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Based on document review and interview the facility failed to provide safe, adequate nursing services for twelve of thirteen current patients and seventeen of twenty discharged patients as evidenced by the multiple omitted medications, late medications, and multiple missed required assessments of patients in restraints as ordered every two hours (Patients #1 - 6, 8 - 11, 13, 15 - 29 and 31 -33).

The findings included:

The failure of the nursing staff to ensure all medications are administered as ordered by the physician for eight of thirteen current patients in the survey sample (Patient Records #21 - 28).

The failure of the facility's staff to notify the physician of late administration of Time Critical Medications for eight of thirteen current patients in the survey sample (Patient Records #21 - #28).

The failure of the facility's staff to follow hospital policy pertaining to Insulin administration for two of thirteen current patients in the survey sample (Patient Records #22 and Patient #29).

The failure of the facility's staff to ensure a Time Sensitive laboratory test was obtained and sent to the laboratory as ordered for one of thirteen current patients in the survey sample (Patient #23).

The failure to follow hospital infection control policies for three of three observations of the facility's staff during patient care (Staff #8 and Staff #9).

The failure of the nursing staff to discontinue restraints as ordered by the physician for one of four current restrained patients in the survey sample (Patient #33).

The failure of the nursing staff to assess the patient in restraints as ordered by the physician for three of four current patients in restraints in the survey sample (Patient #23, #31, and #32).

The failure of the nursing staff to ensure patients in restraints safety and other needs such as elimination, personal hygiene, active/passive range of motion are provided as ordered during routine monitoring for three of four patients in the current survey sample (Patient #23, #31, and #32).

The failure to ensure all medications are administered as ordered by the physician for seventeen (17) of twenty (20) discharged/closed medical records included in the survey sample (Patients #1 - 6, 8 - 11, 13, 15 - 20).

The failure to notify the physician of late administration of Time Critical Medications for seventeen (17) of twenty (20) discharged/closed medical records included in the survey sample (Patients #1 - 6, 8 - 11, 13, 15 - 20).

The failure of hospital staff to follow hospital policy pertaining to "Timely Administration of Medications" in the survey sample (Patient Records #1 - 6, 8 - 11, 13 and 15 - 20).

Based on review of documentation, interviews and policy and procedure it was identified that the facility's governing body failed to ensure that the medical staff is accountable to the governing body for the quality of care provided to patients.

The findings include:

Thirty three (33) medical records (Patient Records #1-#33) were reviewed on 07/28/2014 through 07/30/2014 beginning at 8:45 a.m.

An interview was conducted on 07/29/2014 at approximately 9:00 a.m. with Staff #1 and Staff #2. A request was made for the facility's organizational chart. Review of the facility's organizational chart found relationships and ranks of leadership appropriate among the departments.

Review of seventeen (17) of twenty (20) discharged/closed patients it was determined that the governing body failed to ensure staff were administering all medications as ordered by the physician in the survey sample (Patient Records #1 - 6, 8 - 11, 13 and 15 - 20). Cross Reference Tag: 0144.

Review of seventeen (17) of twenty (20) discharged/closed patients it was determined that the governing body failed to ensure staff notified the physician of late administration of Time Critical Medications in the survey sample (Patient Records #1 - 6, 8 - 11, 13 and 15 - 20). Cross Reference Tag: 0144

Quality Assessment and Performance data was reviewed on 07/30/2014 at approximately 1:00 p.m. The data reviewed was dated from 12/21/13 through 07/2014. No current data pertaining to chart reviews was found. Medication errors, restraint data, and Vancomycin Therapeutic Monitoring are being addressed. The data on Vancomycin Therapeutic Monitoring has not changed for the months of 04/2014 and 05/2014. No specific data found as to how the facility is trying to improve either over dosing or under dosing Vancomycin.

No clear evidence found medication errors or omissions were being accurately tracked. Documentation found on the P & T Quarterly Summary stated "concern is that we are not capturing all medication errors because the numbers are pretty low." Documentation indicates dose omissions are not included in medication errors. The data reviewed suggested a spike of medication omissions of fourteen (14) during the month of 04/2014. This surveyor found a total of seventeen (17) of twenty (20) discharged/closed medical records omitted doses of medications included in the survey sample (Patients #1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 13, 15, 16, 17, 18, 19, 20).

