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Based on record review and interview, the facility failed to provide an updated
nursing care plan for one (Patient #5) of the 18 patients sampled.


The Findings Include:


A review of the clinical records for Patient #5 was conducted on 10/13/2015 at approximately 1:30 p.m. The Care Plan contained documentation regarding identified problems and goals for Patient #5, which included:

1. Knowledge Deficit
2. Discharge Planning
3. Fall Risk
4. Non-Compliant Behavior
5. Blood Pressure Alteration
6. Risk for Skin Breakdown
7. Behavior Disturbance
8. Disturbed Thought Process
9. Impaired Mobility and Activity of Daily Living (ADL's)
10. Ineffective coping and grieving
11. Risk of Harm (To self or others)


1. The patient was interviewed on 10/13/2015 at lunch time. The patient was able to answer questions and was asked about the food and her diet. The patient commented she does eat the food, but it is not like home. The patient continued to comment she eats the meals, but sometimes refuses snacks and a few meals. The spouse was at the facility and he commented she does not eat as she did at home. The husband explains he attempts to be available at lunch to encourage her eating and offers assistance during meal times when he is at the facility. The patient denied having the need for assistance with eating and made a feeding motion with her arm. The Patient stated, "I can feed myself."
The interview with the patient verified she did not want snacks and would eat when she was hungry. The Patient stated, "I would eat when I can go home; I cook and make good food and take care of my family." The patient explained she eats when she wants to and would like to go home.


2. A review of the Nutritional Intake Records revealed the staff documented the patient had varied percentages of meal intake, ranging from 100% to 0% recorded when the patient refused a meal.


A review the random meal consumption was conducted and revealed:


09/02/2015- Lunch 50%, Dinner 90%
09/03/2015- Breakfast 0%, Lunch 100%, Dinner 100%
09/17/2015- Breakfast 0%- Refused, Lunch 100%, Dinner 100%
09/24/2015- Lunch 80%, Dinner 75%
09/29/2015- Breakfast 100%, Lunch 80%, Dinner 0% Refused
10/01/2015- Breakfast 0%, Lunch 80%, Dinner 40%

The above meal intake is documented in the facility record by the staff. The feeding ability is documented as Independent or Set Up, with food tolerance as fair to good when taking meals.

Observations were made throughout the survey during meal times. The staff assisted patients to the dining areas, and offered alternatives or snacks. Various fluids for hydration was observed and available at the nursing station. A refrigerator held snacks and hydration, and during the survey, the observations included patients asking and receiving fluids.


Hydration was available on observation and interviewed patients reported snacks and fluids were available anytime on request. On 10/12/2015 at approximately 12:10 p.m., an observation was conducted with Patient #5 during lunch. The Patient was observed eating lunch independently.


After a review of the Care Plan, an interview was conducted with the Risk Management Coordinator on 10/15/2015 at approximately 2:10 p.m. The Coordinator explained snacks and ice cream socials are provided. A review of the electronic medical record revealed the staff documented Patient #5 has a history of refusing snacks.


A review of the facility's policy dated 4/2013, for review on 2/2014 entitled "Process Plans" was reviewed on 10/15/2015. The section entitled "Policies", Item number 3 contains the following; "The Plan of Care will be updated in the clinical documentation under 'Outcomes' at the end of each shift to reflect the patient's current needs/problems."



A telephone interview with the Quality Improvement Director was conducted on 10/23/2015 at approximately 3:40 p.m. She commented there was not a Nutritional Care Plan, but this would be addressed to ensure the weights and documentation of meal intake was accurate, and would include additional nutritionist support.

Based on observation, staff interview and facility record review, the facility failed to ensure medication was appropriately prepared for administration for Patient # 6, (one of three) sampled patients.
The facility failed to appropriately document, reconcile and clarify a physician's order regarding Synthroid for one (Patient #8) of the of three sampled patients.


The Findings Include:


A wound care observation was initiated at approximately 10:40 a.m. on 10/14/2015 for Patient #6. During this wound care observation, the patient complained of pain. Patient #6 was in a private room on contact precautions due to an infection after a right below-the-knee amputation. The Staff Nurse (A) caring for Patient #6 alerted the nursing station and asked if another nurse could assist. At approximately 11:30 a.m. another staff member was observed giving Staff Nurse (A) a syringe with clear fluid and an opened/accessed vial of medicine.

