The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

TAMPA COMMUNITY HOSPITAL 6001 WEBB RD TAMPA, FL 33615 Oct. 30, 2012
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review, staff interview and policy review it was determined the facility failed to honor the patients rights for 1 (#4) of 13 sampled patients related to obtaining an informed consent from the patient or health care representative.

Findings include:

Patient #4 (MDS) dated [DATE] for a gastrointestinal bleed and sepsis. The patient has a history of cerebral vascular accident (CVA), right hemiparesis, and expressive aphasia. A blood consent was dated 10/20/12 at 9:00 pm that documented "Medical Doctor (MD) in emergency room (ER) request". The consent was not signed by patient or representative but was signed by a witness. On 10/21/12 at 8:25 am the physician ordered a transfusion of 4 units of packed red blood cells (PBRC's). The patient received all 4 units of blood. On 10/22/12 a 5th unit of PRBC's was administered at 8:25 am.

A peripherally inserted central catheter (PICC) was inserted on 10/23/12 at 12:22 pm. A review of the PICC placement consent dated 10/21/12 revealed a Physician had signed the consent and wrote medically necessary above his name.

A review of the facility's policy, " Informed Consent-Consents and Authorization for treatment Plan for patients, policy # RM101, approved 4/2/12, page 2, General Information, paragraph 6. revealed "if the patient is adjudicated incapacitated, found to be incompetent or incapable to consent to treatment, express and informed consent to treatment shall be sought instead from the patient's guardian,guardian advocate or legal representative". Further review of the policy revealed "in the event that informed consent cannot be obtained either from the patient or legal representative and the patient is experiencing a life threatening /emergent situation, (2) physicians familiar with the patients care may make the determination to proceed with the proposed procedure in the absence of the informed consent. Documentation regarding the same will be entered into the patients medical record".

A interview with the case manager was conducted on 10/29/12 at 1:00 pm after review of the clinical record, confirmed there was no documentation of the family being notified to give consent for either the blood transfusion and/or the PICC placement.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review, policy review and staff interviews it was determined the facility failed to honor the patients rights to receive care in a safe setting, for 8 (#1,#5, #6, #7, #8,#9, #10 & #11) of 13 sampled patients by not ensuring enough qualified staff was available to ensure the immediate availability of a registered nurse for bedside care of any patient located on the Medical/Surgical Unit. The continued use of this practice does not ensure safe patient care as demonstrated in sample records.

Findings include:

1. Patient #1 presented to the Emergency department(ED) on 8/12/12. The patient was evaluated by the ED physician at 7:10 pm with a chief complaint of weakness. The ED Physicians impression was urosepsis and septic encepholopathy. The ED Physician noted that present on admission was a vascular/urinary catheter associated infection and bed sores (decubiti).

A review of patient #1's nursing documentation, revealed from 8/13/12 to 8/17/12 nursing documented the skin assessment as within normal limits (WNL). On 8/17/12 at 7:30 am a nursing assessment revealed the patient had (2) pressure ulcers on his sacral and coccyx areas. He also had ecchymotic areas to both heels, left knee and bilateral buttocks and the perineal area was excoriated. The wound care nurse was consulted on 8/19/12 at 1:20 pm (2 days later) and assessed the patient the same day at 3:45 pm.

Further review of patient #1's clinical record revealed the patient was assessed by an Licensed Practical Nurse on 8/17/12 on both 7:00 am to 7:00 pm and 7:00 pm to 7:00 am shifts. There is no documentation of a RN completing an assessment or co-signing the LPN assessments for either shifts.

A review of the "assessment and reassessment" policy, policy # 200, approved 1/31/12, revealed under scope: the assessment process will be a continuous, collaborative effort with all the health care members functioning as a team. the registered nurse, initially assesses the patients needs for care in all settings where patient care is provide. On page 3, section #5c. Skin integrity- all patients are assessed on admission for pressure ulcer risk using the skin integrity scale . Page 4, section 8c., Reassessments: at least one assessment/reassessment should be conducted by a Registered Nurse per calendar day.

Interviews were conducted on 10/24/12 from 10:30 am to 12:00 pm with the Nursing staff of the Medical/Surgical units. During the interviews the staff was questioned on the skin assessments, identifying pressure ulcers, and the process/procedures for treating the patient with skin breakdown. The staff responded that patients are assessed on admission and every shift for skin breakdown. That if a patient has any skin breakdown or potential for skin breakdown than the wound care nurse is consulted immediately. The wound care nurse evaluates the patient within 24 hours and makes recommendations for treatment. If a patient is felt to be a potential candidate for skin breakdown than the nursing staff initiates frequent every 2 hour turning schedule for the patient.


2. Patient #5 was admitted to the Medical/Surgical unit on 10/23/12 after a total knee Arthroscopy surgery. A review of the "Anesthesiology Patient Control Analgesia (PCA) orders" dated 10/23/12 at 11:30 am revealed a PCA for Morphine Sulfate was ordered for the patient. At the top of the order form is written "319", indicating the patient was on 3 north room 319.

A review of the Medication Administration Record (MAR) revealed the PCA had been initiated on 10/23/12 at 12:33 pm. Further review of the Nursing documentation on 10/23/12 revealed a Licensed Practical Nurse had initiated the PCA Morphine pump at approximately 12:20 pm.

A review of the facility's policy, " Medication Administration Patient Controlled Analgesia (PCA), policy # MM 430, reviewed/revised on 9/11, revealed under scope of responsibility;
1. A registered nurse (RN) must program the PCA settings
2. Any licensed nurse may double check the setting
3. any licensed nurse may monitor the PCA device and patient status.

Further review of patient #5's clinical record, medication administration records and nursing documentation did not reveal any RN documentation of initiating and verifying the PCA or assessing the patients status prior to initiation.

Interviews were conducted on 10/24/12 from 10:30 am to 12:00 pm with the Nursing staff of the Medical/Surgical units. The Medical/Surgical Nursing staff (consisting of both LPN's and RN's) were questioned concerning the initiation of the PCA pumps. They responded that the RN reviews the physician orders, assesses the patient, sets up and initiates the PCA pump with a RN or LPN verifying the settings.

3. Patient #6 was admitted to the Medical/Surgical unit on 10/14/12 for wound care to both lower extremities. A review of the patient's clinical record, nursing assessments revealed the LPN completed the patients assessments on 10/20 to 10/22 and 10/24 to 10/27/12. There was no documentation the RN co-signed and/or supervised the LPN's assessments of the patient for these dates. An observation of patient #6 was made on 10/25/12 at approximately 11:00 am. During the observation it was noted the protective boots used to float the patients heels were soiled with yellow drainage and the patients intravenous left forearm (IV) site insertion date was 10/21/12 (outdated per policy), the intravenous site on the right forearm was not marked with an insertion date. The Medical/Surgical manager and the patients nurse were both at the bedside during this observation and confirmed these with the surveyor.


4. Patient #7's History and Physical revealed the patient was admitted with post [DIAGNOSES REDACTED] CVA on 10/15/12 to 3N after being transferred from another acute care facility. The documentation noted the patient was non-verbal, unable to make his needs know and had peg tube for nutrition.

Review of the nursing flow sheet dated 10/20/12 for the 7 A-7P shift noted a LPN completed the nursing assessment as well as for the 10/20/12 7P-7A. On 10/21/12 on the 7A-7P shift a LPN complete the assessment.

Interview on 10/29/12 with the Chief Nursing Officer, Director of Quality and the Risk Manager revealed on 10/20/12 one LPN was now a RN but a computer issue showed her as a LPN.

On 10/23/12 at 9:16 a.m. a RN assessment was completed that revealed the patient's breath sounds remained decreased and coarse. On the 7P-7A shift on 10/23/12 a LPN was assigned to the patient. The LPN did not complete an assessment. Review of the vital signs dated 10/24/12 at 12:09 a.m. revealed a heart rate of 92, respiratory rate of 24, blood pressure 138/72 and an oxygen saturation of 96%.

Review of the nursing flow sheet revealed on 10/24/12 at 12:59 a.m. the monitor technician notified the nurse of an increased heart rate in the 130's. The documentation did not reveal if the LPN caring for the patient was notified or another nurse was notified of the findings. There was no evidence of the LPN assigned to the patient or a RN assessing the patient for the increased heart rate. The Patient Care Technician (PCT) documented at 1:00 a.m. routine patient safety care. The monitor technician documented at 1:53 a.m. that the nurse was notified of cardiac rhythm changes and a code blue was called.

Review of the code blue report revealed the code was called at 1:50 a.m. and the patient was pronounced at 2:07 a.m.

Review of LPN documentation dated 10/24/12 at 8:41 a.m. revealed at 1:15 a.m. he was informed by Respiratory Therapy (RT) the patient's breath sounds were wet and moist and he went to assess the patient. The documentation noted a call was placed to the physician and while waiting for the physician to call back the PCT went to obtain vital signs. The documentation revealed the PCT noted the patient was unresponsive, did not look right and a code blue was called. The documentation did not contain evidence of the nurse's assessment after being notified by the RT of the change in the patient's condition.

Interview with the LPN caring for the patient that night on 10/29/12 at approximately 10:08 a.m. revealed the RN was notified of the change in condition by the LPN. Review of the nursing documentation did not reveal evidence of an assessment by the RN.

Staff interview and clinical record review revealed that nursing failed to provide an assessment of patient on 10/23/12 for the 7P-7A shift. The RN failed to assess the patient with a change of condition related to an increased heart rate and later in the shift related to breath sounds. There was a delay in providing nursing care by not assessing the patient at the time of the changes in condition for a patient that experienced a significant life threatening change in condition.

Various interviews with the Chief Nursing Officer, Risk Manager, Director of Quality, Director of the ICU/ED and the Nurse Information Technologist from 10/26-10/30/12 confirmed the findings.

5. Patient #8 presented to the Emergency Department (ED) on 10/5/12 with a chief complaint of chest pains since the night prior. The history included coronary artery disease with stent placement, diabetes and hypertension. The patient was triaged on 10/5/12 at 12:57 p.m. The vital signs included blood pressure 120/52, heart rate 73. respiratory rate 16, an oxygen saturation of 99% on room air and a pain level of 0 on a scale 0 to 10. Triage documentation noted the patient was alert and oriented. The ED physician examined the patient at 12:50 p.m. The ED physician's impression was chest pain with a history of stents and the patient was stable. ED physician orders revealed a heparin lock was placed. A cardiologist consult was ordered. The plan was to admit the patient. The patient was admitted to 3 North at 3:52 p.m.

The cardiology consult dated 10/5/12 revealed the patient was a symptomatic and had a possible myocardial infarction. The plan was for anticoagulation therapy and if intractable pain was present then a cardiac catheterization.

Review of physician admission orders dated 10/5/12 at 2:20 p.m. revealed to admit to telemetry with medications and laboratory and EKG testing.