Based on document review and interview the facility's staff failed to notify and document in the medical record a patient's family had been informed of a change in condition requiring the patient to be placed in soft wrist restraints for one of thirteen current patients in the survey sample (Patient #23).

The findings included:

Patient #23's medical record was reviewed on July 28, 2014 and July 29, 2014. Patient #23 is a fifty five year old who was admitted to the above named facility on 06/30/2014 for wound care for severe wounds. Patient #23 is on a trach collar (receives oxygen) and has a large amount of secretions. Documentation in Patient #23's medical record indicates the patient was placed in "soft limb restraints" on 06/30/2014 and remains in soft wrist restraints up to the date of exit from the above named facility on 07/30/2014. Documentation in Patient #23's medical record lists the reason for the soft wrist restraints as "pulling at tubes." Patient #23's medical record indicates the patient has been intermittently placed back on the ventilator (machine used to aid in breathing) for respiratory support.

The initial restraint order for Patient #23 was written on the Restraint Order Flow Record (medical) form dated 06/30/2014. The above named facility has a standard preprinted form which requires a physician signature, date, and time of the initiation of the restraints. This form is renewed every 24 hours per the facility's Restraint Policy by the physician after conducting a face to face assessment of the patient. The above named facility requires the registered nurse to document a patient monitoring/assessment every two hours (minimum) on the Restraint Order Flow Record A physician order is required to discontinue restraints.

An interview was conducted with Staff #12 at approximately 2:30 pm on July 29, 2014. Staff #12 reported Patient #23 was in soft wrist restraints on 07/10/2014 and 07/11/2014. Staff #12 confirmed there was an "incident" with a visitor on one of the days he/she cared for Patient #23. Staff #12 volunteered the male visitor approached Staff #11 with questions related to the use of restraints on Patient #23. Staff #12 reported the male visitor and a female visitor (significant other of Patient #23) were "upset" because Patient #23 was restrained.

Staff #12 reported he/she notifies families when patients are placed in restraints. Staff #12 stated he/she was not sure if the family of Patient #23 had ever been notified Patient #23 was placed in soft wrist restraints. No documentation was found in Patient #23's medical record the family was notified Patient #23 was placed in restraints.

Staff #1 was interviewed on July 28, 2014 and July 29, 2014 during chart reviews. Staff #1 reported either the physician or the nurse usually notifies the family when the patient is placed in restraints. Staff #1 was not sure if the notification is documented. Staff #1 was present during the electronic medical record review of Patient #23 and was unable to locate any documentation the family of Patient #23 had been notified the patient was placed in restraints.

Documentation was found in Patient #23's hard copy of the medical record of Consent to Treat. No documentation was located pertaining to informed consent of the application of restraints prior to the initiation of the restraints on 6/30/2014 at approximately 10:55 pm.

A copy of the facility's Patient Rights was requested and received at approximately 12:00 pm on July 28, 2014. The policy states the patient/representative has the right to "make decisions regarding medical care, and receive as much information about any proposed treatment or procedure as you may need in order to give informed consent or refuse a course of treatment."

Based on document review and interview the facility failed to ensure the right to personal privacy for one of thirteen patients in the survey sample (Patient #23). Specifically, one of thirteen patients (Patient #23) was observed by visitors who entered the patient's room and found him/her lying in bed restrained with bilateral soft wrist restraints with wound dressings off and covered in stool.

The findings included:

An interview was conducted with Staff #12 at approximately 2:30 pm on July 29, 2014. Staff #12 reported Patient #23 was in soft wrist restraints on 07/10/2014 and 07/11/2014. Staff #12 confirmed there was an "incident" with a visitor on one of the days he/she cared for Patient #23. Staff #12 volunteered the male visitor approached Staff #11 with questions related to the use of restraints on Patient #23. Staff #12 reported the male visitor and a female visitor (significant other of Patient #23) were "upset" because Patient #23 was restrained and had been incontinent of a large amount of stool in the bed. Staff #12 reported Patient #23 had no dressings on his/her wounds and the stool "was all over the place and in the wounds." Staff #12 stated he/she initially did not know how the dressings had been removed off Patient #23's wounds. Staff #12 reported he/she did not know how long the dressings had been off Patient #23. Staff #12 reported he/she later found out a physician had removed the dressings and left the wounds undressed. Staff #12 stated he/she was never told by the physician the wound dressings had been removed. Staff #12 reported he/she did not know how long Patient #23 had been incontinent of stool. Staff #12 stated he/she could understand the visitors being upset about finding Patient #23 incontinent of stool without wound dressings on. No documentation found in the medical record of Patient #23 of this incident. No nursing note from a registered nurse found on 07/10/2014.

