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.

CLEVELAND REGIONAL MEDICAL CTR 300 E CROCKETT CLEVELAND, TX March 27, 2013
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review and interview the facility failed to:
A. enforce their policy for the assessment and re-assessment. 6 of 7 (patients #1, #2, #3, #4, #5, #7) patients did not have a reassessments by a Registered Nurse (RN) after changing caregivers.
Refer to tag A0392
B. require the registered nurses to supervise and evaluate the nursing care of 4 of 7 (patient #1, #3, #5, #7). 2 of 7 (patient #1, #3) patients reviewed, were transferred from one level of care (emergency room ) to another level of care (Medical/Surgical Unit) and assigned to the care of an Licensed Vocational Nurse (LVN) without the medical needs first being assessed and evaluated by a registered nurse. 3 of 7 (patients #3, #5, #7) medical records reflect these patients were being cared for by Licensed Vocational Nurses greater than 24 hours before being evaluated by a registered nurse.
Refer to tag A0395
C. require registered nurses to assess patients and evaluate their needs prior to assigning the patients to the care of Licensed Vocational Nurse (LVN). 2 of 7 (patient #1, #3) patients reviewed, were transferred from one level of care (emergency room ) to another level of care (Medical/Surgical Unit) and assigned to the care of an LVN without the medical needs first being assessed and evaluated by a registered nurse.
Refer to tag A0397
D. provide a safe setting for patients to receive care.
Refer to tag A0144
This deficient practice created a series of events that led to a medication overdose of patient #1 resulting in an Immediate Jeopardy.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on document review and interview the facility failed to
1. require register nurses to assess patients and evaluate their needs prior to assigning the patients to the care of a License Vocational Nurse (LVN).
2. ensure a report of a patient being transferred from one level of care to another is conducted by registered nurses. The care of 1of 7 (#1) patients reviewed was transferred from an emergency department RN to an LVN on the medical surgical unit.
3. ensure nursing staff received orientation and had competencies to provide care in the emergency department.

This deficient practice created a series of events that led to a medication overdose of patient #1 resulting in an Immediate Jeopardy.

