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.

RIVER PARISHES HOSPITAL 500 RUE DE SANTE LAPLACE, LA March 15, 2012
VIOLATION: MEDICAL STAFF - BYLAWS Tag No: A0047
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the governing body failed to ensure the medical staff followed it bylaws for completion of a patient history and physical (H&P) examination. The physician failed to perform a physical examination to update a H&P that was performed prior to admission for 1 of 8 sampled patients (#3). The physician failed to perform a H&P when a patient's status was changed from observation to inpatient for 1 of 8 sampled patients (#8). Findings:

Patient #3
Review of Patient #3's medical record revealed he was admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #3's "History And Physical" revealed it was performed on 02/11/12 at Hospital A. Review of the entire medical record revealed no documented evidence that a physical examination was performed to update the H&P with any change in Patient #3's condition since 02/11/12.

In a face-to-face interview on 03/12/12 at 2:55pm, Quality and Risk Manager S3 confirmed Patient #3's H&P was not updated as required by the medical staff bylaws.

Patient #8
Review of Patient #8's medical record revealed he (MDS) dated [DATE] with the chief complaint of nausea and generalized weakness. Review of the "Short Stay Summary" dated 01/30/12 revealed the assessment and plan included "lightheadedness, dizzy and low blood pressure on arrival to the emergency room . He got a bolus of fluid and now he feels better, so we will send him if okay with cardiology....". Further review revealed the overall condition was documented as "stable. So depends on the cardiology consult, will make further plan for discharge".

Review of Patient #8's "CHF (congestive heart failure) Orders" dated 01/30/12 at 0152 (1:52am) revealed he was placed in observation and on telemetry.

Review of Patient #8's "Physician's Order" dated 01/31/12 at 1610 (4:10pm) revealed he was transferred to ICU (intensive care unit) and changed to inpatient status with the diagnosis of [DIAGNOSES REDACTED]

In a face-to-face interview on 03/14/12 at 9:55am, Quality and Risk Manager S3 indicated Patient #8 should have had a H&P performed when he became an inpatient.

Review of the "Board of Trustees Meeting Minutes" for the meeting held 01/12/12 revealed the medical staff bylaws' revisions were approved. Further review revealed the revisions were related to the H&P. Further review of the revisions, revealed, in part, "...A medical history and physical examination must be completed and documented for each patient no more than thirty (30) days before or twenty-four (24) hours after admission or registration but prior to surgery or a procedure requiring anesthesia services. ... When the history and physical examination is conducted within thirty (30) days before admission or a registration, an update must be completed and documented by a licensed practitioner who is credentialed and privileged by the hospital's medical staff to perform a history and physical examination. An updated examination of the patient, including any changes in the patient's condition, must be completed and documented within twenty-four (24) hours after admission or registration... The update must accompany an examination for any changes in the patient's condition since the patient's history and physical examination was performed that might be significant for the planned course of treatment...".
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the hospital failed to implement its policy for determining and documenting the presence or absence of an advance directive upon admission for 3 of 6 patients reviewed for advance directives from a total sample of 8 patients (#6, #7, #8). Findings:

Review of the hospital's "Consent For Services And Financial Responsibility" revealed the following: "13. Advance Directive Acknowledgement: I understand that I am not required to have an Advance Directive in order to receive medical treatment... (square box to be marked) I have executed an Advance Directive, if applicable (square box to be marked) I have not executed an Advance Directive (square box to be marked) I would like to formulate an Advance Directive / Receive additional information...".

Review of Patient #6's medical record revealed she was an [AGE] year old female admitted on [DATE]. Review of the "Consent For Services And Financial Responsibility" dated 03/03/12 revealed no documented evidence that the section titled "Advance Directive Acknowledgement" had been completed as evidenced by no mark in any of the squares related to advance directives.

Review of Patient #7's medical record revealed he was a [AGE] year old male admitted on [DATE]. Review of the "Consent For Services And Financial Responsibility" revealed the notation of "pt. (patient) unable to sign no one w/ (with) him". Further review revealed no documented evidence of the date and time the witness signed the form. Further review revealed no documented evidence that advance directives was addressed at a later time. Further review of the "Consent For Services And Financial Responsibility" revealed no documented evidence that the section titled "Advance Directive Acknowledgement" had been completed as evidenced by no mark in any of the squares related to advance directives.

Review of Patient #8's medical record revealed he was a [AGE] year old male admitted on [DATE]. Review of the "Consent For Services And Financial Responsibility", with no documented evidence of the date and time it was signed by the patient's representative, revealed no documented evidence that the section titled "Advance Directive Acknowledgement" had been completed as evidenced by no mark in any of the squares related to advance directives.

In a face-to-face interview on 03/14/12 at 3:10pm, Director of Business Services S18 indicated the admit process required the admit staff to ask patient if they had an advance directive or if they wanted to formulated one. S18 further indicated if a patient wanted to formulate an advance directive, the admit staff was to send the patient to medical records for assistance. She further indicated if a patient already had an advance directive, the admit staff was to find out which facility had a copy and if the patient wanted them to obtain a copy for the medical record. S18 indicated the admit supervisor did daily quality checks on the registration process, but she wasn't sure if the advance directive was part of the quality check. S18 indicated she would check with the supervisor (who was not present the day of this interview) to see if the advance directive was a part of the check that she (admit supervisor) did daily. No further information was presented related to the daily registration quality checks by the completion of the survey.

In a face-to-face interview on 03/15/12 at 8:55am, Quality and Risk Manager S3 presented a copy of the handouts from a staff in-service held in December 2011 that she indicated addressed the nurses' responsibility for addressing advance directive. Review of the in-service handout revealed no documented evidence that advance directives was addressed in the literature. S3 further presented an e-mail dated 01/23/12 from Clinical Informatics Coordinator S20 that stated that the nurse would not be able to lock the assessment if he/she had not addressed the question related to advance directives. S3 indicated S20 had discovered on 03/14/12 that after a computer upgrade performed the previous week, the system no longer prevented the assessment from being able to be locked without advance directives being addressed.

Review of the hospital policy titled "Patient Self-Determination Advance Directives", policy number P-2, revised 03/07, and submitted as the current policy for advance directives by Quality and Risk Manager S3, revealed, in part, "...At the time of admission, patients shall be informed of their right under Louisiana and Federal Law to make decisions regarding medical care, including the right to accept or refuse medical treatment and the right to formulate advanced directive. All admission inpatients, observation patients and outpatient surgical patients shall be asked whether he/she has an advanced directive. Documentation shall be made on the "Conditions of Admission and Treatment" form as to the patient's choice not to execute an advanced directive after receiving information about advanced directives. ... II. Procedure ... A. Admission personnel shall ask if the patient has an Advance Directive. If the patient has executed an Advance Directive it will be noted on the Conditions of Admission and Treatment Form and a copy shall be provided ... and placed in the medical record. ... e. If the patient has no Advance Directive, does not desire one, this shall be documented as such on the Conditions of Admission and Treatment form. ...e. If the patient is incapacitated and unable to make decisions, and a decision-maker is available the information regarding patient's rights will be provided to them...". Review of the policy revealed no documented evidence of the procedure to be used in the event a patient is unable to make the decision and has no representative with him/her.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observation, record review, and interview, the hospital failed to ensure the telemetry patients' privacy was protected by having the last names (with room numbers) of each telemetry patient present on the telemetry monitor screen. There was a telemetry monitor screen in each ICU (intensive care unit) patient room that was visible to anyone entering the room including the ICU patient's family members or visitors. This was evident for 10 of 10 telemetry patients on 03/13/12 (#1, #2, #3, R1, R2, R3, R4, R5, R6, R7). Findings:

Observation on 03/12/12 at 9:25am in the ICU revealed a telemetry monitor was mounted in each ICU patient's room that contained the ability to show the cardiac rhythm of each patient on telemetry. Further observation revealed the monitor had the patient's last name and room number visible on the monitor screen at all times.

Observation on 03/13/12 at 11:20am in the ICU revealed Patients #1, #2, and #3 and Random Patients R1, R2, R3, R4, R5, R6, and R7 had their last name and room number visible on the telemetry monitor screen mounted in each ICU patient's room.

In a face-to-face interview on 03/12/12 at 9:25am, Quality and Risk Manager S3 confirmed the telemetry patients' last name was posted on the telemetry monitor screen that was mounted in each ICU patient's room. When asked about the right to privacy of each patient, S3 indicated a patient's safety would come first, and since nurses need to be watching the screen, the telemetry monitors were placed in each ICU patient's room. S3 indicated she didn't think anyone had ever asked a telemetry patient if it was alright with him/her to have his/her last name on the telemetry monitor screen that was visible to other patients and their family members and visitors. S3 did not explain how having a patient's last name (the patient's room number was listed) on the screen was related to patient safety.

Review of the "Patient's Bill of Rights and Responsibilities", presented by Director of Nursing S2 as the current patient handbook, revealed, in part, "...As a patient, you have a right ... to have physical privacy during medical treatment and personal hygiene functions unless you need assistance... to confidential treatment of information about you...". Further review revealed the confidential treatment of information was related to the patient's medical record. Further review revealed the right to privacy was only addressed as physical privacy and did not address a patient's privacy regarding their admission to the hospital.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure the quality indicator established for the med/surg unit for wound assessments was analyzed which resulted in the hospital failing to identify that wound assessments did not include wound measurements. This was evident in 2 of 3 patients' records reviewed with wound skin assessments from a total of 8 sampled patients (#3, #7). Findings:

Patient #3
Review of Patient #3's medical record revealed he was admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]&P dated 02/11/12 from another hospital's admission revealed his past medical history included congestive heart failure systolic, hypertension, osteoarthritis, gouty arthritis, morbid obesity, obstructive sleep apnea, chronic respiratory failure on home oxygen, mitral disease status post bovine valve replacement, chronic atrial fibrillation, diabetes mellitus, and [DIAGNOSES REDACTED].

Review of the "Patient Anatomical Assessment Report Med-Surg Flowsheets completed each shift by the nurses from 03/04/12 to 03/12/12 for Patient #3 revealed the only wound documented was the wound to the scrotum. Further review revealed the wound was documented as a swelling "Open Wound", the size of the wound was documented as "Medium", the depth of wound was documented as 3.0 cm (centimeters), the color of wound was noted as "Red", and the color of drainage was documented as "Bloody". There was no documented evidence of the length or width of the wound.
Patient #7 Review of Patient #7's medical record revealed he was a [AGE] year old male admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]
Review of Patient #7's "ICU Patient Flowsheet-Standard" dated 03/03/12 at 2000 (8:00pm) revealed the following description of the wounds: coccyx with dressing clean, dry, and intact; duoderm intact; scrotum excoriated; left heel dressing clean, dry, and intact with duoderm intact; skin tear to front of outer lateral knee small , 3.0 cm (centimeters) with no documented evidence whether the measurement was length, width, or depth, the wound and skin around the wound was red, had no drainage, and the dressing was dry and intact.
In a face-to-face interview on 03/14/12 at 2:40pm, Quality and Risk Manager RN S3 indicated the chart audits that were done for wound assessments only were checked to be sure that the anatomical man was used for documentation. S3 further indicated the actual assessment of the wound was not analyzed. She confirmed that the audit did not identify that wound measurements were not being documented by the nursing staff.

