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Based on review of clinic records, policies and procedures, hospital administrative records, and staff interviews, it was determined that the hospital's nursing service failed to be well-organized to ensure services were provided by staff qualified to assess patients care needs and supervise and evaluate the care provided by:

A0397: failing to have a qualified Registered Nurse assigned to the specialized care and needs of Patient #19 that resulted in the patient receiving burns on her right arm; and

A0404: failing to ensure all physician ordered medications were administered following accepted standards of practice. Medications, including a controlled drug, were left with a patient without the nurse present.

The cumulative effect of these processes resulted in the hospital's failure to be in compliance with the Condition of Nursing Services to ensure the provision of quality health care in a safe environment.

Based on record reviews and staff interviews, it was determined the facility failed to ensure the care of Patient #19 was assigned to a Registered Nurse with the qualifications and competence to assess the patient's needs and implement physician orders appropriately resulting in the patient receiving burns to the right arm.

Findings include:

Patient #19 was admitted to the facility on 3/10/2011, with diagnoses including debility, status post left total knee arthroplasty, and Clostridium difficile colitis.

Documentation in the nursing narrative comments dated 3/16/2011 at 3:30 a.m., revealed the patient had an elevated temperature. The physician was notified at 5 a.m. whose orders included to start a "Heplock" intravenous line and intravenous antibiotics. The RN on that shift documented a peripheral intravenous line was inserted in the patient's right arm at 5:30 a.m. On 3/17/11 at 1 a.m., the RN on duty documented that one unit of packed red blood cells was hung for infusion in accordance with earlier physician orders. At 3:20 a.m. the RN documented the blood was infusing "without problems and at 3:45 a.m., the infusion was completed. At 5 a.m. the RN documented the physician was seeing the patient, and the physician ordered labs and IV fluids at 100 cc per hour which the RN started.

There was no nursing narrative documentation between the night shift RN's note at 5 a.m. until 11:50 a.m. when the day shift RN (RN #1) documented: "Lethargic - Does respond and has answered questions. IVF (intravenous fluids) in RUE (right upper extremity) infiltrated into tissue, arm is swollen, red and warm to the touch. D/C (discontinue) IV from site, applied warm compress. Dr. (name) notified - New orders written." The physician's order was dated 3/17/2011 at 8 a.m. and included, "May use K pad to affected arm." RN #1's next entry was at 1:10 p.m., and she documented, "PICC line nurse in, started line in left upper arm. IV ABT (intravenous antibiotics) given, and IVF running...." There was no documentation of the status of the patient's right arm where the IV had earlier infiltrated. At 3:10 p.m. RN #1 documented: "RUE (with) blisters, buttocks (with) superficial skin loss - excoriated peri rectal area...Proshield applied. Notified Dr. (name) - obtained new orders...." The RN documented that she also paged the facility's wound care nurse who was in to the see the patient within the hour. There was no further documentation in the nursing narrative notes that addressed the patient's right upper arm.

The wound care nurse's documentation dated 3/17/2011 at 2 p.m., included the following: "Dr. (name) at the bedside for assessment of right arm and sacrum. Possible thermal injury to inner right arm. Right hand is warm and can easily palpate both radial and ulnar pulses...Edema from anterior hand to upper arm. Patchy scattered areas of erythema from above wrist to arm pit. Erythematous areas are very tender to the touch. No areas of vesicles at this time. Can not determine degree of this injury until it evolves...." The physician's orders for treatment included "apply ice pack now." The wound care nurse's documentation dated 3/18/2011 at 6:30 a.m. included: "Thermal injury inner right arm now extends fro (sic) just above the inner wrist to inner right arm...and ends at the arm pit. Injury is more erythematous today with new formation of vesicles. All vesicles with intact roofs. Per the patient, 'It hurts more today'...Will begin with Biafine cream to burn site with each dressing change...." There were color photographs of the patient's right arm in the record with the wound care nurse's documentation.

There was no documentation in the clinical record that explained the "thermal injury" or "burn" to the patient's inner right arm documented above. It was determined through additional information requested by the surveyor and interviews conducted with staff that the "heat pack" RN #1 applied to the patient's arm was a Hydrocollator Steam Pack which are located in the Therapy Department and used only by trained staff.

