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Based on document review and staff interview, it was determined that the registered nurses (RNs) failed to adequately assess skin intregity status and risk of skin breakdown on admission, supervise and provide preventative care to prevent skin breakdown and pressure ulcers, including repositioning of patients requiring such assistance, providing adequate food and fluid intake, and the nursing care of each patient. The registered nurses failed to follow physician orders for vital signs, failed to document physician telephone order for patient transfer to another facility emergency department (ED), failed to follow facility policy/procedure for Nursing Standards of Care for ensuring patients received adequate food and fluid intake, maintain hygiene and physical activity (such as repositioning and range of motion), document the food and fluid intake, hygiene provided and physical activity provided (see A 395) and failed to ensure that medications were administered as ordered (see A 405).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the nursing services be supervised by a registered nurse.

Based on policy and procedure review, medical record review, and staff interview, a registered nurse failed to ensure that nursing staff: assured there were admission orders for 1 of 5 patients (pt. #1), wrote an order to transfer 1 of 5 patients (pt. #5), completed vital signs BID (two times/day) for the first 24 hours after admission, per physician orders, for 7 of 8 patients (pt #2, #3, #4, #5, #30, #31 & #32), failed to implement the policy that requires a Braden skin care assessment be completed on admission for 8 of 8 patients (pts. #1, #2, #3, #4, #5, #30, #31 & #32) and failed to ensure physician contact for a nutritional consult for 3 of 3 patients (pt #30, #31 & #32).

Findings:
1. Review of the policy "Medical Record Availability", no policy number, with a last review date of 1/24/14, indicated that "...All required health records, either as originals, or accurate reproductions of the originals, shall be maintained in such form as to be legible and readily available...", but lack any requirement for complete documentation of medical records.

2. Review of the policy "Nursing Standards of Care", policy number NR 10.6, last reviewed on 1/24/14, indicated:
a. Under "Standard of Care", in the "Rationale" section, it read: "Nurses and the mental health technicians are the primary health care providers who interact with the patient on a daily basis regarding activities of daily living (ADL)...".
b. Under the "Outcome Criteria" section, it read: "...4..C.1.A Maintain adequate food and fluid intake. 4.C.1.B Maintain hygiene with minimal assistance...4.C.2.C Maintain adequate physical activity...".

3. Review of the policy and procedure "Skin and Wound Care Protocol", policy number CTS-428, with no reviewed/revised date, indicated:
Under "Policy", it read: "All patients admitted to the hospital will be evaluated using the Braden Scale Risk Assessment upon admission and prn (as needed) as patient activity changes...".

4. Review of the policy "Patient Comprehensive Assessment", policy number CTS-116, with no reviewed or revised date, indicated:
On page 74, under "12.0 Pain Assessment", it read: "Pain assessment is a part of the initial assessment completed by nursing staff. It is the responsibility of all clinical staff to assess and periodically reassess patients for pain and relief from pain and responses to treatment."

5. Review of the policy "Dietary and Nutrition Procedures", policy number NR 10.8, last reviewed 1/23/2014, indicated:
On page 2 under "Special Nutrition Procedure/Nutrition Therapy", it read: "(1) Any orders for dietary/nutritional assessments are made by the attending physician..."

6. Review of medical records indicated: Patient #1 was admitted on 7/29/14 and had no admission orders present in the medical record.

7. At 4:40 PM on 10/8/14 and 12:15 PM, 1:15 PM, and 2:15 PM on 10/9/14, interview with staff member #50, the chief nursing officer, indicated: Nursing staff are to ensure that a patient has admission orders, but none for pt. #1 can be found.

8. Review of patient #1's medical record indicated that a Braden Scale Risk
Assessment form was not present in the chart.

9. At 3:15 PM on 10/9/14, interview with staff members #54, a LPN (licensed practical nurse), and #55, a RN (registered nurse), indicated that Braden Scale Risk Assessment forms were not being completed by nursing staff on patient admissions, as required by facility policy.

10. At 11:00 AM on 11/6/14, interview with staff member #57, a unit RN, indicated that Braden Scale Risk Assessments are not being completed for patients upon admission to the facility.

11. Review of the medical record for pt. #1 indicated:
a. The nursing admission evaluation done 7/29/14 had documentation of a "bruise" on the
right hip, to the right of the sacral area.
b. Nursing documentation beginning on 8/3/14 had "wound care" circled on the nursing notes
form, but no specifics as to location, type, size, etc.
c. Nursing noted "skin breakdown" on 8/9/14 at 5 PM, but gave no other description.
d. Nursing noted a 3 cm by 2 cm "open" sacral wound on 8/10/14.

