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.

UT HEALTH EAST TEXAS ATHENS HOSPITAL 2000 SOUTH PALESTINE ST ATHENS, TX 75751 March 15, 2013
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on records review and interviews, the facility failed to:

A. have outcomes for the patient complaints adressed in the quality assurance performance improvement process.

Refer to A0119

B. address the complainant's issues on the complaint investigation on 1 of 1 patient in a timely manner and follow the facility policy.

Refer to A0122

C. ensure patients received care in a safe setting. Nursing staff failed to ensure nutritional assessments were performed in 3 of 10 (# 5, 7, and 9) patients, skin assessments performed in 2 of 10 (# 5 and 9) patients, and fall risk protocols implemented in 6 of 10 (# 2, 4, 7, 8, 9, and 10) patients.
Refer to A0144
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on records review and interview, the facility failed to have outcomes for the patient complaints addressed in the quality assurance performance improvement process.

A review of record titled "Patient Safety/EOC Committee" revealed no outcomes to evaluate what the facility had implemented, or if the corrective action addressed the causes of the complaints with intervention to detect opportunities for improvement in the quality assurance performance improvement process. The record contained data with no documentation of what the facility had learned from the complaint investigations to improve the quality care for the patients.

A review of record titled "Performance Improvement & Patient Safety Summary: 2012" revealed data collected, analyzed, and action for complaints received at the facility. The report did not reflect any outcomes for improvement in the quality assurance performance improvement process. The report contained data with no documentation of what the facility had learned from the complaint investigations to improve the quality patient care.

An interview with staff #7 on 03/14/2013 at 3:00 PM confirmed the reports did not contain documentation of performance improvement outcomes.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on records review and interviews, the facility failed to address the complainant's issues on the complaint investigation on 1 of 1 patient in a timely manner and follow the facility policy.

A review of the record titled "Complaints January 2013" revealed patient #9 was not on the record for "Complaints January 2013." Patient #9's name was found on a list called "complaints in progress." The initial complaint was filed by patient #9's representative on 01/28/2013. The facility wrote a response letter to the complainant on 02/05/2013, but did not address all the patient care issues written by the complainant. A review of the letter from patient #9's representative written to the Director of the Medical Surgical Unit on 02/9/2013 revealed "several facts stand in need of modification." A review of records revealed no further response from the facility to patient #9's representative letter dated 02/09/2013.

A record review of the policy Titled " Patient Complaints/Grievances " revealed;

" Timely Response: 7 days total on grievances. A written response is provided to the patient from the Administration Department, Risk Management Department, or appropriate Department Manager on any grievance.

Occasionally, a grievance is complicated and may require an extensive investigation. On average, a timeframe of 7 days for the provision of the response would be considered appropriate. If the grievance will not be resolved, or if the investigation is not or will not be completed within 7 days, the hospital should inform the patient or the patient's representative that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response within a stated number of days according to the complexity of the investigation, but no longer than 30 days."

A review of records found no response from the facility regarding the letter dated 02/9/2013 written by the complainant discussing patient care issues not addressed by the facility in relation to the original complaint submitted on 1/28/13.

