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Based on interview and record review, the facility failed to ensure that a Registered Nurse (RN) supervised and evaluated the care of 4 of 10 sampled patients (Patient IDs # 1, # 2,#3,#4). A Registered Nurse failed to ensure the following:

Routine x-ray was completed per physician order and an X-ray ordered STAT was completed within the acceptable timeframe (both for Patient # 1).

Post-transfusion laboratory work was competed per physician order for
Patient # 1.

Pain was assessed / reassessed per facility policy for Patient IDs # 1, 2, 3, 4.

Findings include:

TX # 00172398

Patient # 1: x-ray and post transfusion lab work issues

Record review on 02-28-13 of Patient # 1 ' s clinical record revealed he was a 73 year old male admitted on 06-27-12 for inpatient rehab following a fall Patient # 1 had a periprosthetic left shoulder repair at an acute hospital on 06-20-12. History & Physical exam read: " ... " patient has significant amount of pain, especially with elbow flexion... "

Record review of physician orders for Patient # 1 revealed an order dated 07-06-12 for
an x-ray of the left shoulder. Review of the clinical record for Patient # 1 and facility x-ray log revealed the x-ray ordered for Patient # 1 on 07-06-12 had not been completed.

Continued review of the physician orders for Patient # 1 revealed a physician order dated 07-08-12 (time 1100 hours): STAT x-ray left shoulder. Review of the x-ray reports for Patient # 1 revealed this STAT x-ray was completed 5 hours later on 07-08-12 at 4 p.m. Interview on 02-28-13 at 2:30 p.m. with the Quality Director, Staff ID # 2 , she stated that x-rays ordered STAT were to be completed within 2 hours of the order. The results of this STAT x-ray were as follows: " fracture site misaligned: proximal half of plate with wires transfixing fracture is misaligned. "

Further record review for Patient # 1 revealed a physician order dated 07-04-12 " recheck CBC (complete blood count ) 6 hours post transfusion. " Patient # 1 received 2 units of blood on 07-04-12; the completion time for the 2nd unit was 1400 hours. The post-transfusion CBC was due to be drawn on 07-04-12 at 2000 hours (8 p.m.). Review of the laboratory results for Patient # 1 revealed the CBC was drawn the next morning 07-05-12 at 5:35 a.m. (13 ? hours post-transfusion).

Pain Assessment/Reassessment:

Record review on 02-28-13 of the 10 sampled records revealed incomplete /inaccurate pain assessments for the following patients:

Patient #2: admitted on 02-21-13 for comprehensive rehabilitation. Pain assessment was not documented for the day shift on 02-22-13.

Patient # 3: admitted on 02-15-13 for rehabilitation; History of cerebral vascular accident (CVA/stroke). Pain assessment was not documented for the day shift on 02-22-13.

Patient # 4: admitted on 02-22-13 for rehabilitation status post hip-fracture. Pain assessments were not documented for the night shifts on 02-24-13 and 02-27-13.

Patient # 1: admitted on 06-27-12 for rehabilitation following a fall and status post shoulder repair surgery. Pain assessments were not documented for the day shift on 06-30-12 and for the night shift on 07-07-13.

In addition, the pain assessment for Patient # 1 documented for the day shift on 07-04-12 was inaccurate. The documented pain assessment for that time period was " zero pain. " Review of the Nursing Notes dated 07-04-12 for Patient # 1 revealed he had complained of pain at 1700 and rated it at " 9-10 " on the pain scale. He was medicated with two (2) Percocet tablets at this time.

Interview on 02-29-13 at 1:30 p.m. with acting Chief Nursing Officer (CNO) Staff ID # 3, he stated that pain is assessed and documented for each patient each shift. He went on to say that nursing worked 12 hour shifts and the expectation was a pain assessment would be documented for the day shift and the night shift.

Review of facility policy titled " Assessment of Pain, " revised date 5/10, read: " ...C. perform a pain assessment ...2. Complete a baseline pain assessment and document in the initial interdisciplinary assessment, each shift thereafter in the daily nursing re-assessment form ... "