The review of the document (policy) titled, "Assessment/Reassessment: General" revealed,
"Initial Assessment:
9. Obtaining the initial assessment shall be the responsibility of a Registered Nurse.
b. The Registered Nurse is solely responsible for reviewing and confirming the data collection performed by other health care providers and integrating that data with any additional assessment information obtained in order to identify patient needs and care priority."
Review of medical record of patient #1 and the document dated 3/20/2013 and titled, "Nurse Documentation" revealed, at "2:45pm the patient was admitted to the emergency room after the patient was pushed and fell backwards over an end table and chair. The patient initially had a loss of consciousness. The patient was slow to arouse, skin was pale, diaphoretic and hyperventilating. Patient was unsure where he was, initially. A hard C-collar was applied and an IV was started at the scene. Patient was placed on a backboard and brought to the ER."
Further review of patient #1's medical record revealed: "Musculoskeletal: Patient reports sprain to the neck and back. . Distal pulses are intact. Capillary refill is less than 2 seconds distal to the injury site. Contusion noted to the head."
Treatments: IV Demerol 25mg IV initiated at 3/20/2013 3:04pm ... IV Toradol 60mg IV initiated at 3/20/2013 3:05pm ... IV Custom Med (specific) phenergan 12.5mg IV initiated at 3/20/2013 3:01pm ... Custom Med (Manual Entry) IV Norflex 60mg IV initiated at 3/20/2013 3:45pm ... Custom Med (Manual Entry) fentanyl patch 75mcg to chest wall initiated at 3/20/2013 4:00pm ...
A review of the document dated 3/20/2013 and titled, "Emergency Physician Record" revealed, "Chief Complaint: Fall injury to Neck, prior to arrival. Onset/duration: 2 minutes ago. Severity of pain: Moderate. Associated Symptoms: dazed. Location of pain/injury: neck and back. Past History: diabetes, type 2. Hypertension. Cervical disc disease and surgery. Clinical Impression: Concussion without loss of consciousness. Strain, cervical and lumbosacral."
A review of the document dated 3/20/2013 and titled, "Physician Admission Orders" revealed, "Admit to observation for airway observation."
An interview with the ER Physician #25 reported after consulting with patient #1's primary physician #26 the decision was made to admit the patient to the facility for 24 hour observation due to the past history of cervical surgery. Physician #25 reported the patient had reported a sensation when swallowing. Physician #25 reported, physician #26 wanted patient #1 admitted for 24 hours to observe for possible airway complications.
Review of the document dated 3/20/2013 and titled, "Nurse Documentation" revealed, at 5:54 the emergency room staff, RN #23 gave report to LVN #18. The emergency room notes indicate patient #1 was transported by stretcher to room #222. The admitting diagnosis was Airway Observation. The medical record contained no evidence of an RN assessment or observation of the patient by the RN or LVN from 5:54pm until 7:30pm. At 7:30pm the RN assessment was completed by RN #12. At 8:28pm the document titled, "Medication Administration Record" (MAR), documented RN #12 placed a fentanyl patch 100mcg/hr on patient #1. On 3/21/2013 at 5:30am the document titled, "Nurses Notes" documented, "Pt. found respirations shallow 8, pulses present, no responsive to verbal/ tactile stimuli, notified Naomi house supervisor, see cardiopulmonary flow sheet." A review of the document titled, "Cardiopulmonary Arrest Flow Sheet" revealed, at 5:35am the patient was non-responsive, respirations were less than 8 breaths per minutes, pupils pinpoint and non-reactive. A code was called. At 5:40am the patient remained unresponsive. Two fentanyl patches were removed from the patient. Narcan 0.4 milligram(mg) intravenous (IV) was given to the patient. At 5:55am patient #1 received another dose of Narcan 1.6 mg IV. At 6:30am the document revealed the patient was alert and oriented to person, place and time but complained of pain in the upper right chest.
An interview by phone on 3/27/2013 at 9:00am with RN #23 confirmed report on the patient was given to LVN #18. RN #23 was unable to recall if it was mentioned in the report the patient had a fentanyl patch in place. RN #23 was asked if the facility's established process of using a handoff was used? Staff #23 reported it was only the second time to work in the emergency room . Staff #23 reported being an Intensive Care Unit Nurse (ICU) and was unfamiliar with the process of the ER and "no I did not use the handoff sheet".
An interview on 3/27/2013 at 12:00 in the Administrative Conference Room with LVN #18 confirmed RN #23 had given report on patient #1 to the LVN #18. When asked if a facility required handoff sheet had been used, LVN stated "NO". When asked if RN #23 had reported a fentanyl patch had been applied to the patient, LVN #18 stated, "NO". LVN #18 volunteered the information that a handoff sheet was initiated by LVN #18 when the patient report was given to RN #12. LVN #18 confirmed the fentanyl patch was not reported to RN #12. LVN #18 confirmed no assessment or observation of the patient was made. The LVN reported when going to the patient's room the RN charge nurse and the RN house supervisor was observed at the bedside. The LVN reports feeling the patient was in good hands and it being so late in the shift, an assessment or observation of the patient was not done.
An interview with Charge RN #24 on 3/26/2013 at 4:30pm in the Administrative Conference Room confirmed there had not been an assessment of the patient prior to assigning the patient to the LVN. RN #24 confirmed it was the practice of the facility to assign new patients to an LVN. The RN assessment would be done by the oncoming RN. RN #24 confirmed an RN had not taken report on patient #1. The RN confirmed being in the patients room only visiting as a friend and confirmed being unaware a fentanyl patch had been placed on the patient.
A phone interview was conducted on 3/27/2013 at 10:00am with RN #12 confirmed receiving a report from LVN #18. RN #12 the report was taken at the beside and a handoff sheet was used. RN #12 reported there was no mention of the patient having a fentanyl patch at the bedside report or documented on the handoff sheet. RN #12 was asked to explain to the surveyor the events that led up to the second fentanyl patch being placed on the patient by RN #12. RN #12 reported, Per the doctor's orders the medications were being collected from the facility's medication dispensing system. The system is set so that all new medications are not highlighted. If a medication had been initiated or given it would be highlighted on the screen that is viewed by the nurse. The fentanyl patch was not highlighted so I retrieved the patch and applied it to the patient. Before applying the patch I wrote on a blue label my initials, date and time. I always apply a sticker to a fentanyl patch because once it is applied it is transparent on the patient and is easily over looked and if the patient goes home with the patch there is no question when the patch needs to be changed. RN #12 was asked if a skin assessment had been done. The RN reported the patient's gown was not removed exposing the chest. Lung sounds were listen to through the gown. RN #12 reported having no knowledge of the first fentanyl patch having been placed on the patient until the patient stopped breathing and the patient was resuscitated. The second patch was found on the patient with no label or markings indicating when it was applied.
On 3/21/2013 the care of the patient #1 was transferred to the care of LVN #17, working the night shift. The document titled, "Patient Assessment 7P-7A" contained the signature of LVN #17 but there was no required co-signature of a RN. There was no evidence the patient's care or the LVN was supervised by an RN on the night shift.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on document review and interview the facility failed to:
1. require the registered nurses to supervise and evaluate the nursing care of 4 of 7 (patient #1, #3, #5, #7) patients reviewed. There were 2 of 7 (patient #1, #3) patients reviewed that were transferred from the emergency room to the Medical/Surgical Unit and assigned to the care of an Licensed Vocational Nurse (LVN) without the medical needs being assessed and evaluated by a registered nurse. In 3 of 7 (patients #3, #5, #7) medical records reviewed. the patients were being cared for by Licensed Vocational Nurses greater than 24 hours without being assessed by a registered nurse.
REFER TO A-395
2. enforce their policy for the assessment and re-assessment of patients. There were 6 of 7 (patients #1, #2, #3, #4, #5, #7) patients that did not have reassessments performed by a Registered Nurse (RN) after changing caregivers.
REFER TO A-392
3. require register nurses to assess patients and evaluate their needs prior to assigning 2 of 7 (patients #1, #3) patients to the care of Licensed Vocational Nurse (LVN).
REFER TO A-397
This deficient practice created a series of events that led to a medication overdose of patient #1 resulting in an Immediate Jeopardy.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on document review and interview the facility failed to enforce their policy for the assessment and re-assessment of patients. There were 6 of 7 (patients #1, #2, #3, #4, #5, #7) patients that did not have reassessments performed by a Registered Nurse (RN) after changing caregivers.
The review of the document (policy) titled, "Assessment/Reassessment: General," revealed:
"Initial Assessment:
9. Obtaining the initial assessment shall be the responsibility of a Registered Nurse.
b. The Registered Nurse is solely responsible for reviewing and confirming the data collection performed by other health care providers and integrating that data with any additional assessment information obtained in order to identify patient needs and care priority.
Reassessment:
1. ... At a minimum, a Registered Nurse will reassess the patient every 24 hours. The frequency, scope and intensity of reassessment will be determined by the patient's diagnosis or change in diagnosis, the care setting, the patient's desire for care, the patient's response to any previous care and/or any change in caregiver.
4. ....Unit Specific Guidelines: Reassessment criteria includes:
Significant change in patient condition or level of care.
Uncontrolled event placing a patient at risk for an adverse outcome.
Determining response to treatment.
Abnormal findings from, previous exam.
New onset of pain.
After PRN medications are dispensed."