12. Review of patient medical records indicated:
a. Pt. #1, who was admitted on 7/29/14, had:
A. The form "Patient Care Observation Record" page 2 of 2, had areas for documenting
"Hygiene", Safety", "Activity" (such as repositioning and range of motion), % of intake at
meals and amount of liquids consumed, output (urine and bowel movements) missing for: 8/9/14, 8/10/14, and 8/11/14.
B. The form "Patient Care Observation Record" page 2 of 2, was lacking hygiene
documentation for 8/8/14 and 8/7/14; was lacking % of intake for food and liquid on 8/6/14, lacked hygiene, activity, % eaten at dinner, and output on 8/4/14; lacked hygiene, activity, % eaten at all three meals, and urine output on 8/3/14; lacked hygiene and activity on 8/1/14; lacked % eaten at all three meals on 7/31/14; and lacked documentation in all areas of the form on 7/30/14.
C. It could not be determined that nursing staff assisted the patient with nutrition and hydration requirements.
D. Per the discharge summary: "...The patient's condition, however, continued to deteriorate. The patient became increasingly lethargic, was unable to take oral medications, and appeared to be clinically dehydrated with hypotension...". Thus, the patient was transferred to a local acute care facility on 8/11/14.

13. At 12:50 PM on 10/9/14, interview with staff member #50, the chief nursing officer, indicated:
a. Nursing failed to document specifics of the wound that developed for pt. #1 during their
hospitalization.
b. It cannot be determined that skin care precautions were implemented for pt. #1 due to
the lack of documentation by nursing staff.

14. Review of medical records indicated; Pt. #5 was admitted 7/22/14 and a Braden Scale Risk Assessment form was not present in the chart.
a. The patient had: a Nursing Care Plan, beginning 7/22/14, for "Dysphagia - S/S (signs and symptoms) difficulty when talking, eating, chewing." Short term goals were: "1. Assist pt. with dietary choices 2. Assist pt in selecting small bites 3. Assist pt. with fluids." The form "Patient Care Observation Record" page 2 of 2, which lacked documentation of % eaten for all three meals on 7/23/14; hygiene and activity on 7/24/14; hygiene, activity and % eaten for lunch on 7/25/14; hygiene, safety, activity, output, and % eaten for all three meals on 7/26/14; activity on 7/27/14; and % eaten for lunch and dinner on 7/28/14.
b. Pt. #5 had:
i. Orders on admission 7/22/14 for vital signs BID for 24 hours.
ii. Vital signs taken at 2:40 PM on 7/22/14 and then again at 10 AM on 7/23/14 and 7/24/14, but not twice a day for the first 24 hours.
c. Nursing staff documented in the progress notes that the physician was contacted to transfer pt. #5 to the ED (emergency department) for acute care required, but failed to write a physician order for transfer in the order section of the medical record. It could not be determined that the nursing staff followed the care plan for assisting the patient with nutrition and hydration needs.
d. Per the discharge summary for Pt. #5, it was noted: "...The patient is being discharged to an acute medical facility to treat clinically significant dehydration associated with hyperkalemia, azotemia, with a BUN (blood urea nitrogen) of 47 and a potassium of 6.3. The patient also has a clinically significant UTI that may be contributing to [the patient's] renal impairment ... " .

15. At 4:40 PM on 10/8/14 and 12:15 PM, 1:15 PM, and 2:15 PM on 10/9/14, interview with staff member #50, the chief nursing officer, indicated:
Nursing staff failed to write a physician telephone order for the transfer of pt. #5 on 7/28/14 to a local ED.