Based on document review and interview the facility staff failed to follow the restraint policy for four of four restrained patients (Patients #23, #31, #32, and #33).

The findings included:

Four current medical records were reviewed on July 28, 2014 and July 30, 2014 to obtain restraint data (Patient Records #23, #31, #32, and #33).

Documentation in Patient #23's medical record indicates the patient was placed in "soft limb restraints" on 06/30/2014 and remained in soft wrist restraints up to the date of exit from the above named facility on 07/30/2014. Patient #23 was placed in soft wrist restraints due to "pulling at tubes."

Documentation on Patient #23's restraint flow sheet dated 07/10/2014 indicated Patient #23 was assessed by a Registered Nurse at 8:10 am, 10:12 am, 12:34 pm, 2:00 pm, 4:00 pm, 5:00 pm, 8:00 pm, 10:00 pm, and 12:00 pm. The policy titled Restraint Use was requested and received on July 29, 2014 at approximately 4:10 pm. The policy states the ongoing assessment must be done at least every two hours. Documentation on Patient #23's Restraint Order and Flow Record indicates Patient #23 did not have an ongoing assessment every two hours on 07/10/2014. The documentation indicated the Patient went unobserved while in bilateral (both sides) soft wrist restraints from 5:00 pm until 8:00 pm.

Review of Patient #23's medical record revealed the following additional information pertaining to the Restraint Order and Flow Record for Medical use of restraints:

1. No data documented by registered nurse on the Restraint Flow Sheet dated 07/04/2014 for continued reason for restraints by the night shift. The reason for the continued use of restraints is a required section of the Restraint Order and Flow Record.

2. No data documented by registered nurse on the Restraint Flow Sheet dated 07/05/2014 for continued reason for restraints by the night shift. No documentation of required minimum two hour assessment for time period of 7:00 am to 8:59 am.

3. No data documented by registered nurse on the Restraint Flow Sheet dated 07/07/2014 for continued reason for restraints by the night shift.

4. No data documented by registered nurse on the Restraint Flow Sheet dated 07/08/2014 for interventions used to minimize the use of more restrictive restraints.

5. No data documented by registered nurse on the Restraint Flow Sheet dated 07/10/2014 for continued reason for restraints by the day shift.

6. No data documented by registered nurse on the Restraint Flow Sheet dated 07/11/2014, 7/15/14, 7/19/14, 7/23/14 and 7/24/14 for continued reason for restraints by the night shift.

7. Documentation indicates registered nurse assessed Patient #23 at 5:00 pm on 07/12/2014. Next assessment documented by registered nurse three hours later at 8:00 pm on 07/12/2014. Per the facility's policy assessments are to be done by registered nurse every two hours (minimum).

8. No documentation on the Restraint Flow Sheet dated 07/18/2014 and 7/20/14 for the reason for the restraint use.

9. Documentation on the Restraint Flow Sheet indicates registered nurse assessed Patient #23 at 5:00 pm on 07/22/2014. Next assessment documented by registered nurse three hours later at 8:00 pm on 07/22/2014. Per the facility's policy assessments are to be done by registered nurse at a minimum of two hours.

10. Documentation on the Restraint Flow Sheet dated 07/26/2014 indicates Patient #23 last assessed by a registered nurse at 6:00 am. The documentation on 07/27/2014 flow sheet by the registered nurse indicates Patient #23 was assessed at 8:59 am. This documentation indicates Patient #23 was not assessed while in soft wrist restraints for almost three hours during change of shift.

Staff #1 was aware of the findings on the Restraint Flow Sheet of Patient #23.

The facility uses the Richmond Agitation Sedation Scale (RASS). The Richmond Agitation Sedation scale is "used to assess depth of sedation and agitation." According to the Richmond Agitation Sedation Scale a score of zero (0) indicates the patient is alert and calm. A score of -1 the patient is considered drowsy. A score of +1 indicates the patient is restless. A score of +2 through +4 indicates increasing levels of agitation. A RASS score of +3 indicates very agitated with a description of the patient "pulls or removes tubes, catheters, and aggressive." The Richmond Agitation Sedation Scale was reviewed for each patient in restraints to gather more information pertaining to the agitation level of each patient. The RASS assessment was also reviewed to determine if the information on the Restraint Flow Record and the RASS assessment conducted on or about the same time was conflicting.

