared individualized medications) would be labeled. The policy read that proper labeling was to ensure patient safety and reduce risk of medication errors at the time of administration. It indicated that medications needed to be labeled with the order number, prescriber, patient's name, location and account number.

The hospital's Documentation policy, dated 8/2016, read that ready to use IV medication bags were to have the patient's name and rate of administration on them.

Patient 2's record was reviewed. Patient 2 was admitted to the hospital on 9/8/16 with diagnoses that included diarrhea for eight days and vomiting.

On 9/12/16 at 8:40 am, Patient 2's IV pole was observed to have an empty unlabeled bag of vancomycin (antibiotic used to treat intestinal infections). There was no patient or prescriber name, account number or location on the label. In a concurrent interview Registered Nurse (RN) 4 stated she was Patient 2's nurse and stated that the night shift had administered the vancomycin and it had no label. RN 4 confirmed that Patient 2's vancomycin bag should have been labeled with the patient name and information.

On 9/12/16 at 8:50 am, ADM RN 3 stated that the vancomycin bag in Patient 2's room should have been labeled with the patient name and information.

4. The hospital's Peripheral Lines policy, dated 8/2016, read that IV sites would be labeled with the date, time, catheter gauge, length, and initials of person inserting it. The policy indicated that IVs placed in the field (prior to arrival at hospital) would be changed as soon as possible and no longer than 48 hours.

The hospital's Documentation policy, dated 8/2016, read that, "IV site dressings shall be labeled with the date of insertion, time, and initials of person inserting IV."

a. Patient 3's record was reviewed. Patient 3 was admitted to the hospital on 9/11/16 at 10:10 am from the emergency room with diagnoses that included bilateral leg pain and shortness of breath.

On 9/12/16 at 9:48 am Patient 3's IV dressing was observed not labeled with date or initials on it.

On 9/12/16 at 10:10 am, ADM RN 3 was interviewed and confirmed that Patient 3's IV was placed in the field prior to her being brought to the hospital's emergency room. ADM RN 3 confirmed that Patient 3's IV site should have been changed by then and had they not followed the policy

b. Patient 4's record was reviewed. Patient 4 was admitted to the hospital on 9/1/16 with diagnoses that included hyperemesis gravidarum (excessive vomiting while pregnant).

On 9/12/16 at 11 am, Patient 4's IV was observed concurrently with RN 3 to have an unlabeled dressing. RN 3 was interviewed and concurrently confirmed that Patient 4's IV site dressing was unlabeled and there was no date to show how many days ago it was inserted and this did not follow the hospital policy. RN 3 confirmed that Patient 4's IV insertion site was reddened (sign of possible infection) and needed to be changed.

Based on observation, interview and record review, the hospital failed to ensure one of 31 sampled patient's records was complete when communication with the patient's physician regarding medication held (not given), was not documented in the record. This had the potential for the patient's providers to not be aware of what medications were administered. (Patient 5)

Findings:

Patient 5's record was reviewed. Patient 5 was admitted to the hospital on 9/7/16 with diagnoses that included high blood pressure and atrial fibrillation with a rapid ventricular response (arrhythmias, abnormal heart rhythm).

On 9/12/16, Patient 5 was observed with her daughter at the bedside. Patient 5's daughter stated that Patient 5 had been confused the prior evening and the family was concerned that it was caused by her metoprolol (beta blocker medication, used to lower her heart rate), which they were aware was changed.

On 9/14/16, Patient 5's record included a Cardiology Consult (physician specializing in heart disorders), dated 9/8/16, that showed she had experienced a rapid heart rate for four days prior to her admission. The consult showed that she continued to experience an irregular and rapid heart rate in the 110s and 120s (beats per minute, less than 100 is normal). The consult showed that the Cardiologist was increasing Patient 5's metoprolol from 50 milligrams (mg) daily to 100 mg daily in an attempt to control her heart rate.

Patient 5's medication administration record showed that her metoprolol 100 mg was held on 9/11/16 at 8:06 am. There was no notification to the physician or reason documented in Patient 5's record.