Review of nursing documentation revealed the admission assessment was completed on 10/5/12 at 5:28 p.m. by a Licensed Practical Nurse (LPN). Vital signs at 6:05 p.m. were heart rate 72, respiratory rate 22, blood pressure 141/81 and an oxygen saturation level of 89% on room air. There was no evidence of a Registered Nurse (RN) assessment or the LPN reporting the findings, including the oxygen saturation of 89% to the RN. LPN documentation at 6:40 p.m. revealed the patient complained of chest pain of eight out of ten, the physician was called and orders were received for a Nitro (Nitroglycerine) drip and a transfer to the Intensive Care Unit (ICU) STAT. The documentation revealed the house supervisor was notified of a STAT transfer at 6:45 p.m.. The LPN documented at 6:50 p.m. revealed no one in the ICU would take report after three attempts. The patient was wheeled down to ICU and bedside report was given due to the patient's condition not being stable. There was no evidence the RN was advised of the patient's condition or the patient being assessed.

Physician verbal orders dated 10/5/12 at 6:40 p.m. ordered a Nitroglycerine drip at 0.25 micrograms, Lopressor 50 milligrams (mg) now and to transfer to the ICU. There was no route ordered for the Lopressor.

Review of the nursing flow sheet for transfer/discharge date d 10/5/12 at 7:00 p.m. revealed the patient was transferred to the Intensive Care Unit (ICU) accompanied by the LPN, monitor and IV equipment. The documentation noted report was given at the bedside to the agency ICU nurse. The ICU agency nurse documented at 7:10 p.m. the patient was transferred to ICU due to severe chest pain at an eight out of ten and possible pulmonary edema.

The vital signs at 7:10 p.m. were heart rate 153, respiratory rate 28, blood pressure 230/110 and an oxygen saturation of 87% on 2 liters of oxygen. At 7:18 p.m. the vital signs were heart rate 156, blood pressure 212/100 and an oxygen saturation of 88% At 7:19 p.m. the ICU agency nurse initiated a code blue due to the patient being unresponsive and with respiratory distress.

Review of the Code Blue record revealed the patient coded at 7:30 p.m. and expired at 7:57 p.m.

Review of ICU agency nurse documentation dated 10/5/12 at 9:00 p.m. revealed the patient was admitted to the ICU in transfer at 7:50 p.m. with chest pain, respiratory distress, mottled and hypertensive. The documentation noted the Nitro drip was started at 33 micrograms and increased to 100 micrograms due to chest pain and increased blood pressure. The documentation noted the Lopressor was also given intravenously (IV). The documentation noted a code blue was called at 7:19 p.m. The ICU agency nurse documented the Nitro drip was turned off at 7:23 p.m. There was no actual time the Nitro drip was initiated or the Lopressor given. Review of the physician orders and nursing documentation revealed there was no titration order for the Nitro drip or to initiate the drip at 33 micrograms or give the Lopressor IV. The ICU agency nurse's documentation at 9:00 p.m. contain conflicting times of care.

Confidential staff interviews on 10/26/12 and 10/27/12 revealed the intravenous (IV) pump was set at a rate of 100 milliliter per hour for the Nitro drip. The IV fluid pump was set at 10 milliliters per hour. The interviews revealed the agency nurse may have reversed the setting on the pump. The interviews revealed that is what the staff RN saw when the staff RN walked over to the patient' bedside to assist when the patient deteriorated.

Interview with two staff ICU RNs on 10/28/12 at approximately 3:45 p.m. and 4:50 p.m. revealed it is the their policy to have two nurses check the dose and pump setting for all drips. There was no evidence this occurred for patient #8.

Review of policy and procedure "Rapid Response Team Code Purple" #PC 800 reviewed 1/10 revealed a purpose that indicated the Rapid Response Team (RRT) had been shown to reduce morbidity and mortality rates in hospitals. The RRT help improve the staff nurse's critical thinking. Under the section for Procedures the policy indicated staff members and patient, families or visitors concerned about a patient's status may call the RRT line. It stated the RRT has orders that have been approved by the medical staff that may be initiated including Nitroglycerine IV fluids.

Staff interview and clinical record review revealed that nursing failed to provide of a RN assessment on admission, delayed a transfer to ICU with implementation of critical care medications such as the Nitro drip and Lopressor, did not administered critical medications as ordered by the physician, did not follow ICU policy of checking the dose and pump setting with two ICU staff nurses to ensure accuracy, and did not use the services if the RRT on 3 North for a patient that experienced a significant life threatening change in condition.

Various interviews with the Chief Nursing Officer, Risk Manager, Director of Quality, Director of the ICU/ED and the Nurse Information Technologist from 10/26-10/30/12 confirmed the findings.

6. Patient #9 was admitted to the Medical/Surgical (3S) unit on 10/25/12 for persistent nausea and vomiting. The admitting physicians initial impression was end-stage renal disease, massive upper gastrointestinal bleeding, hypertension, ascites and hypotension. On 10/25/12 at 2:00 pm the physician ordered the patient's blood sugar levels to be monitored every 4 hours. A review of the clinical record for 10/25/12 at 4:41 pm revealed the patients blood sugar was "50" documented by the LPN. The next blood sugar was obtained by the RN at 9:18 pm ( almost 5 hours later and was documented as "35". There was no documentation of any interventions for the blood sugar of 50 and no further monitoring of the blood sugar for almost 5 hours. There is also no evidence that a RN co-signed or assessed the patient during the time the patient was taking care of the patient. Further review of patient #9's clinical record revealed the RN from the 7:00 pm to 7:00 am shift documented her assessments and interventions after her shift was completed at 10:46 am.

7. Patient #10 presented to the emergency department (ED) on 10/23/12 at 7:38 pm. The patient was assessed by the ED Physician at 7:53 pm for cough, congestion with a thick sputum. The physicians diagnosis was Dyspnea with productive cough , [DIAGNOSES REDACTED]and hypertension. The patient was admitted to the Medical/Surgical unit on 10/24/12 at 3:06 am. A review of the nursing documentation revealed a LPN assessed the patient on 10/24/12 at 11:32 am; the patient was transferred to the intensive care unit (ICU) at 2:33 pm. There is no documentation of any assessment/co-signature or interaction from the RN prior to the patient going to ICU.

8. Patient #11 (MDS) dated [DATE] with a chief complaint of fecal impaction for 5 days. The triage vital signs were heart rate 71, respiratory rate 16, blood pressure 126/58, and an oxygen saturation of 99% on room air. Review of the ED physician documentation dated 10/10/12 revealed the patient had been constipated for 5 days with abdominal pain and nausea. The documentation noted a history of Alzheimer and dementia. Review of the abdominal CT scan revealed a fecal impaction and moderate gas. Review of blood study results noted a critical CO2 (carbon dioxide) level of 8 (22-32). Review of the critical value report revealed the critical value was called at 2:01 p.m. to the staff. The ED physician's impression was fecal impaction, metabolic acidosis and renal insufficiency. The plan was to admit to telemetry. The patient left the ED to 3N on 10/10/12 at 6:23 p.m. The vital signs at 6:23 were heart rate 95, respiratory rate 23, blood pressure 105/65 and an oxygen saturation of 91% on two liters of oxygen.

Review of verbal admission physician orders dated 10/10/12 at 5:19 p.m. included IV fluids of ? Normal Saline with one amp of Sodium Bicarbonate at 70 milliliters (ml) per hour and a tap water enema upon arrival to floor.

Documentation at 7:33 p.m. revealed the vital signs obtained by the PCT were heart rate 76, respiratory rate 16, blood pressure 98/72 and an oxygen saturation level of 65% on 3 liters of oxygen. Nursing assessment dated [DATE] at 7:45 p.m. revealed it was performed by the RN. The assessment noted the patient responded to deep pain and was non-verbal. The respirations were shallow and the patient was pale. The documentation revealed Normal Saline at 100 milliliters was infusing via the IV.

RN nursing documentation dated 10/11/12 at 2:30 a.m. revealed the RN request RT at the bedside at 7:45 p.m. Review of the Code Blue form revealed a code was called on 10/10/12 at 8:07 p.m. and the patient expired at 8:27 p.m.

Staff interview and clinical record review revealed that nursing failed to provide nursing care in response of a critical low oxygen saturation level of 65% in a timely manner. There was no evidence of RT responding to the request. The nursing staff failed to ensure the physician ordered IV fluid and Sodium Bicarbonate was initiated on arrival to 3 North in a patient with metabolic acidosis.

Various interviews with the Chief Nursing Officer, Risk Manager, Director of Quality, Director of the ICU/ED and the Nurse Information Technologist from 10/26-10/30/12 confirmed the findings.


A review of the facility's policy, "Staff Assignments", policy # ADM 606, reviewed 1/10, revealed under Policy: There will be a sufficient number of qualified Registered Nurses on duty at all times to meet the needs of the patients. Nursing Personnel staffing is sufficient to assure prompt recognition of any untoward change in a patient's condition and to facilitate appropriate interventions. A registered nurse plans, supervises and evaluates the nursing care plan. A registered nurse makes a patient assessment before delegating any aspects of nursing care.

Interviews were conducted on 10/24/12 from 10:30 am to 12:00 pm with the Nursing staff of the Medical/Surgical units. The Medical/Surgical Nursing staff (consisting of both LPN's and RN's) were questioned concerning staffing issues, acuity levels and RN/LPN assessments. The staff responded that some were frustrated with the work load. The RN's are assigned 6 to 7 patients and are assigned to cover a LPN. Which to them in essence is 12 to 14 patients to be assessed during a 12 hour shift. The RN responsibility to the LPN' patients is to do the admission assessment, every 24 hour assessment, any change in condition, push IV medications, etc. The RN's that were interviewed shared they "attempt" to see everyone of the LPN's patients but with the acuity of the patients most of the time they can't see everyone. When questioned concerning the co-signing of the assessments, both RN and LPN's responded that sometimes they only have time to sign off the assessments. One LPN shared that since she is IV certified she usually just does her own assessments, IV push medications and setting up the PCA pumps.
VIOLATION: QAPI Tag No: A0263
Based on clinical record review, staff interviews and review of facility documents it was determined the facility failed to develop, implement and maintain an effective, on-going, hospital-wide, data driven quality assessment and performance improvement program for all patients. The continued use of this practice does not ensure the deliverance of safe patient care, the integration of resources to ensure appropriate staff training and the continued monitoring of patient care.

1. The facility failed to analyze adverse patient events and other aspects of performance by the nursing staff related to administration of critical medications, assessments, implementing emergency measures, administering medications as ordered by the physician and nurses working outside their scope of practice. This practice may have caused harm to patients.
(Refer to A0264)

2. Patient #8 presented to the Emergency Department (ED) on 10/5/12 with a chief complaint of chest pains. The patient was admitted to 3 North at 3:52 p.m. An admission assessment was completed by a Licensed Practical Nurse (LPN). At 6:50 p.m. the patient was complaining of chest pain eight out of ten. Physician verbal orders dated 10/5/12 at 6:40 p.m. ordered a Nitroglycerine drip at 0.25 micrograms, Lopressor 50 milligrams (mg) now and to transfer to the ICU. There was no route ordered for the Lopressor.