The hospital's policy and procedure titled Hydrocollator Steam Pack, Policy #13.9, Revision Date 12/10, was located in the Therapy Department's policies and procedures and included the following: "POLICY Moist Heat Packs (MHP) shall be applied to patient for below listed indications per therapist discretion with patients verbal consent. Patient to be educated as to the goals and indications for MHP therapy. PROCEDURE A. Frequent Indications 1. Pain. 2. Spasm 3. Trauma - after the first 36-48 hours, where local conducted heat is needed to heat superficial tissues, bringing relief of pain and spasm with increased local blood supply. 4. Subacute inflammatory conditions i.e., arthritis (all types), bursitis, periarthritis. 5. Chronic inflammatory conditions i.e., rotator cuff tears, chronic postural stress. 6. Neuritis. 7. In preparation for another treatment, stretching, traction...B. Temperature The thermostat on the commercial unit should be set at 160 degrees - 166 degrees F...D. Method 1. Lift pack from heating unit by loops...2. Place pack in vinyl-terri cover. Add appropriate number of toweling. Usually 4 layers of H.P. covers 4. Apply pack to patient. Instruct patient in what they should feel (mild warmth) and to notify staff if the hot pack becomes too hot. Should the pack be too hot, it is removed and the area is inspected for signs of redness of the skin or blistering...Timer should be set for desired duration of treatment...5. Patient shall be given call light or others means of easily notifying staff...E. Precautions 1. Be sure your patient has a way of notifying clinician if the pack is too warm...3. Use extreme care in applying packs to areas where the patient may have loss of sensation. 4. Use care and judgment when applying packs to elderly. 5. Exercise extra caution when applying packs to patients with thin skin or 'bony areas'."

At the request of the surveyor, hospital administration provided additional documentation that was not part of the patient's medical record. The documentation included a Physical Therapist's (PT) report of going into the patient's room on or around 9 a.m. on 3/17/2011 and finding that a "heat pack" had been applied to the patient's arm with only two layers of protective towels. The PT documented that she examined the patient's arm which was observed to be "slightly pink & warm" and then applied 6 additional layers of towels. The PT documented that she notified the RN Charge Nurse on duty and "educated" her on the layers needed for heat packs, and the RN Charge Nurse then examined the patient's arm. The PT went back to the patient's room at 2:30 p.m. to take her to therapy at which time the patient complained of blisters on her right arm. The PT notified the physician as well as the wound care nurse.

There was also additional documentation of the event not part of the medical record by RN #1 who applied the hydrocollator pack to the patient's arm on 3/17/2011. The RN documented that when she went to see the patient that morning, she noticed her right arm, "...was swollen about twice the size of her left arm." The RN stopped the intravenous fluids that were infusing and went to get assistance from the RN Charge Nurse on duty. RN #1 waited "several minutes" for the Charge Nurse who, "...was in the middle of taking off orders." RN #1 then requested assistance from another RN on duty who observed the patient's right arm and agreed that the IV had infiltrated and suggested applying a warm compress to the area. RN #1 could not locate any K-pad pumps in the clean utility room and then went to the therapy room and, "...grabbed a heated pad with 2 of the terry cloth pads that are supplied on the shelf above the warmer...." The RN applied the heated pad with the two terry cloth pads to the patient's right arm. Approximately ten to fifteen minutes later, the Charge Nurse went to RN #1 and said the Physical Therapist went into the patient's room and found the heated pad on the patient's right arm and removed it because there was not enough padding. The K-pad pump arrived around 1 p.m. at which time RN #1 noticed blisters on the patient's right arm. The RN asked the physician if she needed an order to have the wound care nurse look at the patient, and the physician responded that she did not need an order and could request the wound care nurse to look at the patient. The RN paged the wound care nurse who responded and assessed the patient. RN #1 was notified at that time that the patient had burns.

An interview was conducted on 3/28/2011 with the PT who found the hydrocollator pack on the patient's arm on 3/17/2011. The PT confirmed that she found the heated hydrocollator pack on the patient's right arm when she went to get her for therapy on the morning of 3/17/2011, and she did not recall that any padding had been applied. She stated she immediately removed the pack and went to the Charge Nurse to report it. When the PT went back to the patient's room in the early afternoon for scheduled therapy, the patient complained of pain and blisters on her right arm, and the patient's physician and wound care nurse were notified.