The hospital's Medication Administration policy, dated 6/15, was reviewed and showed that medications were to be administered by nursing "...in an accurate, consistent and efficient manner, in compliance with a physician's order."

The hospital's Bar Code Medication Administration policy, dated 6/15, showed that physicians were to be contacted when a medication was held.

On 9/14/16 at 10:30 am, Adminstrative Registered Nurse (ADM RN B) was interviewed and confirmed that Patient 5's record did not include the reason her metoprolol was held on 9/11/16. ADM RN B stated that there was no documentation that Patient 5's physician was aware of or notified of the metoprolol being held on 9/11/16.

Based on interview and record review, the hospital failed to ensure that one of 31 sampled patient's needs were identified as needing adequate discharge planning to prevent adverse consequences upon discharge when her high blood sugars and newly diagnosed diabetes was not addressed. This had the potential for the patient's condition to go untreated and experience a decline in her clinical condition. (Patient 6)

Findings:

Patient 6's record was reviewed. Patient 6 was admitted to the hospital on 9/10/16 with diagnoses that included intractable pain of the right hip and back.

On 9/14/16, Patient 6's Physicians History and Physical (H&P), dated 9/10/16, showed that she was a poor historian (could not relate her medical history well) and that she said she did not have diabetes (chronic condition that affects the way the body processes blood sugar or glucose). Her H&P indicated that she had no primary care physician and had recently moved to the area from out of state. The H&P contained documentation that Patient 6 had labs done and her blood sugar was 215 milligrams/deciliter (mg/dl) (normal fasting blood sugar is below 100 mg/dl and diabetes is 126 mg/dl or higher, normal non fasting blood sugar is between 79 and 140 mg/dl, blood sugar over 200 mg/dl is considered diabetes). Patient 6's H&P listed diabetes as one of her co-morbidities (simultaneous chronic disease) and her assessment read, "The patient needs to be admitted for pain control and start treating her diabetes." Patient 6's physician plan included treating her diabetes with insulin and further monitoring and testing.

Patient 6's Admitting Physician's Orders, dated 9/10/16, listed "Diabetes/newly diagnosed."

Patient 6's record included a Case Manager Progress Noted, dated 9/10/16, that showed she was assessed as having diabetes and the hospital would start treating her and monitoring her blood sugars. Patient 6's Discharge Plan, dated 9/11/16, did not include reference to her diabetes, diet, or blood sugar monitoring although she was newly diagnosed and had no primary care physician to manage her health.

Patient 6's record included multiple blood glucose readings over 150 mg/dl and her morning (fasting) readings as follows:

9/11/16 at 7:46 am 154 mg/dl;
9/12/16 at 7:20 am 187 mg/dl;
9/13/16 at 7:27 am 124 mg/dl. Normal range indicated as 70 to 110 mg

Patient 6's Physician Discharge Summary, dated 9/14/16 (one day following her discharge on 9/13/16), did not list her diabetes under the sections titled New Diagnoses. The section titled Chronic Diagnoses and Co-Morbidities listed "None." It did read, "She does not have a primary care doctor here in ___________ since she just relocated here." The section titled Discharge Instructions included Diet: Regular. There was no reference found for her newly diagnosed diabetes or treatment. There were no medications prescribed for her diabetes.

On 9/14/16 at 1 pm, the hospital's Assistant Director of Case Management (ADCM) was interviewed and confirmed that Patient 6's clinical record showed she was newly diagnosed with diabetes and that it should have been addressed by the discharge nurse in her Discharge Plan or contacted the physician to clarify it. ADCM confirmed that Patient 6 did not have a primary care provider. ADCM was not able to explain how any follow up provider would be made aware of Patient 6's hyperglycemia (high blood sugar) and newly diagnosed diabetes, since it was not addressed in her Discharge Summary (accessible for review by the provider taking over the care of the patient following discharge from the acute care hospital). ADCM confirmed there was no education about symptoms, diet, lifestyle changes or assessment to see if Patient 6 had the equipment or knowledge for checking her blood sugars.