1. Review of medical record #1 revealed that on 3/20/2013 at 5:54 the emergency room staff, RN #23, gave report to LVN #18. The emergency room notes indicate patient #1 was transported by stretcher to room #222. The admitting diagnosis was Airway Observation.
The medical record contained no evidence of an RN assessment or observation of the patient by the RN or LVN from 5:54pm until 7:30pm.
At 7:30pm, the RN assessment was completed by RN #12. At 8:28pm the document titled, "Medication Administration Record" (MAR), documented RN #12 placed a fentanyl patch 100mcg/hr on patient #1.
On 3/21/2013 at 5:30am the document titled, "Nurses Notes" documented, "Pt. found respirations shallow 8, pulses present, non responsive to verbal/tactile stimuli, notified house supervisor, see cardiopulmonary flow sheet."
A review of the document titled, "Cardiopulmonary Arrest Flow Sheet" revealed, at 5:35am the patient was non-responsive, respirations were less than 8 breaths per minutes, pupils pinpoint and non-reactive. A code was called. At 5:40am the patient remained unresponsive. Two fentanyl patches were removed from the patient. Narcan 0.4 milligram(mg) intravenous (IV) was given to the patient. At 5:55am patient #1 received another dose of Narcan 1.6 mg IV. At 6:30am the document revealed the patient was alert and oriented to person, place and time but complained of pain in the upper right chest.
On 3/21/2013, the care of patient #1 was transferred to the care of LVN #17,working the night shift, 7pm to 7am. The patient assessment contained the signature of LVN #17 but there was no required co-signature of an RN. There was no evidence the patient's care or the LVN was supervised by an RN on the night shift.
2. Review of medical record #2 revealed on 1/11/2013 during the day shift, 7am to 7pm, patient #2 was assigned to LVN #5. At 7pm, the night shift, on 1/11/2013 the care of the patient was transferred to an agency LVN #4. On 1/12/2013 at 7am, day shift, the care of the patient was transferred to LVN #5. The chart documented thirty-six hours that the patient was cared for by LVNs with no evidence of RN supervision or an RN assessment of patient #2.
On 1/12/2013 the medical record documents the care of the patient was transferred, to the care RN #9 on the night shift, 7pm to7am. RN #9 that was staffed on the night shift, 7pm to 7am, signed the document titled, "Patient Assessment 7A-7P" as the supervising RN of the LVN and of the patient's care for the day shift, 7am to 7pm. On 1/13/2013 the medical record reflects the same findings. During the day shift, 7am to 7pm the patient was cared for by LVN #5. The care of the patient was transferred, to RN #8 on night shift, 7pm to 7am. RN #8 that was staffed on nights signed the document titled, "Patient Assessment 7A-7P" as the supervising RN of the LVN and attests to the patient's care for the day shift, 7am to 7pm. There was no other evidence of RN supervision of the LVN or supervision of patient care for the day shift.
On 1/14/2013 the medical record documents the care of the patient was transferred, to the care LVN #6 on the day shift 7am to 7pm. The document titled, "Patient Assessment 7A-7P" had no signature of a supervising RN. There was no other evidence of RN supervision of the LVN or supervision of patient care for the day shift.
On 1/15/2013 the medical record documents the care of the patient was transferred, to the care LVN #6 for the7am till 7pm shift. The document titled, "Patient Assessment 7A-7P" had no signature of a supervising RN. The chart reflects the patient was assessed and discharged from the facility by LVN #6. There was no other evidence of RN supervision of the LVN or supervision of patient care for the 7am shift.
3. Review of patient #3's medical record revealed that the patient was admitted to the medical/surgical floor on 2/13/2013 at 5:05pm. The care of the patient was received by LVN #11. The document titled, "Nurses' Notes", documented, one entry, by staff #11 that read, "Rec. pt. via stretcher to rm. 215. Pt. oriented to surroundings." The document titled, "Patient Assessment 7A-7P" had written in the center of it, "SEE Admit Assessment" and the document was timed at 5:05pm, dated 2/13/2013 and signed by LVN #11. This document was co-signed by the RN #12 that was working the 7pm to 7am shift. The admission assessment and the patient's plan of care were initiated by the RN at 7:30pm. There was no documented evidence in the patient's medical record of an RN assessment after patient #3's change in level of care or no RN supervision of LVN #11 or of patient #3's care for two hours from 5:05pm until the RN assessment was completed at 7:30pm.

On 2/14/2013 the care of the patient was transferred to the care of LVN #13, working the night shift. The document titled, "Patient Assessment 7P-7A" contained the signature of LVN #13 but there was no required co-signature of a RN. There was no evidence the patient's care or the LVN was supervised by an RN.
On 2/16/2013 the care of the patient was transferred to the care of LVN #14, working the day shift. The document titled, "Patient Assessment 7A-7P" contained the signature of LVN #14 but there was no required co-signature of a RN. The care of the patient was then transferred to the care of LVN #15, working the night shift. The document titled, "Patient Assessment 7P-7A" contained the signature of LVN # 13 but there was no required co-signature of a RN. On 2/17/2013 the care of the patient was transferred to the care of LVN #6, working the day shift. The document titled, "Patient Assessment 7A-7P" contained the signature of LVN #6 but there was no required co-signature of a RN. There was no evidence the patient's care or the LVN was supervised by an RN for 36 hours. The on-coming RN #16 on 2/17/2013 and was working the night shift, 7pm to 7am, signed as the supervising RN of LVN # 15 that was caring for the patient on the day shift. RN #16 was not working the day shift and could not have supervised the care of patient #3 or the LVN.
On 2/18/2013 LVN #11 assumed the care of patient #3 on the day shift, 7a to 7pm. The document titled, "Patient Assessment 7A-7P" contained the signature of LVN # 11 but there was no required co-signature of a RN. The care of the patient was then transferred to the care of LVN #17, working the night shift. The document titled, "Patient Assessment 7P-7A" contained the signature of LVN #17 but there was no required co-signature of a RN. Patient #3 did not receive a required RN assessment for greater than 24 hours.