An interview was conducted on 3/28/2011 with RN #1. She reported she received her Registered Nurse license in the early part of March 2011 but was a Licensed Practical Nurse (LPN) prior to that. The RN acknowledged she was assigned to the care of Patient #19 on 3/17/2011. The shift began at 6 a.m. and she first checked on the patient at approximately 8:30 a.m. at which time she noted the patient to be lethargic. The patient was receiving IV fluids in her right arm which she observed to be swollen twice the size as the right arm. The RN was asked if the IV pump was alarming and she responded that it was not, and it appeared the IV fluids were still infusing. She reported she had never seen an IV infiltration prior to this and did not know what to do. She stopped the IV fluids and went to the Charge Nurse on duty for assistance. The Charge Nurse was busy and while waiting for her, RN #1 asked for assistance from another RN who was on duty. That RN observed the patient and confirmed the IV fluids had infiltrated into the patient's tissues and said to apply warm compresses. The patient's physician was notified who ordered a K-pad to be applied. She said there were no K-pads available in the supply room and contacted the manager responsible for equipment and supplies who reported it would have to be ordered. The RN stated she went to the Physical Therapy Department and got a hydrocollator pack and two of the terry-cloth padding towels and applied it to the patient's right arm. Approximately one-half hour later, the Charge Nurse went to her and told her the PT found the hydrocollator pack on the patient's arm and removed it because there was not enough padding and could cause burns. The RN said she observed the blisters around 1:30 and notified the physician and wound care nurse. The RN stated she thought she was doing the "right thing" and did not realize the hydrocollator packs could cause burns if not used with enough padding. She did not go to the Charge Nurse for assistance prior to getting the hydrocollator steam pack. The RN was asked if she received training and orientation when her job description changed from LPN to RN, and she responded that she spent a "few hours" orienting with two staff RN's before being assigned a regular patient load independently. She added that a normal patient assignment is six to seven patients.

A review of RN #1's personnel record revealed an original hire date in 2001 as a Certified Nursing Assistant. Her LPN license was issued by the Arizona State Board of Nursing on 8/22/2003, and her RN licensed was issued on 3/8/2011. There was documentation that she was provided with a job description for an RN at that time. A review of the hospital's nurse staffing schedule for 3/17/2011 revealed RN #1 was assigned seven patients including Patient #19 during her shift.

Based on record reviews and staff interviews, it was determined the hospital failed to ensure Patient #19's nursing documentation included the actual time that patient assessments and reassessments were performed and care and services provided.

Findings include:

The hospital's policy and procedures titled Interdisciplinary Daily Documentation included: "PURPOSE: To document patient assessments and reassessments, care provided, response to care, and functional performance and status in an interdisciplinary manner, depicting the fulfillment of the patient's rehabilitation needs. POLICY: HealthSouth Rehabilitation Hospital of Southern Arizona (HSRHSA) staff will document updated information daily regarding each patient's functional status, care, and response to care, utilizing the Interdisciplinary Daily Documentation (IDD) form. PROCEDURE:...5. Daily Nursing Assessments: a. All patients will have an RN assessment conducted every 24 hours, at a minimum. b. The other assigned nurses will conduct a review of the patient covering the areas needed and/or warranted by the patient's condition (e.g., if the patient is without complaint, does not have a medical condition that warrants it and is medically stable, the night shift would not wake the patient to assess lung sounds). c. If any reassessment findings are abnormal, an assessment will be conducted by an RN and a narrative note will be written describing the problem area, abnormality, the intervention, and the follow-up, signing under the 'Additional problem specific system review completed with significant finding within the narrative'. The time of this assessment will be noted next to the nurse's signature."

-Refer to Tag A397 for specific details related to Patient #19.

The IDD Daily Nursing Assessment form dated 3/17/11 for Patient #1 was signed by RN #1 at "1300" (1 p.m.). The RN's documentation in the Integument section of the form included: "RUE (right upper extremity) (with) blisters." The RN's first narrative comment dated 3/17/2011 was at 11:50 a.m. and included: "Lethargic - Does respond and has answered questions. IVF (intravenous fluids) in RUE (right upper extremity) infiltrated into tissue, arm is swollen, red and warm to the touch. D/C (discontinued) IV from site, applied warm compress." The RN's documentation at "1510" (3:10 p.m.) included: "RUE (with) blisters...."