The LPN documentation at 6:50 p.m. revealed no one in the ICU would take report after three attempts. The patient was wheeled down to ICU and bedside report was given due to the patient's condition not being stable.

The vital signs at 7:10 p.m. were heart rate 153, respiratory rate 28, blood pressure 230/110 and an oxygen saturation of 87% on 2 liters of oxygen. At 7:18 p.m. the vital signs were heart rate 156, blood pressure 212/100 and an oxygen saturation of 88%. The ICU agency nurse initiated a code blue due to the patient being unresponsive and with respiratory distress. Review of the Code Blue record revealed the patient coded at 7:30 p.m. and expired at 7:57 p.m.

Review of ICU agency nurse documentation dated 10/5/12 at 9:00 p.m. revealed the Nitro drip was started at 33 micrograms and increased to 100 micrograms due to chest pain and increased blood pressure. The documentation noted the Lopressor was also given intravenously (IV). There was no actual time the Nitro drip was initiated or the Lopressor given. Review of the physician orders and nursing documentation revealed there was no titration order for the Nitro drip or to initiate the drip at 33 micrograms or give the Lopressor IV.

Confidential staff interviews on 10/26/12 and 10/27/12 revealed the intravenous (IV) pump was set at a rate of 100 milliliter per hour for the Nitro drip. The IV fluid pump was set at 10 milliliters per hour. The interviews revealed the agency nurse may have reversed the setting on the pump. The interviews revealed this is what the staff RN saw when the staff RN walked over to the patient' s bedside to assist when the patient deteriorated.

Staff interview and clinical record review revealed that nursing failed to provide a RN assessment on admission, delayed a transfer to ICU with implementation of critical care medications such as the Nitro drip and Lopressor, did not administered critical medications as ordered by the physician, did not follow ICU policy of checking the dose and pump setting with two ICU staff nurses to ensure accuracy, and did not use the services if the Rapid Response Team on 3 North for a patient that experienced a significant life threatening change in condition.

Interview with the Risk Manager on 10/28/12 at approximately 4:10 p.m. revealed a Root Cause Analysis (RCA) was conducted, the ICU agency nurse was made a "Do Not Use" and a plan to provide education on RRT and verification of drips was to be done. She stated no other measure were implemented or planned. The Risk Manager would not provide the RCA or action plan or any other documentation since it was a Patient Safety Work Product.

Interview with the Risk Manager on 10/27/12 at approximately 5:00 p.m. revealed she was informed in the morning of the event. The pump was sequester and releases since there was no evidence of malfunction. She stated she interviewed all staff involved and reviewed the chart. The interview did not revel evidence of the possibility of the staff identifying the use of two pumps. She stated the chart indicated no evidence of IV fluids being administered only the Nitro drip. The Risk Manager stated the patient was laughing and talking with family on the way down to the ICU. Review of the clinical record revealed no evidence of this. The LPN documentation revealed the patient was experiencing a pain level of 8 out of 10. She stated the physician felt there this was not an issue. She stated the Director of Quality and the Director of Education were no involved in the RCA or the development of the plan.

There was no evidence of a comprehensive route cause analysis of an adverse event involving the medical/surgical unit and the Intensive Care Unit that may have contributed to a patients's death being integrated with the Quality Department. ( Refer to A0288)


3. Review of a mostly redacted "3rd Floor Observation" document, no date, provided by the Risk Manager during the survey revealed that vitals were not being done/documented, assessments not being completed, lack of required documentation for skin assessments and nurses "clicking through the system" without actually doing the assessment.

The document did not include an action plan. Interview with the Risk Manager on 10/30/12 at approximately 9:40 a.m. revealed no other information regarding the document or development of an action plan would be provided due to Patient Safety Work Product.

The surveyor requested a copy of the Action plan for education from both the Director of Quality and Director of Education on 10/30/12 at approximately 11:45 am.

The surveyors were provided a copy of the "Action Plan" dated 6/24/12, on 10/30/12 at 3:00 pm. Attached to the Action Plan was the proposed (3) day nursing orientation (no date) and the "Areas of focus for Nursing/Education", dated 5/10/12. a review of the "Areas of Focus for Nursing/Education", revealed several areas of concerns identified by the Director of Education and the solutions.
Some of the concerns are as follows:
1. 3rd floor ( North & South) and ICU
a. not completing assessments
b. lack of required documentation for skin assessments,turns, rounding, etc.
c. failure to completed forms, i.e. pre-op order sheets
d. Nurses "clicking through system", without actually doing the assessment
e. Scanning of medications, "cheating" by cutting off barcodes
f. Not scanning billable items when in a rush

There was no evidence action had been taken by the facility to develop and implement an action plan to improve and provide safe nursing care. (Refer to A0315)


Based upon the above findings the facility was found to be out of compliance with the Condition of Participation for Quality Assessment Performance Improvement Program.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on staff interview and review of Organizational Performance Improvement and Patient Safety Plan it was determined the facility failed to develop a Quality Assessment Performance Improvement (QAPI) plan to improve patient outcomes. This practice does not ensure areas of improvement are identified and an action plan is developed and evaluated to promote patient safety and ensure goals are met.

Findings include:

Review of the "Organizational Performance Improvement and Patient Safety Plan" approved on 4/24/12 provided by the Risk Manager during the survey revealed no evidence that
1. The program included measurable improvement in indicators for which there was evidence that it will improve health outcomes.
2. Identify and reduce medical errors in high volume problem prone areas.
3. The number and scope of distinct QAPI projects conducted annually must reflects the scope and complexity of the services provided. The plan did not contain evidence of specific project or including such specialty areas as the Behavioral Health Unit or the Addiction Recovery Unit.

Various interviews with the Risk Manager from 10/27-30/12 revealed the facility would not provide meeting minutes, the committee, list of what was discussed, QAPI project (other than routine project such as medication errors, fall, pressure sores, infection) or list of attendees at the meeting due to Patient Safety Work Product.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on staff interview and review of the Organizational Performance Improvement and Patient Safety Plan it was determined the facility failed to analyze adverse patient events and other aspects of performance by the nursing staff related to administration of critical medications, assessments, implementing emergency measures, administering medications as ordered by the physician and nurses working outside their scope of practice. This practice may have caused harm to patients.

Findings include:

1. Patient #8 presented to the Emergency Department (ED) on 10/5/12 with a chief complaint of chest pains since the night prior. The history included coronary artery disease with stent placement, diabetes and hypertension. The patient was triaged on 10/5/12 at 12:57 p.m. The vital signs included blood pressure 120/52, heart rate 73. respiratory rate 16, an oxygen saturation of 99% on room air and a pain level of 0 on a scale 0 to 10. Triage documentation noted the patient was alert and oriented. The ED physician examined the patient at 12:50 p.m. The ED physician ' s impression was chest pain with a history of stents and the patient was stable. ED physician orders revealed a heparin lock was placed. A cardiologist consult was ordered. The plan was to admit the patient. The patient was admitted to 3 North at 3:52 p.m.

The cardiology consult dated 10/5/12 revealed the patient was a symptomatic and had a possible myocardial infarction. The plan was for anticoagulation therapy and if intractable pain was present then a cardiac catheterization.

Review of physician admission orders dated 10/5/12 at 2:20 p.m. revealed to admit to telemetry with medications and laboratory and EKG testing.

Review of nursing documentation revealed the admission assessment was completed on 10/5/12 at 5:28 p.m. by a Licensed Practical Nurse (LPN). Vital signs at 6:05 p.m. were heart rate 72, respiratory rate 22, blood pressure 141/81 and an oxygen saturation level of 89% on room air. There was no evidence of a Registered Nurse (RN) assessment or the LPN reporting the findings, including the oxygen saturation of 89% to the RN. LPN documentation at 6:40 p.m. revealed the patient complained of chest pain of eight out of ten, the physician was called and orders were received for a Nitro (Nitroglycerine) drip and a transfer to the Intensive Care Unit (ICU) STAT. The documentation revealed the house supervisor was notified of a STAT transfer at 6:45 p.m.. The LPN documented at 6:50 p.m. revealed no one in the ICU would take report after three attempts. The patient was wheeled down to ICU and bedside report was given due to the patient's condition not being stable. There was no evidence the RN was advised of the patient's condition or the patient being assessed.

Physician verbal orders dated 10/5/12 at 6:40 p.m. ordered a Nitroglycerine drip at 0.25 micrograms, Lopressor 50 milligrams (mg) now and to transfer to the ICU. There was no route ordered for the Lopressor.

Review of the nursing flow sheet for transfer/discharge date d 10/5/12 at 7:00 p.m. revealed the patient was transferred to the Intensive Care Unit (ICU) accompanied by the LPN, monitor and IV equipment. The documentation noted report was given at the bedside to the agency ICU nurse. The ICU agency nurse documented at 7:10 p.m. the patient was transferred to ICU due to severe chest pain at an eight out of ten and possible pulmonary edema.

The vital signs at 7:10 p.m. were heart rate 153, respiratory rate 28, blood pressure 230/110 and an oxygen saturation of 87% on 2 liters of oxygen. At 7:18 p.m. the vital signs were heart rate 156, blood pressure 212/100 and an oxygen saturation of 88% At 7:19 p.m. the ICU agency nurse initiated a code blue due to the patient being unresponsive and with respiratory distress.

Review of the Code Blue record revealed the patient coded at 7:30 p.m. and expired at 7:57 p.m.

Review of ICU agency nurse documentation dated 10/5/12 at 9:00 p.m. revealed the patient was admitted to the ICU in transfer at 7:50 p.m. with chest pain, respiratory distress, mottled and hypertensive. The documentation noted the Nitro drip was started at 33 micrograms and increased to 100 micrograms due to chest pain and increased blood pressure. The documentation noted the Lopressor was also given intravenously (IV). The documentation noted a code blue was called at 7:19 p.m. The ICU agency nurse documented the Nitro drip was turned off at 7:23 p.m. There was no actual time the Nitro drip was initiated or the Lopressor given. Review of the physician orders and nursing documentation revealed there was no titration order for the Nitro drip or to initiate the drip at 33 micrograms or give the Lopressor IV. The ICU agency nurse's documentation at 9:00 p.m. contain conflicting times of care.

Confidential staff interviews on 10/26/12 and 10/27/12 revealed the intravenous (IV) pump was set at a rate of 100 milliliter per hour for the Nitro drip. The IV fluid pump was set at 10 milliliters per hour. The interviews revealed the agency nurse may have reversed the setting on the pump. The interviews revealed that is what the staff RN saw when the staff RN walked over to the patient' s bedside to assist when the patient deteriorated.

Interview with two staff ICU RNs on 10/28/12 at approximately 3:45 p.m. and 4:50 p.m. revealed it is the their policy to have two nurses check the dose and pump setting for all drips. There was no evidence this occurred for patient #8.

Review of policy and procedure "Rapid Response Team Code Purple" #PC 800 reviewed 1/10 revealed a purpose that indicated the Rapid Response Team (RRT) had been shown to reduce morbidity and mortality rates in hospitals. The RRT help improve the staff nurse's critical thinking. Under the section for Procedures the policy indicated staff members and patient, families or visitors concerned about a patient's status may call the RRT line. It stated the RRT has orders that have been approved by the medical staff that may be initiated including Nitroglycerine IV fluids.