4. Review of medical record #4 revealed on 3/14/2013 the care of the patient was transferred to the care of LVN #11, working the day shift. The document titled, "Patient Assessment 7A-7 " contained the signature of LVN #11. The on-coming RN #16 on 3/14/2013 and was working the night shift, 7pm to 7am, signed as the supervising RN of LVN #11 that was caring for the patient on the day shift. RN #16 was not working the day shift and could not have supervised the care of patient #4 or the LVN.
On 3/15/2013 the care of the patient was transferred to the care of LVN #6, working the day shift. The document titled, "Patient Assessment 7A-7P" contained the signature of LVN #6. The on-coming RN #12 on 3/15/2013 and was working the night shift, 7pm to 7am, signed as the supervising RN of LVN #6 that was caring for the patient on the day shift. RN #12 was not working the day shift and could not have supervised the care of patient #4 or the LVN.
On 3/16/2013 the care of the patient was transferred to the care of LVN #14, working the day shift. The document titled, "Patient Assessment 7A-7P" contained the signature of LVN #14. The on-coming RN #12 on 3/16/2013 and was working the night shift, 7pm to 7am, signed as the supervising RN of LVN #14 that was caring for the patient on the day shift. RN #12 was not working the day shift and could not have supervised the care of patient #4 or the LVN.
On 3/17/2013 the care of the patient was transferred to the care of LVN #14, working the day shift. The document titled, "Patient Assessment 7A-7P" contained the signature of LVN #14. The on-coming RN #12 on 3/17/2013 and was working the night shift, 7pm to 7am, signed as the supervising RN of LVN #14 that was caring for the patient on the day shift. RN #12 was not working the day shift and could not have supervised the care of patient #4 or the LVN.
On 3/18/2013 the care of the patient was transferred to the care of LVN #11, working the day shift. The document titled, "Patient Assessment 7A-7P" contained the signature of LVN #11. The on-coming RN #16 on 3/18/2013 and was working the night shift, 7pm to 7am, signed as the supervising RN of LVN #11 that was caring for the patient on the day shift. RN #16 was not working the day shift and could not have supervised the care of patient #4 or the LVN.
On 3/20/2013 the care of the patient was transferred to the care of LVN #18, working the day shift. The document titled, "Patient Assessment 7A-7P" contained the signature of LVN #18. The on-coming RN #19 on 3/20/2013 and was working the night shift, 7pm to 7am, signed as the supervising RN of LVN #18 that was caring for the patient on the day shift. RN #19 was not working the day shift and could not have supervised the care of patient #4 or the LVN.
On 3/21/2013 the medical record documents the care of the patient was transferred, to the care LVN #18 for the7am till 7pm shift. The document titled, "Patient Assessment 7A-7P" had no signature of a supervising RN. The chart reflects the patient was assessed and discharged from the facility by LVN #18.There was no other evidence of RN supervision of the LVN or supervision of patient care for the 7am shift.
5. Review of medical record #5 revealed on 3/9/2013 the care of the patient was transferred to the care of LVN #15, working the night shift. The document titled, "Patient Assessment 7P-7A" contained the signature of LVN #15 but there was no required co-signature of a RN.
On 3/10/2013 LVN #20 assumed the care of patient #5 on the day shift, 7a to 7pm. The document titled, "Patient Assessment 7A-7 " contained the signature of LVN #20 but there was no required co-signature of a RN. The care of the patient was then transferred to the care of LVN #15, working the night shift. The document titled, "Patient Assessment 7P-7A" contained the signature of LVN #15 but there was no required co-signature of a RN.

On 3/11/2013 LVN #14 assumed the care of patient #5 on the day shift, 7a to 7pm. The document titled, "Patient Assessment 7A-7P" contained the signature of LVN #14 but there was no required co-signature of a RN. The care of the patient was then transferred to the care of LVN #17, working the night shift. The document titled, "Patient Assessment 7P-7A" contained the signature of LVN #17 but there was no required co-signature of a RN.

On 3/12/2013 the care of the patient was transferred to the care of LVN #14, working the day shift. The document titled, "Patient Assessment 7A-7P" contained the signature of LVN #14. The on-coming RN #19 on 3/12/2013 and was working the night shift, 7pm to 7am, signed as the supervising RN of LVN #14 that was caring for the patient on the day shift. RN #19 was not working the day shift and could not have supervised the care of patient #5 or the LVN.
Patient #5 did not receive a required RN assessment for greater than 72 hours.

6. Review of medical record #7 revealed on 1/3/2013 the care of the patient was transferred to the care of LVN #17, working the night shift. The document titled, "Patient Assessment 7P-7A" contained the signature of LVN #17 but there was no required co-signature of a RN.
On 1/7/2013 LVN #20 assumed the care of patient #7 on the day shift, 7a to 7pm. The document titled, "Patient Assessment 7A-7P" contained the signature of LVN #20 but there was no required co-signature of a RN. The care of the patient was then transferred to the care of LVN #21, working the night shift. The document titled, "Patient Assessment 7P-7A" contained the signature of LVN #21 but there was no required co-signature of a RN.
On 1/8/2013 the care of the patient was transferred to the care of LVN #20, working the day shift. The document titled, "Patient Assessment 7A-7P" contained the signature of LVN #20. The on-coming RN #22 on 1/8/2013 and was working the night shift, 7pm to 7am, and signed as the supervising RN of LVN #20 that was caring for the patient on the day shift. RN #22 was not working the day shift and could not have supervised the care of patient #7 or the LVN.
Patient #7 did not receive a required RN assessment for greater than 36 hours.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on document review and interview the facility failed to require the registered nurses to supervise and evaluate the nursing care of 4 of 7 (patient #1, #3, #5, #7). 2 of 7 (patient #1, #3) patients reviewed, were transferred from one level of care (emergency room ) to another level of care (Medical/Surgical Unit) and assigned to the care of an Licensed Vocational Nurse (LVN) without the medical needs first being assessed and evaluated by a registered nurse. 3 of 7 (patients #3, #5, #7) medical records reflect these patients were being cared for by Licensed Vocational Nurses greater than 24 hours without being assessed by a registered nurse.