Additional documentation provided by Hospital administration and an interview with RN #1 conducted on 3/28/2011, revealed RN #1 assessed the patient's intravenous site at approximately 8:30 a.m. on 3/17/2011, and found that it had infiltrated into surrounding tissue. The physician ordered warm compresses to the area. The RN was not able to locate a K-pad in the hospital, and went to the therapy department, took a hydrocollator steam pack, and applied it to the patient's arm without sufficient protective padding which caused blistering and a need for specialized wound care for the burn.

RN #1 stated during an interview on 3/28/2011 that her shift starts at 6 a.m., and she was not aware of a policy and procedure for when the nursing assessment needed to be completed. Patient #19's record was reviewed with RN #1 during the interview, and she stated the times on her entries reflected the time she was documenting rather than the time of actual events, care and services. RN #1 acknowledged she completed the IDD Daily Nursing Assessment form for Patient #19 on 3/17/2011. She also acknowledged her time of the assessment was at "1300" (1 p.m.), however, reported that time did not reflect when the actual assessment was completed. The RN could not recall when she completed the assessment. RN #1 acknowledged the documented times on her narrative documentation dated 3/17/2011 were the times she documented rather than the actual times of events, care, and services provided.

Patient #19's record was reviewed with the Chief Nursing Officer on 3/29/2011, and she acknowledged RN #1's documentation on 3/17/2011 did not reveal the actual time of events. She reported an RN assessment is completed at least every 24-hours, however there was no policy that clarified when the assessment needed to be completed. She stated that after the 24-hour assessment form is completed, the other nurses charted "by exception" and explained that the nurses charted when there was a change in the patient's status.

Documentation in the clinical record did not contain sufficient and accurate documentation of factual events surrounding the infiltration of the IV and the RN's subsequent assessment, reassessment and care provided.

Based on observation, hospital policy, and interview, it was determined the hospital failed to keep all medications secured.

Findings include:

The hospital policy Medication Management, Storage of Medication Policy # MM240, revealed: "POLICY All medications used at HEALTHSOUTH Rehabilitation Hospital of Southern Arizona (HRHSA) will be stored in a manner consistent with State and Federal law, Joint Commission Standards, and the highest standards of professional practice.
PROCEDURE A. Storage of Medications - Nursing Units 1. Medication Carts...When not in use, the cart containing the medication drawers will be locked...4. Monitoring It is the responsibility of the charge nurses to ensure that storage standards on the nursing unit are in compliance. The Director of Pharmacy will assume a parallel responsibility in this function through Pharmacy monthly nursing unit inspections...."

On 3/24/11 at approximately 4:15 p.m., accompanied by the Chief Nursing Officer (CNO), a tour of the medication storage areas was conducted. The Sabino Unit had medications stored in an unlocked refrigerator in the employee break room/medication room. The door to this room was open and had several staff members, including rehabilitation technicians, sitting at a table in the room. There were three refrigerators, one for patient snacks, one for employee food and one for medications. The medication refrigerator was unsecured and had multiple bottles of insulin and three bottles of liquid vancomycin. The CNO stated the refrigerator has never had a lock but the door to the room has a lock with a security code required to enter the room. She did acknowledge the rehabilitation technicians know the code and the room is used as the staff's lunch room and charting room. Nurses and rehabilitation technicians were walking in and out of the room as the door remained open.



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An unattended medication cart was observed in the hallway outside of a patient room on 3/23/2011 at approximately 8:30 a.m. The surveyor was able to easily open one of the drawers that contained numerous patient prescription medications including: Klor-Con M10 (potassium supplement); Carbamazepine (anticonvulsant); and Lovenox (injectable anticoagulant). The RN came out of a patient room at that time and stated she thought she had locked the cart. The RN checked the side of the cart and it was locked, however, not all of the individual drawers locked. The Director of Nursing reported during an interview on 3/23/2011 that the medication carts were "old," and they had been experiencing problems with the locks and obtaining parts for repair.

An unattended medication cart was observed in another part of the hallway outside of a patient room on 3/23/2011 at approximately 1 p.m. The surveyor was able to easily open the individual drawers that contained numerous patient prescription oral and injectable medications. The RN came out of the patient's room and acknowledged he did not lock the cart.

An unattended medication cart was observed outside of a patient room on the morning of 3/28/2011, and the surveyor was able to easily open one of the individual drawers that contained numerous patient prescription oral and injectable medications. The RN came out of the patient's room and checked the side of the cart. The lock had been set, however, not all of the drawers locked.

