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Based upon staff interview and record review, the Condition of Participation: Provision of Services was not met due to the the hospital failing to develop and provide services in accordance with written policies for health care services related to comfort care.

See C272 - Patient Care Policies.
See C273 - Patient Care Policies.
See C294 - Nursing Services.

Based upon interview and record review, the hospital failed to develop a comfort care policy with the advice of a group of professional personnel that includes one or more doctors of medicine or osteopathy and one or more physician assistants, nurse practitioners, or clinical nurse specialists, if they are on staff under the provisions of ?485.631(a)(1); and at least one member is not a member of the hospital staff. Finding includes:

Per interview and confirmed with the Chief Nursing Officer (CNO) on 10/28/13 at 11:34 AM, the hospital does not have a written Policy and Procedure for comfort care and only uses standardized "Comfort Care Orders" which states "check all boxes that apply" and is signed by the Physician.

Per interview on 10/28/13 1:48 PM, the CNO confirmed that during the weekend of 10/26/13 and 10/27/13, the Director of Med/Surg Unit drafted a comfort care policy following the on-site survey on 10/25/13.

Based upon staff interview and clinical record review of 2 of 2 patients, the hospital failed to develop and implement a comfort care policy which includes a description of services directly provided by the hospital. (Patients #1 and #2). Findings include:

1. Per interview and confirmed with the Chief Nursing Officer (CNO) on 10/28/13 at 11:34 AM, the hospital does not have a written Policy and Procedure for comfort care and only uses standardized "Comfort Care Orders" which state "check all boxes that apply" and is signed by the Physician.

Per interview on 10/28/13 1:48 PM, the CNO confirmed that during the weekend of 10/26/13 and 10/27/13, the Director of Med/Surg Unit drafted a comfort care policy following the on-site survey on 10/25/13.

2. Per clinical record review, the standardized "Comfort Care Orders" were checked off and signed by the Physician on 10/19/13 at 18:00 (6:00 PM) for Patient #1.

3. Per clinical record review, the standardized "Comfort Care Orders" were checked off and signed by the Physician on 10/19/13 for Patient #2 (no time documented).

Based upon staff interview and record review, the Hospital and the Director of Nursing (DON) failed to ensure that that one Registered Nurse (RN) was adequately supervised & clinical activities evaluated after identifying that the RN: 1) Documented administration of an anti-anxiety medication (Lorazepam) for a use not specified in the Physician Order; 2) Failed to properly assess one patient and administered unnecessary medication; and 3) Stated "I wanted to speed up the process" and "I wanted to be merciful" for 1 of 3 patients. (RN #1, Patient #1). Findings include:

Per interview and review of "Record of Risk Management Investigation" on 10/28/13 at 12:00, the Director of Quality and Risk was aware of a concern expressed by the Case Manager on 10/22/13 of "quantity of medications given to a patient during the night shift" and that the Director of the Med/Surg Unit "reported Lorazapam was not documented as being appropriately administered for a PRN (as needed) order". The Director of Risk and Quality was also aware that the Director of Med/Surg met with RN #1 on 10/23/13 at 08:30 AM concerning "documentation of lorazepam being inconsistent with the reasoning for 'comfort care' and the 'patient was sleeping'".

Per interview on 10/28/13 at 11:15 AM, the Chief Nursing Officer (CNO) was aware on 10/22/13 at 8:00 AM of the Case Manager's and Director Med/Surg's concerns related to RN #1's clinical record documentation of Lorazepam 2 mg IVP administered to Patient #1 on 10/21/13 to 10/22/13.

Per interview on 10/25/13 at 10:35 AM, the Director of Med/Surg stated she met with RN #1 on 10/23/13 at approx 7:30 AM following his/her 7PM to 7AM shift. The Director of Med/Surg asked why he/she had administered Lorazepam 2 mg IVP (Intravenous push) 9 times without documenting restlessness. RN #1 said he/she had "done it for comfort care". RN #1 stated, "I tried to speed up the process; I wanted to be merciful".

Per "Record of Risk Management Investigation" received on 10/28/13 at 12:00 and confirmed with the Director of Quality and Risk, on 10/23/13, "[Director of Med/Surg] informed me (at approximately 08:30) of [his/her]discussion with RN #1. [Director of Med/Surg] states when she/he asked about the documentation for the administration of lorazapam being inconsistent with the reasoning for "comfort care" and the "patient was sleeping", RN # 1's reply was "I tried to speed up the process" and he/she was "trying to be merciful". [Director of Med/Surg] also informed me that the patient's death was reported to the Medical Examiner's office and RN#1 was the assistant ME who responded to the case. [Director Med/Surg] and I concluded we needed to discuss the situation with our supervisor, [CNO]".