16. Pt. #2 was admitted on 8/6/14 and a Braden Scale Risk Assessment form was not present in the chart.
a. The form "Patient Care Observation Record" page 2 of 2, which had areas for documenting "Hygiene", Safety", "Activity" (such as repositioning and range of motion), % of intake at meals and amount of liquids consumed, output (urine and bowel movements) missing for: 8/10/14, 8/11/14, 8/13/14, 8/14/14, 8/19/14, and 8/22/14.
b. The form "Patient Care Observation Record" page 2 of 2, was lacking documentation of % eaten for Breakfast and lunch for 8/7/14; lacked hygiene and activity documentation for 8/8/14, 8/17/14 and 8/24/14; lacked hygiene, safety and activity documentation on 8/12/14 and 8/16/14; lacked documentation of activity and % eaten for breakfast and lunch on 8/25/14; lacked documentation of % eaten for breakfast and lunch on 8/26/14; and lacked documentation for hygiene, safety, activity, and Lunch/dinner % eaten on 8/27/14.
c. Pt. #2 had:
i. Orders on admission 8/6/14 for vital signs BID for 24 hours.
ii. Vital signs taken at 7:30 PM on admission 8/6/14, and then on 8/7/14 and 8/8/14 (no times noted), but not taken two times/day for the first 24 hours.

17. Pt. #3 was admitted on 8/27/14 and a Braden Scale Risk Assessment form was not present in the chart.
a. The form "Patient Care Observation Record" page 2 of 2, lacking documentation of hygiene and % eaten at lunch on 8/28/14 and lacking documentation of hygiene, safety, and activity on 8/29/14.
b. Pt. #3 had:
i. Orders on admission 8/27/14 for vital signs BID for 24 hours.
ii. Vital signs taken at 8 PM on 8/27/14 and no other vital signs documented as the Vital signs page was missing in the medical record. (Discharge was 8/31/14 so that 4 days of vital signs was missing.)
c. It could not be determined that nursing staff assisted the patient with nutrition & hydration requirements.
d. Pt. #3 was transferred to a local ED was on 8/31/14 due to continued decline in condition due to dehydration and changes in levels of consciousness, per the discharge summary.

18. Pt. #4 was admitted on 8/28/14 and a Braden Scale Risk Assessment form was not present in the chart.
a. The form "Patient Care Observation Record" page 2 of 2, lacked documentation of
activity on 8/29/14 and lacked documentation of % eaten for all three meals on 8/30/14 and 8/31/14.
b. Pt. #4 had:
i. Orders on admission 8/28/14 for vital signs BID for 24 hours.
ii. Vital signs taken at 10 PM on 8/28/14, on 8/29/14 (no time noted), and again on 8/30/14, but not twice a day for the first 24 hours.
c. It could not be determined that nursing staff assisted the patient with nutrition and hydration requirements.
d. For pt. #4, per the discharge summary, it was noted: "...The day of discharge, the patient had become more responsive. There were concerns [the pt] had not been eating or drinking and may have been dehydrated and, hence [the pt] was sent out to [a local acute care facility] for evaluation...".

19. Review of patient #30's medical record on 11/06/14 lacked a Braden Scale Risk Assessment form.
a. Pt. #30 had orders on admission for vital signs BID for 24 hours.
b. VS were documented on the VS flow sheet on 10/30/14 (no time noted), but were the same as the admission VS by the nurse which were done at 6 PM. The next VS were on 10/31/14, with no time noted and then were done twice on 11/2/14, with no time documented for these.
c. Review of patient #30's medical records on 11/6/14 indicated:
i. Pt. #30 had a total score of 8 in the "Nutritional Assessment" section of the nursing admission assessment document where it indicates that "If score 5 or more, inform physician so that a Nutritional Consult is ordered".
ii. There was no documentation that the physician was informed, or that a nutritional consult was made--documentation indicated the nurse checked the box "Nutritional Consult Needed" --"NO".
d. Pt. #30, on the 24 hour observation form, page 2 of 2 was missing for 10/30/14 (pt admitted at 5 PM, not notes fro 5 PM to 12 midnight.) The form for 10/31/14 lacked any dinner % of intake and "liquid" amount, and lacked the "Required every 2 Hours" activity documentation of repositioning for all by 4 checks (8, 10, 12, and 2). The observation record for 11/1/14 lacked documentation in the Activity record for all but 3 checks (4, 8, and 10). The observation record for 11/2/14 lacked documentation in the Activity record for all but 3 checks (12, 2, and 4). The observation record for 11/3/14 lacked documentation in the Activity record for 5 checks (12, 2, 4, 8, and 12 PM). The observation record for 11/4/14 lacked documentation in the Activity record for 8 AM, 10 AM, 12 PM, 4, 6, 8, and 10 PM. The observation record for 11/5/14 lacked documentation in the Activity record for 8 AM, 12 PM, 2, 4, 6, 8, and 10 PM).
e. It could not be determined that a physician was notified that the patient needed a nutritional consultation.