Based on document review, and staff interview, it was determined the facility failed to require the Hydrocollator log was maintained daily for recording the accurate temperature and cleaning of the Hydrocollator.

Findings include:

Policy and Procedure Number 13.9; Revised 12/10; Therapy - Hydrocollator Packs included: "Moist Heat Packs (MHP) shall be applied to patient for below listed indications per therapist discretion with patients verbal consent. Patient to be educated as to the goals and indications for MHP therapy...B. Temperature: The temperature on the commercial unit should be set at 160 degrees - 166 degrees F (Farenheit)."

Policy Number 4.012; Revised 05/10; Inpatient/Outpatient Therapy: Infection Control General Guidelines included: "Hot Packs/Cold Packs...4. Hot pack machines are to be cleaned monthly. They will be drained and all components scrubbed and rinsed thoroughly with a hard surface solution. Gloves are to be worn for the cleaning process. 5. The hot pack machine is filled with distilled water only. After refill, the temperature of the water is tested and logged daily."

The daily cleaning and monitoring log for the outpatient equipment listed: Treatment Tables; Equipment; Bathroom; Daily Temperature Checks with columns for Paraffin Bath 124-128 F; Hydrocollator 160-166 F; and Cold Pack 10-21 F. No log was presented for March, 2011. The February, 2011, log included: check marks with a line down the columns from the 2nd to the 7th of the month for the treatment tables, equipment, bathroom and paraffin bath. The Hydrocollator column included 160 on the 2nd with a line down to the 7th. The Cold Pack Unit revealed -10 recorded on the 2nd with a line down to the 7th. The rest of the log was blank. The January log had check marks starting on the 5th of the month with a line drawn down to the 29th for the Treatment Tables, Equipment, and Bathroom. The Paraffin bath was 110 with notes, "per OT (Occupational Therapy) at all time (sic) and being adjusted by OT." A line was drawn down the log from the 6th through the 21st. The Hydrocollator recorded 160 on the 5th with a line drawn down to the 22nd, and the Cold Pack Unit recorded -10 on the 5th with a line drawn down to the 20th. The December, 2010 Hot Pack/Cold Pack Logs included: documentation on December 5th the Hydrocollator was 160 degrees; the cold pack was -10 degrees. There was a check mark on the 5th that the Hydrocollator was cleaned; the cold pack unit was defrosted /cleaned and the hot pack covers were laundered. The rest of the form was blank. The November log had documentation only on the 4th of the month. The Hydrocollator was 160 degrees and the Cold Pack Unit was -10 degrees. The Hydrocollator, cold pack unit and the hot pack covers were cleaned on the 4th.

The Director of Therapies acknowledged in an interview conducted on 03/23/2011, the logs were not kept accurately for the past year. She verified that a line drawn down the column in a monthly log does not reflect the daily temperature of the equipment being monitored and cleaned.

Based on observation, document review, and staff interview it was determined the facility failed to require the physical therapist use appropriate Personal Protective Equipment (PPE) when performing wound care for 1 of 3 patient's (Patient #22) reviewed in Outpatient Services.

Findings include:

Facility Policy #4.012: Inpatient/Outpatient Therapy: Infection Control General Guidelines includes: "Procedure: General techniques - both Inpatient and Outpatient: 1. All procedures will be done utilizing Standard precautions. Use appropriate PPE to prevent exposure and contamination, to blood, body fluids, mucous membranes, secretions, excretions, and non-intact skin...Management of Patients with Wounds: 1. Any patients with burns, wounds, or other open lesions in which the integrity of the skin is compromised must be treated so as to decrease the chance of exposure to potentially infectious bacteria. 2. All open wounds should be covered for therapy with any wound drainage contained. 3. Any unexplained drainage, redness or swelling of an open wound should be reported to the nursing staff or the referring physician."

A tour of the Outpatient Therapy Unit was conducted by the surveyor on 03/23/2011. The surveyor observed a physical therapist in the open area of the unit expelling drainage from an open sore on the back of a patient. The physical therapist was not wearing gloves and the patient was in the middle of the room with his shirt pulled up. The physical therapist was using Kleenex to contain the drainage that was being obtained from the wound.