This practice setup a series of events that created an Immediate Jeopardy and lead to an medication overdose of patient #1.
The review of the document (policy) titled, "Assessment/Reassessment: General" revealed:
Initial Assessment:
9. Obtaining the initial assessment shall be the responsibility of a Registered Nurse.
b. The Registered Nurse is solely responsible for reviewing and confirming the data collection performed by other health care providers and integrating that data with any additional assessment information obtained in order to identify patient needs and care priority.

Review of medical record of patient #1 and the document dated 3/20/2013 and titled, "Nurse Documentation" revealed, at 2:45pm the patient was admitted to the emergency room after the patient was pushed and fell backwards over an end table and chair. The patient initially had a loss of consciousness. The patient was slow to arouse, skin was pale, diaphoretic and hyperventilating. Patient was unsure where he was, initially. A hard C-collar was applied and an IV was started at the scene. Patient was placed on a backboard and brought to the ER.
Musculoskeletal: Patient reports sprain to the neck and back. . Distal pulses are intact. Capillary refill is less than 2 seconds distal to the injury site. Contusion noted to the head.
Treatments: IV Demerol 25mg IV initiated at 3/20/2013 3:04pm ... IV Toradol 60mg IV initiated at 3/20/2013 3:05pm ... IV Custom Med (specific) phenergan 12.5mg IV initiated at 3/20/2013 3:01pm ... Custom Med (Manual Entry) IV Norflex 60mg IV initiated at 3/20/2013 3:45pm ... Custom Med (Manual Entry) fentanyl patch 75mcg to chest wall initiated at 3/20/2013 4:00pm ...
A review of the document dated 3/20/2013 and titled, "Emergency Physician Record" revealed, Chief Complaint: Fall injury to Neck, prior to arrival. Onset/duration: 2 minutes ago. Severity of pain: Moderate. Associated Symptoms: dazed. Location of pain/injury: neck and back. Past History: diabetes, type 2. Hypertension. Cervical disc disease and surgery. Clinical Impression: Concussion without loss of consciousness. Strain, cervical and lumbosacral.
A review of the document dated 3/20/2013 and titled, "Physician Admission Orders" revealed, Admit to observation for airway observation. Primary physician #26.
An interview with the ER Physician #25 reported after consulting with patient #1's primary physician #26 the decision was made to admit the patient to the facility for 24 hour observation due to the past history of cervical surgery. Physician #25 reported the patient had reported a sensation when swallowing. Physician #25 reported, physician #26 wanted patient #1 admitted for 24 hours to observe for possible airway complications.
Review of the document dated 3/20/2013 and titled, "Nurse Documentation" revealed, at 5:54 the emergency room staff, RN #23 gave report to LVN #18. The emergency room notes indicate patient #1 was transported by stretcher to room #222. The admitting diagnosis was Airway Observation. The medical record contained no evidence of an RN assessment or observation of the patient by the RN or LVN from 5:54pm until 7:30pm. At 7:30pm the RN assessment was completed by RN #12. At 8:28pm the document titled, "Medication Administration Record" (MAR), documented RN #12 placed a fentanyl patch 100mcg/hr on patient #1. On 3/21/2013 at 5:30am the document titled, "Nurses Notes" documented, "Pt. found respirations shallow 8, pulses present, no responsive to verbal/ tactile stimuli, notified Naomi house supervisor, see cardiopulmonary flow sheet." A review of the document titled, "Cardiopulmonary Arrest Flow Sheet" revealed, at 5:35am the patient was non-responsive, respirations were less than 8 breaths per minutes, pupils pinpoint and non-reactive. A code was called. At 5:40am the patient remained unresponsive. Two fentanyl patches were removed from the patient. Narcan 0.4 milligram(mg) intravenous (IV) was given to the patient. At 5:55am patient #1 received another dose of Narcan 1.6 mg IV. At 6:30am the document revealed the patient was alert and oriented to person, place and time but complained of pain in the upper right chest.
An interview by phone on 3/27/2013 at 9:00am with RN #23 confirmed report on the patient was given to LVN #18. RN #23 was unable to recall if it was mentioned in the report the patient had a fentanyl patch in place. RN #23 was asked if the facility's established process of using a handoff was used? Staff #23 reported it was only the second time to work in the emergency room . Staff #23 reported being an Intensive Care Unit Nurse (ICU) and was unfamiliar with the process of the ER and no I did not use the handoff sheet.
An interview on 3/27/2013 at 12:00 in the Administrative Conference Room with LVN #18 confirmed RN #23 had given report on patient #1 to the LVN #18. When asked if a facility required handoff sheet had been used, LVN stated "NO". When asked if RN #23 had reported a fentanyl patch had been applied to the patient, LVN #18 stated, "NO". LVN #18 volunteered the information that a handoff sheet was initiated by LVN #18 when the patient report was given to RN #12. LVN #18 confirmed the fentanyl patch was not reported to RN #12. LVN #18 confirmed no assessment or observation of the patient was made. The LVN reported when going to the patient's room the RN charge nurse and the RN house supervisor was observed at the bedside. The LVN reports feeling the patient was in good hands and it being so late in the shift, an assessment or observation of the patient was done.
An interview with Charge RN #24 on 3/26/2013 at 4:30pm in the Administrative Conference Room confirmed there had not been an assessment of the patient prior to assigning the patient to the LVN. RN #24 confirmed it was the practice of the facility to assign new patients to an LVN. The RN assessment would be done by the oncoming RN. RN #24 confirmed an RN had not taken report on patient #1. The RN confirmed being in the patients room only visiting as a friend and confirmed being unaware a fentanyl patch had been placed on the patient.
A phone interview was conducted on 3/27/2013 at 10:00am with RN #12 confirmed receiving a report from LVN #18. RN #12 the report was taken at the beside and a handoff sheet was used. RN #12 reported there was no mention of the patient having a fentanyl patch at the bedside report or documented on the handoff sheet. RN #12 was asked to explain to the surveyor the events that led up to the second fentanyl patch being placed on the patient by RN #12. RN #12 reported, Per the doctor's orders the medications were being collected from the facility's medication dispensing system. The system is set so that all new medications are not highlighted. If a medication had been initiated or given it would be highlighted on the screen that is viewed by the nurse. The fentanyl patch was not highlighted so I retrieved the patch and applied it to the patient. Before applying the patch I wrote on a blue label my initials, date and time. I always apply a sticker to a fentanyl patch because once it is applied it is transparent on the patient and is easily over looked and if the patient goes home with the patch there is no question when the patch needs to be changed. RN #12 was asked if a skin assessment had been done. The RN reported the patient's gown was not removed exposing the chest. Lung sounds were listen to through the gown. RN #12 reported having no knowledge of the first fentanyl patch until the patient stopped breathing and the patient was resuscitated. The first patch was found on the patient with no label or markings indicating when it was applied.
On 3/21/2013 the care of the patient #1 was transferred to the care of LVN #17, working the night shift. The document titled, "Patient Assessment 7P-7A" contained the signature of LVN #17 but there was no required co-signature of a RN. There was no evidence the patient's care or the LVN was supervised by an RN on the night shift.