Per interview on 10/25/13 at 10:35 AM, the Director of Med/Surg met with RN #1 on 10/23/13 after working 7 PM to 7AM following Patient #1's death on 10/22/13. Per interview with Human Resources Generalist on 10/28/13 at 9:50 AM, RN #1 was not scheduled to work again until 10/28/13 and will be suspended for 3 days starting 10/28/13.

Per interview with RN #1 on 10/28/13 10:00 AM, medical record reviewed with RN #1 concerning 7 PM to 7 AM documentation on 10/21/13 to 10/23/13. RN #1's documentation of Lorazepam 2 mg IVP administered for comfort care was read out loud during the interview. Confirmed with RN #1 that Lorazepam was documented as being given for comfort care. RN #1 confirmed that the MD Order for Lorazepam 2mg IVP was to be administered for agitation, restlessness or anxiety. RN #1 confirmed total number of doses of Lorazepam 2 mg IVP he/she administered from 7PM to 7AM 10/21/13 to 10/22/13 was 9 doses.

During the interview, RN #1 Stated he/she "felt [Patient #1] was suffering"; "high pulse rate indicated suffering" to him/her; "This was the most restful night that she had had". When asked "What other characteristics led him/her to believe [Patient #1] was suffering?" The RN stated [Patient #1] "was basically sleeping with increase in medications given".

Per clinical record review, of the "Patient Progress Notes" from 10/21/13 to 10/22/13, RN #1 documented the following from 10/21/13 to 10/22/13:
19:37 Lorazepam 2 mg IVP; Reason: Comfort Care
20:55 Lorazepam 2 mg IVP; Reason: Comfort Care
21:52 Lorazepam 2 mg IVP; Reason: Comfort Care
23:02 Lorazepam 2 mg IVP; Reason: Comfort Care
01:05 Lorazepam 2 mg IVP; Reason: Comfort Care
02:10 Lorazepam 2 mg IVP; Reason: Comfort Care
03:19 Lorazepam 2 mg IVP; Reason: Comfort Care
04:28 Lorazepam 2 mg IVP; Reason: Comfort Care
05:40 Lorazepam 2 mg IVP; Reason: Comfort Care

Per clinical record review of the "Hourly Rounding Log" from 10/21/13 to 10/22/13, RN #1 documented at 19:40, 20:52, 22:07, 22:38, 23:35, 00:12, 01:04, 03:03, and 05:42 "Patient Asleep". In addition at 05:42, RN #1 documented "[Patient #1] repositioned and cleaned. Mouth care done. [She/He] showed no signs of distress when she was moved to be cleaned".

Per interview on 10/28/13, the LNA stated she/he worked with RN #1 and cared for Patient #1 on 10/21/13 to 10/22/13, 7 PM to 7 AM shift. On 10/21/13 the LNA was told Patient #1 had been put on comfort measures, mouth care, and no Vital Signs. When LNA saw Patient #1 after report, she/he looked like she/he was sleeping, no moaning, no agitation, not restless, and did not hit at at LNA when touched. RN #1 and the LNA turned Patient #1 from back to left side; turned her together. Patient #1 did not hit or strike at them when turned. LNA did not attempt to give fluids because Patient #1 wasn't awake; LNA was afraid Patient #1 could not swallow and would aspirate.

Based upon interview and record review, the Condition of Participation: Periodic Evaluation and Quality Assurance Review was not met due the the hospital failing to implementing a corrective action plan after identifying that one registered nurse (RN) documented administration of an anti-anxiety medication (Lorazepam) for a use not specified in the Physician Order for 1 of 3 patients (Patient #1, RN #1), and not identifying during the annual program review of health care policies that a written policy had not been developed for health care services related to comfort care.

See C334 - Periodic Evaluation
See C336 - Quality Assurance

Based upon staff interview and record review, the hospital failed to identify during the annual program review of health care policies that a written policy had not been developed for health care services related to comfort care. Finding includes:

Per interview and confirmed with the Chief Nursing Officer (CNO) on 10/28/13 at 11:34 AM, the hospital does not have a written Policy and Procedure for "Comfort Care" and only uses standardized "Comfort Care Orders", which state "check all boxes that apply" and is signed by the Physician.

Per interview and confirmed with the Chief Nursing Officer (CNO) on 10/28/13 at 1:48 PM, a Comfort Care Policy was drafted over the weekend of 10/26/13 and 10/27/13 following the on-site survey on 10/25/13.

Based upon staff interview and record review, the hospital failed to implement a corrective action plan after identifying that one RN: 1) Documented administration of an anti-anxiety medication (Lorazepam) for a use not specified in the Physician Order; 2) Failed to properly assess one patient and administered unnecessary medication; and 3) Stated "I tried to speed up the process" and "I wanted to be merciful" for 1 of 3 patients. (RN #1, Patient #1).