An interview with staff #7 on 03/14/2013 at 3:00 PM and staff #2 on 03/15/2013 at 1:30 PM confirmed the complaint investigation had been completed on 02/05/2013. Staff # 7 stated "we are not going to respond any further to the complainant, we are expecting a lawsuit."
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview and record review the facility failed ensure patients received care in a safe setting. Nursing staff failed to ensure nutritional assessments were performed in 3 of 10 (# 5, 7, and 9) patients, skin assessments were performed in 2 of 10 (# 5 and 9) patients, and fall risk protocols were implemented in 6 of 10 (# 2, 4, 7, 8, 9, and 10) patients.
This deficient practice had the potential to cause harm to patients admitted to the hospital.
Findings include:
1.) Review of the policy titled "Nutrition Screening and Assessment" policy dated 10/08/10 revealed "all patients would be screened by nursing for nutritional risk within 24 hours of admission using predetermined nutrition triggers. The dietitian would complete a nutrition assessment for all patients identified at potential nutrition risk via nutritional screen within 72 hours."
Some of the triggers listed on the nursing assessment that generated an assessment by the dietitian included:
Reduction intake
Recent Diarrhea
Albumin less than 3
Review of the policy titled "Pressure Ulcer Prevention/Treatment Guidelines" dated 06/2007 revealed the following:
"Consult dietitian to assist with nutritional assessment and planning. Implement recommendations."
Review of physician order's revealed Patient #9 was a [AGE] year old female admitted on [DATE] with a diagnoses of altered mental status, acute type B influenza, acute urinary tract infection and acute asthma exacerbation. The physician order indicated an order for a low sodium/low cholesterol or 1800 calorie ADA (American Diabetes Association) diet.
Review of lab reports revealed the following:
01/17/13 an Albumin of 3.9 (reference range being 3.5-4.9) and a Total protein of 6.9 (5.5-8.0).
01/20/13 the Albumin had decreased to 2.9 and the Total protein was 5.3.
01/21/13 the Albumin was 2.7 and the Total Protein was 5.1.
Both labs were indicators of nutritional and protein status.
Review of a prn (whenever needed) medication administration record revealed Patient #9 was treated for diarrhea on 01/19, 01/20, 01/21, and 01/24/13.
Review of physician orders dated 01/23/12 revealed an order to change Patient #9's diet to a clear liquid diet.
Review of a patient care record dated 01/24/13 at 8:15 a.m. revealed Patient #9 had skin breakdown.
Review of Patient #9's record revealed the first nursing nutritional screen was performed 01/24/13 which was 7 days after being admitted into the facility.
Review of the nutritional progress notes dated 01/24/13, 12:08 p.m. from the dietitian revealed the first dietary assessment performed on Patient #9 since being admitted to the hospital. The assessment made no reference to the low Albumin/Total Protein and skin breakdown. There was documentation the patient had flu and diarrhea symptoms, and was placed on a clear liquid diet. According to documentation from the dietician the assessment was performed due to length of stay in the hospital. There were no recommendations to address the skin breakdown or low lab values.
During an interview on 03/15/13 at 9:05 a.m., Staff # 3 reported there was a problem with completing the nutritional assessments because the dietitian was not in the facility but 2-3 days per week.
During an interview on 03/15/13 at 10:15 a.m., Staff #10 reported she was the dietitian. Staff #10 stated "nursing does the screen on admit and the triggers prompt my assessment. I have 72 hours after the prompted trigger to make an assessment. If the patients are there for 7 days or more I would screen them anyway and this is called the length of stay assessment. When patients have skin breakdown I makes sure they have a protein supplement. Staff #10 checked Patient #9's chart and reported the first dietary assessment was done on 01/24/13 and wounds/skin was not identified on the assessment by nursing.
2.) Review of the policy titled "Wounds: Prevention and Management" dated 06/2007 revealed the following key points of an assessment:
"Location of wound,etiology, classification and/or stage, size, depth, amount of wound tunneling and undermining, wound bed, wound exudate, surrounding skin, wound edges, signs and symptoms of wound infection, and pain. Document the wound assessment."
Review of physician order's revealed Patient #9 was a 59 year old female admitted on [DATE] with a diagnoses of altered mental status, acute type B influenza, acute urinary tract infection and acute asthma exacerbation.
Review of an Intensive Care Unit (ICU) assessment dated [DATE] revealed Patient #9 was at risk for skin breakdown. The Braden Scale tool used to assess skin breakdown risk showed Patient #9 had a score of 15 (range listed for "at risk" was 15-18).
Review of a patient care record dated 01/21/13 and 01/22/13 revealed Patient #9 skin was altered, but there was no documentation of how or where.
Review of a patient care record dated 01/24/13 at 8:15 a.m. revealed Patient #9 coccyx (tail bone area) was red. There was no documentation of an assessment of how large or if it was blanchable or not. There was no documentation of treatments provided to the coccyx.
During an interview on 03/14/13 at 2:30 p.m. Staff #4 reported Patient #9's coccyx was red and excoriated. She gave the protective skin barrier ointment to a student to use on the coccyx as per the facility skin protocol.
During an interview on 03/15/13 at 9:05 a.m. Staff #3 reported the nurses should be documenting an assessment when they check that the skin is altered. Staff #3 confirmed there was no documented assessment of how Patient #9's coccyx looked in the chart.
During an interview on 03/15/13 at 1:30 p.m., Staff # 2 reported they did not have a policy or protocol to explain what interventions to use according to the different scorings on the Braden scale assessment.
3.) Review of physician orders revealed Patient #5 was a [AGE] year old female admitted on [DATE] with a diagnosis of acute dehydration. Patient #5 was ordered to receive a mechanical soft diet with nectar thick liquids.
Review of the Emergency Department (ED) assessment dated [DATE] revealed Patient #5's skin was intact.
Review of an ICU assessment dated [DATE] revealed Patient #5 had a Braden scale score of 12 (range from 10-12) indicating she was at high risk for skin breakdown.
Review of a Patient care record dated 03/14/13 revealed Patient #5 had skin breakdown and there was an area noted to be red in the upper crease of the gluteal fold. There was documentation staff applied barrier cream to the affected area. There was no documentation of an assessment of the the size or stage of the sore.
Review of lab dated 03/15/13 revealed Patient #5 had a low Albumin of 2.8 (reference ranges being 3.5-4.0) and a Total Protein of 5.4 (reference ranges being 5.5-8.0)
Review of the chart revealed no initial nurse screening for nutrition nor a nutritional assessment by the dietitian completed on Patient #5.
4.) Review of physician orders revealed Patient #7 was a [AGE] year old female admitted on [DATE] with diagnoses of renal failure, dehydration and a minor head injury. According to the physician orders Patient #7 was placed on a low sodium/low cholesterol diet.
Review of a lab report dated 03/13/13, revealed Patient #7 had a low Albumin of 2.5 (reference ranges being 3.5-4.9).
Review of a nursing assessment dated [DATE] revealed a nutritional screen was performed, but no referral for a dietary consult by the dietitian was made.
During an interview on 03/15/13 at 10:15 a.m., Staff #10 (dietitian) said she had "72 hours to assess the patients after receiving a dietary screen from nursing." Staff #10 checked her list of patients who needed nutritional screens and reported Patient #10 was not listed. She had not received a referral for a consult.
5.) Review of the policy titled "Fall Risk Assessment and Safely Alert" dated 12/2010 revealed the following:
*All patients entering the facility will have a fall risk assessment completed to determine fall risk.
* Every patient will be reassessed at least every shift and PRN to identify any change in his/her safety risk score.
* If and when a fall risk assessment safety score is greater than 45 the patient is placed on Fall Risk Safety Alert.
b. Fall Prevention Protocol:
i. Yellow arm band placed on patient
ii. Slip resistant socks provided to patient
iii. Yellow star placed on the door entry
iv. Frequent toileting assistance
v. Evaluate room assignment
vi. Consider activating the bed alarm