20. Review of patient #31's medical record on 11/06/14 lacked a Braden Scale Risk Assessment form.
a. Pt. #31 had orders on admission for vital signs BID for 24 hours.
b. VS were taken on admission and then on 11/1/14 and 11/2/14, with no time noted, and not taken two times/day for the first 24 hours.
c. Review of patient #31's medical records on 11/6/14 indicated:
i. Pt. #31 had a total score of 6 in the "Nutritional Assessment" section of the nursing admission assessment document where it indicates that "If score 5 or more, inform physician so that a Nutritional Consult is ordered".
ii. There was no documentation that the physician was informed, or that a nutritional consult was mad. In the area of: "Nutritional Consult Needed" -- "YES or NO", neither box was checked.
d. Pt. #31, on the "Patient Care Observation Record" form, the 10/31/14 form was completely blank after the patient was admitted at 1:15 PM (no meals, liquids, output or activity was documented). The forms for 11/1/14, 11/4/14, and 11/5/14 lacked any every two hour activity documentation. On 11/2/13, the form lacked documentation for 8 AM through to 10 PM.
e. It could not be determined that a physician was notified that the patient needed a nutritional consultation.

21. Review of patient #32's medical record on 11/06/14 lacked a Braden Scale Risk Assessment form.
a. Pt. #32 had orders on admission for vital signs BID for 24 hours.
b. VS were taken on admission and on the flow sheet only those of 11/6/14 were documented (none on 11/5/14).
c. Review of patient #32's medical records on 11/6/14 indicated:
i. Pt. #32 was scored as 0 (zero) risk in the nutritional assessment section of the nursing admission assessment form, but was "Age 65 or > (5)" (pt. was 94 years of age), and "Critical diagnosis...Diabetes...(5)", which would total 10 points and required discussion with a physician for a nutritional consult.
ii. The section "Nutritional Consult Needed" "Yes/No" was left blank.
d. Pt. #32, on the "Patient Care Observation Record" form, the patient's every two hour activity was not documented from 8 AM through to 10 PM on 11/5/14.
e. It could not be determined that a physician was notified that the patient needed a nutritional consultation.

22. At 11:15 AM on 10/9/14, interview with staff member #53, the corporate clinical services director, indicated:
a. It was agreed that the form "Patient Care Observation Record" page 2 of 2 was missing in medical records as listed above, and when present, was incomplete.
b. Facility policy does not address completeness of forms, but it is expected that all areas of forms will be completed by nursing staff.

23. At 12:15 PM on 10/9/14 and 2:45 PM on 11/6/14, interview with staff member #50, the chief nursing officer, indicated nursing staff are not following physician orders for taking patient vital signs twice a day for the first 24 hours after admission.

24. At 3:15 PM on 10/9/14, interview with staff members #54, a LPN (licensed practical nurse), and #55, a RN (registered nurse), indicated that Braden Scale Risk Assessment forms were not being completed by nursing staff on patient admissions, as required by facility policy.

25. At 11:00 AM on 11/6/14, interview with staff member #57, a unit RN, indicated that Braden Scale Risk Assessments are not being completed for patients upon admission to the facility.

26. At 2:45 PM on 11/16/14, interview with staff member #50, the CNO, indicated:
a. The nutritional scoring for patients #30, #31, and #32 were reviewed and it was agreed that #30 and #31 should have had a physicians contact regarding a possible nutritional/dietary consult, and #32 was scored incorrectly by nursing staff.
a. The Dietary and Nutrition policy isn't specific as to how nursing staff are to document a contact with the physician if a patient scores above a 5.
b. Nursing staff needs some re education related to the nutritional assessment and how to proceed with a high scoring patient.

Based on policy and procedure review, medical record review, and staff interview, the facility failed to ensure that medications were administered as ordered & followed the facility policy for 7 of 10 patients. (Pts. #1, 2, 3, 5, 30, 31, and 33)

Findings:
1. Review of the policy "Medication Administration and Records", policy number PHR - 159, last revised/effective, 10/2013, indicated:
a. Under 1.0, "Statement of Purpose", it reads: "To establish procedures for timely, accurate, and safe administration of medication."
b. Under 2.0, "Statement of Policy", it reads: "2.1 Guidelines for proper documentation of all administered medications (ie. omissions, holds, discontinued, first dose response, PRNS [as needed meds])."
c. On page 3, under 4.2 "Medication Administration Procedure", it reads: "4.2.1 At the designated times, the nurse will administer all medications to patients...".
d. On page 4, under 4.2 "Medication Administration Procedure", it reads: "4.2.5.2 Should any medication dose be missed for any reason, the physician shall be notified and record of such incident is recorded in the chart. This action is done to ensure all medications are administered as ordered and documented according to policy."