Review of the hospital's "Performance Improvement Plan", policy number P-8, reviewed 03/11 and submitted by Quality and Risk Manager RN S3 as the current plan, revealed, in part, "...D. Measure: The scope of our measurement activities include the basis for determining the level of performance of existing processes and the outcomes resulting from these processes. ... E. Assess: The assessment process is multidisciplinary as appropriate for the process or outcome under review. Conclusions from measurement about the need for more intensive measurement and assessment are drawn by interpreting the data and by comparing it to pre-established criteria, a single sentinel event, control limits, or review of all occurrences...".
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure the quality indicator established for the med/surg unit for wound assessments was analyzed which resulted in the hospital failing to identify that wound assessments did not include wound measurements. This was evident in 2 of 3 patients' records reviewed with wound skin assessments from a total of 8 sampled patients (#3, #7). Findings:

Patient #3
Review of Patient #3's medical record revealed he was admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]&P dated 02/11/12 from another hospital's admission revealed his past medical history included congestive heart failure systolic, hypertension, osteoarthritis, gouty arthritis, morbid obesity, obstructive sleep apnea, chronic respiratory failure on home oxygen, mitral disease status post bovine valve replacement, chronic atrial fibrillation, diabetes mellitus, and [DIAGNOSES REDACTED].

Review of the "Patient Anatomical Assessment Report Med-Surg Flowsheets completed each shift by the nurses from 03/04/12 to 03/12/12 for Patient #3 revealed the only wound documented was the wound to the scrotum. Further review revealed the wound was documented as a swelling "Open Wound", the size of the wound was documented as "Medium", the depth of wound was documented as 3.0 cm (centimeters), the color of wound was noted as "Red", and the color of drainage was documented as "Bloody". There was no documented evidence of the length or width of the wound.
Patient #7 Review of Patient #7's medical record revealed he was a [AGE] year old male admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]
Review of Patient #7's "ICU Patient Flowsheet-Standard" dated 03/03/12 at 2000 (8:00pm) revealed the following description of the wounds: coccyx with dressing clean, dry, and intact; duoderm intact; scrotum excoriated; left heel dressing clean, dry, and intact with duoderm intact; skin tear to front of outer lateral knee small , 3.0 cm (centimeters) with no documented evidence whether the measurement was length, width, or depth, the wound and skin around the wound was red, had no drainage, and the dressing was dry and intact.
In a face-to-face interview on 03/14/12 at 2:40pm, Quality and Risk Manager RN S3 indicated the chart audits that were done for wound assessments only were checked to be sure that the anatomical man was used for documentation. S3 further indicated the actual assessment of the wound was not analyzed. She confirmed that the audit did not identify that wound measurements were not being documented by the nursing staff.

Review of the hospital's "Performance Improvement Plan", policy number P-8, reviewed 03/11 and submitted by Quality and Risk Manager RN S3 as the current plan, revealed, in part, "...D. Measure: The scope of our measurement activities include the basis for determining the level of performance of existing processes and the outcomes resulting from these processes. ... E. Assess: The assessment process is multidisciplinary as appropriate for the process or outcome under review. Conclusions from measurement about the need for more intensive measurement and assessment are drawn by interpreting the data and by comparing it to pre-established criteria, a single sentinel event, control limits, or review of all occurrences...".
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on record review and interviews, the hospital failed to set priorities for its performance improvement activities that focused on high-risk, high-volume, problem-prone areas that could affect patient safety and quality of care. The hospital did not include the monitoring of up to 14 telemetry patients by the 2 ICU (intensive care unit) RNs (registered nurses) in addition to their 2-3 assigned ICU patients as part of their focus on patient safety and quality of care. Findings:

Observation on 03/13/12 at 11:20am in the ICU revealed there were 4 patients with plans in process to receive a fifth patient. Further review revealed the telemetry monitors recording the rhythm strips of 10 patients on the med/surg/telemetry unit were being monitored by the ICU nurses (#1, #2, #3, R1, R2, R3, R4, R5, R6, R7). This observation was confirmed by Quality and Risk Manager S3.

Review of the nurse staffing patterns presented by DON (director of nursing) S2 for the weeks of 01/22/12 to 01/28/12, 02/05/12 to 02/11/12, and 03/05/12 to 03/11/12 revealed the following dates with the number of ICU patients and the number of telemetry patients being monitored:
01/22/12 - 2 ICU patients; 9 telemetry patients with 2 RNs on each shift (7:00am to 7:00pm and 7:00pm to 7:00am)
02/23/12 - 3 ICU patients; 6 telemetry patients with 2 RNs on each shift
01/28/12 - 4 ICU patients; 2 telemetry patients with 1 RN and 1 LPN on the 7:00am to 7:00pm shift and 2 RNs on the 7:00pm to 7:00am shift
02/05/12 - 6 ICU patients; 6 telemetry patients with 2 RNs on the day shift and 3 RNs on the night shift
02/06/12 - 5 ICU patients; 6 telemetry patients with 3 RNs from 7:00am to 3:00pm and 2 RNs from 3:00pm to 7:00am
02/07/12 - 4 ICU patients; 7 telemetry patients with 2 RNs on each shift
02/11/12 - 2 ICU patients; 11 telemetry patients with 2 RNs on each shift
03/05/12 - 4 ICU patients; 10 telemetry patients with 2 RNs on each shift
03/06/12 - 6 ICU patients; 10 telemetry patients with 3 RNs on each shift
03/07/12 - 5 ICU patients; 11 telemetry patients with 3 RNs on the day shift and 2 RNs on the night shift
03/08/12 - 5 ICU patients; 10 telemetry patients with 2 RNs on the day shift and 3 RNs on the night shift
03/09/12 - 4 ICU patients; 9 telemetry patients with 2 RNs on each shift
03/11/12 - 2 ICU patients; 8 telemetry patients with 2 RNs on each shift.

In a face-to-face interview on 03/14/12 at 2:40pm, Quality and Risk Manager RN S3 indicated the hospital did not have quality indicators developed for the monitoring of telemetry patients. She further indicated they had previously included telemetry patients as an indicator, but it was related to checking that physician orders were present that included parameters for high and low alarms.

Review of the hospital's "Performance Improvement Plan", policy number P-8, reviewed 03/11 and submitted by Quality and Risk Manager RN S3 as the current plan, revealed, in part, "...The organizational Leaders and the Hospital Quality Council will oversee the priorities for assessment and improvement activities. The following criteria shall be considered in establishing these priorities: ... High volume diagnoses/procedures/processed High risk diagnoses/procedures/processes Patient safety activities/medical error/ risk reduction Problem-prone procedures/processes...".

Review of the hospital policy titled "Continuous Cardiac Telemetry Monitoring", policy number T-2, revised 04/11, and submitted by Quality and Risk Manager S3 as the current telemetry policy, revealed, in part, "...Telemetry monitoring of patients is done by staff competent to read and interpret EKGs (electrocardiogram) in conjunction with the nursing staff on the Med/Surg nursing unit. ... B. Central Monitor - located in the ICU. Has the capability of admitting/discharging, setting alarm parameters and interpreting ECG signals for a total of 14 patients on Med/Surg, out patient surgery, OB (obstetrics) and main radiology department. Satellite central monitors also located in all ICU rooms and at the med/surg nurses station. C. Workstation - located in ICU. Has the capability of storing and reporting patient hemodynamic trends as collected in the telemetry system...".

Review of the hospital policy titled "Mission And Scope Of Service" (for ICU), revised 04/11 and submitted by Quality and Risk Manager S3 as a current ICU policy, revealed, in part, "...III. Skill Level of Personnel a. Skill Level: The nursing staff is an all RN staff. RN's must have current ACLS (advanced cardiac life support), PALS (pediatric advanced life support), and BLS (basic life support). CCRN (critical care registered nurse) certification is encouraged... Average daily census = (equals) 2-3 patients...".
VIOLATION: NURSING SERVICES Tag No: A0385
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review, and interviews, the hospital failed to meet the Condition of Participation for Nursing Services as evidenced by:

1) Failing to ensure the number of ICU (intensive care unit) registered nurses (RNs) met the daily staffing pattern (1 RN to 2-3 ICU patients) established by hospital policy by having ICU RNs responsible for monitoring up to 14 telemetry patients' cardiac rhythms in addition to caring for their assigned intensive care patients on 01/22/12, 01/23/12, 01/28/12, 02/05/12, 02/06/12, 02/07/12, 02/11/12, 03/05/12, 03/06/12, 03/07/12, 03/08/12, 03/09/12, 03/11/12, and 03/13/12. ICU patients' care was assigned to a LPN (licensed practical nurse) on the 7:00am to 7:00pm shift on 01/28/12 (Patient #6) and on the 7:00pm to 7:00am shift on 03/03/12 (Patients #6 and #7), rather than a RN as required by hospital policy (see findings in tag A0392);

2) Failing to ensure the registered nurse (RN) assigned the nursing care of each patient to nursing personnel according to the patient's needs and the specialized qualifications and competence of the nursing staff. The nursing care of 3 of 6 ICU (intensive care unit) patients' records reviewed from a total of 8 sampled patients (#6, #7, #8) was provided by 3 LPNs (licensed practical nurses) (S11, S14, S15) who had not received orientation and training and assessed as competent to provide care to ICU patients on 01/28/12, 02/04/12, 02/05/12, 02/06/12, 03/03/12, and 03/04/12. The wound care assessments and treatment was performed by a wound care RN who had not been assessed as competent to perform these duties from a total of 2 wound care RNs' personnel files reviewed (S9) (see findings in tag A0397); and