During a tour of the Medical Surgical Unit on 3/14/2013 at 1:30 PM with Staff #6 and Staff #11, a request was made to observe patients who required bed alarms. Room #s' 102 B, 115, 121, and 134 B were identified as having the fall risk protocol in place. The following was observed during the tour:

*On entrance into Room # 102B (Patient #7) there was no yellow star observed on the door. The patient did not have on yellow non-skid socks, and the instructions for fall risk protocol was not observed anywhere at the bedside.

*On entrance into Room #115 (Patient #8) there was no yellow star observed on the door. The patient did not have on yellow non-skid socks, the bed alarm was turned off, and the instructions for fall risk protocol was not observed anywhere at the bedside.

*On the entrance of the doorway of Room #116 (Patient #10) there was a yellow star indicating fall risk. Staff #11 removed the yellow star from Room #116 and placed it on the door of Room #115. Staff #11 did not check to see if the patient in Room #116 was on the fall risk protocol.

Review of the chart of Patient #10 (in Room #116) revealed she was to have the fall risk protocol in place.

*On entrance into Room #121 room, revealed Patient #4 had no yellow arm band, no yellow non-skid socks, the bed alarm was turned off, and the instructions for fall risk protocol was not observed anywhere at the bedside.

An an interview with Staff #6 and #11 at the end of tour on 3/14/2013 at 2:30 PM confirmed the patients in room 102 B, 115, 116, and 121, did not have the fall risk protocol in place.



6.) Review of physician orders revealed Patient #2 was a [AGE] year old female admitted on [DATE] with a diagnosis of a total knee arthroplasty.
Review of the November 2012 complaint log revealed on 11/26/12 Patient #2 had a knee replacement and the family asked that a bed alarm to be placed on the bed. It was documented the patient fell out of bed and laid on the floor approximately 3 hours. There was documentation the patient kept yelling and attempting to get help. A bed alarm had been put on bed after the incident.
Review of a "Morse Fall Risk Scale" dated 11/26, 11/27 and 11/28/12 revealed Patient #2 was at risk for falls with a score greater than 45.
Review of Patient Observation notes dated 11/26 and 11/27/12 ( 8:00 a.m.) revealed Patient #2 had a bed alarm on.

Review of Patient Observation notes dated 11/27/12, 10:00 a.m. revealed there was no alarm documented as being on the patient up until 11/28/12 at 2:10 a.m. when the patient was found in the floor. The patient denied falling ,but said she slid to her buttock. There was no documentation of the alarm being on the patient during the fall at 2:10 a.m.. There was no assessment to justify removing the bed alarm.

During an interview on 03/15/13 at 1:30 p.m., Staff #2 reported there was no policy addressing when to place on or remove bed alarms. This was left up to nursing judgment.

7.) Review of physician order's revealed Patient #9 was a [AGE] year old female admitted on [DATE] with a diagnoses of altered mental status, acute type B influenza, acute urinary tract infection and acute asthma exacerbation.

Review of a "Morse Fall Risk Scale" dated 01/17/13 revealed Patient #9 had a score greater than 45 indicating she was at risk for falls.

Review of a "Patient Care Record" dated 01/17/13 revealed a bed alarm was placed on Patient #9 at the request of a family member. The family member voiced Patient #9 would get confused at night and climb out of bed. There was documentation of the alarm being on up until 01/20/13 at 5:00 a.m.. After this date there was only one documentation of usage of the bed alarm again and that was on 01/23/13 at 6:00 p.m.

There was no assessment or physician order to justify de-activating the bed alarm.

Review of a "Morse Fall Risk Scale" dated 01/21-25/13 revealed Patient #9 still had a score greater than 45 indicating she was at risk for falls.

Review of a facility complaint letter dated 01/28/13 revealed a family member complained of Patient #9's call button not being attached and she had fallen onto or between the bed on 01/23/13.