Staff interview and clinical record review revealed that nursing failed to provide a RN assessment on admission, delayed a transfer to ICU with implementation of critical care medications such as the Nitro drip and Lopressor, did not administered critical medications as ordered by the physician, did not follow ICU policy of checking the dose and pump setting with two ICU staff nurses to ensure accuracy, and did not use the services if the RRT on 3 North for a patient that experienced a significant life threatening change in condition.

Interview with the Risk Manager on 10/27/12 at approximately 5:00 p.m. revealed she was informed in the morning of the event. The pump was sequester and released since there was no evidence of malfunction. She stated she interviewed all staff involved and reviewed the chart. The interview did not reveal evidence of the possibility of the staff identifying the use of two pumps. She stated the chart indicated no evidence of IV fluids being administered ,only the Nitro drip. The Risk Manager stated the patient was laughing and talking with family on the way down to the ICU. Review of the clinical record revealed no evidence of this. The LPN documentation revealed the patient was experiencing a pain level of 8 out of 10. She stated the physician felt this was not an issue. She stated the Director of Quality and the Director of Education were not involved in the RCA or the development of the plan.

Interview with the attending physician (who was the Chief of Staff) for patient #8 on 10/30/12 at approximately 9:15 a.m. revealed he did a partial review of the medical record. He stated he was interviewed but not part of the whole RCA process. He indicated it is not known if the nitro drip and Lporessor were a contributing factor or not but could have been.

Interview with the Risk Manager on 10/28/12 at approximately 4:10 p.m. revealed a Root Cause Analysis (RCA) was conducted, the ICU agency nurse was made a "Do Not Use" and a plan to provide education on RRT and verification of drips was to be done. She stated no other measure were implemented or planned. The Risk Manager would not provide the RCA or action plan or any other documentation since it was a Patient Safety Work Product.

There was no evidence of a comprehensive route cause analysis of an adverse event involving the medical/surgical unit and the Intensive Care Unit that may have contributed to a patients's death.
VIOLATION: PROVIDING ADEQUATE RESOURCES Tag No: A0315
Based on staff interview and review of documentation provided by the facility administration it was determined the facility failed to ensure resources were provided to measure, assess, improve, and sustain quality of care on the medical surgical units. This practices may have caused potential harm to patient.

Findings include:

Review of a mostly redacted "3rd Floor Observation" document, no date, provided by the Risk Manager during the survey revealed that vitals were not being done/documented, assessments not being completed, lack of required documentation for skin assessments and nurses "clicking through the system" without actually doing the assessment

The document did not include an action plan. Interview with the Risk Manager on 10/30/12 at approximately 9:40 a.m. revealed no other information regarding the document or development of an action plan would be provided due to Patient Safety Work Product.

A review of emails presented to the surveyors by the Chief Nursing Officer (CNO) revealed communication with the ex-Medical/Surgical Nurse Manager was aware of medication and assessment issues by nursing on the unit as early as 7/3/12. The CNO had requested a action plan from the nurse manager and determine what the issues were. During an interview conducted on 10/29/12 at 1:50 pm the CNO shared that after trying to work with the Nurse Manager concerning the issues for approximately (8) weeks, the Nurse Manger was finally terminated.

An confidential interview was conducted on 10/30/12 at 11:12 am with the Director of Education. The Director was questioned on what his role is in RCA and training/inservicing nursing staff. He responded that unfortunately he is not involved in the RCA of incidents. But that he is involved in the nursing orientation and unit specific training. He is not involved in the orientation for Agency Nurses. Usually the Management of a particular unit will request the inservices. The Director stated he was hired in April 2012 and presented a action plan in May 2012 to the administration for review. The surveyor requested a copy of the Action plan for education from both the Director of Quality and Director of Education on 10/30/12 at approximately 11:45 am.

The surveyors was provided a copy of the "Action Plan" dated 6/24/12, on 10/30/12 at 3:00 pm. Attached to the Action Plan was the proposed (3) day nursing orientation (no date) and the "Areas of focus for Nursing/Education", dated 5/10/12. a review of the "Areas of Focus for Nursing/Education", revealed several areas of concerns identified by the Director of Education and the solutions.
Some of the concerns are as follows:
1. 3rd floor ( North & South) and ICU
a. not completing assessments
b. lack of required documentation for skin assessments,turns, rounding, etc.
c. failure to completed forms, i.e. pre-op order sheets
d. Nurses "clicking through system", without actually doing the assessment
e. Scanning of medications, "cheating" by cutting off barcodes
f. Not scanning billable items when in a rush

There was no evidence action had been taken by the facility to develop and implement an action plan to improve and provide safe nursing care.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on record review, policy review and staff interview, it was determined the nursing staff :

1. failed to appropriately conduct a skin assessment of a patient for (5) days, failed to implement immediate interventions, failed to consult the wound care nurse for (2) days following the discovery of the wounds and/or upon admission of a patient with known skin breakdown (7 days after admission), causing a delay in treatment and the possibly causing further skin damage and deterioration in the patients health. (Refer to A-395)

2. failed to document the RN initiating and verifying the PCA or assessing the patient's status prior to initiation. ( Refer to A-395 and A-405)

3. failed to appropriately monitor Intravenous sites, failed to provide a sanitary equipment to facilitate wound healing, and failed provide assessments/reassessments of the patient by an RN or provide RN supervision of patient care for several days. This has a potential for an increase in infection both from the patient's feet and IV site which could lead to deterioration of the patient's health and well- being. (Refer to A-395)

4. failed to provide of a RN assessment on admission, delayed a transfer to the Intensive Care Unit (ICU) with implementation of critical care medications such as the Nitro drip and Lopressor, did not administered critical medications as ordered by the physician, did not follow ICU policy of checking the dose and pump setting with two ICU staff nurses to ensure accuracy, and did not use the services if the Rapid response team (RRT) on 3 North for a patient that experienced a significant life threatening change in condition. (Refer to A-395)

5. failed to reassess; monitor or intervene for a patient who was at a critical low blood sugar of "50". There was no documentation of a RN assessment/co-signature for the LPN assessment. (Refer to A-395)

6. failed to provide an assessment of patient on 10/23/12 for the 7P-7A shift. The RN failed to assess the patient with a change of condition related to an increased heart rate and later in the shift related to breath sounds. There was a delay in providing nursing care by not assessing the patient at the time of the changes in condition for a patient that experienced a significant life threatening change in condition. (Refer to A-395)

7. failed to document any assessment/co-signature or interaction from the RN prior to the patient going to ICU. ( Refer to A-395)

8. failed to provide nursing care in response of a critical low oxygen saturation level of 65% in a timely manner. There was no evidence of Respiratory Therapy (RT) responding to the request for RT. The nursing staff failed to ensure the physician ordered IV fluid and Sodium Bicarbonate was initiated on arrival to 3 North in a patient with metabolic acidosis. (Refer to A-395)

9. The facility failed to provide adequate supervision and evaluation of 1 (#A) of one non employee licensed registered nurse. This practice does not provide for the safe delivery of nursing care and services that may have caused harm to a patient. Nurse #A failed to administer critical medications as ordered by the physician and did not follow ICU policy of checking the dose and pump setting with two ICU staff nurses to ensure accuracy. (Refer to A-395; A-398 and A-405).

The cumulative effect of the failure of the Nursing Staff to appropriately assess and evaluate the needs of the patient, failure to follow physician orders, notify the registered nurse and physician of changes in condition, failure to administer medications as ordered, failure to initiate the Rapid Response Team and delays in patient treatments have resulted in the determination the facility is out of compliance with the Condition of Participation for Nursing Services.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review, policy review and staff interviews it was determined the facility failed to ensure enough staff was available for 2 of 2 Medical/Surgical units in the facility and to ensure the immediate availability of a registered nurse for bedside care for 8 (#1,#5, #6, #7, #8,#9, #10 & #11) of 13 sampled patients. The continued use of this practice does not ensure safe patient care as demonstrated in sample records.
Findings include:

1. Patient #1 presented to the Emergency department (ED) on 8/12/12. The patient was evaluated by the ED physician at 7:10 pm with a chief complaint of weakness. The ED Physicians impression was urosepsis and septic encepholopathy. The ED Physician noted that present on admission was a vascular/urinary catheter associated infection and bed sores (decubiti).

A review of patient #1's nursing documentation, revealed from 8/13/12 to 8/17/12 nursing documented the skin assessment as within normal limits (WNL). On 8/17/12 at 7:30 am a nursing assessment revealed the patient had (2) pressure ulcers on his sacral and coccyx areas. He also had ecchymotic areas to both heels, left knee and bilateral buttocks and the perineal area was excoriated. The wound care nurse was consulted on 8/19/12 at 1:20 pm (2 days later) and assessed the patient the same day at 3:45 pm.

Further review of patient #1's clinical record revealed the patient was assessed by an Licensed Practical Nurse on 8/17/12 on both 7:00 am to 7:00 pm and 7:00 pm to 7:00 am shifts. There is no documentation of a RN completing an assessment or co-signing the LPN assessments for either shifts.

A review of the "assessment and reassessment" policy, policy # 200, approved 1/31/12, revealed under scope: the assessment process will be a continuous, collaborative effort with all the health care members functioning as a team. the registered nurse, initially assesses the patients needs for care in all settings where patient care is provide. On page 3, section #5c. Skin integrity- all patients are assessed on admission for pressure ulcer risk using the skin integrity scale . Page 4, section 8c., Reassessments: at least one assessment/reassessment should be conducted by a Registered Nurse per calendar day.

Interviews were conducted on 10/24/12 from 10:30 am to 12:00 pm with the Nursing staff of the Medical/Surgical units. During the interviews the staff was questioned on the skin assessments, identifying pressure ulcers, and the process/procedures for treating the patient with skin breakdown. The staff responded that patients are assessed on admission and every shift for skin breakdown. That if a patient has any skin breakdown or potential for skin breakdown than the wound care nurse is consulted immediately. The wound care nurse evaluates the patient within 24 hours and makes recommendations for treatment. If a patient is felt to be a potential candidate for skin breakdown than the nursing staff initiates frequent every 2 hour turning schedule for the patient.


2. Patient #5 was admitted to the Medical/Surgical unit on 10/23/12 after a total knee Arthroscopy surgery. A review of the "Anesthesiology Patient Control Analgesia (PCA) orders" dated 10/23/12 at 11:30 am revealed a PCA for Morphine Sulfate was ordered for the patient. At the top of the order form is written "319",indicating the patient was on 3 north room 319.

A review of the Medication Administration Record (MAR) revealed the PCA had been initiated on 10/23/12 at 12:33 pm. Further review of the Nursing documentation on 10/23/12 revealed a Licensed Practical Nurse had initiated the PCA Morphine pump at approximately 12:20 pm.

