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Based on record review and interviews the hospital failed to ensure the registered nurse supervised and evaluated the nursing care for each patient as evidence by:

1) failing to ensure the Registered Nurse performed complex assessments/reassessments in accordance with hospital policy and the Louisiana State Board of Nursing scope of practice as evidenced by failing to have documented assessment/reassessment by the Registered Nurse resulting in delegation of the assessment of a patient with a surgical abdomen with assessment changes to a Licensed Practical Nurse. (#5)

2) failing to assess and stage wounds weekly according to the hospital policy for 1 out of 1 patients reviewed for wounds out of a sample of 7. (#3)

3) failing to notify a physician when medication was not available for a newly admitted patient, which resulted in the patient not receiving his antihypertensive medication and his statin medication as ordered by the physician for 1 out of 7 sampled patients. (#2)

Findings:

1) Patient #5

In an interview on 09/15/11 at 1:30 p.m. with S13RN she stated she was the RN Charge Nurse on 08/11/11 and 08/12/11 on day shift. S13RN stated that she was the person that faxed the x-ray report taken on 08/11/11 of the abdomen to the office of S7MD (who performed the surgery on patient #5). S13RN stated that the family of patient #5 was concerned about patient #5's intake and his abdominal distension. S13RN stated she did inform S3MD who ordered an x-ray of the abdomen of patient #5. S13RN stated that there were no changes in the assessment of the abdomen of patient #5 from 08/11/11 to 08/12/11. S13RN stated she did assess the abdomen of patient #5 on both days but "RN's assess the patients but do not document the assessments." Review of the Nursing notes for the day shift on 08/11/11 and 08/12/11 revealed no documentation of an assessment being performed on patient #5 by S13RN.

In an interview on 09/15/11 at 3:10 p.m. with S9RN she stated she was the RN Charge Nurse on duty for the night shift on 08/11/11 and 08/12/11. S9RN stated that she received in report that patient #5 had "Abdomen slight distension and tight." S9RN stated she was aware that an x-ray had been done during the day shift so there were no changes to report to the physician. S9RN further stated that patient #5 did have a BM on 08/11/11. S9RN stated there were no significant changes on 08/12/11 to report to the physician that were not already documented. S9RN stated the family of patient #5 "had concerns nearly every time they came in." S9RN stated the family questioned if "tests" were being done and this indicated displeasure with the care being given. S9RN stated she did not report these concerns. Review of the Nursing notes for the night shift on 08/11/11 and 08/12/11 revealed no documentation of an assessment being performed on patient #5 by S9RN.

In an interview on 09/15/11 at 11:15 a.m. with S11RN she stated she was the RN Charge Nurse on the day shift on 08/13/11 and 08/14/11. S11RN stated that she was informed in report of patient #5 having a "rigid" abdomen. S11RN stated that the abdomen of patient #5 was "no different from the previous weekend" when she also worked. S11RN stated that she did call S20MD with the x-ray report for the x-ray done on 08/13/11 as the physician ordered. S11RN stated that the mental status of patient #5 "waxed and waned" from admit. S11RN stated that on 08/14/11 there were no new changes to report to the physician. S11RN further stated the RN is not required to document assessments at any time. Review of the Nursing notes for the day shift on 08/13/11 and 08/14/11 revealed no documentation of an assessment being performed on patient #5 by S11RN.

Review of the nursing notes for the night shift of 08/13/11 and 08/14/11 revealed there was no documentation of an assessment on patient #5 by the RN Charge Nurse, S12RN.

In an interview on 09/16/11 at 10:36 a.m. with S19DON she stated that an assessment of the abdomen on patient #5 was a complex assessment and should not be delegated by the RN to an LPN per the textbook used as a Nursing Guideline by Sage Rehabilitation Hospital. S19DON also confirmed there were no documented RN assessments on patient #5 for his entire admission except the admission assessment.