Patient #23's RASS scores were reviewed from 07/01/2014 through 07/15/2014. On 07/10/2014 Patient #23 had two nursing assessments documented by two different registered nurses. Documentation at 9:00 am and at 8:08 pm by both registered nurses scored Patient #23 with a RASS score of zero (0). The score of zero (0) indicates Patient #23 was alert and calm. Documentation by Staff #12 at 9:00 am on the Restraint Flow Sheet indicated Patient #23 remained in bilateral wrist restraints due to "pulling at tubes." Documentation by the night nurse on the Restraint Flow Sheet Data sheet done at 8:00 pm indicates Patient #23 remained in restraints due to "pulling at tubes." This documentation on the Restraint Flow Record and the RASS score represent conflicting information pertaining to
Patient #23.

Patient #23's RASS scores were reviewed for the two week period of 07/01/2014 through 07/15/2014. During the two week period Patient #23 remained in bilateral wrist restraints. On 07/08/2014 at 1:00 am and 07/09/2014 at 9:45 pm Patient #23 received a RASS score of +1 which indicates the patient was restless. The rest of the two week time period reviewed Patient #23 received a RASS score of zero (0) or -1. A RASS score of zero (0) describes the patient as alert and cooperative. A RASS score of -1 indicates the patient is drowsy.

Staff #13 was interviewed on 07/30/2014 at approximately 2:30 pm. Staff #13 confirmed the facility uses the RASS score to assess patients' agitation. Staff #13 confirmed it would be unusual to have a RASS score of zero or -1 and remain in restraints. Staff #13 confirmed he/she would notify a family when a patient is placed in restraints. Staff #13 reported he/she does not always document a family being notified the patient is in restraints.

Staff #14 and Staff #15 were interviewed at approximately 3:00 pm on July 30, 2014. Both staff confirmed the RASS scale is used to determine the level of a patients' agitation. Both staff confirmed the RASS score should correlate to documentation on the Restraint Flow Sheet.

Patient #31's medical record was reviewed on July 30, 2014 at approximately 9:45 am. Patient #31 is a 71 year old who has a history of bilateral amputations and presented to an outside facility's emergency room with alteration in mental status. Patient #31 was diagnosed with a urinary tract infection and sepsis. Patient #31 was diagnosed with a wound infection of the left stump and underwent surgical debridement. Upon admission to the above name facility on 07/10/2014 the physician documented Patient #31 was alert and oriented.

Documentation on Patient #31's Restraint Order and Flow Record reported the patient was placed into bilateral soft wrist restraints on 07/13/2014 due to "pulling at Foley and trying to get out of bed."

1. Patient #31 was assessed by a registered nurse at 5:00 am on 07/13/2014. The next documented assessment by a registered nurse was on 07/14/2014 at 7:30 am. According to the facilities Restraint Order and Flow Record for Medical use of restraints a registered nurse must assess the patient every two hours at a minimum.

2. Patient #31 was assessed by a registered nurse on 07/15/2014 at 6:10 am. The next documented assessment by a registered nurse on the Restraint Order and Flow Record was 07/17/2014 at 8:30 am.

3. Restraint Order and Flow Record dated 7/18/2014 had no physician signature on the form. Patient #31 remained in bilateral soft wrist and bilateral mitt restraints for a twenty four hour period without a physician order.

4. Patient #31 was assessed by a registered nurse according to documentation on the Restraint Order and Flow Record dated 07/18/2014 at 5:08 pm. The next documented assessment on 07/18/2014 was 7:30 pm.

5. Patient #31 was assessed by a registered nurse according to the documentation on the Restraint Order and Flow Record dated 07/20/2014 at 12:02 pm. The next documented assessment by the registered nurse was 2:28 pm.

6. Patient #31 was assessed by a registered nurse according to the documentation on the Restraint Order and Flow Record dated 07/23/2014 at 5:00 am. The next documented assessment by a registered nurse was 8:50 am on 07/24/2014. Documentation indicates Patient #31 was not assessed by a registered nurse while in soft wrist restraints for greater than 2 hours.

