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Based on clinical record review and staff interview, nursing staff failed to update the individualized nursing care plan and to provide appropriate care/service based on the patient's assessed needs. This failure affected 1 of 10 patients (# 2) as evidenced by not having an identified plan of care for the patient's oral needs and to prevent tongue injury. Nursing staff failed to develop and establish a plan of care to meet the patient's (#2) needs as it relates to a Gastrostomy tube.

The findings include:


1. Review of the clinical record for Patient # 2 disclosed the patient has a history of seizure disorder and subconsciously bites her tongue. The review failed to yield evidence the interdisciplinary / patient care team initiated a plan of care to manage potential injuries secondary to increased tongue biting.
The patient subsequently bit her tongue causing extensive injury which required surgical repair.

Review of a consult report dated 02/25/14 revealed documented, the patient is noted to have a tongue bite, tongue laceration, which was repaired at the bedside under local anesthesia. "Examination is significant for an anterior tongue laceration in the midline. The laceration is approximately 4 cm in full thickness and the tongue is split."

The record review revealed, the patient again bit her tongue causing excessive bleeding and was assessed again by the physician, on 3/04/2014, who documented "the patient has a bite block in place. The patient is being prevented from re-biting the tongue with the bite block; will continue with the bite block, and then the mouth needs to be irrigated with Peridex mouth wash three times a day."
On 3/10/2014 the physician documented, "The patient keeps the teeth clenched on the bite block. Exam of the tongue reveals that the laceration is opened again. This is a left lateral split." The physician plan written is to "repair this laceration at the bedside in the next 24 hours. "


During an interview, on 3/11/2014 at 4:29 PM, with the Registered Nurse (#1) who stated she cared for the patient when the patient returned from Intensive Care and when she took care of the patient there was some type of apparatus taped in place in the patient's mouth as a bite block. She further stated that the patient's relative stated it was "icky" looking, but the nurse didn't know what the apparatus in the patient's mouth was or what it was made of so she asked respiratory and found out that it was a tongue blade wrapped in gauze but when the patient yawn it would fall out. She also stated she called the physician to find out what he wanted done regarding this apparatus in the patient's mouth. She also stated the Wound Care Nurse and the Physician stated an order is not necessary to change the tongue blade wrapped in gauze in the patient's mouth, but to change it every three days.

During the Respiratory Therapist's assessment on 3/10/14 in the presence of the surveyor, it was observed the patient continually bit down on the plastic apparatus currently in her mouth and would not open her mouth for the evaluation. The therapist confirmed that the patient has a history of biting her tongue and she recalls they were using a gauze wrapped tongue blade to try and prevent her from biting her tongue but it apparently would fall out on occasion.

At the time of medical record review an established plan of care to manage potential risk factors, such as injury, from the patient unconsciously biting her tongue was not found or provided.

An interview was conducted with the Chief Clinical Officer on 3/12/2014 in the afternoon, who confirmed the patient's plan of care was not updated to reflect her oral care needs to prevent the patient from biting her tongue. She stated she would contact Respiratory Therapy. She also informed the surveyor that she was unable to locate a physician order prescribing for the Bite Block.

Nursing and Respiratory Care / Service failed to develop and establish a plan of care with interventions outlined to provide the necessary care and services for oral care for an unresponsive patient #2, with a history of seizure disorder and biting of her tongue.

2. The clinical record review failed to yield evidence of the staff updating the patient's (#2) plan of care to reflect the insertion of the gastrostomy tube on 1/24/2014 nor does the record identify the patient care needs regarding the gastrostomy tube. The patient's current care plans does not include a plan of care for the patient's Gastrostomy Tube.

An interview was conducted on 3/11/2014 in the afternoon with the Chief Clinical Officer who confirmed the patient's care plan does not reflect an identified care plan specifically for the Gastrostomy Tube but she stated the patient has physician orders in place to provide for most of the patient's needs regarding the gastrostomy tube.