A review of the facility's policy, " Medication Administration Patient Controlled Analgesia (PCA),policy # MM 430, reviewed/revised on 9/11,revealed under scope of responsibility;
1. A registered nurse (RN) must program the PCA settings
2. Any licensed nurse may double check the setting
3. any licensed nurse may monitor the PCA device and patient status.

Further review of patient #5's clinical record, medication administration records and nursing documentation did not reveal any RN documentation of initiating and verifying the PCA or assessing the patients status prior to initiation.

Interviews were conducted on 10/24/12 from 10:30 am to 12:00 pm with the Nursing staff of the Medical/Surgical units. The Medical/Surgical Nursing staff (consisting of both LPN's and RN's) were questioned concerning the initiation of the PCA pumps. They responded that the RN reviews the physician orders, assesses the patient, sets up and initiates the PCA pump with a RN or LPN verifying the settings.

3. Patient #6 was admitted to the Medical/Surgical unit on 10/14/12 for wound care to both lower extremities. A review of the patient's clinical record, nursing assessments revealed the LPN completed the patients assessments on 10/20 to 10/22 and 10/24 to 10/27/12. There was no documentation the RN co-signed and/or supervised the LPN's assessments of the patient for these dates. An observation of patient #6 was made on 10/25/12 at approximately 11:00 am. During the observation it was noted the protective boots used to float the patients heels were soiled with yellow drainage and the patients intravenous left forearm (IV) site insertion date was 10/21/12 (outdated per policy), the intravenous site on the right forearm was not marked with an insertion date. The Medical/Surgical manager and the patients nurse were both at the bedside during this observation and confirmed these with the surveyor.


4. Patient #7's History and Physical revealed the patient was admitted with post [DIAGNOSES REDACTED] CVA on 10/15/12 to 3N after being transferred from another acute care facility. The documentation noted the patient was non-verbal, unable to make his needs know and had peg tube for nutrition.

Review of the nursing flow sheet dated 10/20/12 for the 7A-7P shift noted a LPN completed the nursing assessment as well as for the 10/20/12 7P-7A. On 10/21/12 on the 7A-7P shift a LPN complete the assessment.

Interview on 10/29/12 with the Chief Nursing Officer, Director of Quality and the Risk Manager revealed on 10/20/12 one LPN was now a RN but a computer issue showed her as a LPN.

On 10/23/12 at 9:16 a.m. a RN assessment was completed that revealed the patient's breath sounds remained decreased and coarse. On the 7P-7A shift on 10/23/12 a LPN was assigned to the patient. The LPN did not complete an assessment. Review of the vital signs dated 10/24/12 at 12:09 a.m. revealed a heart rate of 92, respiratory rate of 24, blood pressure 138/72 and an oxygen saturation of 96%.

Review of the nursing flow sheet revealed on 10/24/12 at 12:59 a.m. the monitor technician notified the nurse of an increased heart rate in the 130s. The documentation did not reveal if the LPN caring for the patient was notified or another nurse was notified of the findings. There was no evidence of the LPN assigned to the patient or a RN assessing the patient for the increased heart rate. The Patient Care Technician (PCT) documented at 1:00 a.m. routine patient safety care. The monitor technician documented at 1:53 a.m. that the nurse was notified of cardiac rhythm changes and a code blue was called.

Review of the code blue report revealed the code was called at 1:50 a.m. and the patient was pronounced at 2:07 a.m.

Review of LPN documentation dated 10/24/12 at 8:41 a.m. revealed at 1:15 a.m. he was informed by Respiratory Therapy (RT) the patient's breath sounds were wet and moist and he went to assess the patient. The documentation noted a call was placed to the physician and while waiting for the physician to call back the PCT went to obtain vital signs. The documentation revealed the PCT noted the patient was unresponsive, did not look right and a code blue was called. The documentation did not contain evidence of the nurse's assessment after being notified by the RT of the change in the patient's condition.

Interview with the LPN caring for the patient that night on 10/29/12 at approximately 10:08 a.m. revealed the RN was notified of the change in condition by the LPN. Review of the nursing documentation did not reveal evidence of an assessment by the RN.

Staff interview and clinical record review revealed that nursing failed to provide an assessment of patient on 10/23/12 for the 7P-7A shift. The RN failed to assess the patient with a change of condition related to an increased heart rate and later in the shift related to breath sounds. There was a delay in providing nursing care by not assessing the patient at the time of the changes in condition for a patient that experienced a significant life threatening change in condition.

Various interviews with the Chief Nursing Officer, Risk Manager, Director of Quality, Director of the ICU/ED and the Nurse Information Technologist from 10/26-10/30/12 confirmed the findings.

5. Patient #8 presented to the Emergency Department (ED) on 10/5/12 with a chief complaint of chest pains since the night prior. The history included coronary artery disease with stent placement, diabetes and hypertension. The patient was triaged on 10/5/12 at 12:57 p.m. The vital signs included blood pressure 120/52, heart rate 73. respiratory rate 16, an oxygen saturation of 99% on room air and a pain level of 0 on a scale 0 to 10. Triage documentation noted the patient was alert and oriented. The ED physician examined the patient at 12:50 p.m. The ED physician's impression was chest pain with a history of stents and the patient was stable. ED physician orders revealed a heparin lock was placed. A cardiologist consult was ordered. The plan was to admit the patient. The patient was admitted to 3 North at 3:52 p.m.

The cardiology consult dated 10/5/12 revealed the patient was a symptomatic and had a possible myocardial infarction. The plan was for anticoagulation therapy and if intractable pain was present then a cardiac catheterization.

Review of physician admission orders dated 10/5/12 at 2:20 p.m. revealed to admit to telemetry with medications and laboratory and EKG testing.

Review of nursing documentation revealed the admission assessment was completed on 10/5/12 at 5:28 p.m. by a Licensed Practical Nurse (LPN). Vital signs at 6:05 p.m. were heart rate 72, respiratory rate 22, blood pressure 141/81 and an oxygen saturation level of 89% on room air. There was no evidence of a Registered Nurse (RN) assessment or the LPN reporting the findings, including the oxygen saturation of 89% to the RN. LPN documentation at 6:40 p.m. revealed the patient complained of chest pain of eight out of ten, the physician was called and orders were received for a Nitro (Nitroglycerine) drip and a transfer to the Intensive Care Unit (ICU) STAT. The documentation revealed the house supervisor was notified of a STAT transfer at 6:45 p.m.. The LPN documented at 6:50 p.m. revealed no one in the ICU would take report after three attempts. The patient was wheeled down to ICU and bedside report was given due to the patient's condition not being stable. There was no evidence the RN was advised of the patient's condition or the patient being assessed.

Physician verbal orders dated 10/5/12 at 6:40 p.m. ordered a Nitroglycerine drip at 0.25 micrograms, Lopressor 50 milligrams (mg) now and to transfer to the ICU. There was no route ordered for the Lopressor.

Review of the nursing flow sheet for transfer/discharge date d 10/5/12 at 7:00 p.m. revealed the patient was transferred to the Intensive Care Unit (ICU) accompanied by the LPN, monitor and IV equipment. The documentation noted report was given at the bedside to the agency ICU nurse. The ICU agency nurse documented at 7:10 p.m. the patient was transferred to ICU due to severe chest pain at an eight out of ten and possible pulmonary edema.

The vital signs at 7:10 p.m. were heart rate 153, respiratory rate 28, blood pressure 230/110 and an oxygen saturation of 87% on 2 liters of oxygen. At 7:18 p.m. the vital signs were heart rate 156, blood pressure 212/100 and an oxygen saturation of 88% At 7:19 p.m. the ICU agency nurse initiated a code blue due to the patient being unresponsive and with respiratory distress.

Review of the Code Blue record revealed the patient coded at 7:30 p.m. and expired at 7:57 p.m.

Review of ICU agency nurse documentation dated 10/5/12 at 9:00 p.m. revealed the patient was admitted to the ICU in transfer at 7:50 p.m. with chest pain, respiratory distress, mottled and hypertensive. The documentation noted the Nitro drip was started at 33 micrograms and increased to 100 micrograms due to chest pain and increased blood pressure. The documentation noted the Lopressor was also given intravenously (IV). The documentation noted a code blue was called at 7:19 p.m. The ICU agency nurse documented the Nitro drip was turned off at 7:23 p.m. There was no actual time the Nitro drip was initiated or the Lopressor given. Review of the physician orders and nursing documentation revealed there was no titration order for the Nitro drip or to initiate the drip at 33 micrograms or give the Lopressor IV. The ICU agency nurse's documentation at 9:00 p.m. contain conflicting times of care.

Confidential staff interviews on 10/26/12 and 10/27/12 revealed the intravenous (IV) pump was set at a rate of 100 milliliter per hour for the Nitro drip. The IV fluid pump was set at 10 milliliters per hour. The interviews revealed the agency nurse may have reversed the setting on the pump. The interviews revealed that is what the staff RN saw when the staff RN walked over to the patient' bedside to assist when the patient deteriorated.

Interview with two staff ICU RNs on 10/28/12 at approximately 3:45 p.m. and 4:50 p.m. revealed it is the their policy to have two nurses check the dose and pump setting for all drips. There was no evidence this occurred for patient #8.

Review of policy and procedure "Rapid Response Team Code Purple" #PC 800 reviewed 1/10 revealed a purpose that indicated the Rapid Response Team (RRT) had been shown to reduce morbidity and mortality rates in hospitals. The RRT help improve the staff nurse's critical thinking. Under the section for Procedures the policy indicated staff members and patient, families or visitors concerned about a patient's status may call the RRT line. It stated the RRT has orders that have been approved by the medical staff that may be initiated including Nitroglycerine IV fluids.

Staff interview and clinical record review revealed that nursing failed to provide of a RN assessment on admission, delayed a transfer to ICU with implementation of critical care medications such as the Nitro drip and Lopressor, did not administered critical medications as ordered by the physician, did not follow ICU policy of checking the dose and pump setting with two ICU staff nurses to ensure accuracy, and did not use the services if the RRT on 3 North for a patient that experienced a significant life threatening change in condition.

Various interviews with the Chief Nursing Officer, Risk Manager, Director of Quality, Director of the ICU/ED and the Nurse Information Technologist from 10/26-10/30/12 confirmed the findings.

6. Patient #9 was admitted to the Medical/Surgical (3S) unit on 10/25/12 for persistent nausea and vomiting. The admitting physicians initial impression was end-stage renal disease, massive upper gastrointestinal bleeding, hypertension, ascites and hypotension. On 10/25/12 at 2:00 pm the physician ordered the patient's blood sugar levels to be monitored every 4 hours. A review of the clinical record for 10/25/12 at 4:41 pm revealed the patients blood sugar was "50" documented by the LPN. The next blood sugar was obtained by the RN at 9:18 pm ( almost 5 hours later and was documented as "35". There was no documentation of any interventions for the blood sugar of 50 and no further monitoring of the blood sugar for almost 5 hours. There is also no evidence that a RN co-signed or assessed the patient during the time the patient was taking care of the patient. Further review of patient #9's clinical record revealed the RN from the 7:00 pm to 7:00 am shift documented her assessments and interventions after her shift was completed at 10:46 am.