3) Failing to ensure the registered nurse (RN) supervised and evaluated the nursing care of each patient. The RN delegated the care and head-to-toe assessments of 3 ICU (intensive care unit) patients to 3 LPNs (licensed practical nurses) (S11, S14, S15) who had not received orientation and training and were assessed as competent to provide care to ICU patients on 01/28/12, 02/04/12, 02/05/12, 02/06/12, 03/03/12, and 03/04/12. This was evident in 3 of 6 ICU patients' records reviewed from a total of 8 sampled patients (#6, #7, #8). The RN delegated the patient admission assessment to a LPN for 1 of 8 sampled patients (#6). The RN failed to perform accurate and timely wound assessments according to hospital policy for 2 of 3 patients' reviewed with wound skin assessments from a total of 8 sampled patients (#3, #7). The RN failed to assess a patient experiencing [DIAGNOSES REDACTED], ensure treatment was provided as ordered, and notified the physician for 1 of 1 patient reviewed with [DIAGNOSES REDACTED] from a total of 8 sampled patients (#1). The RN failed to obtain a physician's order for parameters for telemetry monitoring and documented the parameters as a telephone order for 2 of 7 random patients' and 3 sampled patients' records reviewed for telemetry parameter orders from a total of 8 sampled patients (R2, R3) (see findings in tag A0395).
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review, and interviews, the hospital failed to ensure the number of ICU (intensive care unit) registered nurses (RNs) met the daily staffing pattern (1 RN to 2-3 ICU patients) established by hospital policy by having ICU RNs responsible for monitoring up to 14 telemetry patients' cardiac rhythms in addition to caring for their assigned intensive care patients on 01/22/12, 01/23/12, 01/28/12, 02/05/12, 02/06/12, 02/07/12, 02/11/12, 03/05/12, 03/06/12, 03/07/12, 03/08/12, 03/09/12, 03/11/12, and 03/13/12. ICU patients' care was assigned to a LPN (licensed practical nurse) on the 7:00am to 7:00pm shift on 01/28/12 (Patient #6) and on the 7:00pm to 7:00am shift on 03/03/12 (Patients #6 and #7), rather than a RN as required by hospital policy. Findings:

Observation on 03/13/12 at 11:20am in the ICU revealed there were 4 patients with plans in process to receive a fifth patient. Further review revealed the telemetry monitors recording the rhythm strips of 10 patients on the med/surg/telemetry unit were being monitored by the ICU nurses (#1, #2, #3, R1, R2, R3, R4, R5, R6, R7). This observation was confirmed by Quality and Risk Manager S3.

Review of the nurse staffing patterns presented by DON (director of nursing) S2 for the weeks of 01/22/12 to 01/28/12, 02/05/12 to 02/11/12, and 03/05/12 to 03/11/12 revealed the following dates with the number of ICU patients and the number of telemetry patients being monitored:
01/22/12 - 2 ICU patients; 9 telemetry patients with 2 RNs on each shift (7:00am to 7:00pm and 7:00pm to 7:00am)
02/23/12 - 3 ICU patients; 6 telemetry patients with 2 RNs on each shift
01/28/12 - 4 ICU patients; 2 telemetry patients with 1 RN and 1 LPN on the 7:00am to 7:00pm shift and 2 RNs on the 7:00pm to 7:00am shift
02/05/12 - 6 ICU patients; 6 telemetry patients with 2 RNs on the day shift and 3 RNs on the night shift
02/06/12 - 5 ICU patients; 6 telemetry patients with 3 RNs from 7:00am to 3:00pm and 2 RNs from 3:00pm to 7:00am
02/07/12 - 4 ICU patients; 7 telemetry patients with 2 RNs on each shift
02/11/12 - 2 ICU patients; 11 telemetry patients with 2 RNs on each shift
03/05/12 - 4 ICU patients; 10 telemetry patients with 2 RNs on each shift
03/06/12 - 6 ICU patients; 10 telemetry patients with 3 RNs on each shift
03/07/12 - 5 ICU patients; 11 telemetry patients with 3 RNs on the day shift and 2 RNs on the night shift
03/08/12 - 5 ICU patients; 10 telemetry patients with 2 RNs on the day shift and 3 RNs on the night shift
03/09/12 - 4 ICU patients; 9 telemetry patients with 2 RNs on each shift
03/11/12 - 2 ICU patients; 8 telemetry patients with 2 RNs on each shift.

Review of the "ICU Daily Charge Nurse Worksheet" dated 01/28/12 revealed a RN called in sick on the day shift and was replaced with LPN S14.

Review of the "ICU Daily Charge Nurse Worksheet" dated 02/05/12 revealed the day shift had 2 ICU RNs and LPN S15 assigned to the day shift.

Review of the "ICU Daily Charge Nurse Worksheet" dated 03/03/12 revealed the ICU RN on the night shift called in sick and was replaced by LPN S11. Further review revealed House Supervisor RN S10's name was listed with a line marked through it. Review of the "Personnel On Duty" form dated 03/03/12 revealed the following names were listed for ICU: 1 ICU RN's name, 1 ICU RN's name circled, LPN S11, and House Supervisor RN S10.

Patient #6
Review of Patient #6's medical record revealed she was an [AGE] year old female admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]" revealed the head-to-toe assessments in ICU on 03/03/12 at 8:30pm, 03/04/12 at 12:00am, and 03/04/12 at 4:00am were performed by LPN S11. Further review revealed no documented evidence that a RN had performed a head-to-toe assessment every 4 hours as required by hospital policy for patients in ICU.

Review of Patient #6's "ICU Patient Flowsheet - Standard" from the admission of 01/28/12 revealed the head-to-toe assessments in ICU were performed by LPN S14 on 01/28/12 at 8:00am, 12:00pm, and 4:00pm. Further review revealed no documented evidence that a RN had performed a head-to-toe assessment every 4 hours as required by hospital policy.

In a face-to-face interview on 03/14/12 at 8:55am, Quality and Risk Manager S3 confirmed that ICU was staffed with 1 RN and 1 LPN on the day shift of 01/28/12. S3 indicated there were 4 patients in ICU during that shift. S3 confirmed there was no documented evidence that a RN had performed the head-to-toe assessments for Patient #6 every 4 hours as required by hospital policy.

Patient #7
Review of Patient #7's medical record revealed he was a [AGE] year old male admitted on [DATE] with the chief complaint of shortness of breath. Review of the H&P dictated on 03/01/12 at 1:51pm revealed a workup was done which showed a possible aspiration pneumonia. Further review revealed Patient #7 had a history of hypertension, [DIAGNOSES REDACTED], diabetes, benign prostatic hypertrophy, dementia, cerebrovascular accident, degenerative joint disease, and coronary artery disease with a recent cardiac bypass.

Review of Patient #7's "ICU Patient Flowsheet - Standard" on 03/03/12 at 8:00pm, 03/04/12 at 12:00am, and 03/04/12 at 4:00am revealed the head-to-toe assessments in ICU were performed by LPN S11. Further review revealed no documented evidence that a RN had performed a head-to-toe assessment every 4 hours as required by hospital policy.

In a face-to-face interview on 03/14/12 at 7:45am, LPN S11 indicated that she had been employed at the hospital since 04/11, and this was her first hospital employment since becoming a LPN. S11 further indicated her previous employment had been in physician's office practices. S11 indicated she worked in ICU on the night shift of 03/03/12 and 02/04/12. She further indicated that on the night shift of 03/03/12 she was assigned the care of Patients #6 and #7. S11 indicated Patient #7 was "sometimes unresponsive", had tube feedings, and had earlier that evening received two units of packed red blood cells due to a low hematocrit and hemoglobin. She further indicated Patient #6 had been transferred from the med/surg unit during her shift "but was stable when she came to ICU". S11 indicated "I didn't find she was out of my scope of practice" and didn't have difficulty taking care of either of the 2 patients. S11 confirmed that she performed the required every 4 hours patient head-to-toe assessments and gave patient medications except intravenous push medications, which were administered by the RN.

Review of the hospital policy titled "Continuous Cardiac Telemetry Monitoring", policy number T-2, revised 04/11, and submitted by Quality and Risk Manager S3 as the current telemetry policy, revealed, in part, "...Telemetry monitoring of patients is done by staff competent to read and interpret EKGs (electrocardiogram) in conjunction with the nursing staff on the Med/Surg nursing unit. ... B. Central Monitor - located in the ICU. Has the capability of admitting/discharging, setting alarm parameters and interpreting ECG signals for a total of 14 patients on Med/Surg, out patient surgery, OB (obstetrics) and main radiology department. Satellite central monitors also located in all ICU rooms and at the med/surg nurses station. C. Workstation - located in ICU. Has the capability of storing and reporting patient hemodynamic trends as collected in the telemetry system...".

Review of the hospital policy titled "Mission And Scope Of Service" (for ICU), revised 04/11 and submitted by Quality and Risk Manager S3 as a current ICU policy, revealed, in part, "...III. Skill Level of Personnel a. Skill Level: The nursing staff is an all RN staff. RN's must have current ACLS (advanced cardiac life support), PALS (pediatric advanced life support), and BLS (basic life support). CCRN (critical care registered nurse) certification is encouraged...Average daily census = (equals) 2-3 patients...".

Review of the hospital policy titled "Standards of Nursing Care Intensive Care Unit", revised 05/121 and submitted by Quality and Risk Manager S3 as a current ICU policy, revealed, in part, "...B. Assessment ... 4. A complete head-to-toe assessment will be completed by a RN and documented on the ICU flowsheet at least every four (4) hours...".
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**






Based on observation, record review, and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care of each patient. The RN delegated the care and head-to-toe assessments of 3 ICU (intensive care unit) patients to 3 LPNs (licensed practical nurses) (S11, S14, S15) who had not received orientation and training and were assessed as competent to provide care to ICU patients on 01/28/12, 02/04/12, 02/05/12, 02/06/12, 03/03/12, and 03/04/12. This was evident in 3 of 6 ICU patients' records reviewed from a total of 8 sampled patients (#6, #7, #8). The RN delegated the patient admission assessment to a LPN for 1 of 8 sampled patients (#6). The RN failed to perform accurate and timely wound assessments according to hospital policy for 2 of 3 patients' records reviewed with wound skin assessments from a total of 8 sampled patients (#3, #7). The RN failed to assess a patient experiencing [DIAGNOSES REDACTED], ensure treatment was provided as ordered, and notified the physician for 1 of 1 patient reviewed with [DIAGNOSES REDACTED] from a total of 8 sampled patients (#1). The RN failed to obtain a physician's order for parameters for telemetry monitoring and documented the parameters as a telephone order for 2 of 7 random patients' and 3 sampled patients' records reviewed for telemetry parameter orders from a total of 8 sampled patients (R2, R3). The RN failed to ensure a patient's blood pressure and pulse were assessed prior to administering Norvasc and Metoprolol for 1 of 1 patient reviewed with orders for Norvasc and Metoprolol from a total of 8 sampled patients (#2). Findings:

ICU patient care and head-to-toe assessments by the LPN:
Patient #6
Review of Patient #6's medical record revealed she was an [AGE] year old female admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]" revealed the head-to-toe assessments in ICU on 03/03/12 at 8:30pm, 03/04/12 at 12:00am, and 03/04/12 at 4:00am were performed by LPN S11.