The hospital's Discharge Planning Process policy, dated 6/2015, showed that patients' discharge plans were centered on their care and wellness and indicated High-Risk Screening Criteria used included patients with chronic illnesses (diabetes) and over 75 years old (both of which described Patient 6). The primary objective was to "Provide assistance to patients and families in order to enable them to achieve optimal physical and psychosocial functioning."

Based on interview and record review, the hospital failed to ensure that nursing staff were sufficient to meet patients needs for six of 31 sampled patients when:

1. Patients 14, 15, and 16 were not repositioned every two hours.

2. Patients 15 and 16 failed to have personal care such as bathing and linen changes provided.

3. Patient 2's intravenous (IV, tube inserted in the vein to deliver medication and fluids) medication label was not labeled with the patient's name.

4. Patients 3 and 4's IV site was not labeled with the date and time of insertion.

These failures have the potential to result in medication administration errors, nurses not being aware of what medications the patient had received or when the dose was administered, infection, pressure sores developing or worsening, and unstable health conditions.

Findings:

1. On 9/14/16, the hospital's policy titled, "Medical/Surgical Staff Plan," dated 8/2015, read, "1. A Registered Nurse (RN) plans, assesses, supervises, and evaluates the nursing care of each patient. 2. A Registered Nurse makes a patient care assignment by delegating appropriate aspects of nursing care to licensed and ancillary nursing personnel... 4. The patient care assignment is commensurate (based on) with the qualifications of each nursing staff member, the identified needs of the patient, and the prescribed medical regimen."

On 9/13/16 at 3:30 pm, Administrative Nurse (ADM RN) 2 stated that RNs are assigned according to state minimum patient to nurse ratios, 1 nurse to 5 patients for medical surgical nursing units and the hospital will adjust staffing for patients with increased acuity (increased care requirements). The hospital routinely plans to staff these units with Certified Nurse Assistants (CNAs) but there was no State requirement for this type of personnel. ADM RN 2 explained that if CNAs are available they staff three CNAs for day shift (6:45 am to 2:45 pm), two for evening shift (2:45 pm to 10:45 pm), and one for night shift (10:45 pm to 6:45 am). ADM RN 2 further explained that the RN will delegate tasks to the CNAs but the RN is responsible for all the patient care. When asked what happens when there is not enough CNAs for a shift, ADM RN 2 stated the RN must perform all the patient care and if that is not possible, the RN must report this to the Charge Nurse who will problem solve to meet the patients' needs.

Confidential interviews were conducted with six nursing staff, RNs and CNAs, from 8/30 to 9/14/16. The interviews revealed that the hospital did not staff the medical surgical units with the planned CNAs, and the RNs were expected to complete all the duties performed by CNAs such as repositioning, bathing, linen changes, taking vital signs, toileting, and feeding patients in addition to their other duties. RNs expressed that while they did the best they could in the time allotted, they were not able to complete all the duties and confirmed that patients did not get turned or bathed as often as required.

On 9/14/16, the hospital policy, titled, "Wound Care Protocol General Guidelines," dated 7/2016, read, "Adhere to turning, reposition at least every 2 hours. Document on hourly rounding form."

1a. On 7/13/16, Patient 15's record was reviewed. Patient 15 was admitted to the hospital on 7/21/16 with diagnoses that included dry gangrene (dead tissue caused by lack of blood supply) and osteomyelitis (bone infection) of the right leg. Patient 15's record indicated repositioning every two hours as a nursing intervention. Patient 15's record record contained hourly rounding forms that failed to contain evidence of patient repositioning every two hours (or refusals) as follows:

- 7/22/16 9 am to 6 pm (9 hours)
- 7/23/16 7 am to 7 pm (12 hours)
- 7/28/16 11 pm to 7 am (8 hours)
- 7/29/16 12 noon to 7 pm (6 hours)

Staffing records were reviewed for 7/29/16 day shift and indicated that one CNA was present for 28 patients.