There was no documentation in the nurses notes nor an incident report about a fall on 01/23/13. The only documentation found on a fall was in the family member complaint to the facility dated 01/28/13.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observations, interviews and records review, the facility failed to:
A. provide Registered Nurse (RN) supervision and assessments in nutrition in 3 of 10 (#s'5, 7, and 9) patients, skin assessments in 2 of 10 (#s' 5 and 9) patients, and implementation of fall risk protocols in 6 of 10 (#s' 2, 4, 7, 8, 9, and 10) patients.
Refer to tag A0392
B. ensure medications were administered on time and according to physician orders in 1 of 10 (#9) patients.
Refer to tag A0405
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review the facility failed ensure nutritional assessments were performed in 3 of 10 (# 5, 7, and 9) patients, skin assessments in 2 of 10 (# 5 and 9) patients and implementation of fall risk protocols in 6 of 10 (# 2, 4, 7, 8, 9, and 10) patients.
This deficient practice had the potential to harm all patients admitted into the hospital.
Findings include:
1.) Review of the policy titled "Nutrition Screening and Assessment" policy dated 10/08/10 revealed "all patients would be screened by nursing for nutritional risk within 24 hours of admission using predetermined nutrition triggers. The dietitian would complete a nutrition assessment for all patients identified at potential nutrition risk via nutritional screen within 72 hours."
Some of the triggers listed on the nursing assessment that generated an assessment by the dietitian included:
Reduction intake
Recent Diarrhea
Albumin less than 3
Review of the policy titled "Pressure Ulcer Prevention/Treatment Guidelines" dated 06/2007 revealed the following:
"Consult dietitian to assist with nutritional assessment and planning. Implement recommendations."
Review of physician order's revealed Patient #9 was a [AGE] year old female admitted on [DATE] with a diagnoses of altered mental status, acute type B influenza, acute urinary tract infection and acute asthma exacerbation. The physician order indicated an order for a low sodium/low cholesterol or 1800 calorie ADA (American Diabetes Association) diet.
Review of lab reports revealed the following:
01/17/13 an Albumin of 3.9 (reference range being 3.5-4.9) and a Total protein of 6.9 (5.5-8.0).
01/20/13 the Albumin had decreased to 2.9 and the Total protein was 5.3.
01/21/13 the Albumin was 2.7 and the Total Protein was 5.1.
Both labs were indicators of nutritional and protein status.
Review of a prn (whenever needed) medication administration record revealed Patient #9 was treated for diarrhea on 01/19, 01/20, 01/21, and 01/24/13.
Review of physician orders dated 01/23/12 revealed an order to change Patient #9' s diet to a clear liquid diet.
Review of a patient care record dated 01/24/13 at 8:15 a.m. revealed Patient #9 had skin breakdown.
Review of Patient #9's record revealed the first nursing nutritional screen was performed 01/24/13 which was 7 days after being admitted into the facility.
Review of the nutritional progress notes dated 01/24/13, 12:08 p.m. from the dietitian revealed the first dietary assessment performed on Patient #9 since being admitted to the hospital. The assessment made no reference to the low Albumin/Total Protein and skin breakdown. There was documentation the patient had flu and diarrhea symptoms, and was placed on a clear liquid diet. According to documentation from the dietician the assessment was performed due to length of stay in the hospital. There were no recommendations to address the skin breakdown or low lab values.
During an interview on 03/15/13 at 9:05 a.m., Staff # 3 reported there was a problem with completing the nutritional assessments because the dietitian was not in the facility but 2-3 days per week.
During an interview on 03/15/13 at 10:15 a.m., Staff #10 reported she was the dietitian. Staff #10 stated "nursing does the screen on admit and the triggers prompt my assessment. I have 72 hours after the prompted trigger to make an assessment. If the patients are there for 7 days or more I would screen them anyway and this is called the length of stay assessment. When patients have skin breakdown I makes sure they have a protein supplement. Staff #10 checked Patient #9's chart and reported the first dietary assessment was done on 01/24/13 and wounds/skin was not identified on the assessment by nursing.
2.) Review of the policy titled "Wounds: Prevention and Management" dated 06/2007 revealed the following key points of an assessment:
"Location of wound,etiology, classification and/or stage, size, depth, amount of wound tunneling and undermining, wound bed, wound exudate, surrounding skin, wound edges, signs and symptoms of wound infection, and pain. Document the wound assessment."
Review of physician order' s revealed Patient #9 was a 59 year old female admitted on [DATE] with a diagnoses of altered mental status, acute type B influenza, acute urinary tract infection and acute asthma exacerbation.
Review of an Intensive Care Unit (ICU) assessment dated [DATE] revealed Patient #9 was at risk for skin breakdown. The Braden Scale tool used to assess skin breakdown risk showed Patient #9 had a score of 15 (range listed for "at risk" was 15-18).
Review of a patient care record dated 01/21/13 and 01/22/13 revealed Patient #9 skin was altered, but there was no documentation of how or where.
Review of a patient care record dated 01/24/13 at 8:15 a.m. revealed Patient #9 coccyx (tail bone area) was red. There was no documentation of an assessment of how large or if it was blanchable or not. There was no documentation of treatments provided to the coccyx.
During an interview on 03/14/13 at 2:30 p.m. Staff #4 reported Patient #9's coccyx was red and excoriated. She gave the protective skin barrier ointment to a student to use on the coccyx as per the facility skin protocol.
During an interview on 03/15/13 at 9:05 a.m. Staff #3 reported the nurses should be documenting an assessment when they check that the skin is altered. Staff #3 confirmed there was no documented assessment of how Patient #9's coccyx looked in the chart.
During an interview on 03/15/13 at 1:30 p.m., Staff # 2 reported they did not have a policy or protocol to explain what interventions to use according to the different scorings on the Braden scale assessment.
3.) Review of physician orders revealed Patient #5 was a [AGE] year old female admitted on [DATE] with a diagnosis of acute dehydration. Patient #5 was ordered to receive a mechanical soft diet with nectar thick liquids.
Review of the Emergency Department (ED) assessment dated [DATE] revealed Patient #5 's skin was intact.
Review of an ICU assessment dated [DATE] revealed Patient #5 had a Braden scale score of 12 (range from 10-12) indicating she was at high risk for skin breakdown.
Review of a Patient care record dated 03/14/13 revealed Patient #5 had skin breakdown and there was an area noted to be red in the upper crease of the gluteal fold. There was documentation staff applied barrier cream to the affected area. There was no documentation of an assessment of the the size or stage of the sore.
Review of lab dated 03/15/13 revealed Patient #5 had a low Albumin of 2.8 (reference ranges being 3.5-4.0) and a Total Protein of 5.4 (reference ranges being 5.5-8.0)
Review of the chart revealed no initial nurse screening for nutrition nor a nutritional assessment by the dietitian completed on Patient #5.
4.) Review of physician orders revealed Patient #7 was a [AGE] year old female admitted on [DATE] with diagnoses of renal failure, dehydration and a minor head injury. According to the physician orders Patient #7 was placed on a low sodium/low cholesterol diet.
Review of a lab report dated 03/13/13, revealed Patient #7 had a low Albumin of 2.5 (reference ranges being 3.5-4.9).
Review of a nursing assessment dated [DATE] revealed a nutritional screen was performed, but no referral for a dietary consult by the dietitian was made.
During an interview on 03/15/13 at 10:15 a.m., Staff #10 (dietitian) said she had "72 hours to assess the patients after receiving a dietary screen from nursing." Staff #10 checked her list of patients who needed nutritional screens and reported Patient #10 was not listed. She had not received a referral for a consult.
5.) Review of the policy titled " Fall Risk Assessment and Safely Alert " dated 12/2010 revealed the following:
*All patients entering the facility will have a fall risk assessment completed to determine fall risk.
* Every patient will be reassessed at least every shift and PRN to identify any change in his/her safety risk score.
* If and when a fall risk assessment safety score is greater than 45 the patient is placed on Fall Risk Safety Alert.
b. Fall Prevention Protocol:
i. Yellow arm band placed on patient
ii. Slip resistant socks provided to patient
iii. Yellow star placed on the door entry
iv. Frequent toileting assistance
v. Evaluate room assignment
vi. Consider activating the bed alarm