Review of Patient #6's "ICU Patient Flowsheet - Standard" from the admission of 01/28/12 revealed the head-to-toe assessments in ICU were performed by LPN S14 on 01/28/12 at 8:00am, 12:00pm, and 4:00pm.

In a face-to-face interview on 03/14/12 at 8:55am, Quality and Risk Manager S3 confirmed that ICU was staffed with 1 RN and 1 LPN on the day shift of 01/28/12. S3 indicated there were 4 patients in ICU during that shift.

Patient #7
Review of Patient #7's medical record revealed he was a [AGE] year old male admitted on [DATE] with the chief complaint of shortness of breath. Review of the H&P dictated on 03/01/12 at 1:51pm revealed a workup was done which showed a possible aspiration pneumonia. Further review revealed Patient #7 had a history of hypertension, [DIAGNOSES REDACTED], diabetes, benign prostatic hypertrophy, dementia, cerebrovascular accident, degenerative joint disease, and coronary artery disease with a recent cardiac bypass.

Review of Patient #7's "ICU Patient Flowsheet - Standard" on 03/03/12 at 8:00pm, 03/04/12 at 12:00am, and 03/04/12 at 4:00am revealed the head-to-toe assessments in ICU were performed by LPN S11.

In a face-to-face interview on 03/14/12 at 7:45am, LPN S11 indicated that she had been employed at the hospital since 04/11, and this was her first hospital employment since becoming a LPN. S11 further indicated her previous employment had been in physician's office practices. S11 indicated she worked in ICU on the night shift of 03/03/12 and 02/04/12. She further indicated that on the night shift of 03/03/12 she was assigned the care of Patients #6 and #7.

Patient #8
Review of Patient #8's medical record revealed he was a [AGE] year old male admitted on [DATE] with the chief complaint of nausea and generalized weakness. Review of his "Short Stay Summary" dictated on 01/30/12 revealed a prior history of chronic obstructive pulmonary disease, gastroesophageal reflux disease, congestive heart failure, [DIAGNOSES REDACTED], hypertension, and [DIAGNOSES REDACTED]status post pacemaker.

Review of Patient #8's "Physician's Orders" dated 01/31/12 at 1610 (4:10pm) revealed an order to transfer him to ICU with a diagnosis of [DIAGNOSES REDACTED]

Review of Patient #8's "ICU Patient Flowsheet-Standard" on 02/04/12 at 8:00pm and on 02/05/12 at 12:00am and 4:00am revealed the head-to-toe assessments in ICU were performed by LPN S11. Further review revealed the head-to-toe assessment in ICU on 02/05/12 at 8:00am was performed by LPN 15.

Review of the personnel files of LPNs S11, S14, and S15 revealed no documented evidence of orientation and training in ICU and an assessment of competency to care for the ICU patient. Further review revealed S11, S14, and S15 had job descriptions for a LPN on the Med/Surg Unit.

In a face-to-face interview on 03/12/12 at 9:35am, Quality and Risk Manager RN S3 confirmed that a LPN replaced a RN (due to a call-in) as one of the 2 nurses in ICU on 01/28/12.

In a face-to-face interview on 03/13/12 at 10:00am with Quality and Risk Manager RN S3 and Director of Nursing (DON) S2 present, S3 indicated the ICU staff became upset when "by fluke" the ICU ended up with 1 ICU RN and 1 LPN on a shift in January 2012. S2 indicated on 03/03/12 an ICU nurse called in sick, and LPN S11 was determined to be the most competent to send to work ICU. S2 further indicated House Supervisor S10 remained in ICU throughout the shift and charted on paper since she was not quick with computer charting. S2 nor S3 could offer an explanation for the head-to-toe assessments being performed by a LPN when the hospital policy required them to be done every 4 hours by a RN.

In a face-to-face interview on 03/14/12 at 7:45am, LPN S11 confirmed that she did not have orientation and training for ICU and an assessment of her competency to provide care to the ICU patient prior to being assigned to ICU.

Review of the hospital policy titled "Intensive Care Unit Description", revised 05/11 and presented by Quality and Risk Manager RN S3 as a current policy, revealed, in part, "...V. Criteria For Selection (selection) Of Personnel: A. Professional Level of staff: Registered Nurse ... VII. The role of the Nurse: The ICU/CCU (cardiac care unit) is staffed with RN's who are trained in recognizing and interpreting the symptoms of [DIAGNOSES REDACTED]

Review of the hospital policy titled "ICU/CCU Staffing Plan Summary", revised 04/10 and submitted by Quality and Risk Manager RN S3 as a current policy, revealed, in part, "...All patient care services are primarily delivered by Registered Nurses. Licensed Practical Nurses, and certified or non-certified non-licensed personnel may perform delegated duties/tasks within their realm of practice or job descriptions...".

Review of the hospital policy titled "Mission And Scope Of Service" (for ICU), revised 04/11 and submitted by Quality and Risk Manager S3 as a current ICU policy, revealed, in part, "...III. Skill Level of Personnel a. Skill Level: The nursing staff is an all RN staff. RN's must have current ACLS (advanced cardiac life support), PALS (pediatric advanced life support), and BLS (basic life support). CCRN (critical care registered nurse) certification is encouraged...".

Review of the hospital policy titled "Standards of Nursing Care Intensive Care Unit", revised 05/121 and submitted by Quality and Risk Manager S3 as a current ICU policy, revealed, in part, "...B. Assessment ... 4. A complete head-to-toe assessment will be completed by a RN and documented on the ICU flowsheet at least every four (4) hours...".

RN delegated admission assessment to LPN:
Patient #6 Review of Patient #6's medical record revealed she was an [AGE] year old female admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED][DIAGNOSES REDACTED]with a paced rhythm, gout, hypercholesterolemia, and urinary tract infection.
Review of Patient #6's "Admission-Inpatient & (and) Observation Standard) revealed the admission assessment was performed on 03/03/12 at 1610 (4:10pm) by LPN S15. Further review revealed S15 assessed Patient #6's past medical history, height, weight, mobility, home medications, vital signs, education needs, nutrition, neurological status, fall risk, deep vein thrombosis risk, psychological status, pain, and respiratory, cardiovascular, gastrointestinal, neurovascular, integumentary, genitourinary systems. There was no documented evidence that a RN performed the nursing admission assessment as required by hospital policy.

In a face-to-face interview on 03/14/12 at 8:55am, Quality and Risk Manager RN S3 confirmed the admit assessment was performed by LPN S15.

Review of the hospital policy titled "Assessment And Reassessment Of Patients", policy number A-3, revised 08/08, and presented by Quality and Risk Manager RN S3 as the current assessment policy, revealed, in part, "...B. Patient Care Services 1. Nursing services a. At the time of admission, each patient will have needs assessed by an RN. The LPN and unlicensed caregiver may perform certain aspects of data collection as outlined by unit guidelines, policies and procedures, and standards of care. The nursing admission history will be completed by the RN as soon as possible upon arrival to the nursing unit, but shall not exceed eight hours. ... b. Data collection regarding discharge planning, medical risk factors, social risk factors, and nursing assessment will completed by an RN...".

Wound assessments:
Patient #3
Review of Patient #3's medical record revealed he was admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]&P dated 02/11/12 from another hospital's admission revealed his past medical history included congestive heart failure systolic, hypertension, osteoarthritis, gouty arthritis, morbid obesity, obstructive sleep apnea, chronic respiratory failure on home oxygen, mitral disease status post bovine valve replacement, chronic atrial fibrillation, diabetes mellitus, and [DIAGNOSES REDACTED].

Review of Patient #3's "Patient Anatomical Assessment Report Med-Surg Flowsheet - Standard" dated 03/04/12 at 19:05 (7:05 p.m.) and the "Wound Care Altered Skin Integrity Flowsheet" dated 03/05/12 revealed RN S9 documented "consulted for low Braden score. All skin assessed. Pt has skin breakdown/mass to scrotal area. Physician S21 aware. Pt was actually scheduled for surgery on scrotal mass ... Nurses are putting barrier cream on area. Heels are offloaded. No further recommendations at this time".