7. Patient #10 presented to the emergency department (ED) on 10/23/12 at 7:38 pm. The patient was assessed by the ED Physician at 7:53 pm for cough, congestion with a thick sputum. The physicians diagnosis was Dyspnea with productive cough , [DIAGNOSES REDACTED]and hypertension. The patient was admitted to the Medical/Surgical unit on 10/24/12 at 3:06 am. A review of the nursing documentation revealed a LPN assessed the patient on 10/24/12 at 11:32 am; the patient was transferred to the intensive care unit (ICU) at 2:33 pm. There is no documentation of any assessment/co-signature or interaction from the RN prior to the patient going to ICU.

8. Patient #11 (MDS) dated [DATE] with a chief complaint of fecal impaction for 5 days. The triage vital signs were heart rate 71, respiratory rate 16, blood pressure 126/58, and an oxygen saturation of 99% on room air. Review of the ED physician documentation dated 10/10/12 revealed the patient had been constipated for 5 days with abdominal pain and nausea. The documentation noted a history of Alzheimer and dementia. Review of the abdominal CT scan revealed a fecal impaction and moderate gas. Review of blood study results noted a critical CO2 (carbon dioxide) level of 8 (22-32). Review of the critical value report revealed the critical value was called at 2:01 p.m. to the staff. The ED physician's impression was fecal impaction, metabolic acidosis and renal insufficiency. The plan was to admit to telemetry. The patient left the ED to 3N on 10/10/12 at 6:23 p.m. The vital signs at 6:23 were heart rate 95, respiratory rate 23, blood pressure 105/65 and an oxygen saturation of 91% on two liters of oxygen.

Review of verbal admission physician orders dated 10/10/12 at 5:19 p.m. included IV fluids of ? Normal Saline with one amp of Sodium Bicarbonate at 70 milliliters (ml) per hour and a tap water enema upon arrival to floor.

Documentation at 7:33 p.m. revealed the vital signs obtained by the PCT were heart rate 76, respiratory rate 16, blood pressure 98/72 and an oxygen saturation level of 65% on 3 liters of oxygen. Nursing assessment dated [DATE] at 7:45 p.m. revealed it was performed by the RN. The assessment noted the patient responded to deep pain and was non-verbal. The respirations were shallow and the patient was pale. The documentation revealed Normal Saline at 100 milliliters was infusing via the IV.

RN nursing documentation dated 10/11/12 at 2:30 a.m. revealed the RN request RT at the bedside at 7:45 p.m. Review of the Code Blue form revealed a code was called on 10/10/12 at 8:07 p.m. and the patient expired at 8:27 p.m.

Staff interview and clinical record review revealed that nursing failed to provide nursing care in response of a critical low oxygen saturation level of 65% in a timely manner. There was no evidence of RT responding to the request. The nursing staff failed to ensure the physician ordered IV fluid and Sodium Bicarbonate was initiated on arrival to 3 North in a patient with metabolic acidosis.

Various interviews with the Chief Nursing Officer, Risk Manager, Director of Quality, Director of the ICU/ED and the Nurse Information Technologist from 10/26-10/30/12 confirmed the findings.


A review of the facility's policy, "Staff Assignments", policy # ADM 606, reviewed 1/10, revealed under Policy: There will be a sufficient number of qualified Registered Nurses on duty at all times to meet the needs of the patients. Nursing Personnel staffing is sufficient to assure prompt recognition of any untoward change in a patient's condition and to facilitate appropriate interventions. A registered nurse plans, supervises and evaluates the nursing care plan. A registered nurse makes a patient assessment before delegating any aspects of nursing care.

Interviews were conducted on 10/24/12 from 10:30 am to 12:00 pm with the Nursing staff of the Medical/Surgical units. The Medical/Surgical Nursing staff (consisting of both LPN's and RN's) were questioned concerning staffing issues, acuity levels and RN/LPN assessments. The staff responded that some were frustrated with the work load. The RN's are assigned 6 to 7 patients and are assigned to cover a LPN. Which to them in essence is 12 to 14 patients to be assessed during a 12 hour shift. The RN responsibility to the LPN' patients is to do the admission assessment, every 24 hour assessment, any change in condition, push IV medications, etc. The RN's that were interviewed shared they "attempt" to see everyone of the LPN's patients but with the acuity of the patients most of the time they can't see everyone. When questioned concerning the co-signing of the assessments, both RN and LPN's responded that sometimes they only have time to sign off the assessments. One LPN shared that since she is IV certified she usually just does her own assessments, IV push medications and setting up the PCA pumps.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and policy, procedure and clinical record reviews it was determined the Registered Nurse failed to supervise and evaluate nursing care to patients experiencing a significant change in condition requiring immediate critical nursing invention, skin care needs,assessments and adhering to policies and procedures for 8 (#1,#5, #6, #7, #8,#9, #10 & #11) of 13 sampled records. This practice may cause a prolonged hospital stay and does not ensure patient goals are met. This practice may have caused potential harm, including death, to patients.

Findings include:

1. Patient #1 presented to the Emergency department(ED) on 8/12/12. The patient was evaluated by the ED physician at 7:10 pm with a chief complaint of weakness. The ED Physicians impression was urosepsis and septic encepholopathy. The ED Physician noted that present on admission was a vascular/urinary catheter associated infection and bed sores (decubiti).

A review of patient #1's nursing documentation, revealed from 8/13/12 to 8/17/12 nursing documented the skin assessment as within normal limits (WNL).On 8/17/12 at 7:30 am a nursing assessment revealed the patient had (2) pressure ulcers on his sacral and coccyx areas. He also had ecchymotic areas to heels, left knee and bilateral buttocks and the perineal area was excoriated. The wound care nurse was consulted on 8/19/12 at 1:20 pm (2 days later) and assessed the patient the same day at 3:45 pm.

Further review of patient #1's clinical record revealed the patient was assessed by an Licensed Practical Nurse on 8/17/12 on both 7:00 am to 7:00 pm and 7:00 pm to 7:00 am shifts. There is no documentation of a RN completing an assessment or co-signing the LPN assessments for either shifts.

A review of the "assessment and reassessment" policy, policy # 200, approved 1/31/12, revealed under scope: the assessment process will be a continuous, collaborative effort with all the health care members functioning as a team. the registered nurse, initially assesses the patients needs for care in all settings where patient care is provide. On page 3, section #5c. Skin integrity- all patients are assessed on admission for pressure ulcer risk using the skin integrity scale . Page 4, section 8c., Reassessments: at least one assessment/reassessment should be conducted by a Registered Nurse per calendar day.

Interviews were conducted on 10/24/12 from 10:30 am to 12:00 pm with the Nursing staff of the Medical/Surgical units. During the interviews the staff was questioned on the skin assessments, identifying pressure ulcers, and the process/procedures for treating the patient with skin breakdown. The staff responded that patients are assessed on admission and every shift for skin breakdown. That if a patient has any skin breakdown or potential for skin breakdown than the wound care nurse is consulted immediately. The wound care nurse evaluates the patient within 24 hours and makes recommendations for treatment. If a patient is felt to be a potential candidate for skin breakdown than the nursing staff initiates frequent every 2 hour turning schedule for the patient.

After review of the clinical record, policy review and interviews it was determined that nursing failed to appropriately conduct a skin assessment of the patient for (5) days, failed to implement immediate interventions, failed to consult the wound care nurse for (2) days following the discovery of the wounds and/or upon admission of a patient with known skin breakdown (7 days after admission), causing a delay in treatment and the possibly causing further skin damage and deterioration in the patients health.

2. Patient #5 was admitted to the Medical/Surgical unit on 10/23/12 after a total knee Arthroscopy surgery. A review of the "Anesthesiology Patient Control Analgesia (PCA) orders" dated 10/23/12 at 11:30 am revealed a PCA for Morphine Sulfate was ordered for the patient. At the top of the order form is written "319",indicating the patient was on 3 north room 319.

A review of the Medication Administration Record (MAR) revealed the PCA had been initiated on 10/23/12 at 12:33 pm. Further review of the Nursing documentation on 10/23/12 revealed a Licensed Practical Nurse had initiated the PCA Morphine pump at approximately 12:20 pm.

A review of the facility's policy, " Medication Administration Patient Controlled Analgesia (PCA),policy # MM 430, reviewed/revised on 9/11,revealed under scope of responsibility;
1. A registered nurse (RN) must program the PCA settings
2. Any licensed nurse may double check the setting
3. any licensed nurse may monitor the PCA device and patient status.

Further review of patient #5's clinical record, medication administration records and nursing documentation did not reveal any RN documentation of initiating and verifying the PCA or assessing the patient ' s status prior to initiation.

Interviews were conducted on 10/24/12 from 10:30 am to 12:00 pm with the Nursing staff of the Medical/Surgical units. The Medical/Surgical Nursing staff (consisting of both LPN ' s and RN ' s) was questioned concerning the initiation of the PCA pumps. They responded that the RN reviews the physician orders, assesses the patient, sets up and initiates the PCA pump with a RN or LPN verifying the settings.

3. Patient #6 was admitted to the Medical/Surgical unit on 10/14/12 for wound care to both lower extremities. A review of the patient's clinical record, nursing assessments revealed the LPN completed the patient ' s assessments on 10/20 to 10/22 and 10/24 to 10/27/12. There was no documentation the RN co-signed and/or supervised the LPN's assessments of the patient for these dates. An observation of patient #6 was made on 10/25/12 at approximately 11:00 am. During the observation it was noted the protective boots used to float the patients heels were soiled with yellow drainage and the patients intravenous left forearm (IV) site insertion date was 10/21/12 (outdated per policy), the intravenous site on the right forearm was not marked with an insertion date. The Medical/Surgical manager and the patients nurse were both at the bedside during this observation and confirmed these with the surveyor.

The facility staff failed to appropriately monitor Intravenous sites, failed to provide a sanitary equipment to facilitate wound healing, and failed provide assessments/reassessments of the patient by an RN or provide RN supervision of patient care for several days. This has a potential for an increase in infection both from the patient ' s feet and IV site which could lead to deterioration of the patient ' s health and well- being.

4. Patient #7's History and Physical revealed the patient was admitted with post [DIAGNOSES REDACTED] CVA on 10/15/12 to 3N after being transferred from another acute care facility. The documentation noted the patient was non-verbal, unable to make his needs know and had peg tube for nutrition.

Review of the nursing flow sheet dated 10/20/12 for the 7A-7P shift noted a LPN completed the nursing assessment as well as for the 10/20/12 7P-7A. On 10/21/12 on the 7A-7P shift a LPN complete the assessment.

Interview on 10/29/12 with the Chief Nursing Officer, Director of Quality and the Risk Manager revealed on 10/20/12 one LPN was now a RN but a computer issue showed her as a LPN.