During a tour of the Medical Surgical Unit on 3/14/2013 at 1:30 PM with Staff #6 and Staff #11, a request was made to observe patients who required bed alarms. Room #s' 102 B, 115, 121, and 134 B were identified as having the fall risk protocol in place. The following was observed during the tour:

*On entrance into Room # 102B (Patient #7) there was no yellow star observed on the door. The patient did not have on yellow non-skid socks, and the instructions for fall risk protocol was not observed anywhere at the bedside.

*On entrance into Room #115 (Patient #8) there was no yellow star observed on the door. The patient did not have on yellow non-skid socks, the bed alarm was turned off, and the instructions for fall risk protocol was not observed anywhere at the bedside.

*On the entrance of the doorway of Room #116 (Patient #10) there was a yellow star indicating fall risk. Staff #11 removed the yellow star from Room #116 and placed it on the door of Room #115. Staff #11 did not check to see if the patient in Room #116 was on the fall risk protocol.

Review of the chart of Patient #10 (in Room #116) revealed she was to have the fall risk protocol in place.

*On entrance into Room #121 room, revealed Patient #4 had no yellow arm band, no yellow non-skid socks, the bed alarm was turned off, and the instructions for fall risk protocol was not observed anywhere at the bedside.

An interview with Staff #6 and #11 at the end of tour on 3/14/2013 at 2:30 PM confirmed the patients in room 102 B, 115, 116, and 121, did not have the fall risk protocol in place.



6.) Review of physician orders revealed Patient #2 was a [AGE] year old female admitted on [DATE] with a diagnosis of a total knee arthroplasty.
Review of the November 2012 complaint log revealed on 11/26/12 Patient #2 had a knee replacement and the family asked that a bed alarm to be placed on the bed. It was documented the patient fell out of bed and laid on the floor approximately 3 hours. There was documentation the patient kept yelling and attempting to get help. A bed alarm had been put on bed after the incident.
Review of a "Morse Fall Risk Scale" dated 11/26, 11/27 and 11/28/12 revealed Patient #2 was at risk for falls with a score greater than 45.
Review of Patient Observation notes dated 11/26 and 11/27/12 ( 8:00 a.m.) revealed Patient #2 had a bed alarm on.

Review of Patient Observation notes dated 11/27/12, 10:00 a.m. revealed there was no alarm documented as being on the patient up until 11/28/12 at 2:10 a.m. when the patient was found in the floor. The patient denied falling ,but said she slid to her buttock. There was no documentation of the alarm being on the patient during the fall at 2:10 a.m.. There was no assessment to justify removing the bed alarm.

During an interview on 03/15/13 at 1:30 p.m., Staff #2 reported there was no policy addressing when to place on or remove bed alarms. This was left up to nursing judgment.

7.) Review of physician order's revealed Patient #9 was a [AGE] year old female admitted on [DATE] with a diagnoses of altered mental status, acute type B influenza, acute urinary tract infection and acute asthma exacerbation.

Review of a "Morse Fall Risk Scale" dated 01/17/13 revealed Patient #9 had a score greater than 45 indicating she was at risk for falls.

Review of a "Patient Care Record" dated 01/17/13 revealed a bed alarm was placed on Patient #9 at the request of a family member. The family member voiced Patient #9 would get confused at night and climb out of bed. There was documentation of the alarm being on up until 01/20/13 at 5:00 a.m.. After this date there was only one documentation of usage of the bed alarm again and that was on 01/23/13 at 6:00 p.m.

There was no assessment or physician order to justify de-activating the bed alarm.

Review of a "Morse Fall Risk Scale" dated 01/21-25/13 revealed Patient #9 still had a score greater than 45 indicating she was at risk for falls.

Review of a facility complaint letter dated 01/28/13 revealed a family member complained of Patient #9's call button not being attached and she had fallen onto or between the bed on 01/23/13.