Review of the "Patient Anatomical Assessment Report Med-Surg Flowsheets completed each shift by the nurses from 03/04/12 to 03/12/12 reflected the only wound documented was the wound to the scrotum. Further review revealed the wound was documented as a swelling "Open Wound", the size of the wound was documented as "Medium", the depth of wound was documented as 3.0 cm (centimeters), the color of wound was noted as "Red", and the color of drainage was documented as "Bloody". There was no documented evidence of the length or width of the wound.
Observation of Patient #3's wound on 03/13/12 at approximately 1:35 p.m., in the presence of RN S7 Charge Nurse and RN S6 revealed he had a scrotal wound. Measurement of the wound by S7 revealed the scrotal wound measured 8 cm in width and 8 cm in length. The patient was observed at that time to be lying on his back.
In a face-to-face interview on 03/13/12 at 2:19 p.m., RN S9, wound care charge nurse, revealed she remembered Patient #3 was admitted with problems with CHF (congestive heart failure). S9 indicated the patient needed surgery to the scrotum and was scheduled to have surgery at another hospital, but the patient had some medical problems and had to be transferred to this hospital. S9 further indicated that she was consulted because the patient had a "low Braden score". S9 indicated she assessed Patient #3 when he was admitted , and he had a scrotal mass with a skin tear. S9 confirmed that no measurements were done at that time. During this interview S9 revealed Patient #3 would have been a patient who required weekly reassessments, but she was not sure why he was not reassessed weekly.
Observation of Patient #3's scrotal area on 03/13/12 at approximately 2:35 p.m. with Wound Care RN S9 revealed his scrotal area had necrotic tissue, and the necrotic area was surrounded by an open pink area. S9 measured the area and indicated the area around the wound was "2.2 cm" circumference. During S9's assessment of the patient, she noted the patient also had an open area on his "right" buttock which measured 0.8 cm in width by 0.7 cm in length. S9 stated the skin was intact around the open area, and there was a small amount of serosanguinous drainage noted. At that time RN S9 indicated the area was a Stage 2 pressure ulcer. During the time of this observation, Patient #3 was observed to be lying on his right side, and the scrotal wound was assessed from the backside of the patient.
In a face-to-face interview on 03/13/12 at approximately 3:00 p.m.regarding Patient #3's wounds, RN S6 indicated she had observed a wound on the patient's right buttock which was reddened and looked like it was a "stage I" pressure ulcer. S6 further indicated she had not documented the wound noted on the buttock "yet" but she was about to document it.
Review of #3's "Patient Anatomical Assessment Report Med-Surg Flowsheet - Standard" dated 03/13/12 at 7:35 a.m. revealed an assessment completed by RN S6. Review of the flowsheet revealed the patient had a "Swelling" open wound to the scrotum. Documentation concerning the wound reflected: the size of the wound was "Medium", the depth of the wound was "0.0 cm and in the comment section documentation reflected "8cm x 8 cm". The color of the wound was "Red". There was no documentation to reflect the color of the skin around the wound. Further reviewrevealed the color of drainage at the site of the scrotal wound was "Bloody" . Further review revealed RN S6 documented that Patient #3 had a wound noted to the right buttock. Review reflected "Type of Finding" was a pressure ulcer. Further review revealed "(Please see Pressure Ulcer Flowsheet for Documentation)". Continued review revealed the size of the ulcer was documented as "Small", depth of the wound was documented as "0.5 cm", and the color of the wound was documented as "Red" . Color of Drainage at the site was documented as "None".
In a face-to-face interview on 03/13/12 at approximately 3:30 p.m., Quality and Risk Manager RN S3 indicated RN S6 "locked" her assessment documentation at 3:07 p.m. S3 further indicated there was no further documentation related to Patient #3's pressure ulcer.
Review of the " Patient Anatomical Assessment Report" for 03/13/12 revealed it was completed by RN S19 on 03/13/12 at 1945 (7:45 p.m.). Further review of the assessment of the scrotum wound and right buttock pressure ulcer revealed the documentation was the same as the documentation noted by RN S6. There was no further documentation concerning the patient ' s wound.
In a face-to-face interview on 3/14/12 at approximately 9:45 a.m., Quality and Risk Manager RN S3 indicated the pressure ulcer flowsheet tool that was "referred to" in the assessment of Patient #3's wound had not been implemented yet. S3 confirmed that the only documentation concerning the patient's wound would be the documentation noted on the "Patient Anatomical Assessment Report Med-Surg Flowsheet" document.
In a face-to-face interview on 3/14/12 at 10:00 a.m.,RN S9 indicated the nurses on the "Med-Surg" unit do not stage pressure ulcers unless they have a wound care background, and they feel comfortable with staging. During this interview, S9 indicated Patient #3's pressure ulcer was a "Stage 3" pressure ulcer.
Review of Patient #3's "Wound Care Altered Skin Integrity Flowsheet" dated 03/13/12 and completed by Wound Care RN S9 revealed he had a scrotal mass, and the area around the mass had a ridge around it. Further review revealed "excoriation to the right side... The ridge is 0.2 cm at its widest and goes around the circumference...". Further review revealed Patient #3 also had a Stage 3 pressure ulcer to the left buttock which measured 0.8 cm in length, 0.7 cm in width, and 0.1 cm in depth. Documentation revealed a scant amount of "ss" (serosanguinous) drainage, and the periwound appearance was intact.
Review of the "Wound Care/Altered Skin Integrity Flowsheet" dated 03/14/12 revealed Patient #3 was assessed to have a Stage 3 pressure ulcer to the right buttock which measured 0.4 cm in length, 0.7 cm in width, and 0.1 cm in depth. Further review of the flowsheet revealed the right buttock pressure ulcer had a small amount of serosanguinous drainage. Further review he had a Stage 3 pressure ulcer on the left lateral "penis tip" which measured 0.8 cm in length, 0.3 cm in width, and 0.1 cm in depth. It was noted that the pressure ulcer on the tip of the penis had a scant amount of serosanguinous drainage.
Review of documentation completed on 03/14/12 revealed Patient #3 had a total of 4 wounds. Documentation revealed there were three Stage 3 pressure ulcers and a scrotal wound noted.
In a face-to-face interview on 03/14/12 at approximately 12:15 p.m. Quality and Risk Manager RN S3 indicated that nurses were expected to complete a head-to-toe assessment on patients every shift. S3 further indicated that nurses were expected to assess, describe, and document wounds. S3 confirmed that the Wound Care Nurses were the only nurses who were expected to stage the wounds.
Patient #7 Review of Patient #7's medical record revealed he was a [AGE] year old male admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]
Review of Patient #7's "ICU Patient Flowsheet-Standard" dated 03/03/12 at 2000 (8:00pm) revealed the following description of the wounds: coccyx with dressing clean, dry, and intact; duoderm intact; scrotum excoriated; left heel dressing clean, dry, and intact with duoderm intact; skin tear to front of outer lateral knee small , 3.0 cm (centimeters) with no documented evidence whether the measurement was length, width, or depth, the wound and skin around the wound was red, had no drainage, and the dressing was dry and intact.
Review of Patient #7's "Physician's Orders" dated 03/01/12 at 5:00am revealed an order for "wound care evaluate & treat".
Review of Patient #7's "Wound Care/Altered Skin Integrity Flowsheet" dated 03/01/12 (Thursday) revealed he was assessed by Wound Care RN S16 from 9:32am to 9:55am. Further review revealed Patient #7 had an ulcer to the sacrum, documented as "?" pressure, that measured 4 cm in length, 1 cm in width, and 0.2 cm deep. Further review revealed he had a skin tear to the left lateral ankle and an unstageable pressure ulcer to the left heel. Further review revealed no documented evidence that the wounds were reassessed by the wound care nurse on Monday 03/05/12 as required by hospital policy.
In a face-to-face interview on 03/14/12 at 10:10am, Wound Care RN S16 indicated she would not have reassessed Patient #7's wounds, because he was discharged before it was a week from his initial assessment. S16 presented a policy during the interview from the Wound Care Center titled "Inpatient Wound Care Team Assessments/Consults Policy & Procedure that stated that "Wound Care Team patients will be reassessed by the wound care team weekly".
In a face-to-face interview on 03/14/12 at 11:35am, Quality and Risk Manager RN S3 indicated the Wound Care Center policy presented by RN S16 was not a hospital policy. S3 further indicated that according to hospital policy, Patient #7's wounds should have been reassessed on 03/05/12.
Review of the hospital's policy titled "Wound Care Protocol", policy number W-2, reviewed 04/11, and presented by Quality and Risk Manager RN S3 as the current wound care policy, revealed, in part, "The nursing staff will, through assessment, identify patients with skin tears, pressure sores, venous stasis sores, wounds caused by arterial insufficiency or those at risk for developing pressure sores. Necessary measures will be implemented to prevent and/or treat skin breakdown. Use of the protocol requires a physician's order past interventions for Stage I. ... Reassessments of the wounds will occur on Monday's and Thursday's by the wound care team. ... Points Of Emphasis ... 3. High risk candidates include the following: unconscious, weak, sedated, elderly, bedridden, paralyzed, obese... II. Procedure ...1. Conduct a total skin assessment of every patient immediately upon admission, once per shift, after any status change and upon discharge ... 2. Examine any pressure sore area thoroughly and document its: Diameter, Depth, Surrounding Skin Condition, Presence Of Any Of Necrotic Tissue, Drainage, Undermining, Tunneling, Eschar, Odor ... 5. If a pressure sore is noted, alert the physician, document notification, and obtain orders for treatment...".

Patient assessment of [DIAGNOSES REDACTED]:
Review of Patient #1's "Sliding Scale Insulin Protocol" dated 03/09/12 at 2100 (9:00pm) revealed the following orders: type of insulin: Novolog; accucheck ac & hs (before meals and at bedtime); sliding scale insulin: accucheck results minus 100 divided by 30 equals the number of units to administer subcutaneously; if accucheck results less than 50 or greater than 500, order lab for verification and notify MD of results; if blood sugar less than 60, administer 1 amp of D50 (dextrose 50) IVP (intravenous push) and notify MD.

Review of Patient #1's "Blood Glucose Intervention Flowsheet-Standard" dated 03/11/12 at 21:40 (9:40pm) electronically signed by LPN (licensed practical nurse) S22 revealed the blood glucose was 35, the repeated result was 35, a blood glucose to be drawn by lab was ordered, Dextrose 50 was administered intravenously, and a carbohydrate snack was provided.

Review of Patient #1's "Patient Care Notes" revealed an entry on 03/11/12 at 22:25 (10:25pm) by LPN S22 that "pt (patient) given 1 cup aj (apple juice) added with 6 packs of sugar, pudding and crackers, tolerated 100% (per cent)". Review of the entire medical record on computer for 03/11/12 from 9:40pm through 10:30pm with the assistance of Quality and Risk Manager RN S3 revealed no documented evidence of an assessment of Patient #1 by the RN during this hypoglycemic event, the results of the blood glucose ordered to be drawn by the lab, the results of the blood sugar at 15 and 20 minutes after treatment as required by hospital policy, and that the physician was notified.

Review of the hospital policy titled "Hypoglycemic, Treatment Of", policy number H-8, revised 02/07, reviewed 03/11, and submitted by Quality and Risk Manager RN S3 as the current policy for [DIAGNOSES REDACTED], revealed, in part, "... C. Special Considerations 1. Notify physician of all [DIAGNOSES REDACTED] ... II. [DIAGNOSES REDACTED] Defined ... B. All blood glucose levels less than 60 mg/dl (milligrams per deciliter) must be treated immediately, regardless of whether symptoms are present. ... III. Treatment A. Treatment of Mild [DIAGNOSES REDACTED] (Patient conscious and cooperative) ... 2. Blood sugar less than 60 mg/dl (if blood sugar under 50, double treatment.) If blood sugar (less than equal to) 59 mg/dl, verify with lab. (Do Not withhold treatment.) a) Give 15 gms (grams) carbohydrate Examples: 3-4 glucose tablets or tube of glucose gel. 4-6 oz (ounces) fruit juice or non-diet soft drink (it is not necessary to add sugar) 8 oz milk (non fat or low fat) b) Repeat blood sugar 15 and 20 minutes. Repeat treatment if symptoms persist and/or blood glucose falls below 60 mg/dl. Note: If the patient will not be eating a meal within the next 1-2 hours, follow immediate treatment with additional food that contains some protein...".

In a face-to-face interview on 03/14/12 at 9:05am, RN S13 indicated she was the RN in charge at the time that LPN S22 documented Patient #1's blood sugar as 35. She further indicated the nursing staff would normally order lab to draw a blood glucose level, but at that time lab was busy in the emergency department. S13 indicated she administered the D50. S13 further indicated she told LPN S22 not to have the lab drawn when the lab tech was available, because the blood sugar level had come up. S13 indicated she didn't know if the physician was notified of the hypoglycemic event as required by physician order as well as hospital policy, because she "wouldn't have been the one to call the doctor, it would have been the LPN". S13 confirmed there was no documented assessment of Patient #1 by a RN at the time the blood glucose was noted to be 35 as well as after the treatment was provided. When asked about the hypoglycemic policy stating sugar was not necessary to be added to the juice and some form of protein should be given if a meal would not be consumed in the 1-2 hours, S13 indicated "we try to treat the glucose rather than consider policy". S13 indicated she was not aware that the RN needed to notify the physician and that an assessment should be performed by the RN to determine if the care of the patient experiencing a hypoglycemic event could be delegated to a LPN.

