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Based on interview and review of policy, procedure and clinical records it was determined the facility failed to ensure the Registered Nurse supervised and evaluated care related to assessments for four (#8, #7, #5, #4) of ten sampled patients. The Registered Nurse failed to follow physician orders for one (#2) of ten sampled patients.

Findings include:

1. Review of the medical record for patient #8 revealed the patient was admitted on 8/14/2015 to the Intensive Care Unit (ICU). Review of the 2015 Organizational Plan for the Delivery of Patient Care, Treatment and Services stated on page 9 of 17 nursing reassessment for a patient in ICU will be every 4 hours.

Review of the nursing reassessment for patient #8 revealed on 8/21/2015 an RN reassessment was completed at 7:45 p.m. and on 8/22/2015 at 8:00 a.m. There was no evidence an RN reassessed the patient between 7:45 p.m. and 8:00 a.m.

Interview with the Chief Clinical Officer on 10/28/15 at 1:00 p.m. confirmed the findings.

2. Review of the medical record for patient #7 revealed the patient was admitted to the facility on 10/22/2015. The patient had a history of heart failure, right below the knee amputation and morbid obesity. Review of the nursing admission assessment revealed no evidence the RN assessed the patient's risk for falls.

Interview with the RN Charge Nurse on 10/27/15 at 2:25 p.m. confirmed there was no fall risk assessment completed on admission and stated all patients are assessed upon admission for risk of fall.


3. Review of the medical record for patient #5 revealed the patient was admitted on 10/20/2015 to the Medical/Surgical Unit. Review of the 2015 Organizational Plan for the Delivery of Patient Care, Treatment and Services stated on page 9 of 17 nursing reassessment for a patient in the Medical/Surgical Unit will be assessed every 12 hours.

Review of the nursing reassessment for patient #5 revealed on 10/23/2015 an RN reassessment was not completed for the day shift (7:00 a.m.-7:00 p.m.).

Interview with the Chief Clinical Officer on 10/27/15 at 11:15 a.m. confirmed the findings.

4. Review of patient #2's physician admission orders dated 4/8/15 ordered telemetry monitoring. Review of the physician orders revealed no orders to continue the telemetry. Review of nursing documentation and telemetry strips revealed the patient was still on telemetry.

Review of the record and interview with the Chief Clinical Officer on 10/27/15 at approximately 2:31 p.m. revealed telemetry orders are to be renewed every 72 hours. She confirmed there was no evidence of the renewal after the admission order or that the physician was notified of the need to renew the order if
indicated.

5. Patient #4 was admitted on 8/26/15. The patient's stay included rooms on the 2nd and 3rd floor medical/surgical units. Review of admission and on going physician orders noted orders for oxygen via nasal cannula ranging from 3-4 liters. Review of nursing assessment from admission through discharge on 8/29/15 revealed no evidence of the patient being on oxygen.

Interview with the CCO on 10/28/15 at approximately 2:40 p.m. revealed nursing does not include the documentation of oxygen use by the patient in the assessment. Respiratory Therapy does the documentation of oxygen.

Based on observations, interviews and review of policies, procedures and clinical records reviews it was determined the facility failed to ensure medications were administered according to physician orders, documented and stored in a safe manner for one (#3) of ten sampled patients.

Findings include:

Patient #3's physician order dated 10/25/15 ordered Cepacol lozenge one every four hours as needed for a sore throat. Review of the Medication Administration Record (MAR) revealed on 10/25/15 Cepacol was administered at 6:00 p.m. and 10:15 p.m. On 10/27/15 the Cepacol was administered 9:45 a.m. Review of nursing documentation revealed the medication was effective for pain relief from the sore throat. Observation of the Cepacol unit dose pack in the locked medication box in the patient's room with the Chief Clinical Officer (CCO) on 10/27/15 at approximately 1:05 p.m. revealed four lozenges were left from a package of nine. Review of the nursing documentation and MAR noted documentation for three lozenges. There was no evidence of when or if the two missing doses were administered. The CCO confirmed the findings at the time of the observation and record review.

Review of Policy and Procedure "Administration of Medication" #H-MM 05-001 dated 5/15 stated the individual administering the medication must document all medication immediately after administration and the clinical assessment if necessary. If the medication is not administered the rationale is to be documented. It also stated medications must be properly secured and never left unattended.

During tour on 10/27/15 at approximately 10:30 a.m. revealed a bottle of Theophylline and Chlornexidine 0.12% on top of the locked medication box. The medication was no secured, unattended and available to patients, staff and visitors that enter the room. The CCO confirmed the observation at the time of the observation.