Review of a textbook, Nursing Interventions and Clinical Skills 3rd Edition; Elkin, Perry, Potter; copyright 2004 Mosby, Inc., presented as the current reference for nursing at Sage Rehabilitation Hospital, revealed: "Skill 13.4. Assessing the Abdomen. Abdominal assessment is complex because of the multiple organs located within and near the abdominal cavity...Delegation Considerations. This skill requires the critical thinking and knowledge application unique to an RN. For this skill, delegation is inappropriate..."

Review of the Louisiana State Board of Nursing Professional Standards, Chapter 37 Nursing Practice, revealed the following: "?3703. Definition of Terms Applying to Nursing Practice A. Terms applying to legal definitions of nursing practice, R.S.37:913, (13) and (14). Delegating Nursing Interventions?entrusting the performance of selected nursing tasks by the registered nurse to other competent nursing personnel in selected situations. The registered nurse retains the accountability for the total nursing care of the individual. The registered nurse is responsible for and accountable to each consumer of nursing care for the quality of nursing care he or she receives, regardless of whether the care is provided solely by the registered nurse or by the registered nurse in conjunction with other licensed or unlicensed assistive personnel. a. The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. This assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required.

2) Patient #3
Review of the medical record for Patient #3 revealed she was admitted to the rehabilitation services of the hospital on 07/14/11 and she was discharge on 07/26/11. Her diagnoses was S/P (status post) left hip fracture, S/P Debridement Sacral Wound on 07/12/11 and Stage 3 Sacral Wound. Review of the hospital's Interdisciplinary Assessment and Plan of Care revealed the sacral wound was assessed and staged on admit on 07/14/11 by S13RN. Review of the assessment revealed the pressure ulcer was located on her sacrum. The wound was staged as a Stage III with the length listed as 3 cm. (centimeters), the width 3 cm., and the depth 0.5 cm. The key definition on the assessment form listed a Stage III pressure ulcer as a full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia.

Review of the Progress Notes dated 07/20/11 form S20MD revealed the sacral wound was small, but a Stage III and had a odor. Review of the Progress Notes on 07/21/11 from S20MD revealed a wound infection and the patient was on the antibiotic Cipro.

Review of the entire medical record revealed the only assessment and staging of the patient's sacral wound was on admission on 07/14/11.

An interview was conducted with S19DON and S21Physical Therapist on 09/15/11 at 11:15 a.m. They stated if a patient had a pressure ulcer usually greater than a Stage I (Stage II to IV), physical therapy would be consulted. If the patient had seen a doctor already the physical therapist would continue the physician's order. They went on to state with review of the medical record of Patient #3, S5MD had changed the treatment to the sacral wound on 07/12/11, when the patient was admitted as a skilled patient. On 07/14/11 S13RN had assessed and staged the wound on admission to the rehab services and there was no consult for physical therapy for wound care. The Director of Nurses (S19DON) confirmed the wound was not staged and assessed again while the patient was in the hospital, but daily wound care was done by the nurses. The patient was discharged on 07/26/11. S19DON and S21PT stated up to the end of May 2011, a physician was coming once a week to do wound care rounds with S21PT and the physician would assess and stage the wounds. At the end of May the physician stopped coming to the hospital and just this week his partner started coming to do the weekly wound care rounds. When the DON was questioned on how the nurses knew when to assess and stage the wounds, she stated the whole system would have to be looked at, she thought that was the break in their current system. Patient #3 went 12 days without an assessment or staging of her Sacral wound.

Review of the current hospital policy for Woundcare revealed in part," 1) ...ii. If the patient presents with any wound that is determined to be a Stage 2-Stage 4 pressure ulcer, an unstageable pressure ulcer, or a wound with evident slough or eschar; nursing should complete a referral for physical therapy/wound care specialist to evaluate the patient ...2) c. Physical Therapy/woundcare specialist will reassess all patients that they have received a referral for (Stage 2-Stage 4 pressure wound) on a weekly basis. This reassessment will be documented in the patient's chart under the progress note section."