Per interview and review of "Record of Risk Management Investigation" on 10/28/13 at 12:00, the Director of Quality and Risk was aware of a concern expressed by the Case Manager on 10/22/13 of "quantity of medications given to a patient during the night shift" and that the Director of the Med/Surg Unit "reported Lorazapam was not documented as being appropriately administered for a PRN (as needed) order". The Director of Risk and Quality was also aware that the Director of Med/Surg met with RN #1 on 10/23/13 at 08:30 AM concerning "documentation of lorazepam being inconsistent with the reasoning for "comfort care" and "patient was sleeping".

Per interview on 10/28/13 at 11:15 AM, the Chief Nursing Officer (CNO) was aware on 10/22/13 at 8:00 AM of the Case Manager's and Director Med/Surg's concerns related to RN #1's clinical record documentation of Lorazepam 2 mg IVP administered to Patient #1 on 10/21/13 to 10/22/13.

Per interview on 10/25/13 at 10:35 AM, the Director of Med/Surg stated she met with RN #1 on 10/23/13 at approx 7:30 AM following his/her 7PM to 7AM shift. The Director of Med/Surg asked why he/she had administered Lorazepam 2 mg IVP (Intravenous push) 9 times without documenting restlessness. RN#1 said he/she had done it for comfort care. RN #1 stated, "I tried to speed up the process; I wanted to be merciful".

Per "Record of Risk Management Investigation" and confirmed with the Director of Quality and Risk on 10/28/13 at 12:00, an internal investigation began on 10/22/13 after the "[Director of Med/Surg] informed me (at approximately 08:30) of [his/her]discussion with RN #1. [Director of Med/Surg] states when she/he asked about the documentation for the administration of lorazapam being inconsistent with the reasoning for "comfort care" and the "patient was sleeping", RN # 1's reply was "I tried to speed up the process" and he/she was "trying to be merciful". [Director of Med/Surg] also informed me that the patient's death was reported to the Medical Examiner's office and RN#1 was the assistant ME who responded to the case. [Director Med/Surg] and I concluded we needed to discuss the situation with our supervisor, [CNO]".


Per staff interview and confirmed with the Director of Med/Surg Unit on 10/25/13 at 11:55, Patient #1 had a Comfort Care Order signed by the Physician on 10/19/13 at 18:00 (6:00 PM). The order states "For anxiety/restlessness: Lorazepam (0.5 mg PO/IV/SQ (by mouth/ intravenous/subcutaneous) every 2 hours as needed. May repeat in 45 minutes if anxiety/restlessness not resolved". In addition, on 10/21/13 at 17:30 (5:30 PM), the Physician Order states "[increase] Lorazapam to 2 mg (milligram) IV every one hour PRN (as needed)". From 19:37 PM (7:37 PM) to 05:40 AM (5:40 AM) on 10/21/13 to 10/22/13, RN #1 administered 9 doses of 2 mg Lorazepam IVP (intravenous push) without an indication of restlessness or anxiety.

Per clinical record review, of the "Patient Progress Notes" from 10/21/13 to 10/22/13, RN #1 documented the following from 10/21/13 to 10/22/13:
19:37 Lorazepam 2 mg IVP; Reason: Comfort Care
20:55 Lorazepam 2 mg IVP; Reason: Comfort Care
21:52 Lorazepam 2 mg IVP; Reason: Comfort Care
23:02 Lorazepam 2 mg IVP; Reason: Comfort Care
01:05 Lorazepam 2 mg IVP; Reason: Comfort Care
02:10 Lorazepam 2 mg IVP; Reason: Comfort Care
03:19 Lorazepam 2 mg IVP; Reason: Comfort Care
04:28 Lorazepam 2 mg IVP; Reason: Comfort Care
05:40 Lorazepam 2 mg IVP; Reason: Comfort Care

Per clinical record review of the "Hourly Rounding Log" from 10/21/13 to 10/22/13, RN #1 documented at 19:40, 20:52, 22:07, 22:38, 23:35, 00:12, 01:04, 03:03, and 05:42 "Patient Asleep". In addition at 05:42, RN #1 documented that "[Patient #1] repositioned and cleaned. Mouth care done. [She/He] showed no signs of distress when she was moved to be cleaned".

Per interview and confirmed with the Chief Nursing Officer (CNO) on 10/28/13 at 11:34 AM, the hospital does not have a written Policy and Procedure for "Comfort Care" and only uses standardized "Comfort Care Orders "which states "check all boxes that apply" and is signed by the Physician.

Per interview and confirmed with the Chief Nursing Officer (CNO) on 10/28/13 at 1:48 PM, a Comfort Care Policy was drafted over the weekend of 10/26/13 and 10/27/13 following the on-site survey on 10/25/13.


Per interview and confirmed with the CNO, on 10/28/13 at 1:48, the Director of Med/Surg Unit emailed all staff the weekend of 10/26/13 and 10/27/13 concerning PRN Medications and attached a copy of the policy titled "Medication Administration" following the on-site survey on 10/25/13.