The Outpatient Physical Therapy Charge Sheet for Patient #22 on 03/21/11, included: "... reports removing K-tape this morning & caregiver found 'a spot' - appears to be small cyst with (symbol) 'pimple'...Recommended hot compress on cyst on pt's back to see if white head/material would come out. Cyst may have formed due to combo of K-tape & pressure on spinous process of vertebrae that is apex of kyphosis."

The Outpatient Physical Therapy Charge Sheet for 03/23/11, included: "Pt reports 'that boil opened up'. Pt's caregiver states they have been doing the hot compress and it has 'started festering up'. ck'd (checked) cyst on back, expelled large amount of purulent material. Pt. to cont. (continue) with (symbol) hot compress."

The Physical Therapist acknowledged in an interview conducted on 03/23/11, she hadn't touched the patient's skin by using the Kleenex, but should have worn gloves.

The Director of Therapies verified the physical therapist should have taken the patient to one of the bays in the therapy room and performed wound care wearing the appropriate PPE.

The Infection Control Coordinator verified she conducts monthly environmental rounds in Outpatient Therapy. She acknowledged she hadn't been involved in the Outpatient Therapy's infection control services.

Based on observation, record reviews and staff interviews, it was determined the hospital failed to ensure all medications were administered to Patient #10 following accepted standards of practice when medications were left at the bedside and a medication administered was not documented in the Medication Administration Record.

Findings include:

The hospital's policy and procedure titled Medication Administration and Documentation, Policy #MM.200, Revised Date 01/11 included the following: "PURPOSE:..2. To ensure that medication orders are written clearly and transcribed accurately, that only medications needed to treat the patient's condition are ordered, and that medication administration occurs safely with proper documentation...Administration:...6. The health practitioner administering the medication is responsible for the following:...n. Stay with the patient until they have taken their medication. Never leave medications alone with the patient...Documentation: 1. All entries noting administration of medication must be entered properly in the medical record. After the dose(s) have been consumed entries must include the following: a. Name of the medication. b. Dosage administered. c. Route of administration...d. Actual time of administration. e. Legible initials and signature of the individual who administered medication. f. Patient's response to medications including 'as needed' (prn) medications and scheduled pain medications."

Patient #10 was admitted to the hospital on 3/26/2011, with diagnoses including recent stroke, diverticulitis, and "L1" (lumbar) compression fracture. The physician's admission orders for medications included two different scheduled oral antibiotics and an order for the pain medication, Percocet-5 (generic name Oxycodone/APAP 5/325 mg) 1 tab by mouth every four hours as needed for a pain scored of 3-6.

On 3/28/2011 at 12:45 p.m., the surveyor knocked and went into Patient #10's room. The patient was sitting up in a wheelchair with her lunch tray in front of her on the over-the-bed table. The patient picked up a clear plastic pill cup that contained two unopened medications that was sitting on the lunch tray and stated the nurse left them there. The RN came into the patient's room, and the patient asked the RN what the medications were. The RN responded that one of the pills was her antibiotic and the other was her pain medication. The nurse took the pill cup containing the medications, told the patient she would be back, and left the room. The patient told the surveyor the nurse "forgot" she left the medications on the tray, and the patient was afraid to take them because she did not know what they were. The RN reported to the surveyor during a later interview that she was getting applesauce for the patient to take the medications in and was called to help another patient.

The patient's clinical record was reviewed on 3/29/2011. The RN's narrative documentation on 3/28/2011 at 1 p.m. included: "Med (medicated) x 2 for back pain, & x 1 for muscle spasms (with) some relief." The Medication Administration Record (MAR) for 3/28/2011 at 12:01 a.m. through 3/29/2011 at 12 midnight revealed the patient received one tab of Percocet-5 at 7:45 a.m. There was documentation that the patient received the 12 p.m. scheduled oral antibiotic at 12 noon on 3/28/2011, but no documentation that she received Percocet at that time. There was no documentation on the Healthsouth PRN Medication Response Tool that the patient received pain medication at 12 noon on 3/28/2011.

The Director of Pharmacy provided documentation that one tab of Percocet-5 was removed by the RN from the automated medDispense Station on 3/28/2011 at 11:51 a.m. and was not returned.

The Chief Nursing Officer acknowledged during an interview on 3/29/2011 at 10:15 a.m., that all medications administered should be documented on the patient's MAR and the RN would need to be contacted to determine whether or not the Percocet was administered on 3/28/2011 at 12 noon.