3) Patient #2

Review of the medial record revealed Patient #2 was admitted on 07/08/11 at 1500 (3 p.m.) with the diagnoses of Debility. Review of the medication orders revealed the orders were faxed to the pharmacy on 07/08/11 at 1700 (5 p.m.) by S13RN.

Review of the MAR dated 07/08/11 revealed Coreg (antihypertensive medication) 12.5 mg(milligrams) i (1) tab(tablet) po (by mouth) 2 x a day was scheduled to be administered at 0800 (8 a.m.) and 2000 (8 p.m.). The 2000 (8 p.m.) was circled and a handwritten note was written besides it stating, "haven't arrived from pharmacy." Lipitor (a cholesterol reducing medication) was ordered 10 mg po daily to be administered at 2000 ( 8 p.m.). The 2000 (8 p.m.) dose was circled and a handwritten note beside it stated, "haven't arrived via pharmacy."

Review of the Nursing Notes in part dated 07/08/11 and time 2000 (8 p.m.) revealed, "... HS (bedtime) meds unavailable, haven't arrived via pharmacy..." The note was signed by S22LPN.

An interview was conducted with S19DON on 09/15/11. She stated it vary's how long it takes pharmacy to get a newly admitted patient their medications. She went on to state a lot of time they fax the medication to pharmacy prior to the patient arriving to the hospital to make sure the medication are at the hospital for the patient. If a medication is not available for a patient the nurse is suppose to notify the physician if the patient misses a dose and write an incident report.

An interview was conducted with S22LPN on 09/16/11 at 8:40 a.m. S22LPN reviewed the medical record and confirmed she was the nurse that wrote on the 07/08/11 MAR the Coreg and Lipitor was not available to be administered to the patient on the evening of 07/08/11. She went on to state the medication was not available to be given to the patient and she thinks she notified the charge nurse of the medication not being available, but she doesn't remember and she did not document she notified the charge nurse. She went on to state she forgot to fill out an incident report on the unavailability of the medication and she doesn't remember getting a hold order for the medication from the physician. In June 2011 she stated the protocol changed, according to the new protocol, she should have reported the medication unavailable to the charge nurse and filled out an incident report. She stated it must have "slipped her mind". She stated the DON did an inservice on 06/15/11 on what to do if the medication wasn't in the facility. She stated the nurse is suppose to tell the charge nurse, contact the pharmacy and then fill out an incident report. She verified she attended the inservice by the sign in sheet.

Review of the June 15, 2011 inservice revealed the following, "Upon admit, if you do not have the medications from pharmacy and you can't get it out of the accudose, you are to call the doctor and ask it it is okay to begin the medication at another time or the next day. You then need to write the order stating that the doctor gave the verbal order to begin the medications at the designated time. If the doctor says no and it is to be given that day, you are to call pharmacy and inform them of this."

Based on record review and interviews the hospital failed to ensure staff had annual Tuberculosis surveillance with accordance to Center of Disease Control as evidenced by 4 out of 5 records reviewed having no documentation evidence of Tuberculosis skin test read within the 48 to 72 hours guidelines from The Center of Disease Control (S5MD, S9RN, S13RN, and S14LPN).
Findings:

Review of the PPD (Purified Protein Derivative) skin test form for S5MD and S14LPN revealed there was no time of administration and no time when the PPD was read documented on the form.

Review of the Tuberculosis Screening Program form for S9RN and S13 RN revealed a time was documented for administration of the PPD, but no time was documented for reading of the PPD.

An interview was conducted with S23Assistant Director of Nurses on 09/16/11 at 10 a.m. He stated he was in charge of the TB testing for the employees. He confirmed with the times not documented when the PPD was administered and/or read, he was unable to tell if the PPD fell within the 48-72 hours guidelines from CDC of when to read the skin tests.

Review of the hospital's current policy for Tuberculosis Skin Testing/Screening, Policy Number F.15, revealed in part, "...Tests shall be interpreted according to current Centers for Disease Control and Prevention (CDC) guidelines..."