An interview was conducted on 3/12/2014 in the afternoon with the Chief Clinical Officer who confirmed that the patient's care plan does not reflect an identified care plan specifically for the Gastrostomy Tube and the patient's care needs relevant to the Gastrostomy Tube.

Based on clinical record review and staff interview, nursing staff failed to ensure the administraion of medications is in accordance with prescription and nursing standards of practice. This failure affected 1 of 10 sampled patients (# 2) as evidenced by the staff: (1) failure to adhere to physician orders regarding prescribed parameters for medication administration; (2) failure to follow established standards of practice for acknowledgement of patient allergies and/or adverse drug reaction, and not administering medications identified as an allergy or for which the patient has had adverse drug reaction.

The findings include:

1. A review of the medication prescribed and administered to patient #2, from 01/17/2014 to 02/03/2014, to treat High Blood Pressure was conducted on 3/11/2014 with the Pharmacy Director. The review disclosed:

The physician prescribed for the patient to receive Metoprolol 5 mg every 4 hours (9AM, 1PM and 5 PM etc schedule) hold for systolic blood pressure less than 120 mmHg or heart rate less than 70 beats per minute.
a. 1/23/2014 at 9:00 PM, the nurse administered Metoprolol when the patient's documented blood pressure was 100/82.
b. 1/24/2014 at 1:00 AM, the patient's documented blood pressure was 107/92.
c. 1/26/2013 at 9:00 PM, the patient's documented blood pressure was 96/47.
d. 1/30/14 at 1:00 PM, the patient's blood pressure was 116/64.
e. 1/30/2014 at 4:00 PM, the patient's blood pressure was 104/51.
f. On 1/31/2014, the nurse administered the 1:00 PM dose of Metoprolol at 3:12 PM (2 hours after the dose is prescribed). Review of the clinical record did not provide evidence the nurse contacted the physician regarding administering the medication late.

An interview was conducted on 3/11/2014 during the review with the Pharmacy Director who confirmed the above doses were administered when the documented blood pressure indicate the medication was to be held and the nurse administered one dose 2 hours late.

Review of the facility's policy and procedure regarding Medication Management documents "Medications administered more frequently than daily but no more frequently than every four hours shall be administered within 1 hour before or after the scheduled time. Clinical circumstances may necessitate omitting medications, deviating from standard administration schedules, or may necessitate administering time-critical and non-time critical medications early or late beyond the definitions outlined in this policy. When this occurs the following procedure should be followed. b. Documenting the reason administration of the dose was early or delayed."


2. Review of the Medication Administration Record (MAR) for Patient # 2 disclosed the patient was administered 2 doses of medications identified on the patient's list of allergies.
The initial assessment of Patient # 2 identified that the patient has an adverse drug reaction to Hydrocodone bit (from Vicodin), Oxycodone HCL ( from Percocet).
Further review of the physician orders identified a physician order on 12/11/2013 at 10:08 PM prescribing for the patient to receive Oxycodone 5 mg/acetaminophen 325 mg by mouth one tablet every 4 hours as needed for pain.
The MAR documents the nurse administered Oxycodone on 12/11/2013 at 11:00 PM and on 12/12/2013 at 4:00 AM.

An interview was conducted on 3/11/2014 at 9:44 AM with the Director of Pharmacy who confirmed Patient #2 received 2 doses Oxycodone. She stated that the medication order was received late, after pharmacy hours, thus the nurse obtained the medication from the controlled substance cabinet. The pharmacist would have reviewed the patient's profile before dispensing the medication. If medication is prescribed for which the patient has an identified allergy, the physician is contacted to inform of allergy and to discuss risk versus benefit if the physician wants the patient to receive the medication. In the situation with Patient # 2, the order was received after hours, the pharmacist did not review it until the following morning and the medication was discontinued at that time. The patient had already received the two doses of the medication.