7. Patient #31 was assessed by a registered nurse according to the documentation on the Restraint Order and Flow Record dated 07/24/2014 at 5:00 am. The next documented assessment by a registered nurse on the Restraint Flow Record was at 7:25 am on 07/25/2014.

8. No documentation by night shift registered nurse on 07/27/2014 and 07/28/2014 of required assessment and documentation of the reason the patient continued to be restrained.

Patient #31's nursing assessments were requested and received on July 30, 2014 at approximately 2:00 pm. Documentation of Patient #31's RASS scores were reviewed from 07/22/2014 through 07/29/2014. Patient #31's RASS scores were rated as either 0 (zero) or +1. On 7/22/2014 both assessments done by two different registered nurses gave Patient #31 a RASS score of 0 (zero). This score indicated the patient was alert and oriented. A nurse note by the registered nurse caring for Patient #31 on 07/22/2014 at 1:00 pm stated "patient reported to be feeling fine. Patient is watching TV and eating lunch." The patient remained restrained according to documentation on the Restraint Flow Record. A second note by the staff registered nurse on 07/22/2014 reported the patient was feeling fine and had no signs of distress.

Documentation by a staff registered nurse dated 07/27/2014 at 10:51 am reported Patient #31 remained in bilateral wrist and mitt restraints. The note states "patient is now resting quietly in the bed with no signs of distress." The RASS score documented by the registered nurse at 11:34 am scored Patient #31 at a +1. A score of +1 indicates the patient is restless.

Patient #32's medical record was reviewed on July 30, 2014 at approximately 10:20 am. Patient #32 was admitted to the above named facility for wound care and antibiotics for multiple decubitus ulcers. Patient #32 has a past medical history of hypernatremia (elevated sodium levels), wounds infected with Staphylococcus Aureus (gram positive bacteria which causes infection), and dementia (decline in mental ability).

1. Patient #32 according to documentation on the Restraint Order and Flow Record was assessed by a registered nurse on 06/07/2014 at 5:01 am. The next documented assessment by a registered nurse was on 06/08/2014 at 8:15 am. This time frame exceeds the required two hour assessment by a registered nurse.

2. No documentation on 06/08/2014 by the day shift registered nurse of required reason for the continued use of restraints.

3. No documentation from 7:00 am to 4:59 pm by the day registered nurse for the required two hour assessments. No documentation of the restraints being discontinued by the medical doctor.

4. No documentation on 06/11/2014 by the night shift registered nurse of the required reason for the continued use of restraints.

5. Patient #32 assessed by registered nurse on 06/11/2014 at 5:10 am. The documentation on the Restraint Flow Record indicated the next assessment done by a registered nurse was 9:00 am on 06/12/2014. This documentation indicated Patient #32 was not assessed by a registered nurse for almost 4 hours while in restraints. The patient had one hand mitted according to documentation.

6. No documentation on 06/13/2014, 06/14/2014, and 06/15/2014 by the night shift registered nurse on the Restraint Flow Record of the required reason for the continued use of restraints.

7. Patient #32 assessed by registered nurse on 06/16/2014 at 6:00 am. The next documented assessment on the Restraint Flow Record was dated 06/17/2014 at 9:00 am. This time lapse in nursing assessments exceeded the two hour assessment requirement per the facility's policy.

Patient #32's shift nursing assessments were requested and received on July 30, 2014 at approximately 3:20 pm. Documentation of Patient #32's RASS scores were reviewed from the time period of 07/20/2014 through 07/29/2014. Patient #32 received a RASS score of either 0 (zero) or +1 for most of the time period reviewed. Two times during the time period reviewed Patient #32's RASS score was documented by the registered nurse as +2. The patient received a RASS score of +2 on 07/25/2014 and 07/29/2014.

Patient #32's nursing notes were requested and received on July 30, 2014 at approximately 3:30 pm. Documentation by certified nursing assistant on 07/23/2014 reported the patient "slept good." The patient remained restrained in bilateral mitts the entire night shift of 07/22/2014 according to documentation by the registered nurse on the Restraint Flow Record. Documentation on 07/23/2014 by the registered nurse in the nursing note indicated the mitts were removed at 9:13 am. Documentation on the Restraint Flow Sheet did not indicate the mitts were removed.

