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Based on review of documentation and interview it was determined that the hospital failed to ensure that a Registered Nurse (RN) supervised and evaluated the care provided to patient #1.

Findings were:
The hospital failed to ensure that there was documentation that a Registered Nurse (RN) supervised and evaluated the care for patient #1 on the dates listed below:

3/11/2018, documentation on 7a-7p shift by LVN only, no documentation found by RN for this shift evaluating or supervising the care provided.

3/10/2018, documentation on 7a-7p shift by LVN only, no documentation found by RN for this shift evaluating or supervising the care provided.

3/09/2018, documentation on 7a-7p shift by LVN only, no documentation found by RN for this shift evaluating or supervising the care provided.

3/07/2018, documentation on 7p-7a shift by LVN only, no documentation found by RN for this shift evaluating or supervising the care provided.

2/25/2018, documentation on 7p-7a shift by LVN only, no documentation found by RN for this shift evaluating or supervising the care provided.

2/23/2018, documentation on 7a-7p shift by LVN only, no documentation found by RN for this shift evaluating or supervising the care provided.

2/19/2018, documentation on 7a-7p shift by LVN only, no documentation found by RN for this shift evaluating or supervising the care provided.

2/14/2018, documentation on 7p-7a shift by LVN only, no documentation found by RN for this shift evaluating or supervising the care provided.

2/11/2018, documentation on 7p-7a shift by LVN only, no documentation found by RN for this shift evaluating or supervising the care provided.

2/10/2018, documentation on 7p-7a shift by LVN only, no documentation found by RN for this shift evaluating or supervising the care provided.

2/09/2018, documentation on 7a-7p and 7p-7a shift by LVNs only, no documentation found by RN for the 7a-7p or 7p-7a shift evaluating or supervising the care provided. In an interview with staff member #2 on the morning of 10/17/2018 the above findings were confirmed.

Review of policy (provided to the surveyor for review) entitled: "Documentation Guidelines for Nursing" with an approval date of 4/30/2014 stated under item number 5. "An RN and LVN must sign the 24-hour flow sheet each shift indicating that the assessment was validated and agreement with the 24-hour plan of care." The policy was also found to state: "The RN has the responsibility to supervise subordinates, thus validation of the LVN assessment findings and change of condition is required."

Review of job hospital job description entitled: "Registered Nurse" stated in the position summary: "The Registered Nurse (RN) performs those activities for which the RN has been prepared through education and training. The RN provides nursing supervision in the planning for and provision of nursing care to patients, and directs and evaluates care given by other licensed nurses and personnel. The RN provides education, assesses needs, plans for, implements, evaluates and documents care being provided by nursing staff to each patient. The RN is responsible for both nursing care directly provided by that nurse and the care provided by others under her/his supervision." The Qualification section stated: "2. Must hold a current state license and must maintain license renewal in accordance with the standards of the State Board of Nursing."

Review of job hospital job description entitled: "House Supervisor "stated in the position summary: "Under general direction the House Supervisor is responsible for the patient care activities on his/her designated shift. He/She consults with staff, physicians, and Chief Clinical Officer on nursing procedures and interpretation of hospital policies to ensure patient needs are met. The House Supervisor must be able to manage department and the provision of nursing service according to the Standards of Nursing Practiced consistent with facility philosophy of care and state and federal laws and regulations." The Qualification section stated: "2. Must hold a current state license and must maintain license renewal in accordance with the standards of the State Board of Nursing."

Based on review of documentation and interview it was determined that the hospital failed to ensure that the medical record for patient #1 was promptly completed.

Findings were:
The medical record for patient #1 was not promptly completed as incomplete documents were found in the medical record to include care plans not being completed. Review of the Weekly Interdisciplinary Team Conference/Plan of Care Report, dated Feb 14 2018 was documented as an ongoing care plan. Review of this care plan revealed that under the medical area there was no current goal listed (patient #1 had diagnoses of respiratory failure and kidney failure).

Under the safety section, there was no current goal listed (patient #1 was documented as being impaired and had poor and impulsive judgement). He was documented as having a history of falls.

Under the bladder/bowel section there was no current goal listed (patient #1 was documented as being incontinent of bladder and bowel). The area where the date of the last BM (bowel movement) was to be documented was blank.

Under the respiratory/gas exchange section there was no current goal listed (patient #1 had a diagnosis of respiratory failure).

Under the skin integrity/circulation section there was no current goal listed (patient #1 was documented as having a wound on his coccyx).

Under the education section there was no current goal listed.