Telemetry parameters without a physician order:
Random Patient R2
Review of Random Patient R2's medical record revealed a "Telemetry-Routine Order" documented as a telephone order from Physician S23 and received by Med/Surg Charge RN S7 on 03/12/12 at 10:00am. Further review revealed the telemetry parameters were a high limit of 150 and a low limit of 50.

Random Patient R3
Review of Random Patient R3's medical record revealed a "Telemetry-Routine Order" documented as a telephone order from Physician S24 and received by Med/Surg Charge RN S7 on 03/12/12 at 1900 (7:00pm). Further review revealed the telemetry parameters were a high limit of 150 and a low limit of 50.

In a face-to-face interview on 03/13/12 at 9:20am, Med/Surg Charge RN S7 indicated she filled in the low and high limits for the telemetry parameters for Random Patients R2 and R3. She confirmed that she did not call the physician for the verbal order but documented it as a telephone order. S7 confirmed she determined the telemetry parameters, and the telemetry policy did not give default telemetry limits to be used in place of the physician's order.

Review of the hoaspital policy titled "Continuous Cardiac Telemetry Monitoring", policy number T-2, revised 04/11, and presented by Quality and Risk Manager RN S3 as the current policy for telemetry, revealed, in part, "...A. All patients will have patient specific telemetry orders approved by a physician. B. If orders are not present, the admittting RN will contact the physician for orders specific to the patient...".

Blood pressure and pulse assessed prior to administering Norvasc and Metoprolol:
Review of Patient #2's medical record revealed she was a [AGE] year old female admitted on [DATE] with the chief complaint of shortness of breath. Further review revealed she had a history of hypertension, lupus, [DIAGNOSES REDACTED], chronic renal insufficiency, [DIAGNOSES REDACTED], gout, and generalized anxiety disorder.

Review of Patient #2's "Medication Reconciliation" revealed she had an order to continue Norvasc 10 mg by mouth daily and Metoprolol Tartrate 50 mg by mouth twice a day.

Review of Patient #2's "Medication Name Administration Record" (MAR) revealed she received Norvasc 10 mg by mouth on 03/12/12 at 9:15am with no documented evidence of her blood pressure or heart rate at the time of administration. Further review revealed Patient #2 received Metoprolol 50 mg by mouth on 03/11/12 at 2118 (9:18pm) and on 03/12/12 at 9:15am with no documented evidence of her blood pressure or heart rate prior to administering the medication.

In a face-to-face interview on 03/12/12 at 1:40pm, Quality and Risk Manager RN S3 indicated the nursing staff had access to the 2012 Lippincott's Nursing Drug Guide as a resource for medication administration standards. She further indicated the nurses reviewed the vital signs taken at 8:00am by the nursing assistants to determine if the Norvasc and Metoprolol should be administered at 9:00am.

Review of the 2012 Lippincott's Nursing Drug Guide revealed, in part, "...Norvasc ...Assessment ...Physical: ...P (pulse), BP (blood pressure)... Metoprolol ... Nursing Considerations Assessment ... Physical: ...P, BP...".
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for each patient based on assessment of the patient's nursing care needs for 3 of 3 patients reviewed for a nursing care plan from a total of 8 sampled patients (#1, #2, #3). The nursing staff failed to implement the physician's plan for medical care related to labs, medications, and accuchecks for 3 of 8 sampled patients (#1, #2, #3). Findings:

Nursing Care Plan:
Patient #1
Review of Patient #1's medical record revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]#1's past medical history included coronary artery bypass grafting, myocardial infarction, diabetes, peripheral vascular disease with stents and bypass, chronic pain of her legs, chronic obstructive pulmonary disease, and hyperlipemia.

Review of Patient #1's "Sliding Scale Insulin Protocol" dated 03/09/12 at 2100 (9:00pm) revealed an order for accuchecks ac & hs (before meals and at bedtime) and sliding scale insulin. Further review of her medical record revealed Patient #1 had a blood sugar of 35 on 03/11/12 at 2140 (9:40pm) which required treatment with 1 ampule of Dextrose 50 intravenous push.

Review of Patient #1's "Care Plan" developed 03/10/12 revealed problem #1 was "medical - surgical plan of care" with the objective that Patient #1 "will receive evidence based care for med - surg". Further review revealed some of the interventions listed were to monitor vital signs, oxygen saturation, and blood sugar. There was no documented evidence that the care plan was updated with the change in Patient #1's condition when she experienced a hypoglycemic episode on 03/11/12. Further review revealed problem #2 was "infusion or access plan of care" with the objective that she "will remain free of complications related to intravenous infusion and access". Review of both problems revealed no documented evidence of short term and long range goals with target dates for expected achievement of the goals. Further review revealed Patient #1's plan of care was not individualized but a computer-generated plan that was identical to that of Patient #2 and Patient #3.

Patient #2
Review of Patient #2's medical record revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED][DIAGNOSES REDACTED], chronic renal insufficiency, [DIAGNOSES REDACTED], gout, and generalized anxiety disorder. Further review revealed Patient #2 had possible steroids-induced diabetes.

Review of Patient #2's "Care Plan" developed 03/11/12 revealed problem #1 was "medical - surgical plan of care" with the objective that Patient #1 "will receive evidence based care for med - surg". Further review revealed some of the interventions listed were to monitor vital signs, oxygen saturation, and blood sugar. Further review revealed problem #2 was "infusion or access plan of care" with the objective that she "will remain free of complications related to intravenous infusion and access". Review of both problems revealed no documented evidence of short term and long range goals with target dates for expected achievement of the goals. Further review revealed Patient #2's plan of care was not individualized but a computer-generated plan that was identical to that of Patient #1 and Patient #3.

Patient #3
Review of Patient #3's medical record revealed he was admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]&P dated 02/11/12 from another hospital's admission revealed his past medical history included congestive heart failure systolic, hypertension, osteoarthritis, gouty arthritis, morbid obesity, obstructive sleep apnea, chronic respiratory failure on home oxygen, mitral disease status post bovine valve replacement, chronic atrial fibrillation, diabetes mellitus, and [DIAGNOSES REDACTED].

Review of Patient #3's admission assessment revealed he had a wound to the scrotum.

Review of Patient #3's "Care Plan" developed 03/10/12 revealed problem #1 was "medical - surgical plan of care" with the objective that Patient #1 "will receive evidence based care for med - surg". Further review revealed some of the interventions listed were to monitor vital signs, oxygen saturation, and blood sugar. Further review revealed problem #2 was "infusion or access plan of care" with the objective that she "will remain free of complications related to intravenous infusion and access". Review of both problems revealed no documented evidence of short term and long range goals with target dates for expected achievement of the goals. Further review revealed Patient #3's plan of care was not individualized (no plan for the wound) but a computer-generated plan that was identical to that of Patient #1 and Patient #2.

In a face-to-face interview on 03/13/12 at 11:50am, Quality and Risk Manager RN S3 presented a list of care plans available in the computer system. S3 indicated there was a care plan for congestive heart failure, but it did not "drop down" as a choice for Patients #1 and #2. S3 confirmed the care plans for Patients #1, #2, and #3 were identical, not individualized, and were not updated with changes in the patient's condition.

Review of the hospital policy titled "Assessment And Reassessment Of Patients", policy number A-3, revised 08/08, and submitted by Quality and Risk Manager RN S3 as a current policy, revealed, in part, "...Assessment is the systematic collection and review of the patient-specific data as per scope of practice for each discipline; assessment includes the prioritization of patient problems or needs. ... The data is analyzed to create information necessary to decide the approach to meet care or treatment needs. ... The practice of nursing by a registered nurse shall mean assuming responsibility and accountability for those nursing actions which include, but are not limited to: ... c. Executing a nursing treatment regimen through the selection, performance and management of proper nursing practices and executing diagnostic therapeutic regimens prescribed by licensed medically privileged practitioners ... B. Patient Care Services 1. Nursing services ... g. A problem list will be identified in patient care plan...".

Physician's plan for medical care:
Patient #1
Review of Patient #1's medical record revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]#1's past medical history included coronary artery bypass grafting, myocardial infarction, diabetes, peripheral vascular disease with stents and bypass, chronic pain of her legs, chronic obstructive pulmonary disease, and hyperlipemia.

Review of Patient #1's "Physician's Orders" revealed a clarification order dated 03/10/12 at 1220 (12:20pm) for Onglyza 5 mg (milligrams) one daily, with no documented evidence of the route for administration. Further review revealed an order written on 03/11/12 at 4:00pm for Aldactone 25 mg by mouth daily.

Review of Patient #1's "Administration Documentation" revealed Onglyza was not administered on 03/10.12 at 12:35pm with the reason documented as "patient does not have with her". Further review of the medical record revealed no documented evidence that Aldactone was administered as ordered on [DATE] at 4:00pm.

In a face-to-face interview on 03/12/12 at 10:25am, Pharmacist S5 indicated Onglyza was available and should have been administered.

In a face-to-face interview on 03/12/12 at 10:28am, Quality and Risk Manager S3 confirmed there was no documented evidence in Patient #1's record that her physician was notified of the missed dose of Onglyza.

In a face-to-face interview on 03/12/12 at 10:40am, both Quality and Risk Manager S3 and Pharmacist S5 reviewed Patient #1's medical record and confirmed that Aldactone was not administered on 03/11/12 when ordered at 4:00pm. S5 indicated the pharmacy closed at 4:00pm, but Aldactone was available in the night cabinet.

Review of Patient #1's "Sliding Scale Insulin Protocol" dated 03/09/12 at 2100 (9:00pm) revealed the following orders: type of insulin: Novolog; accucheck ac & hs (before meals and at bedtime); sliding scale insulin: accucheck results minus 100 divided by 30 equals the number of units to administer subcutaneously; if accucheck results less than 50 or greater than 500, order lab for verification and notify MD of results; if blood sugar less than 60, administer 1 amp of D50 (dextrose 50) IVP (intravenous push) and notify MD.

Review of Patient #1's "Blood Glucose Intervention Flowsheet-Standard" dated 03/11/12 at 21:40 (9:40pm) electronically signed by LPN (licensed practical nurse) S22 revealed the blood glucose was 35, the repeated result was 35, a blood glucose to be drawn by lab was ordered, Dextrose 50 was administered intravenously, and a carbohydrate snack was provided.