Review of patient #3's medical record revealed the patient was admitted to the medical/surgical floor on 2/13/2013 at 5:05pm. The care of the patient was received by LVN #11. The document titled "Nurses' Notes" documented, one entry, by staff #11 that read, "Rec. pt. via stretcher to rm. 215. Pt. oriented to surroundings." The document titled, "Patient Assessment 7A-7P" had written in the center of it, "SEE Admit Assessment" and the document was timed at 5:05pm, dated 2/13/2013 and signed by LVN #11. This document was co-signed by the RN #12 that was working the other 7pm to 7am shift. The admission assessment and the patient's plan of care were initiated by the RN at 7:30pm. There was no documented evidence in the patient's medical record of an RN assessment after patient #3's was change from one level of care (Emergency Department) to another level of care (Medical/Surgical Unit) or no RN supervision of LVN #11 or of patient #3's care for two hours from 5:05pm until the RN assessment was completed at 7:30pm.
On 2/14/2013 the care of the patient was transferred to the care of LVN #13, working the night shift. The document titled, "Patient Assessment 7P-7A" contained the signature of LVN #13 but there was no required co-signature of a RN. There was no evidence the patient's care or the LVN was supervised by an RN.
On 2/16/2013 the care of the patient was transferred to the care of LVN #14, working the day shift. The document titled, "Patient Assessment 7A-7P" contained the signature of LVN #14 but there was no required co-signature of a RN. The care of the patient was then transferred to the care of LVN #15, working the night shift. The document titled, "Patient Assessment 7P-7A" contained the signature of LVN #13 but there was no required co-signature of a RN. On 2/17/2013 the care of the patient was transferred to the care of LVN #6, working the day shift. The document titled, "Patient Assessment 7A-7 " contained the signature of LVN #6 but there was no required co-signature of a RN. There was no evidence the patient's care or the LVN was supervised by an RN for 36 hours. The on-coming RN #16 on 2/17/2013 and was working the night shift, 7pm to 7am, signed as the supervising RN of LVN #15 that was caring for the patient on the day shift. RN #16 was not working the day shift and could not have supervised the care of patient #3 or the LVN.
On 2/18/2013 LVN #11 assumed the care of patient #3 on the day shift, 7a to 7pm. The document titled, "Patient Assessment 7A-7P" contained the signature of LVN #11 but there was no required co-signature of a RN. The care of the patient was then transferred to the care of LVN #17, working the night shift. The document titled, "Patient Assessment 7P-7A" contained the signature of LVN #17 but there was no required co-signature of a RN. Patient #3 did not receive a required RN assessment for greater than 24 hours.

Review of medical record #5 revealed on 3/9/2013 the care of the patient was transferred to the care of LVN #15, working the night shift. The document titled, "Patient Assessment 7P-7A" contained the signature of LVN #15 but there was no required co-signature of a RN.
On 3/10/2013 LVN #20 assumed the care of patient #5 on the day shift, 7a to 7pm. The document titled, "Patient Assessment 7A-7P" contained the signature of LVN #20 but there was no required co-signature of a RN. The care of the patient was then transferred to the care of LVN #15, working the night shift. The document titled, "Patient Assessment 7P-7A" contained the signature of LVN #15 but there was no required co-signature of a RN.

On 3/11/2013 LVN #14 assumed the care of patient #5 on the day shift, 7a to 7pm. The document titled, "Patient Assessment 7A-7P" contained the signature of LVN #14 but there was no required co-signature of a RN. The care of the patient was then transferred to the care of LVN #17, working the night shift. The document titled, "Patient Assessment 7P-7A" contained the signature of LVN #17 but there was no required co-signature of a RN.
On 3/12/2013 the care of the patient was transferred to the care of LVN #14, working the day shift. The document titled, "Patient Assessment 7A-7P" contained the signature of LVN #14. The on-coming RN #19 on 3/12/2013 and was working the night shift, 7pm to 7am, signed as the supervising RN of LVN #14 that was caring for the patient on the day shift. RN #19 was not working the day shift and could not have supervised the care of patient #5 or the LVN.
Patient #5 did not receive a required RN assessment for greater than 72 hours.