2. Review of patient medical records indicated:
a. Pt. #2 had on the MAR, no documentation regarding medications listed for administration and not marked as given, or circled as held, or refused as follows:
A. Vitamin B 12 1000 mcg tab po (orally) every AM was not documented at 8 AM on 8/23/14, 8/25/14, or 8/28/14.
B. Methadone 2.5 mg tab po was not documented BID (twice per day) at: 8 AM on 8/23/14, 8/25/14, and 8/28/14 and at 8 PM on 8/27/14 and 8/28/14.
C. Colace capsules 100 mg BID at 8 AM on 8/23/14, 8/25/14, and 8/28/14, and at 8 PM on 8/27/14 and 8/28/14.
D. Ensure TID (three times/day) at 7 PM on 8/24/14, 8/25/14, 8/27/14, and 8/28/14 and 10 AM and 2 PM on 8/25/14, 8/27/14, and 8/28/14.
E. Augmentin 875 mg tab BID was not documented at 8 AM and 8 PM on 8/25/14 and 8/26/14.
F. Norvasc, Miralax, Thera -M, and Effexor XR was not documented as given at 8 AM on 8/23/14.
G. Tums, Risperdal, and Trazadone were not documented as given at 8 AM on 8/23/14.
H. Levaquin 250 mg po BID was not documented at 8 PM 8/24/14 through 8/28/14, or at 8 AM on 8/26/14, 8/27/14, and 8/28/14 and the medication was not noted as DC'd (discontinued).

b. Pt. #5 had an order written at 6 PM on 7/25/14 for Macrodantin for a UTI that was not started until 8 AM on 7/27/14.

c. For pt. #1, Levaquin was ordered for pneumonia with a daily dose to begin on 8/6/14 and end on 8/15/14, but there was no documentation on the MAR (medication administration record) that Levaquin was administered on 8/8/14 for the 8 AM daily dose, or that it was "held", "refused", or other reason for no documentation of administration.

d. Pt. #3 had an order on 8/29/14 for Depakote sprinkles 125 mg now and tid, but there was no documentation on the MAR of administration of the medication on 8/30/14 at 2 PM and 8 PM and on 8/31/14 at 8 AM, 2 PM, or 8 PM.

e. Pt. #30, per the MARS on 10/31/14, indicated that the 2 PM dose of Tylenol 1000 mg, (to be given orally tid), and the 2 PM Calcium Vit. D3 500 mgs (orally tid), were not initialed as given or documented as refused. And, on 11/1/14, the 8 PM Divalproex (Depakote) 500 mg, to be given orally every bedtime, was not initialed as given, or documented as refused.

f. Pt. #31, on the MARS for 11/1/14, had a 6 AM Levothyroxine 25 mg daily that was not initialed by a nurse as given, or noted as refused, and the 11/4/14 8 PM Bactrim DS was not initialed by a nurse, or noted as refused, held, or some other notation.

g. On 11/6/14, pt. #33 was observed receiving a scheduled 12:00 PM Ultram (Tramadol) 50 mg, but the MAR also had the 4:00 PM dose initialed as given. The medical record indicated the Ultram was to be administered QID (0800, 1200, 1600 & 2000 hours)

3. At 11:15 AM on 10/9/14, interview with staff member #53, the corporate clinical services director, indicated nursing staff are not completing the MAR document per facility policy and standards of practice.

4. At 2:45 PM on 10/9/14, interview with staff members #50, the chief nursing officer, and #54, one of the licensed practical nurses at the facility, indicated:
a. Nursing staff are not completing the MAR as required by facility policy, and standards of practice.
b. It is confusing to have both a hand written MAR and a computer generated MAR with the same dates, as some staff document on one, and other staff document on the other form.
c. Pt. #5 had no documentation that they refused to take their Macrodantin at the prescribed times and it is unknown why there was a delay between the order time of 6 PM 7/25/14 and the first dose on 7/27/14 at 8 AM. The medication should have started the AM of 7/26/14.