Review of Patient #1's "Patient Care Notes" revealed an entry on 03/11/12 at 22:25 (10:25pm) by LPN S22 that "pt (patient) given 1 cup aj (apple juice) added with 6 packs of sugar, pudding and crackers, tolerated 100% (per cent)". Review of the entire medical record on computer for 03/11/12 from 9:40pm through 10:30pm with the assistance of Quality and Risk Manager RN S3 revealed no documented evidence of an assessment of Patient #1 by the RN during this hypoglycemic event, the results of the blood glucose ordered to be drawn by the lab, the results of the blood sugar at 15 and 20 minutes after treatment as required by hospital policy, and that the physician was notified.

Review of the hospital policy titled "Hypoglycemic, Treatment Of", policy number H-8, revised 02/07, reviewed 03/11, and submitted by Quality and Risk Manager RN S3 as the current policy for [DIAGNOSES REDACTED], revealed, in part, "... C. Special Considerations 1. Notify physician of all [DIAGNOSES REDACTED] ... II. [DIAGNOSES REDACTED] Defined ... B. All blood glucose levels less than 60 mg/dl (milligrams per deciliter) must be treated immediately, regardless of whether symptoms are present. ... III. Treatment A. Treatment of Mild [DIAGNOSES REDACTED] (Patient conscious and cooperative) ... 2. Blood sugar less than 60 mg/dl (if blood sugar under 50, double treatment.) If blood sugar (less than equal to) 59 mg/dl, verify with lab. (Do Not withhold treatment.) a) Give 15 gms (grams) carbohydrate Examples: 3-4 glucose tablets or tube of glucose gel. 4-6 oz (ounces) fruit juice or non-diet soft drink (it is not necessary to add sugar) 8 oz milk (non fat or low fat) b) Repeat blood sugar 15 and 20 minutes. Repeat treatment if symptoms persist and/or blood glucose falls below 60 mg/dl. Note: If the patient will not be eating a meal within the next 1-2 hours, follow immediate treatment with additional food that contains some protein...".

In a face-to-face interview on 03/14/12 at 9:05am, RN S13 indicated she was the RN in charge at the time that LPN S22 documented Patient #1's blood sugar as 35. She further indicated the nursing staff would normally order lab to draw a blood glucose level, but at that time lab was busy in the emergency department. S13 indicated she administered the D50. S13 further indicated she told LPN S22 not to have the lab drawn when the lab tech was available, because the blood sugar level had come up. S13 indicated she didn't know if the physician was notified of the hypoglycemic event as required by physician order as well as hospital policy, because she "wouldn't have been the one to call the doctor, it would have been the LPN". S13 confirmed there was no documented assessment of Patient #1 by a RN at the time the blood glucose was noted to be 35 as well as after the treatment was provided. When asked about the hypoglycemic policy stating sugar was not necessary to be added to the juice and some form of protein should be given if a meal would not be consumed in the 1-2 hours, S13 indicated "we try to treat the glucose rather than consider policy". S13 indicated she was not aware that the RN needed to notify the physician and that an assessment should be performed by the RN to determine if the care of the patient experiencing a hypoglycemic event could be delegated to a LPN.

Patient #2
Review of Patient #2's medical record revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED][DIAGNOSES REDACTED], chronic renal insufficiency, [DIAGNOSES REDACTED], gout, and generalized anxiety disorder. Further review revealed Patient #2 had possible steroids-induced diabetes.

Review of Patient #2's "Physician's Orders" dated 03/11/12 at 2155 (9:55pm) revealed an order for Humalog per S/S (sliding scale). Review of Patient #2's "Blood Glucose Intervention Flow sheet-Standard" revealed her blood sugars were checked on 03/11/12 at 8:00pm, 03/12/12 at 7:30am, and 03/12/12 at 12:00pm. Further review revealed Novalog insulin was administered each time the blood sugar was assessed. Review of the medical record on 03/12/12 at 1:10pm revealed no documented evidence of a sliding scale protocol that contained the frequency of accuchecks and the order for the amount of Humalog to be given.

In a face-to-face interview on 03/12/12 at 1:10pm, Quality and Risk Manager RN S3 confirmed the sliding scale protocol was supposed to be pulled and placed in the physician's orders as a standing order but was not present for Patient #2 when accuchecks were done and insulin was administered. After S3 had the nurse get the sliding scale protocol for the record, it was noted Humalog was to be administered per sliding scale, but there was no documented evidence of the frequency the accuchecks were to be performed. S3 indicated the protocol would need a clarification order from the physician.

Patient #3
Review of Patient #3's medical record revealed he was admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]&P dated 02/11/12 from another hospital's admission revealed his past medical history included congestive heart failure systolic, hypertension, osteoarthritis, gouty arthritis, morbid obesity, obstructive sleep apnea, chronic respiratory failure on home oxygen, mitral disease status post bovine valve replacement, chronic atrial fibrillation, diabetes mellitus, and [DIAGNOSES REDACTED].

Review of Patient #3's "Physician's Orders" dated 03/09/12 at 8:45am received by telephone order by Contract RN S8 from Company A revealed an order for Albumin 25 grams IVPB (intravenous piggyback) on dialysis now.

Review of Patient #3's "Hemodialysis Treatment Sheet" dated 03/09/12 revealed Contract RN S8 from Company A administered Albumin 25 grams IVPB at 10:00am, 1 hour and 15 minutes after it was ordered.

In a face-to-face interview on 03/13/12 at 11:32am, Contract RN S8 from Company A indicated she was a RN employed by Company A which was the contracted company to provide hemodialysis services at the hospital. S8 further indicated she received the verbal order for Albumin on 03/09/12 for Patient #3. S8 indicated sometimes she received physician orders but wouldn't write them until after the dialysis had started. S8 indicated the Albumin administration was based on an assessment of the patient's blood pressure and sometimes it may not be needed stat, but it was necessary to have the medication on hand. S8 could offer no further explanation for the Albumin ordered to be administered now at 8:45am not being given until 1 hour and 15 minutes later.

Review of Patient #3's "Physician's Orders" dated 03/08/12 at 11:35am revealed an order for a stat PT (prothrombin time). Review of Patient #3's lab report revealed the lab received the request at 11:54am on 03/08/12, the blood sample was collected on 03/08/12 at 1630 (4:30pm), and the results reported on 03/08/12 at 1705 (5:05pm). The result of the stat PT was reported 5 hours and 30 minutes after it was ordered stat.

In a face-to-face interview on 03/14/12 at 7:40am, Quality and Risk Manager RN S3 indicated her follow-up in the delay of the stat PT for Patient #3 revealed that the lab's stat printer went down, and lab didn't know it was down until the OR (operating room) contacted them about a stat blood count for a patient in OR. S3 indicated the nurse should have followed up timely when she did not receive results of a lab test ordered stat.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the hospital failed to ensure the registered nurse (RN) assigned the nursing care of each patient to nursing personnel according to the patient's needs and the specialized qualifications and competence of the nursing staff. The nursing care of 3 of 6 ICU (intensive care unit) patients' records reviewed from a total of 8 sampled patients (#6, #7, #8) was provided by 3 LPNs (licensed practical nurses) (S11, S14, S15) who had not received orientation and training and assessed as competent to provide care to ICU patients on 01/28/12, 02/04/12, 02/05/12, 02/06/12, 03/03/12, and 03/04/12. The wound care assessments and treatment was performed by a wound care RN who had not been assessed as competent to perform these duties from a total of 2 wound care RNs' personnel files reviewed (S9). Findings:

ICU patient care provided by LPNs:
Review of the "ICU Daily Charge Nurse Worksheet" dated 01/28/12 revealed a RN called in sick on the day shift and was replaced with LPN S14.

Review of the "ICU Daily Charge Nurse Worksheet" dated 03/03/12 revealed the ICU RN on the night shift called in sick and was replaced by LPN S11. Further review revealed House Supervisor RN S10's name was listed with a line marked through it. Review of the "Personnel On Duty" form dated 03/03/12 revealed the following names were listed for ICU: 1 ICU RN's name, 1 ICU RN's name circled, LPN S11, and House Supervisor RN S10.

Review of the personnel files of LPNs S11, S14, and S15 revealed no documented evidence of orientation and training in ICU and an assessment of competency to care for the ICU patient. Further review revealed S11, S14, and S15 had job descriptions for a LPN on the Med/Surg Unit.

In a face-to-face interview on 03/14/12 at 7:45am, LPN S11 confirmed that she did not have orientation and training for ICU and an assessment of her competency to provide care to the ICU patient prior to being assigned to ICU.

Patient #6
Review of Patient #6's medical record revealed she was an [AGE] year old female admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]" revealed the head-to-toe assessments in ICU on 03/03/12 at 8:30pm, 03/04/12 at 12:00am, and 03/04/12 at 4:00am were performed by LPN S11.

Review of Patient #6's "ICU Patient Flowsheet - Standard" from the admission of 01/28/12 revealed the head-to-toe assessments in ICU were performed by LPN S14 on 01/28/12 at 8:00am, 12:00pm, and 4:00pm.

In a face-to-face interview on 03/14/12 at 8:55am, Quality and Risk Manager S3 confirmed that ICU was staffed with 1 RN and 1 LPN on the day shift of 01/28/12. S3 indicated there were 4 patients in ICU during that shift.

Patient #7
Review of Patient #7's medical record revealed he was a [AGE] year old male admitted on [DATE] with the chief complaint of shortness of breath. Review of the H&P dictated on 03/01/12 at 1:51pm revealed a workup was done which showed a possible aspiration pneumonia. Further review revealed Patient #7 had a history of hypertension, [DIAGNOSES REDACTED], diabetes, benign prostatic hypertrophy, dementia, cerebrovascular accident, degenerative joint disease, and coronary artery disease with a recent cardiac bypass.

Review of Patient #7's "ICU Patient Flowsheet - Standard" on 03/03/12 at 8:00pm, 03/04/12 at 12:00am, and 03/04/12 at 4:00am revealed the head-to-toe assessments in ICU were performed by LPN S11.

In a face-to-face interview on 03/14/12 at 7:45am, LPN S11 indicated that she had been employed at the hospital since 04/11, and this was her first hospital employment since becoming a LPN. S11 further indicated her previous employment had been in physician's office practices. S11 indicated she worked in ICU on the night shift of 03/03/12 and 02/04/12. She further indicated that on the night shift of 03/03/12 she was assigned the care of Patients #6 and #7.