On 10/23/12 at 9:16 a.m. a RN assessment was completed that revealed the patient's breath sounds remained decreased and coarse. On the 7P-7A shift on 10/23/12 a LPN was assigned to the patient. The LPN did not complete an assessment. Review of the vital signs dated 10/24/12 at 12:09 a.m. revealed a heart rate of 92, respiratory rate of 24, blood pressure 138/72 and an oxygen saturation of 96%.

Review of the nursing flow sheet revealed on 10/24/12 at 12:59 a.m. the monitor technician notified the nurse of an increased heart rate in the 130s. The documentation did not reveal if the LPN caring for the patient was notified or another nurse was notified of the findings. There was no evidence of the LPN assigned to the patient or a RN assessing the patient for the increased heart rate. The Patient Care Technician (PCT) documented at 1:00 a.m. routine patient safety care. The monitor technician documented at 1:53 a.m. that the nurse was notified of cardiac rhythm changes and a code blue was called.

Review of the code blue report revealed the code was called at 1:50 a.m. and the patient was pronounced at 2:07 a.m.

Review of LPN documentation dated 10/24/12 at 8:41 a.m. revealed at 1:15 a.m. he was informed by Respiratory Therapy (RT) the patient's breath sounds were wet and moist and he went to assess the patient. The documentation noted a call was placed to the physician and while waiting for the physician to call back the PCT went to obtain vital signs. The documentation revealed the PCT noted the patient was unresponsive, did not look right and a code blue was called. The documentation did not contain evidence of the nurse's assessment after being notified by the RT of the change in the patient's condition.

Interview with the LPN caring for the patient that night on 10/29/12 at approximately 10:08 a.m. revealed the RN was notified of the change in condition by the LPN. Review of the nursing documentation did not reveal evidence of an assessment by the RN.

Staff interview and clinical record review revealed that nursing failed to provide an assessment of patient on 10/23/12 for the 7P-7A shift. The RN failed to assess the patient with a change of condition related to an increased heart rate and later in the shift related to breath sounds. There was a delay in providing nursing care by not assessing the patient at the time of the changes in condition for a patient that experienced a significant life threatening change in condition.

Various interviews with the Chief Nursing Officer, Risk Manager, Director of Quality, Director of the ICU/ED and the Nurse Information Technologist from 10/26-10/30/12 confirmed the findings.
Patient #7 was admitted status post CVA on 10/15/12 to 3N with a physicians order for telemetry.
Review of the nursing flow sheet revealed on 10/24/12 at 12:59 a.m. the monitor technician notified the nurse of an increased heart rate in the 130s. The monitor technician documented at 1:53 a.m. the nurse was notified of cardiac rhythm changes and a code blue was called.
Review of the policy and procedure" Monitoring of Telemetry Patients", # PC359 reviewed 5/13/12 revealed if the monitor technician noted an abnormal rhythm, the technician would obtain a rhythm strip. Under section Procedure #7 indicated the Monitor technician will document a rhythm strip every four hours and place on the telemetry form.

Review of the clinical record with the Risk Manager, Director of Quality and the Nurse Information Technologist on 10/26/12 and 10/27/12 revealed no evidence of rhythm strips in the record.

5. Patient #8 presented to the Emergency Department (ED) on 10/5/12 with a chief complaint of chest pains since the night prior. The history included coronary artery disease with stent placement, diabetes and hypertension. The patient was triaged on 10/5/12 at 12:57 p.m. The vital signs included blood pressure 120/52, heart rate 73. respiratory rate 16, an oxygen saturation of 99% on room air and a pain level of 0 on a scale 0 to 10. Triage documentation noted the patient was alert and oriented. The ED physician examined the patient at 12:50 p.m. The ED physician ' s impression was chest pain with a history of stents and the patient was stable. ED physician orders revealed a heparin lock was placed. A cardiologist consult was ordered. The plan was to admit the patient. The patient was admitted to 3 North at 3:52 p.m.

The cardiology consult dated 10/5/12 revealed the patient was a symptomatic and had a possible myocardial infarction. The plan was for anticoagulation therapy and if intractable pain was present then a cardiac catheterization.

Review of physician admission orders dated 10/5/12 at 2:20 p.m. revealed to admit to telemetry with medications and laboratory and EKG testing.

Review of nursing documentation revealed the admission assessment was completed on 10/5/12 at 5:28 p.m. by a Licensed Practical Nurse (LPN). Vital signs at 6:05 p.m. were heart rate 72, respiratory rate 22, blood pressure 141/81 and an oxygen saturation level of 89% on room air. There was no evidence of a Registered Nurse (RN) assessment or the LPN reporting the findings, including the oxygen saturation of 89% to the RN. LPN documentation at 6:40 p.m. revealed the patient complained of chest pain of eight out of ten, the physician was called and orders were received for a Nitro (Nitroglycerine) drip and a transfer to the Intensive Care Unit (ICU) STAT. The documentation revealed the house supervisor was notified of a STAT transfer at 6:45 p.m.. The LPN documented at 6:50 p.m. revealed no one in the ICU would take report after three attempts. The patient was wheeled down to ICU and bedside report was given due to the patient's condition not being stable. There was no evidence the RN was advised of the patient's condition or the patient being assessed.

Physician verbal orders dated 10/5/12 at 6:40 p.m. ordered a Nitroglycerine drip at 0.25 micrograms, Lopressor 50 milligrams (mg) now and to transfer to the ICU. There was no route ordered for the Lopressor.

Review of the nursing flow sheet for transfer/discharge date d 10/5/12 at 7:00 p.m. revealed the patient was transferred to the Intensive Care Unit (ICU) accompanied by the LPN, monitor and IV equipment. The documentation noted report was given at the bedside to the agency ICU nurse. The ICU agency nurse documented at 7:10 p.m. the patient was transferred to ICU due to severe chest pain at an eight out of ten and possible pulmonary edema.

The vital signs at 7:10 p.m. were heart rate 153, respiratory rate 28, blood pressure 230/110 and an oxygen saturation of 87% on 2 liters of oxygen. At 7:18 p.m. the vital signs were heart rate 156, blood pressure 212/100 and an oxygen saturation of 88% At 7:19 p.m. the ICU agency nurse initiated a code blue due to the patient being unresponsive and with respiratory distress.

Review of the Code Blue record revealed the patient coded at 7:30 p.m. and expired at 7:57 p.m.

Review of ICU agency nurse documentation dated 10/5/12 at 9:00 p.m. revealed the patient was admitted to the ICU in transfer at 7:50 p.m. with chest pain, respiratory distress, mottled and hypertensive. The documentation noted the Nitro drip was started at 33 micrograms and increased to 100 micrograms due to chest pain and increased blood pressure. The documentation noted the Lopressor was also given intravenously (IV). The documentation noted a code blue was called at 7:19 p.m. The ICU agency nurse documented the Nitro drip was turned off at 7:23 p.m. There was no actual time the Nitro drip was initiated or the Lopressor given. Review of the physician orders and nursing documentation revealed there was no titration order for the Nitro drip or to initiate the drip at 33 micrograms or give the Lopressor IV. The ICU agency nurse's documentation at 9:00 p.m. contain conflicting times of care.

Confidential staff interviews on 10/26/12 and 10/27/12 revealed the intravenous (IV) pump was set at a rate of 100 milliliter per hour for the Nitro drip. The IV fluid pump was set at 10 milliliters per hour. The interviews revealed the agency nurse may have reversed the setting on the pump. The interviews revealed that is what the staff RN saw when the staff RN walked over to the patient' s bedside to assist when the patient deteriorated.

Interview with two staff ICU RNs on 10/28/12 at approximately 3:45 p.m. and 4:50 p.m. revealed it is the their policy to have two nurses check the dose and pump setting for all drips. There was no evidence this occurred for patient #8.

Review of policy and procedure "Rapid Response Team Code Purple" #PC 800 reviewed 1/10 revealed a purpose that indicated the Rapid Response Team (RRT) had been shown to reduce morbidity and mortality rates in hospitals. The RRT help improve the staff nurse's critical thinking. Under the section for Procedures the policy indicated staff members and patient, families or visitors concerned about a patient's status may call the RRT line. It stated the RRT has orders that have been approved by the medical staff that may be initiated including Nitroglycerine IV fluids.

Staff interview and clinical record review revealed that nursing failed to provide of a RN assessment on admission, delayed a transfer to ICU with implementation of critical care medications such as the Nitro drip and Lopressor, did not administered critical medications as ordered by the physician, did not follow ICU policy of checking the dose and pump setting with two ICU staff nurses to ensure accuracy, and did not use the services if the RRT on 3 North for a patient that experienced a significant life threatening change in condition.

Various interviews with the Chief Nursing Officer, Risk Manager, Director of Quality, Director of the ICU/ED and the Nurse Information Technologist from 10/26-10/30/12 confirmed the findings.

6. Patient #9 was admitted to the Medical/Surgical (3S) unit on 10/25/12 for persistent nausea and vomiting. The admitting physicians initial impression was end-stage renal disease, massive upper gastrointestinal bleeding, hypertension, ascites and hypotension. On 10/25/12 at 2:00 pm the physician ordered the patient's blood sugar levels to be monitored every 4 hours. A review of the clinical record for 10/25/12 at 4:41 pm revealed the patients blood sugar was "50" documented by the LPN. The next blood sugar was obtained by the RN at 9:18 pm ( almost 5 hours later and was documented as "35". There was no documentation of any interventions for the blood sugar of 50 and no further monitoring of the blood sugar for almost 5 hours. There is also no evidence that a RN co-signed or assessed the patient during the time the patient was taking care of the patient. Further review of patient #9's clinical record revealed the RN from the 7:00 pm to 7:00 am shift documented her assessments and interventions after her shift was completed at 10:46 am.

It was determined that nursing did not reassess; monitor or intervene for a patient who was at a critical low blood sugar of "50". There was no documentation of a RN assessment/co-signature for the LPN assessment.

7. Patient #10 presented to the emergency department (ED) on 10/23/12 at 7:38 pm. The patient was assessed by the ED Physician at 7:53 pm for cough, congestion with a thick sputum. The physicians diagnosis was Dyspnea with productive cough , [DIAGNOSES REDACTED]and hypertension. The patient was admitted to the Medical/Surgical unit on 10/24/12 at 3:06 am. A review of the nursing documentation revealed a LPN assessed the patient on 10/24/12 at 11:32 am; the patient was transferred to the intensive care unit (ICU) at 2:33 pm.
There is no documentation of any assessment/co-signature or interaction from the RN prior to the patient going to ICU.


6. Patient #11 (MDS) dated [DATE] with a chief complaint of fecal impaction for 5 days. The triage vital signs were heart rate 71, respiratory rate 16, blood pressure 126/58, and an oxygen saturation of 99% on room air. Review of the ED physician documentation dated 10/10/12 revealed the patient had been constipated for 5 days with abdominal pain and nausea. The documentation noted a history of Alzheimer and dementia. Review of the abdominal CT scan revealed a fecal impaction and moderate gas. Review of blood study results noted a critical CO2 (carbon dioxide) level of 8 (22-32). Review of the critical value report revealed the critical value was called at 2:01 p.m. to the staff. The ED physician's impression was fecal impaction, metabolic acidosis and renal insufficiency. The plan was to admit to telemetry. The patient left the ED to 3N on 10/10/12 at 6:23 p.m. The vital signs at 6:23 were heart rate 95, respiratory rate 23, blood pressure 105/65 and an oxygen saturation of 91% on two liters of oxygen.