Review of medical record #7 revealed on 1/3/2013 the care of the patient was transferred to the care of LVN #17, working the night shift. The document titled, "Patient Assessment 7P-7A" contained the signature of LVN #17 but there was no required co-signature of a RN.
On 1/7/2013 LVN #20 assumed the care of patient #7 on the day shift, 7a to 7pm. The document titled, "Patient Assessment 7A-7P" contained the signature of LVN #20 but there was no required co-signature of a RN. The care of the patient was then transferred to the care of LVN #21, working the night shift. The document titled, "Patient Assessment 7P-7A" contained the signature of LVN #21 but there was no required co-signature of a RN.
On 1/8/2013 the care of patient #7 was transferred to the care of LVN #20, working the day shift. The document titled, "Patient Assessment 7A-7P" contained the signature of LVN #20. The on-coming RN #22 on 1/8/2013 and was working the night shift, 7pm to 7am, and signed as the supervising RN of LVN #20 that was caring for the patient on the day shift. RN #22 was not working the day shift and could not have supervised the care of patient #7 or the LVN.
Patient #7 did not receive a required RN assessment for greater than 36 hours.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on document review and interview the facility failed to require register nurses to assess patients and evaluate their needs prior to assigning the patients to the care of Licensed Vocational Nurse (LVN). 2 of 7 (patient #1, #3) patients reviewed, were transferred from one level of care (emergency room ) to another level of care (Medical/Surgical Unit) and assigned to the care of an LVN without the medical needs first being assessed and evaluated by a registered nurse.
This practice setup a series of events that created an Immediate Jeopardy and lead to an medication overdose of patient #1.
The review of the document (policy) titled, "Assessment/Reassessment: General" revealed,
"Initial Assessment:
9. Obtaining the initial assessment shall be the responsibility of a Registered Nurse.
b. The Registered Nurse is solely responsible for reviewing and confirming the data collection performed by other health care providers and integrating that data with any additional assessment information obtained in order to identify patient needs and care priority."