Weekly Interdisciplinary Team Conference/Plan of Care Report, dated 3-1-18. Review of the care plan revealed that the area where the care plan can be checked as whether the care plan is initial, ongoing or discharge had not been checked. Under the medical, safety and bladder/bowel and respiratory/gas exchange section there was no documentation found.

Under the skin integrity/circulation section there was no current goal listed (patient #1 was documented as having a wound on his coccyx).

Under the education section there was no current goal listed.

Additionally when the surveyor requested the initial care plan for patient #1, no initial care plan was provided.

Other incomplete documents found in the medical record included:

Review of the Promise Hospital of Wichita Falls Adult Pneumoccal and Influenza Immunization Order Form, revealed that the area where the date and time were to be documented in the upper right corner were blank. Additionally the area where the physician was to date after signature at the bottom of the form was blank.

Review of the Promise Hospital of Wichita Falls Discontinuation/Continuation of Foley Catheter Order Sheet, revealed the comment: "This patient has had an indwelling catheter since____/____/____." No date had been filled in.

Review of Subcutaneous Insulin Part 2, Correction dose algorithms for subcutaneous Novolog Insulin, revealed that the area at the bottom of the form (next to the signature area) where the physician is to date and time the order was blank with no date or time found.

Review of Standard Admission Orders dated 3/14/2018 at 1945 hours revealed on the bottom of page two that these orders were T. O. (telephone orders). The area at the bottom of the form on page two (next to the signature area) where the physician is to date and time the order was blank with no date or time found.

Review of hospital policy entitled: "Interdisciplinary Care Plan" with an effective date of 01/26/2017 stated: "The interdisciplinary team shall coordinate with the patient/family to develop an individualized care plan to meet the patient's needs or wishes. Based on the assessment and reassessment process qualified professionals shall collaboratively develop a written plan of care." "6. The plan of care shall then be updated weekly upon evaluating the effectiveness of the interventions taken. Goal Met shall be dated when the needs of the patient are met and reviewed will be dated and signed when continued." "8. Performance Improvement: The Department Head of each discipline shall be held accountable for assuring timeliness and appropriateness of documentation on the medical record."

Review of policy entitled: "Hospital Chart Completion" No effective date found on copy provided to the surveyor. stated on page one: "The hospital maintains a complete and accurate medical record for each patient." Page two: "Missing signatures cannot be excluded when counting incomplete and/or delinquent medical records." Page two: "A medical record is considered to be delinquent if it remains incomplete for 30 days after discharge (14 days for California facilities). When calculating the delinquency rate, the first day following discharge is counted as day one the incomplete status, not the allocation day (the day the chart becomes available to the physician responsible for its completion)."

In an interview with staff members #2 and #3 the above findings were confirmed.

Based on review of documentation and interview it was determined that the hospital failed to ensure that telephone orders were authenticated promptly.

Findings were:
Telephone orders were not authenticated promptly. A review of the medical record of patient #1 revealed multiple telephone orders.
Review of physical restraint orders revealed that patient #1 was physically restrained (wrist restraints) on the following dates:

TORB on 2/28/18 at 0000 hours (wrist restraint bilateral), physician signed order on 4/20/18 at 2:20pm

TORB on 2/26/18 at 0000 hours (wrist restraint bilateral), physician signed order on 4/20/18 at 2:10p

TORB on 2/25/18 at 0000 hours (wrist restraint bilateral), physician signed order on 4/20/18 at 2:10p

TORB on 2/24/18 at 0000 hours (wrist restraint bilateral), physician signed order on 4/20/18 at 2:20pm

TORB on 2/23/18 at 0000 hours (wrist restraint bilateral), physician signed order on 4/20/18 at 2:20pm

TORB on 2/21/18 at 0000 hours (wrist restraint bilateral), physician signed order on 4/20/18 at 2:20pm

TORB on 2/20/18 at 0000 hours (wrist restraint bilateral), physician signed order on 4/20/18 at 2:10pm

Review of policy entitled: "Verbal/Telephone Orders and Transcription Of" with an effective date of April, 2017 stated: "Verbal/telephone orders from a credentialed physician shall be accepted in accordance with the Medical Staff bylaws. Verbal orders shall be discouraged as much as possible." "d. All verbal/telephone orders must be counter signed by the physician as soon as possible."

Review of policy entitled: "Hospital Chart Completion" No effective date found on copy provided to the surveyor. stated on page three: "All telephone orders must be authenticated within the timeframes specified by federal and state law. If there is no specific timeframes designated by state law, then telephone orders must be authenticated within 48 hours."

In an interview with staff member #2 the above findings were confirmed.