Patient #8
Review of Patient #8's medical record revealed he was a [AGE] year old male admitted on [DATE] with the chief complaint of nausea and generalized weakness. Review of his "Short Stay Summary" dictated on 01/30/12 revealed a prior history of chronic obstructive pulmonary disease, gastroesophageal reflux disease, congestive heart failure, [DIAGNOSES REDACTED], hypertension, and [DIAGNOSES REDACTED]status post pacemaker.

Review of Patient #8's "Physician's Orders" dated 01/31/12 at 1610 (4:10pm) revealed an order to transfer him to ICU with a diagnosis of [DIAGNOSES REDACTED]

Review of Patient #8's "ICU Patient Flowsheet-Standard" on 02/04/12 at 8:00pm and on 02/05/12 at 12:00am and 4:00am revealed the head-to-toe assessments in ICU were performed by LPN S11. Further review revealed the head-to-toe assessment in ICU on 02/05/12 at 8:00am was performed by LPN 15.

In a face-to-face interview on 03/12/12 at 9:35am, Quality and Risk Manager RN S3 confirmed that a LPN replaced a RN (due to a call-in) as one of the 2 nurses in ICU on 01/28/12.

In a face-to-face interview on 03/13/12 at 10:00am with Quality and Risk Manager RN S3 and Director of Nursing (DON) S2 present, S3 indicated the ICU staff became upset when "by fluke" the ICU ended up with 1 ICU RN and 1 LPN on a shift in January 2012. S2 indicated on 03/03/12 an ICU nurse called in sick, and LPN S11 was determined to be the most competent to send to work ICU. S2 further indicated House Supervisor S10 remained in ICU throughout the shift and charted on paper since she was not quick with computer charting. S2 nor S3 could offer an explanation for the head-to-toe assessments being performed by a LPN when the hospital policy required them to be done every 4 hours by a RN.

Review of the hospital policy titled "Intensive Care Unit Description", revised 05/11 and presented by Quality and Risk Manager RN S3 as a current policy, revealed, in part, "...V. Criteria For Selcetion (selection) Of Personnel: A. Professional Level of staff: Registered Nurse ... VII. The role of the Nurse: The ICU/CCU (cardiac care unit) is staffed with RN's who are trained in recognizing and interpreting the symptoms of [DIAGNOSES REDACTED]

Review of the hospital policy titled "ICU/CCU Staffing Plan Summary", revised 04/10 and submitted by Quality and Risk Manager RN S3 as a current policy, revealed, in part, "...B. The Nurse Manager or designee has 24-hour accountability and responsibility for the Unit, including staffing. Staffing decisions are delegated to the Charge Nurse with Nursing Supervisor approval during evening hours, weekends, and holidays. ... Additional Staff Is Needed ... 2. The nursing supervisor will assess available staff on other units included, but not limited to: On call or called-off Med-Surg staff, Registry Med-Surg nurses, Emergency Department staff that may be floated to the ICU, Med-Surg
staff that may be able to take an ICU overflow patient in a designated overflow room, Staff from other departments as deemed appropriate...II. Summation ...All patient care services are primarily delivered by Registered Nurses. Licensed Practical Nurses, and certified or non-certified non-licensed personnel may perform delegated duties/tasks within their realm of practice or job descriptions...".

Review of the hospital policy titled "Mission And Scope Of Service" (for ICU), revised 04/11 and submitted by Quality and Risk Manager S3 as a current ICU policy, revealed, in part, "...III. Skill Level of Personnel a. Skill Level: The nursing staff is an all RN staff. RN's must have current ACLS (advanced cardiac life support), PALS (pediatric advanced life support), and BLS (basic life support). CCRN (critical care registered nurse) certification is encouraged...".

Review of the hospital policy titled "Standards of Nursing Care Intensive Care Unit", revised 05/121 and submitted by Quality and Risk Manager S3 as a current ICU policy, revealed, in part, "...B. Assessment ... 4. A complete head-to-toe assessment will be completed by a RN and documented on the ICU flowsheet at least every four (4) hours...".

Wound Care Nurse Competency:
Review of Patient #3's medical record revealed he was a [AGE] year old male admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]"Patient Anatomical Assessment Report Med-Surg Flowsheet - Standard" dated 03/04/12 at 19:05 (7:05 p.m.) and the "Wound Care Altered Skin Integrity Flowsheet" dated 03/05/12 revealed Wound Care RN S9 documented "consulted for low Braden score. All skin assessed. Pt has skin breakdown/mass to scrotal area. Physician S21 aware. Pt was actually scheduled for surgery on scrotal mass ... Nurses are putting barrier cream on area. Heels are offloaded. No further recommendations at this time".

Review of Wound Care RN S9's personnel file revealed she was the charge nurse of the wound management program. Further review revealed no documented evidence that she had been assessed and determined competent to perform wound care assessments and treatment. Review of Wound Care RN S9's "Department Charge Nurse Orientation Competency" presented by Director of OR (operating room) S17 revealed general orientation, administrative orientation, and clinical orientation was conducted on 03/11/08.

In a face-to-face interview on 03/14/12 at 2:40pm, Director of OR S17 confirmed she did not have a competency assessment for wound care and assessment for Charge Nurse Wound Care RN S9.

Review of the Wound Care Center policy titled "Wound Management Program", policy number WMP-007, submitted 12/02, and presented by Director of OR S17 as a current policy, revealed, in part, "...Orientation Agenda The form is intended as a guide for the new employee during the orientation process. ... Sections I through V are a review of WMP (wound management program) Policy & (and) Procedure Manuals and Videos. ... Section VII is Demonstration/Documentation of competency check off. The new employee will be deemed competent when this section is signed and dated. This section is not completed until, in the judgement of the preceptor, the employee is competent to carry out these procedures without supervision...".
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the hospital failed to ensure all drugs and biologicals were administered as ordered by the physician and according to acceptable standards of practice for 3 of 6 patients' records reviewed for medication administration from a total of 8 sampled patients (#1, #2, #3). Findings:

Patient #1
Review of Patient #1's medical record revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #1's "Physician's Orders" revealed a clarification order dated 03/10/12 at 1220 (12:20pm) for Onglyza 5 mg (milligrams) one daily, with no documented evidence of the route for administration. Further review revealed an order written on 03/11/12 at 4:00pm for Aldactone 25 mg by mouth daily.

Review of Patient #1's "Administration Documentation" revealed Onglyza was not administered on 03/10.12 at 12:35pm with the reason documented as "patient does not have with her". Further review of the medical record revealed no documented evidence that Aldactone was administered as ordered on [DATE] at 4:00pm.

In a face-to-face interview on 03/12/12 at 10:25am, Pharmacist S5 indicated Onglyza was available and should have been administered.

In a face-to-face interview on 03/12/12 at 10:28am, Quality and Risk Manager S3 confirmed there was no documented evidence in Patient #1's record that her physician was notified of the missed dose of Onglyza.

In a face-to-face interview on 03/12/12 at 10:40am, both Quality and Risk Manager S3 and Pharmacist S5 reviewed Patient #1's medical record and confirmed that Aldactone was not administered on 03/11/12 when ordered at 4:00pm. S5 indicated the pharmacy closed at 4:00pm, but Aldactone was available in the night cabinet.

Patient #2
Review of Patient #2's medical record revealed she was a [AGE] year old female admitted on [DATE] with the chief complaint of shortness of breath. Further review revealed she had a history of hypertension, lupus, [DIAGNOSES REDACTED], chronic renal insufficiency, [DIAGNOSES REDACTED], gout, and generalized anxiety disorder.

Review of Patient #2's "Medication Reconciliation" revealed she had an order to continue Norvasc 10 mg by mouth daily and Metoprolol Tartrate 50 mg by mouth twice a day.

Review of Patient #2's "Medication Name Administration Record" (MAR) revealed she received Norvasc 10 mg by mouth on 03/12/12 at 9:15am with no documented evidence of her blood pressure or heart rate at the time of administration. Further review revealed Patient #2 received Metoprolol 50 mg by mouth on 03/11/12 at 2118 (9:18pm) and on 03/12/12 at 9:15am with no documented evidence of her blood pressure or heart rate prior to administering the medication.

In a face-to-face interview on 03/12/12 at 1:40pm, Quality and Risk Manager RN S3 indicated the nursing staff had access to the 2012 Lippincott's Nursing Drug Guide as a resource for medication administration standards. She further indicated the nurses reviewed the vital signs taken at 8:00am by the nursing assistants to determine if the Norvasc and Metoprolol should be administered at 9:00am.

Review of the 2012 Lippincott's Nursing Drug Guide revealed, in part, "...Norvasc ...Assessment ...Physical: ...P (pulse), BP (blood pressure)... Metoprolol ... Nursing Considerations Assessment ... Physical: ...P, BP...".

Patient #3
Review of Patient 33's medical record revealed he was a [AGE] year old male admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #3's "Physician's Orders" dated 03/09/12 at 8:45am received by telephone order by Contract RN S8 from Company A revealed an order for Albumin 25 grams IVPB (intravenous piggyback) on dialysis now.

Review of Patient #3's "Hemodialysis Treatment Sheet" dated 03/09/12 revealed Contract RN S8 from Company A administered Albumin 25 grams IVPB at 10:00am, 1 hour and 15 minutes after it was ordered.

In a face-to-face interview on 03/13/12 at 11:32am, Contract RN S8 from Company A indicated she was a RN employed by Company A which was the contracted company to provide hemodialysis services at the hospital. S8 further indicated she received the verbal order for Albumin on 03/09/12 for Patient #3. S8 indicated sometimes she received physician orders but wouldn't write them until after the dialysis had started. S8 indicated the Albumin administration was based on an assessment of the patient's blood pressure and sometimes it may not be needed stat, but it was necessary to have the medication on hand. S8 could offer no further explanation for the Albumin ordered to be administered now at 8:45am not being given until 1 hour and 15 minutes later.

Review of the hospital policy titled "Medications", policy number M-6, revised 03/11, and presented by Quality and Risk Manager S3 as the current policy, revealed, in part, "...13. If a patient cannot take medications at the time prescribed ... return the medication to the medication cart and administer at the earliest opportunity, charting time actually administered. Chart the reason the medication was not administered on the MAR or Nursing Notes and notify the physician. ...C. Administration of Medications ... 5. If a medication is held or delayed for any reason this must be documented in the medical record. The physician should be notified. ... 10. Document medication administration on MAR, and electronic medical record as applicable. In the nurse's notes, include any assessment data that refer to the patient's response to the medication or any adverse effects of the medication...".

Review of the hospital policy titled "Standard Medication Administration Times", policy number M-5, revised 03/12, and presented by Quality and Risk Manager S3 as the current policy, revealed, in part, "...Medication may be given one hour prior or after the hour. ... C. It is recommended that the first dose of medication be given as soon as obtained. The next dose should be given by standard administration time schedule...".