The review of a web-based alert regarding the use of Fentanyl patches issued by the" Institute for Safe Medication Practices" revealed the following:
"Improved methods of documentation can help guard against applying multiple patches to patients. In the hospital, the drug entry on the medication administration record should be accompanied by a second entry where nurses can document the location and time of application and removal of the patches. A dosing calendar could serve the same purpose at home. An auxiliary label can also be applied to the patch to prompt documentation of application date and time; visibility may be poor if written directly on the patch (and a pen may puncture the patch). One manufacturer provides TEGADERM-like dressings to patients who contact them about their fentanyl patches falling off."
Further review of the alerts issued by the "Institute for Safe Medication Practices" revealed, "Each time a fentanyl patch is newly applied to a patient's skin, a pen or magic marker should be used to write the date, time, and initials of the medication nurse on the patch. During the time the patient wears the patch, this documentation should be regularly checked against medication administration records. The patch should also be inspected for cuts, needle holes or other evidence of tampering, such as a dried-out appearance."
Review of medical record of patient #1 and the document dated 3/20/2013 and titled, "Nurse Documentation" revealed, at 2:45pm the patient was admitted to the emergency room after the patient was pushed and fell backwards over an end table and chair. The patient initially had a loss of consciousness. The patient was slow to arouse, skin was pale, diaphoretic and hyperventilating. Patient was unsure where he was, initially. A hard C-collar was applied and an IV was started at the scene. Patient was placed on a backboard and brought to the ER.
Musculoskeletal: Patient reports sprain to the neck and back. Distal pulses are intact. Capillary refill is less than 2 seconds distal to the injury site. Contusion noted to the head.
Treatments: IV Demerol 25mg IV initiated at 3/20/2013 3:04pm ... IV Toradol 60mg IV initiated at 3/20/2013 3:05pm ... IV Custom Med (specific) phenergan 12.5mg IV initiated at 3/20/2013 3:01pm ... Custom Med (Manual Entry) IV Norflex 60mg IV initiated at 3/20/2013 3:45pm ... Custom Med (Manual Entry) fentanyl patch 75mcg to chest wall initiated at 3/20/2013 4:00pm ...
A review of the document dated 3/20/2013 and titled, "Emergency Physician Record" revealed, Chief Complaint: Fall injury to Neck, prior to arrival. Onset/duration: 2 minutes ago. Severity of pain: Moderate. Associated Symptoms: dazed. Location of pain/injury: neck and back. Past History: diabetes, type 2. Hypertension. Cervical disc disease and surgery. Clinical Impression: Concussion without loss of consciousness. Strain, cervical and lumbosacral.
A review of the document dated 3/20/2013 and titled, "Physician Admission Orders" revealed, Admit to observation for airway observation. Primary physician #26.
An interview with the ER Physician #25 reported after consulting with patient #1's primary physician, #26, the decision was made to admit the patient to the facility for 24 hour observation due to the past history of cervical surgery. Physician #25 reported the patient had reported a sensation when swallowing. Physician #25 reported, physician #26 wanted patient #1 admitted for 24 hours to observe for possible airway complications.
Review of the document dated 3/20/2013 and titled, "Nurse Documentation" revealed, at 5:54 the emergency room staff, RN #23 gave report to LVN #18. The emergency room notes indicate patient #1 was transported by stretcher to room #222. The admitting diagnosis was Airway Observation. The medical record contained no evidence of an RN assessment or observation of the patient by the RN or LVN from 5:54pm until 7:30pm. At 7:30pm the RN assessment was completed by RN #12. At 8:28pm the document titled, "Medication Administration Record" (MAR), documented RN #12 placed a fentanyl patch 100mcg/hr on patient #1. On 3/21/2013 at 5:30am the document titled, "Nurses Notes" documented, "Pt. found respirations shallow 8, pulses present, no responsive to verbal/tactile stimuli, notified house supervisor, see cardiopulmonary flow sheet." A review of the document titled, "Cardiopulmonary Arrest Flow Sheet" revealed, at 5:35am the patient was non-responsive, respirations were less than 8 breaths per minutes, pupils pinpoint and non-reactive. A code was called. At 5:40am the patient remained unresponsive. Two fentanyl patches were removed from the patient. Narcan 0.4 milligram(mg) intravenous (IV) was given to the patient. At 5:55am patient #1 received another dose of Narcan 1.6 mg IV. At 6:30am the document revealed the patient was alert and oriented to person, place and time but complained of pain in the upper right chest.
An interview by phone on 3/27/2013 at 9:00am with RN #23 confirmed report on the patient was given to LVN #18. RN #23 was unable to recall if it was mentioned in the report the patient had a fentanyl patch in place. RN #23 was asked if the facility's established process of using a handoff was used? Staff #23 reported it was only the second time to work in the emergency room . Staff #23 reported being an Intensive Care Unit Nurse (ICU) and was unfamiliar with the process of the ER and "no I did not use the handoff sheet."
An interview on 3/27/2013 at 12:00 in the Administrative Conference Room with LVN #18 confirmed RN #23 had given report on patient #1 to the LVN #18. When asked if a facility required handoff sheet had been used, LVN stated "NO". When asked if RN #23 had reported a fentanyl patch had been applied to the patient, LVN #18 stated, "NO" . LVN #18 volunteered the information that a handoff sheet was initiated by LVN #18 when the patient report was given to RN #12. LVN #18 confirmed the fentanyl patch was not reported to RN #12. LVN #18 confirmed no assessment or observation of the patient was made. The LVN reported when going to the patient's room the RN charge nurse and the RN house supervisor was observed at the bedside. The LVN reports feeling the patient was in good hands and it being so late in the shift, an assessment or observation of the patient was done.
An interview with Charge RN #24 on 3/26/2013 at 4:30pm in the Administrative Conference Room confirmed there had not been an assessment of the patient prior to assigning the patient to the LVN. RN #24 confirmed it was the practice of the facility to assign new patients to an LVN. The RN assessment would be done by the oncoming RN. RN #24 confirmed an RN had not taken report on patient #1. The RN confirmed being in the patients room only visiting as a friend and confirmed being unaware a fentanyl patch had been placed on the patient.
A phone interview was conducted on 3/27/2013 at 10:00am with RN #12 who confirmed receiving a report from LVN #18. RN #12 the report was taken at the beside and a handoff sheet was used. RN #12 reported there was no mention of the patient having a fentanyl patch at the bedside report or documented on the handoff sheet. RN #12 was asked to explain to the surveyor the events that led up to the second fentanyl patch being placed on the patient by RN #12. RN #12 reported, per the doctor's orders the medications were being collected from the facility's medication dispensing system. The system is set so that all new medications are not highlighted. If a medication had been initiated or given it would be highlighted on the screen that is viewed by the nurse. The fentanyl patch was not highlighted so I retrieved the patch and applied it to the patient. Before applying the patch I wrote on a blue label my initials, date and time. I always apply a sticker to a fentanyl patch because once it is applied it is transparent on the patient and is easily over looked and if the patient goes home with the patch there is no question when the patch needs to be changed. RN #12 was asked if a skin assessment had been done. The RN reported the patient's gown was not removed exposing the chest. Lung sounds were listen to through the gown. RN #12 reported having no knowledge of the first fentanyl patch until the patient stopped breathing and the patient was resuscitated. The first patch was found on the patient with no label or markings indicating when it was applied.
On 3/21/2013 the care of the patient #1 was transferred to the care of LVN #17, working the night shift. The document titled, "Patient Assessment 7P-7A" contained the signature of LVN #17 but there was no required co-signature of a RN. There was no evidence the patient's care or the LVN was supervised by an RN on the night shift.
Review of patient #3's medical record revealed the patient was admitted to the medical/surgical floor on 2/13/2013 at 5:05pm. The care of the patient was received by LVN #11. The document titled "Nurses' Notes" documented, one entry, by staff #11 that read, "Rec. pt. via stretcher to rm. 215. Pt. oriented to surroundings." The document titled, "Patient Assessment 7A-7P " had written in the center of it, "SEE Admit Assessment" and the document was timed at 5:05pm, dated 2/13/2013 and signed by LVN #11. This document was co-signed by the RN #12 that was working the other 7pm to 7am shift. The admission assessment and the patient's plan of care were initiated by the RN at 7:30pm. There was no documented evidence in the patient's medical record of an RN assessment after patient #3 was changed from one level of care (Emergency Department) to another level of care (Medical/Surgical Unit) or no RN supervision of LVN #11 or of patient #3's care for two hours from 5:05pm until the RN assessment was completed at 7:30pm.
On 2/14/2013 the care of patient #3 was transferred to the care of LVN #13, working the night shift. The document titled, "Patient Assessment 7P-7A" contained the signature of LVN #13 but there was no required co-signature of a RN. There was no evidence the patient's care or the LVN was supervised by an RN.
On 2/16/2013 the care of the patient #3 was transferred to the care of LVN #14, working the day shift. The document titled, "Patient Assessment 7A-7P" contained the signature of LVN #14 but there was no required co-signature of a RN. The care of the patient was then transferred to the care of LVN #15, working the night shift. The document titled, "Patient Assessment 7P-7A" contained the signature of LVN #13 but there was no required co-signature of a RN. On 2/17/2013 the care of the patient was transferred to the care of LVN #6, working the day shift. The document titled, "Patient Assessment 7A-7P" contained the signature of LVN #6 but there was no required co-signature of a RN. There was no evidence the patient's care or the LVN was supervised by an RN for 36 hours. The on-coming RN #16 on 2/17/2013 and was working the night shift, 7pm to 7am, signed as the supervising RN of LVN #15 that was caring for the patient on the day shift. RN #16 was not working the day shift and could not have supervised the care of patient #3 or the LVN.
On 2/18/2013 LVN #11 assumed the care of patient #3 on the day shift, 7a to 7pm. The document titled, "Patient Assessment 7A-7P" contained the signature of LVN #11 but there was no required co-signature of a RN. The care of the patient was then transferred to the care of LVN #17, working the night shift. The document titled, "Patient Assessment 7P-7A" contained the signature of LVN #17 but there was no required co-signature of a RN. Patient #3 did not receive a required RN assessment for greater than 24 hours.