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Based on review of medical records and staff interview it was determined the registered nurse failed to supervised and evaluated the care related to assessments an implementation of physician orders for three (#1, #2, #5) of ten patient sampled.

Findings included:

1. Review of the nursing documentation for patient #1 dated 4/01/2016 at 4:43 a.m. revealed the RN (Registered Nurse) documented the patient had labored breathing, shortness of breath, productive cough with brown white, thick sputum and coarse breath sounds. Review of the record revealed the respiratory therapist noted the patient's oxygen saturation was 89% on oxygen at 2 liters via nasal cannula with coarse lung sounds and a small amount of thick tan sputum.

Review of the record revealed no evidence of nursing intervention or physician notification of the patient's change in condition noted on 4/01/2016 at 4:43 a.m.

Review of the medical record and interview with the CNO (Chief Nursing Officer) on 1/19/2017 at approximately 12:30 p.m. confirmed the findings.

2. Review of patient #2's medical record revealed a physician order for neurological checks every 2 hours were ordered upon admission on 3/09/2016. Review of the nursing documentation revealed no evidence the neurological checks were completed every 2 hours as ordered.

Interview with the CNO on 1/19/2017 at approximately 2:30 pm confirmed the findings.

3. On 01/19/17 at approximately 11:35 a.m. review of Patient #5's history and physical (H&P) revealed the patient was admitted on [DATE] at approximately 11:30 a.m. to the Medical Unit for safe alcohol withdrawal. The patient was noted to have a long history of alcohol abuse. On admission the patient was noted to have tremors, palpitations and an anxious mood.

Review of physician orders dated 01/18/17 at 12:10 p.m. revealed orders for Clinical Institute of Withdrawal Assessment (CIWA-each item on the scale is scored independently and the summation of the scores yields an aggregate value that correlates to the severity of alcohol withdrawal with ranges of scores designed to prompt specific management decisions). The RN assessments were ordered to occur every 4 hours and included the following components:
Nausea and vomiting
Tactile disturbances
Auditory disturbances
Headache/Fullness in head
Orientation/clouding on sensorium
Review of the same orders revealed neurological assessments should be performed every 6 hours by the RN.

Review of the CIWA revealed a scale that each of the above components must be assigned every 4 hours.
0 None
1 Mild
4 Intermittent/Dry Heaves
7 Constant

Review of nursing assessments for CIWA every 4 hours and neurological assessments every 6 hours revealed the following:
01/18/17 at 4:10 p.m.-no CIWA assessment performed.
01/18/17 at 6:10 p.m.-no Neurological assessment performed.
01/18/17 at 8:10 p.m.-no CIWA assessment performed.
01/18/17 at 10:00 p.m.-CIWA assessment performed.
01/19/17 at 12:10 a.m.- no CIWA and no Neurological assessment performed.
01/19/17 at 3:57 a.m.-CIWA assessment performed.
01/19/17 at 4:10 a.m.-no CIWA assessment no performed.
01/19/17 at 6:10 a.m.-no Neurological assessment performed.
01/19/17 at 8:10 a.m.-no CIWA assessment performed.
01/19/17 at 12:10 a.m.-no CIWA and no Neurological assessment performed.

A total of 6 CIWA assessments should have occurred in the above timeframe. There were only 2 CIWA assessments found in the medical record. A total of 4 Neurological assessments should have occurred in the above timeframe. There were no neurological assessments documented in the medical record.

On 01/19/17 at 12:25 p.m. an interview with the RN caring for Patient #5 confirmed the above findings.

On 01/19/17 at 12:30 p.m. an interview with the unit Charge RN confirmed the CIWA assessments were ordered to occur every 4 hours and the Neurological assessments were to occur every 6 hours. The Charge RN confirmed the nursing assessments had not been performed as ordered on [DATE] and 01/19/17 by the RNs.

On 01/19/17 at 12:40 p.m. an interview performed with the Director of Advanced Clinical and the CNO confirmed the findings. They stated they could not find any further documentation of CIWA or Neurological assessments being performed by nursing on the date of admission, 01/18/17 or the following day, 01/19/17.
Based on policy and medical record reviews and staff interviews it was determined the facility failed to ensure medications were administered in accordance with physician orders for one (#4) of 10 patient records reviewed.

Findings included:

Review of the facility policy titled "Medication Reconciliation" Policy # MM.039 with a review date of 11/15 showed reconciliation of medication may be defined as all medication appropriately and consciously continued, discontinued, or modified ...upon any transfer to a different level of care the transferring physician will need to continue, discontinue or edit orders ...Pharmacy will verify the orders ...transfer to a different level of care will be defined as the following ...from surgery to a medical/surgical, progressive care or ICU (Intensive Care Unit) bed.

On 01/19/17 at approximately 10:55 a.m. review of patient #4's history and physical (H&P) dated 01/16/17 at 6:51 a.m. revealed the patient was taken to surgery later that day for abdominal surgery. Review of the post anesthesia care unit (PACU) documentation revealed the patient left PACU and returned to the nursing unit at 9:33 p.m.

Review of physician orders for the antibiotic Flagyl 500 milligrams (mg) IV (Intravenous) every 8 hours revealed the initial order was placed before surgery. It was dated 01/16/17 at 1:30 p.m. There were no further physician orders for the Flagyl found in the medical record.

Review of the medication administration record (MAR) revealed Patient #4 received the Flagyl 500 mg IV every 8 hours from 01/16/17 at 1:30 p.m. through the post operatively period on 01/19/17 without a physician order to continue the medication as required by facility policy.

An interview on 1/19/17 at 4:12 p.m. with the Pharmacist confirmed the Flagyl should have been discontinued. It should have been reordered post operatively if the physician wanted it to be continued. The Pharmacist confirmed there was not a new order for Flagyl post operatively. The Pharmacist confirmed if the physician did not discontinue an orders post operatively the patient will continue to receive pre operatively ordered medications.

On 01/19/17 at approximately 10:45 a.m. an interview conducted with the Director of Advanced Clinicals confirmed there was no physician's order for Flagyl post operatively in Patient #4's medical record.