1b. On 7/13/16, Patient 16's record was reviewed. Patient 16 was admitted to the hospital on 7/14/16 with diagnoses that included severe pain from breast cancer that had spread to the liver and ribs. Patient 16's care plan listed repositioning every two hours under interventions for skin care. Patient 16's record contained hourly rounding forms completed by RNs for each hour that failed to contain evidence of patient repositioning every two hours (or refusals) as follows:

- 7/16/16 3 pm to 7 pm (4 hours)
- 7/17/16 9 am to 5 pm (9 hours)

Staffing records were reviewed for the above shift and indicated that one CNA was present for 34 patients on 7/16/16 evening shift, and no CNA was present on 7/17/16 day shift for 32 patients.

1c. On 7/13/16, Patient 14's record was reviewed. Patient 14 was admitted to the hospital on 7/6/16 with diagnoses that included sepsis (a life threatening infection which can lead to multiple organ failure) and a history of lung cancer that had spread to the brain, chest, and adrenal gland (regulate hormones). Patient 14's nursing record indicated her skin was fragile and she developed skin tears easily. Patient 14's care plan listed repositioning every two hours under interventions for skin care. Patient 14's record contained hourly rounding forms completed by RNs for each hour that failed to contain evidence of patient repositioning every two hours (or refusals) as follows:

- 7/7/16 8 pm to 7/8/16 at 6 am (10 hours);
- 7/8/16 7 pm to 7/9/16 at 6 am (10 hours);
- 7/9/16 7 am to 7/10/16 at 6 pm (35 hours)
- 7/24/16 7 pm to 11 pm (4 hours)
- 7/26/16 7 am to 6 pm (11 hours)
- 7/27/16 7 am to 2 pm (7 hours)
- 7/28/16 3 pm to 7/29/16 at 6 am (16 hours)

On 9/13/16 at 3:30 pm, ADM RN reviewed the above patient records and acknowledged that repositioning was not documented as required for Patients 14, 15, and 16.

2. On 7/14/16, the hospital policy, titled,"AM, PM, and HS Care," dated 6/2015, read, "AM (morning) care: mouth care, daily hygiene/skin care provided appropriate for patient's condition... New linens offered per patient preference. PM care: Mouth care, daily hygiene/skin care and freshening or straightening of the linens."

2a. Patient 15's record was reviewed. Patient 15's record contained hourly rounding forms that indicated that Patient 15 did not have a "wash up" (bath/shower/sponge bath) documented from admission on 7/21 to 7/30/16 (9 days) with the exception of a documented refusal on 7/23 and 7/24/16, in which a linen change only was documented.

2b. Patient 16's record was reviewed. Patient 16's history and physical indicated she was incontinent of urine. Patient 16's hourly rounding forms indicated that Patient did not have a "wash up" or linen change documented from 7/17 to 7/19/16, (3 days).

On 9/13/16 at 3:30 pm, ADM RN reviewed Patient 15 and 16's records and acknowledged that bathing and linen changes or refusals were not documented for Patients 15 and 16.


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3. On 9/13/16, the hospital's Unit Dose Medication Labeling policy, dated 6/2016, read that unit dose medications (pharmacy prepared individualized medications) would be labeled. The policy read that proper labeling was to ensure patient safety and reduce risk of medication errors at the time of administration. It indicated that medications needed to be labeled with the order number, prescriber, patient's name, location and account number.

The hospital's Documentation policy, dated 8/2016, read that ready to use IV medication bags were to have the patient's name and rate of administration on them.

Patient 2's record was reviewed. Patient 2 was admitted to the hospital on 9/8/16 with diagnoses that included diarrhea for eight days and vomiting.

On 9/12/16 at 8:40 am, Patient 2's IV pole was observed to have an empty unlabeled bag of vancomycin (antibiotic used to treat intestinal infections). There was no patient or prescriber name, account number or location on the label. In a concurrent interview Registered Nurse (RN) 4 stated she was Patient 2's nurse and stated that the night shift had administered the vancomycin and it had no label. RN 4 confirmed that Patient 2's vancomycin bag should have been labe