Staff Nurse (A) was observed taking the syringe and explaining to Patient #6 the medicine was, "almost ready." Staff Nurse (A) was observed on the computer confirming the dose of the injection, Staff Nurse, pain medication and the time between doses were accurate.


Staff Nurse (A) was observed walking toward the bedside. When Staff Nurse (A) was asked what the injectable was, she stated it was, "Dilauded." She commented she had checked the dose on the computer and it was correct. Staff Nurse (A) then made the vial visible and stated, "This is Dilauded 1 milligram per milliliter," and stated the remaining liquid in the vial would not be used and would be destroyed. When asked regarding how she would be able to confirm the liquid in the syringe is Dilauded, Staff Nurse (A) commented she did not draw the medication into the syringe and therefore, would not be able to "positively" confirm the liquid in the syringe was Dilauded. Staff Nurse (A) commented she would not administer the fluid in the syringe.


The nurse was observed contacting the nursing station, asking another nurse to bring into the patient's room an unopened vial of medication and packaged sterile syringe. Another nurse entered the Patient's room with an unopened, sealed medication vial and sterile syringe.


The nurses were then observed verifying the patient identification, the medication dose and route of administration. Once the medication, dose, route and patient were confirmed, Staff Nurse (A) drew up the appropriate amount of the medication from the vial. The nurses were observed disposing the vial containing the unused portion of the medication by placing the vial in the Sharp's container (Biohazard container designed to contain contaminated needles). Both Nurses confirmed the non-used (wasted medication amount) and Staff Nurse (A) administered the medication appropriately.


After the procedure and the wound care observation was completed, an interview was conducted with the Risk Manager (RM). The RM explained she had heard what happened and verified the medication should not be considered for administration unless the nurse administering the medication is the person preparing the medication.


An interview with the Pharmacist was conducted on 10/14/2015 at 3:55 p.m., and he commented this practice was not the expectation of the hospital staff.



On 10/14/2015, a visit was made to the hospital's off-site adolescent psychiatric facility. A review of the physician's orders and the Medication Administration Record (MAR) for Patient #8 was reviewed. The physician's order was documented in the order sheet as "Synthroid 0.075 mcg po q (every) 6 a.m.", as a telephone order dated on 10/13/2015. The order entry dated 10/13/2015 was signed by the nurse receiving the order at 2:25 p.m. on 10/13/2015 as a RBO (read back order). An entry on the order sheet was written as "24-hour Check (documented as checkmark)", dated 10/14/2015, indicating the medication orders were reviewed and verified for accuracy and confirmed the twenty-four hour chart (physician order verification) was completed.



The charge nurse for the unit reviewed the order and commented this is an inappropriate order. The charge nurse explained the order was written in micrograms (mcg's) incorrectly. The charge nurse explained the receiving nurse and the night nurse verifying the orders should have noticed the order as written, "0.075 mcg", should have been "75 mcg". The charge nurse for the unit removed the Levothyroxine from the medication security system. The tablets dispensed by the pharmacy included the medication label was written as : "Levothyroxine Sodium 75 MCG TAB (tablet)." The manufacturer label read as "Synthroid 75 mcg" tablet. The charge nurse explained the order was documented on the physician's order sheet incorrectly.


The charge nurse verified the physician would be contacted to obtain a clarification order. The Director of the Unit was made aware of the finding. The Director commented he would check into the order.


An interview with the facility's Director of Pharmacy was conducted at 3:55 p.m. The Director commented the order was not questioned by the nurse on the floor and the pharmacist dispensed the appropriate microgram dose tablet.



At 4:00 p.m., the pharmacist demonstrated on the computerized record, a verified physician clarification order as Levothyroxine (Synthroid) 75 mcg tablet by mouth daily. The pharmacist explained the patient received the correct medication, correct dosage and correct route, but added both the nurse and pharmacist should have caught the incorrect transcription on the original order. The clarification physician order dosage as Levothyroxine (Synthroid) 75 mcg tablet by mouth everyday at 6 a.m.