There was no documentation in the nurses notes nor an incident report about a fall on 01/23/13. The only documentation found on a fall was in the family member complaint to the facility dated 01/28/13.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the facility failed to ensure medications were administered as ordered by the physician in 1 of 10 patients (#9) reviewed for medication administration.
This deficient practice had the potential to cause harm in all patients admitted to the Medical-Surgical unit.
Findings include:
Review of physician orders revealed Patient #9 was a [AGE] year old female admitted on [DATE] with diagnoses of altered mental status, acute type B influenza, acute urinary tract infection and acute asthma exacerbation.
The following errors were found:
1.) Review of physician orders for patient #9 dated 01/17/13 revealed staff were to administer the anti- diabetic agent Novolin Regular 2 units per sliding scale protocol for blood sugar levels between 181-240 and administer 25 milliliters (mls) of Dextrose 50% in Water (D50W) for blood sugar levels less than 80.
Review of medication administration records revealed the following:
* Novolin Regular insulin 2 units per sliding scale was to be administered for a blood sugar of 190 on 01/18/13 at 11:30 a.m. and this was not given.
On 01/18/13 at 9:00 p.m. the blood sugar was 70, 01/21/13 at 4:30 p.m. it was 75 and on 01/22/13 at 4:30 p.m. it was 73. D50W was not administered as ordered.
Review of the policy titled "Glucometer Testing" dated 03/2010 revealed for test results greater than 40 mg/dl or less than 400 mg/dl, staff were to follow the treatment as prescribed by the physician.
2.) Review of the physician orders for patient #9 dated 01/17/13 revealed staff were to administer the anti-psychotic agent Navane 10 mg (4) tablets at bedtime.
Review of the medication administration records revealed Navane (Thiothixene) 20 mg was administered at night on 01/17/13, 01/18/13, 01/19/13, 01/20/13, and 01/22/13 instead of 40 mgs.
Review of the policy titled "Safe Medication Administration Guidelines" dated 10/2011 revealed staff were to verify the medication was being administered in the prescribed dose, and by the correct route.
3.) Review of physician orders for patient #9 dated 01/17/13 revealed staff were to administer the respiratory agent Xopenex 1.25 milligrams (mgs) per hand held nebulizer (HHN) every 4 hours and every 2 hours as needed for shortness of breath.
* Review of nursing medication administration records, pulmonary treatment records and ventilator flow sheets revealed no documentation of Xopenex being administered on 01/17, 01/18 and 01/19/13.
The following doses of Xopenex 1.25 milligrams (mgs) per hand held nebulizer (HHN) were administered late:
*On 01/20/13 at 11:45 a.m. a Xopenex treatment was given; then 7 hours later at 6:57 p.m., the next Xopenex treatment was given.
*On 01/20/13 at 10:37 p.m. the Xopenex treatment was given and over 5 hours later another Xopenex treatment was given on 01/21/13 at 3:54 a.m.
*On 01/21/13 at 10:30 a.m. a Xopenex treatment was given and over 9 hours later a Xopenex treatment was given on 01/21/2013 at 7:50 p.m..
*On 01/22/13 at 3:45 a.m.; over 7 hours later a Xopenex treatment was given.
*On 01/23/13 at 3:25 p.m. a Xopenex treatment was given and then over 5 hours later a Xopenex treatment was given at 8:30 p.m.
*On 01/24/13 at 7:50 a.m., which was over 11 hours later from the last treatment a Xopenex treatment was given.
4.) Review of physician orders for patient #9 dated 01/17/13 revealed staff was to administer the steroid agent Solu-Medrol 60 milligrams (mgs) intravenous every 6 hours.
Review of a medication administration record revealed Solu-Medrol 60 mgs was administered on 01/17/13 at 7:00 p.m. and then again 5 hours later at 12:00 midnight instead of every 6 hours as ordered.
A review of the policy titled "Safe Medication Administration Guidelines " dated 10/2011 revealed staff were to verify the medication was given at the correct time. "Medications were to be administered no more than 30 minutes before the scheduled time and no more than 30 minutes after the scheduled time."
During an interview on 03/15/13 at 11:00 a.m., Staff #3 confirmed all the medication errors. Staff #3 reported they had reviewed the record, but had not discovered or addressed the medication errors.