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Based on observation, record review, and interview, the facility failed to ensure that the nursing staff implement the nursing care plan by enforcing the policy on Fall Prevention in 2 of 3 Sampled Patients (SP) (#23, and #24); and and that the nursing assessments were completed in 2 out of 10 sampled patients (SP)#3 and #4.

The findings include:
1). Clinical record review of SP#23 conducted on 12-11-2013 revealed an admission date on 12-09-2013 . Review of the Assessment Form showed that the patient is on Fall Precautions and that the patient must have a (yellow) Fall Risk armband on, and non-slip (yellow socks) footwear.

An observation of SP#23 was conducted on 12-11-2013 at 9:45 a.m. with the Charge Nurse (CN) of 4 West and it was observed that SP#23 did not have a (yellow) Fall Risk armband on nor the yellow socks in use.

The above findings were confirmed from the Charge Nurse on 12-11-2013 at 9:45 a.m. that there was failure to follow the Fall Precautions for this patient.

Clinical record review of SP#24 conducted on 12-11-2013 revealed an admission date on 11-11-2013. Review of the Assessment Form showed that the patient is on Fall Precautions and that the patient must have a (yellow) Fall Risk armband on and (yellow socks) non-slip footwear.

An observation of SP#24 was conducted on 12-11-2013 at 9:50 a.m. with the Charge Nurse of 4 West and it was observed that SP#24 did not have a (yellow) Fall Risk armband on. The above finding was confirmed from the Charge Nurse on 12-11-2013 at 9:50 a.m. that there was failure to follow the Fall Precautions for this patient.

The Charge Nurse stated on 12-11-2013 at 9:55 a.m. the patients should have the yellow socks and yellow armbands on. I don't know why they were not on the patients.

Review of the policy: Fall Prevention Program showed that the purpose is to establish minimal safety interventions to be implemented for the at-risk patients. The procedure include an identification system that include the following: a yellow arm band. The fall prevention activities are implemented for all patients: patients are provided with non-slip footwear and instructed to wear them.



2) Review of SP#3 face sheet revealed that the patient was admitted to the facility on 12/06/2013. Review of the Nursing Assessments from 12/06/2013 to 12/09/2013 revealed that there was no nursing assessment documented for SP#3 on 12/07/2013 on the 7am to 7pm shift.

On 12/09/2013 at 2:05pm, in an interview with sampled employee (SE) #G, who was SP#3 Nurse on 12/07/2013 on the 7am to 7pm shift, the Nurse stated, that I assessed the patient but I did not document, I thought I did.

Review of SP#4 medical records on 12/09/2013 to 12/11/2013 revealed that the patient was admitted to the facility on 12/05/2013. Review of Nursing Assessments from 12/05/2013 to 12/09/2013 revealed that there is no nursing assessments documented for SP#4 on 12/07/2013 on the 7am to 7pm shift.

On 12/09/2013 at 2:05pm in an interview with SE#F who was SP#4 nurse on 12/07/2013 on the 7am to 7pm shift, the RN stated that I came in at 11am, I did the assessment, I did not document. I had a critically ill patient at the same time.

In an interview with the Director of 4 West on 12/09/2013 at 2pm, the Director stated that the nursing assessments are done every shift and prn (as needed).

These findings were also confirmed with the Director of 5 East and the Director of 4 West on 12/09/2013 and on 12/11/2013


Review of the facility ' s Unit Specific Assessment/Reassessment policy criteria showed that for Medical/Surgical areas which includes 5 East, assessments must be initiated within 4 hours and completed within 8 hours and reassessments should be completed every shift and as needed.

Based on record review and interview, the facility failed to ensure that medications given are based upon the orders of the medical staff and in accordance with the facility's policy, in 1 out of 10 sampled patients (SP) #1.

The findings include:

Review of SP#1 Physician Orders revealed an order that started on 09/04/2013 at 08:00 am for Regular Insulin AC (before meals) and HS (at sleep) on the medium Insulin sliding scale, and an order for Insulin Detemir(Levemir) 25 units that also began on 09/04/2013 at 08:30 am. According to the Medication Administration Record (eMAR), the patient was scheduled for Regular insulin daily (before meals and at hours of sleep) at 08:00 am, 12:30 pm, 17:30 pm, and 22:00 pm and Insulin Levemir was scheduled daily at 08:30 am.
Review of the orders for the Regular Insulin Medium sliding scale showed for:
Blood sugars(BS) of 151-200 = 2 units
Blood sugars(BS) of 201-250 = 6 units
Blood sugars(BS) of 251-300 =8 units
Blood sugars(BS) of 301-350 = 10 units
Blood sugars (BS) > greater than 350, the physician was to be called.
Review of SP#1 record revealed that the point of care (POC) Blood Glucose (BG) results on 09/04/2013 at 09:21 am was 85. The Insulin (Levemir) scheduled for 08:30 am was not given, and the reason for non -administration was charted as hypoglycemia.

On 09/05/2013; at 16:44 pm, the patient ' s BG/BS result was 397 and 10 units of Regular Insulin was given at 18:04 pm. At 21:23pm, the patient ' s BG/BS was 422 and 10 units of Regular insulin was also given. On 09/06/2013 at 05:45pm the patient ' s BG/BS was 379 and 10 units of Regular insulin was given . A On 09/06/2013 at 16:18 pm, the patients BG/BS was 369 and 10 units of Regular insulin was given. On 09/07/2013, Insulin Levemir scheduled for 08:30 am was given at 09:56 am (the patient ' s BG/BS was 323. At 12:04pm the patient ' s BG/BS was 361 and 10 units of Regular insulin was given. At 16:18pm the patient ' s BG/BS results was 475. Review of the patient medical records revealed that there was no documentation that the physician was called and there was no dosage of regular insulin ordered when the above Blood Glucose's (BG/BS) were above 350.

In a telephone interview with SE #A on 12/10/2013 at 3:37pm, the RN stated I work days. I don ' t remember the patient. But if the blood sugar is high I usually call the doctor, even if insulin is given.


The findings were confirmed with the Director of 5 East on 12/10/2013 at 1:00pm that there was failure of the staff to follow the policy regarding medication administration.

Review of the policy Preparation and Administration of Medication stated that medications will be administered only upon the order of physicians, who are members of the medical staff, and that before administering a medication, the licensed independent practitioner or qualified individual administering the medication should verify that the medication is administered at the proper time, in the prescribed dose. The policy also stated that if the medication is given outside the scheduled time frame, the nurse will document on the Meditech eMAR system, the reason for the variance.