Based on record review and interview, the facility failed to appropriately document, reconcile and clarify a verbal physician's order regarding medication for one (Patient #8) of three sampled patients.

The Findings Include:


On 10/14/2015 at approximately 2:30 p.m., a visit was made to the hospital off-site adolescent psychiatric facility. A review of the physician's orders and the Medication Administration Record for Patient #8 were reviewed. The physician's order was documented in the order sheet as "Synthroid 0.075 mcg po q (every) 6 a.m." as a telephone order dated 10/13/2015. The order entry dated 10/13/2015 was signed by the nurse receiving the order at 2:25 p.m. on 10/13/2015 as an RBO (read back order). An entry on the order sheet was written as "24-hour Check (checkmark) 10/14/2015", indicating the medication orders were reviewed and verified for accuracy and confirmed the twenty-four hour chart (physician order verification) was completed.


The charge nurse of the unit reviewed the order and commented this is an inappropriate order. The charge nurse explained the order was written in micrograms (mcg's) incorrectly. The charge nurse explained the receiving nurse and the night nurse verifying the orders should have noticed the order as written, "0.075 mcg" should have been "75 mcg". The charge nurse for the unit removed the Levothyroxine from the medication security system. The tablets dispensed by the pharmacy included the medication label was written as: "Levothyroxine Sodium 75 MCG TAB (tablet)." The manufacturer's label read as "Synthroid 75 mcg" tablet. The charge nurse explained the order was documented on the physician's order sheet incorrectly.


The charge nurse verified the physician would be contacted to obtain a clarification order. The Director of the Unit was made aware of the finding. The director commented he would check into the order.


An interview with the facility's Director of Pharmacy was conducted at 3:55 p.m. The Director commented the order was not questioned by the nurse on the floor and the pharmacist dispensed the appropriate microgram dose tablet.


The pharmacist demonstrated on the computerized record, the physician's clarification order as "Levothyroxine (Synthroid) 75 mcg tablet by mouth daily". The pharmacist explained the patient received the correct medication, correct dosage and correct route, but added both the nurse and pharmacist should have caught the incorrect transcription on the original verbal order. The expectation is the order would be checked and reconciled for accuracy for the medication, medication indication, dosage, and route, as outlined in the policy for verbal orders and medication reconciliation.

Based on observation, staff interviews and facility record review, the hospital failed to provide appropriate infection control measures regarding appropriate hand hygiene during nursing care and dressing change for one (Patient #6) of the three patients sampled.


The Findings Include:

A wound care observation was initiated at approximately 10:40 a.m. on 10/14/2015 for Patient #6. The patient was admitted into the facility on 09/02/2015 and underwent a below-the-knee amputation. Due to a drug resistant infection, Patient #6 was in a private room on contact isolation. The patient required a two-person assist for positioning during the dressing change. The Wound Care Nurse (WCN) and the nurse (Staff Nurse "A") providing patient care donned Personal Protective Equipment (PPE), including mask, gloves and gown. The dressing change required multiple glove changes to maintain aseptic (clean) techniques during the removal of the current dressing, cleaning of the wound, and reapplication of the clean dressing. During the dressing change, the WCN was observed removing the contaminated gloves. The WCN was observed appropriately disposing the contaminated gloves. The WCN donned a clean set of gloves without performing hand hygiene.


After the wound care was complete, the WCN removed and disposed her gloves, and was observed performing hand hygiene at the sink. The RM was interviewed after the wound care observation. The RM commented the policy would require hand hygiene before and after donning gloves.


A review of the facility's Infection Control Policy for Contact Precautions was conducted on 10/14/2015. The policy was entitled "Special Precautions Revision Date 07/2015. The policy regarding contact isolation for the Multiple Drug Resistant Organisms (MDRO) Revised Date: 03/2015 Procedure, contained the following:


"d.) Hand Hygiene performed immediately after removal of PPE"


On 10/15/2015 at approximately 3:20 p.m., the WCN was interviewed regarding the wound care observation. When asked, the WCN commented she thought she had used hand sanitizer after the removal of the gloves.