Review of verbal admission physician orders dated 10/10/12 at 5:19 p.m. included IV fluids of ? Normal Saline with one amp of Sodium Bicarbonate at 70 milliliters (ml) per hour and a tap water enema upon arrival to floor.

Documentation at 7:33 p.m. revealed the vital signs obtained by the PCT were heart rate 76, respiratory rate 16, blood pressure 98/72 and an oxygen saturation level of 65% on 3 liters of oxygen. Nursing assessment dated [DATE] at 7:45 p.m. revealed it was performed by the RN. The assessment noted the patient responded to deep pain and was non-verbal. The respirations were shallow and the patient was pale. The documentation revealed Normal Saline at 100 milliliters was infusing via the IV.

RN nursing documentation dated 10/11/12 at 2:30 a.m. revealed the RN request RT at the bedside at 7:45 p.m. Review of the Code Blue form revealed a code was called on 10/10/12 at 8:07 p.m. and the patient expired at 8:27 p.m.

Staff interview and clinical record review revealed that nursing failed to provide nursing care in response of a critical low oxygen saturation level of 65% in a timely manner. There was no evidence of RT responding to the request. The nursing staff failed to ensure the physician ordered IV fluid and Sodium Bicarbonate was initiated on arrival to 3 North in a patient with metabolic acidosis.

Various interviews with the Chief Nursing Officer, Risk Manager, Director of Quality, Director of the ICU/ED and the Nurse Information Technologist from 10/26-10/30/12 confirmed the findings.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on clinical record review, policy review and staff interview it was determined the facility failed to keep one (#6) of 13 patients reviewed plan of care current for skin integrity.

Findings include:

Patient # 6 was admitted to the Medical/Surgical Unit on 10/14/12 for wound care to both lower extremities. The patients history included coronary artery disease and dementia. A review of the Interdisplinary Plan of Care revealed the skin integrity focus was initiated on 10/15/12. The intervention is to monitor skin integrity and the desired outcomes was for the skin to remain intact. Further review of the Plan of Care; daily evaluation sections was not initialed from 10/21/12 to 10/27/12.
The Director of Quality confirmed the findings on 10/27/12 at approximately 4:00 pm.

A review of the facility policy, " Assessment and Reassessment", policy # 200, approved 1/31/12, page 3, paragraph 7b, revealed "all current problems are reviewed with the patient/family and are addressed at least daily in the patients medical record.
VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
Based on interviews and review of policy, procedures, orientation forms and clinical records it was determined the facility did not ensure non employee licensed nurses adhered to Intensive Care Unit polices and procedure, were oriented to the unit and care provided was evaluated. The facility failed to provide adequate supervision and evaluation of 1 (#A) of one non employee licensed registered nurse. This practice does not provide for the safe delivery of nursing care and services that may have caused harm to a patient.

Findings include:

1. Patient #8 presented to the Emergency Department (ED) on 10/5/12 with a chief complaint of chest pains. The history included coronary artery disease with stent placement and hypertension. ED physician orders revealed a heparin lock was placed. The patient was admitted to 3 North at 3:52 p.m.

Licensed Practical Nurse (LPN) documentation at 6:40 p.m. revealed the patient complained of chest pain of eight out of ten. Physician verbal orders dated 10/5/12 at 6:40 p.m. ordered a Nitroglycerine drip at 0.25 micrograms, Lopressor 50 milligrams (mg) now and to transfer to the ICU. There was no route ordered for the Lopressor.

Review of the nursing flow sheet for transfer/discharge date d 10/5/12 at 7:00 p.m. revealed the patient was transferred to the Intensive Care Unit (ICU) accompanied by the LPN, monitor and IV equipment. The documentation noted report was given at the bedside to the agency ICU nurse (#A).

The vital signs at 7:10 p.m. were heart rate 153, respiratory rate 28, blood pressure 230/110 and an oxygen saturation of 87% on 2 liters of oxygen. At 7:18 p.m. the vital signs were heart rate 156, blood pressure 212/100 and an oxygen saturation of 88% At 7:19 p.m. the ICU agency nurse initiated a code blue due to the patient being unresponsive and with respiratory distress.

Review of the Code Blue record revealed the patient coded at 7:30 p.m. and expired at 7:57 p.m.

Review of ICU agency nurse (#A)documentation dated 10/5/12 at 9:00 p.m. revealed the patient was admitted to the ICU in transfer at 7:50 p.m. with chest pain, respiratory distress, mottled and hypertensive. The documentation noted the Nitro drip was started at 33 micrograms and increased to 100 micrograms due to chest pain and increased blood pressure. The documentation noted the Lopressor was also given intravenously (IV). The documentation noted a code blue was called at 7:19 p.m. The ICU agency nurse documented the Nitro drip was turned off at 7:23 p.m. There was no actual time the Nitro drip was initiated or the Lopressor given. Review of the physician orders and nursing documentation revealed there was no titration order for the Nitro drip or to initiate the drip at 33 micrograms or give the Lopressor IV. The ICU agency nurse's documentation at 9:00 p.m. contain conflicting times of care.

Confidential staff interviews on 10/26/12 and 10/27/12 revealed the intravenous (IV) pump was set at a rate of 100 milliliter per hour for the Nitro drip. The IV fluid pump was set at 10 milliliters per hour. The interviews revealed the agency nurse may have reversed the setting on the pump. The interviews revealed that is what the staff RN saw when the staff RN walked over to the patient' s bedside to assist when the patient deteriorated.

Interview with two staff ICU RNs on 10/28/12 at approximately 3:45 p.m. and 4:50 p.m. revealed it is the their policy to have two nurses check the dose and pump setting for all drips. There was no evidence this occurred for patient #8.

Staff interview and clinical record review revealed nurse #A failed to administered critical medications as ordered by the physician and did not follow ICU policy of checking the dose and pump setting with two ICU staff nurses to ensure accuracy.

Review of the information file for agency ICU nurse #A revealed a copy of a current RN license, Cardiopulmonary Resuscitation and Advanced Cardiac Life Support certification. There was no evidence of a unit orientation, unit competency skills, or any evaluation of care provided.

Interview with the Risk Manager on 10/30/12 at approximately 9:40 a.m. revealed the facility did not have a copy #A's orientation and could only provide a blank form since it was a Patient Safety Work Produce. She stated the facility did not have a competency form that the staffing agency maintained that information. She indicated the staffing agency does the nurses evaluation and nurse #A was last evaluated on 7/2/11.

The risk manager presented a blank form "Agency Nurse (RN/LPN) orientation Checklist". The form indicated the agency nurse had received two hours of orientation to the unit but had 12 hours to complete the checklist. The form noted all skills must have a return demonstration. The skills included demonstration and safety use of the IV pumps and different types of code procedures. The forms contains an area for unit specific competency to be listed.

Review of policy and procedure "Agency Staff HR Management", no number, reviewed 3/08 indicated the agency nurse was to report to the nursing office two hours prior to working for the first time at the hospital for orientation. The agency nurse would complete the "Nursing Orientation Review Test" The policy stated the agency nurse and the chare nurse/designee would sign off on the Department Orientation Form. The policy indicated at the end of the first shift a performance evaluation would be completed by the supervisor or charge nurse.

Interview with the Risk Manager on 10/30/12 at approximately 9:40 a.m. revealed orientation and evaluation documentation would not be provided due to Patient Safety Work Product.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on staff interview and clinical record reviews it was determined the nursing staff failed to administered medications as ordered by the physician for 4 (#7, #8, #11, #13) of 13 sampled records. This practice does not ensure effective medication therapy, may prolong a hospital stay and may cause harm to patients.

Findings include:

1. Patient #8 was admitted to the 3 North nursing unit for chest pain on 10/5/12 at 5:28 p.m. Licensed Practical Nurse ( LPN) documentation on 10/5/12 at 6:40 p.m. revealed the patient complained of chest pain of eight out of ten on a 0 to 10 scale. Physician verbal orders dated 10/5/12 at 6:40 p.m. ordered a Nitroglycerine (Nitro) drip at 0.25 micrograms, Lopressor 50 milligrams (mg) now and to transfer to the Intensive Care Unit (ICU). There was no route ordered for the Lopressor. There was no evidence of the nurse clarifying the route for the Lopressor.

Review of ICU agency nurse documentation dated 10/5/12 at 9:00 p.m. revealed the Nitro drip was started at 33 micrograms and increased to 100 micrograms. The documentation noted the Lopressor was also given intravenously (IV). There was no documentation of the time the Nitro drip was initiated or the Lopressor given. Review of the physician orders revealed no evidence of a titration order for the Nitro drip or to initiate the drip at 33 micrograms or give the Lopressor IV.

Confidential staff interviews on 10/26/12 and 10/27/12 revealed the patient had intravenous (IV) fluids set at a rate of at 10 milliliters per hour. There was no physician order for the IV fluids.

Various interviews with the Chief Nursing Officer, Risk Manager, Director of Quality, Director of the ICU/ED and the Nurse Information Technologist from 10/26-10/30/12 confirmed the findings.

2. Patient #7's physician order dated 10/20/12 instructed for Solumedrol 60 milligrams (mg) intravenously every 12 hours. Review of the Medication Administration Record (MAR) revealed on 10/21/12 the patient received one dose at 10:04 a.m.

Interviews with the Risk Manager and Director of Quality on 10/26/12 at approximately 3:45 p.m., during the record review, confirmed the findings.

3. Patient #11's blood study results noted a critical CO2 (carbon dioxide) level of 8 (22-32). Review of verbal admission physician orders dated 10/10/12 at 5:19 p.m. included IV fluids of ? Normal Saline with one amp of Sodium Bicarbonate at 70 milliliters (ml) per hour.

Nursing documentation at 7:33 p.m. revealed the patient had arrived to the 3 North nursing unit. Nursing documentation dated 10/10/12 at 7:45 p.m. revealed Normal Saline at 100 milliliters was infusing via the IV. There was no evidence of the IV fluids being administered as ordered.

Various interviews with the Chief Nursing Officer, Risk Manager, Director of Quality, Director of the ICU/ED and the Nurse Information Technologist from 10/27-10/30/12 confirmed the findings.

4. Patient #13's physician orders dated 10/22/12 at 12:01 a.m. ordered Clondine 0.1 mg three times a day. Review of the MAR revealed on 10/23/12 at 5:55 a.m., 10/24/12 at 5:12 a.m. and 10/25/12 at 5:45 a.m. the medication was held due to clinician decision. Review of the MAR and nursing documentation revealed no evidence as to why the clinician made the decision to hold the medication or that the physician was notified.

Interview with the Risk Manager, Director of Quality and the Nurse Information Technologist on 10/30/12 at approximately 2:23 p.m. confirmed the findings.