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Based on record review, staff interview, and review of policy and procedures, it was determined the Registered Nurse failed to evaluate and supervise the nursing care for two (#1, #2) of three patients sampled. This practice does not provide for safe nursing care, does not ensure that patients goals are met, and may cause a delay in discharge.

Findings include:

1. Review of patient #1's physician's orders dated 1/26/10 at 11:30 a.m. instructed for the patient to be out of bed to the chair and ambulate with help. Review of the nurse's documentation revealed on 1/26/10 the patient was not out of bed nor assisted to ambulate. Review of the physician orders revealed an order on 1/27/10, no time, for the patient to be out of bed to the chair at least two times a day and ambulate with help. Review of the nurse's documentation revealed the patient was out of bed to the chair one time and assisted to ambulate one time. Review of nursing documentation on 1/28/10 revealed the patient was out of bed to the chair and assisted to ambulate one time. Review of nursing documentation on 1/29/10 revealed the patient was out of bed to the chair one time at 8:15 a.m. There was no documentation the patient was assisted to ambulate or out of bed a second time. Review of nursing documentation on 1/30/10 revealed the patient was not assisted out of bed or assisted to ambulate by nursing. Review of nursing documentation on 1/31/10 revealed the patient was not assisted out of bed or assisted to ambulate.

2. Review of the physician's orders for patient #1 revealed an order on 1/24/10 at 6:20 p.m., for SCD (Sequential Compression Device) to be applied. Review of the nursing documentation from 1/24/10 to 2/01/10 revealed no documentation the SCD's had been applied.

3. Physician orders for patient #1 dated 1/24/10 instructed for Percocet 1 to 2 tablets by mouth every six hours as needed for pain. Review of the Medication Administration Record (MAR) documentation revealed the Percocet was administered as ordered. Review of the facility's policy, "Medication Administration", last revised 3/10, revealed medications ordered as needed must have a specified indication for use. When assessing a patient for as needed medication, the nurse will administer the lowest dose ordered and evaluate for efficacy. Review of the facility's pain treatment record and nursing notes for the patient revealed nursing failed to document the assessment and need for pain medication and also failed to evaluate the efficacy of the medication on several occasions. On 1/24/10 at 8:35 p.m. nursing documentation revealed the patient complained of back pain as 4-5 on a scale of 1-10 with 10 being the worst. Review of the MAR revealed the patient was administered one Percocet by mouth at 8:35 p.m. No documentation could be located for evaluation of the effectiveness of the pain medication administered. On 1/25/10 at 9:12 p.m. nursing documentation revealed the patient complained of back pain as 5-6 on a scale of 1-10. Review of the MAR revealed the patient was administered one Percocet by mouth at 9:12 p.m. No documentation could be located for evaluation of the effectiveness of the pain medication administered. Review of the MAR for 1/26/10 at 8:15 p.m., 1/27/10 at 6:49 p.m., 1/28/10 at 1:31 p.m., 1/29/10 at 1:31 p.m., and 1/30/10 at 12:11 p.m. showed Percocet was administered. No documentation could be located for the assessment of the patient's need for pain medication and no documentation of the effectiveness of the pain medication.

4. Patient #2's physician's orders revealed on 3/18/10 at 10:10 p.m. an order for Fentanyl 100 mcg (micrograms) IVP (intravenous push) every one hour as needed for pain. Review of the MAR revealed on 3/20/10 at 7:49 a.m., 11:44 a.m., 2:41 p.m., 3:20 p.m., 4:47 p.m., and 6:09 p.m., the patient was medicated for pain as ordered. No documentation could be located for the assessment of the patient's need for pain medication and no documentation of the effectiveness of the pain medication.

Interview with the Compliance Director on 3/23/10 at 3:15 p.m. confirmed the above findings.

Based on medical record review, staff interview, and review of policy and procedures it was determined the nurses did not provide medications according to physician orders for one (#1) of three patients sampled. This practice does not promote for the safe administration of medication.

Findings include:

1. Patient #1's Medication Administration Record (MAR) revealed Hyzaar (a combination of two medications hydrochlorothiazide and losartan) was administered on 1/24/10 at 8:35 p.m. and on 1/25/10 at 8:58 a.m. Review of the medication reconciliation form revealed the physician checked "no" for Hyzaar. Review of the physician's orders on 1/25/10 at 12:10 p.m. revealed an order to discontinue HCTZ (hydrochlorothiazide). Review of the physicians notes for 1/25/10 revealed the physician documented that the HCTZ was given to the patient but not ordered. Interview with the Compliance Director on 3/23/10 at approximately 3:15 confirmed the above findings. Review of the facility's policy, "Medication Administration", last revised 3/10, stated a medication variance report must be completed to report medication related errors. Interview with the Assistant Vice President of Nursing Acute Care on 3/23/10 at 3:35 p.m. confirmed a medication variance report should be completed. Interview with the Compliance Director on 3/23/10 at approximately 5:00 p.m. stated a medication variance report could not be located.