The Attachment D Guidelines For Applying Restraints -Medical was reviewed on July 30, 2014. Under the subtitle Limb Restraints it states "for patient safety, use 2-3 limb restraints: never use one limb restraint by itself-always use in combination with another limb restraint or vest."

Patient #32's Restraint Order and Flow Record indicated on 06/05/2014 through 06/07/2014 the patient was restrained with one limb restraint on the left with a left mitt.

Patient #33's medical record was reviewed on July 30, 2014 at approximately 11:00 am. Patient #33 is a sixty three year old admitted to the above named facility for rehabilitation and intravenous antibiotic therapy. Patient #33 has a past medical history of end stage renal disease (kidney disease) and receives dialysis three times a week.

Documentation on Patient #33's Restraint Order and Flow Record indicated the patient was placed in bilateral soft wrist restraints on 07/27/2014 due to "pulling at tubes and unable to follow safety instructions."

1. The Restraint Order and Flow Record dated 07/27/2014 indicated the date of the initiation of restraints (no other restraint records found in hard copy of the patient's chart). Documentation on the form by the physician indicated the physician signed in the wrong area on the form (signed in discontinue restraints section at 8:00 am). The registered nurse documented Patient #33 was in restraints from 7:00 am to 2:00 pm. No order was found to place the Patient in restraints on 07/27/2014 at 8:00 am. On 07/29/2014 the physician discontinued the restraints at 7:00 am. No Restraint Order and Flow Record dated 07/28/2014 was found in Patient #33's medical record.

Based on document review and interview the facility continued restraints without a physician order for two of four current patients (Patient #31 and #33).

The findings included:

Review of Patient #31's medical record on July 30, 2014 at 9:45 am revealed the Restraint Order and Flow Record dated 7/18/2014 had no physician signature on the form. Patient #31 remained in bilateral soft wrist and bilateral mitt restraints for a twenty four hour period without a physician order.

Review of Patient #33's medical record on July 30, 2014 at 11:00 am revealed the Restraint Order and Flow Record dated 07/27/2014 indicated the date of the initiation of restraints (no other restraint records found in hard copy of the patient's chart). Documentation on the form by the physician indicated the physician signed in the wrong area on the form (signed in discontinue restraints section at 8:00 am). The registered nurse documented Patient #33 was in restraints from 7:00 am to 2:00 pm. No order was found to place the Patient in restraints on 07/27/2014 at 8:00 am. On 07/29/2014 the physician discontinued the restraints at 7:00 am. No Restraint Order and Flow Record dated 07/28/2014 was found in Patient #33's medical record.

Staff #1 was present during the findings in the medical records of Patient #31 and #33 on July 30, 2014. Staff #1 reported he/she thought the physician had forgotten to sign the order on the Restraint Order and Flow Record of Patient #31. Staff #1 stated he/she thought the physician had signed in the wrong area on the Restraint Order and Flow Record of Patient #33.

Based on document review the facility failed to ensure restraints were discontinued at the earliest time possible for four of four current restrained patients in the survey sample (Patient #23, #31, #32 and #33).

The findings included:

Cross Reference: 0167

Review of Patient #23, #31, #32 and #33's medical records revealed multiple missed documentation pertaining to the continued reasons for restraints which is a required part of the nursing assessment on the Restraint Flow Record by the registered nurse. It is during these nursing assessments the patient is evaluated for potential discontinuation of the restraints.

Review of Patient #23's Restraint Flow Sheet Record on July 29, 2014 revealed the following information.

1. No data documented by registered nurse on the Restraint Flow Sheet dated 07/04/2014 for continued reason for restraints by the night shift.

2. No data documented by registered nurse on the Restraint Flow Sheet dated 07/05/2014 for continued reason for restraints by the night shift. No documentation of required minimum two hour assessment for time period of 7:00 am to 8:59 am.

3. No data documented by registered nurse on the Restraint Flow Sheet dated 07/07/2014 for continued reason for restraints by the night shift.

4. No data documented by registered nurse on the Restraint Flow Sheet dated 07/10/2014 for continued reason for restraints by the day shift.

5. No data documented by registered nurse on the Restraint Flow Sheet dated 07/11/2014 for continued reason for restraints by the night shift.

6. No data documented by registered nurse on the Restraint Flow Sheet dated 07/15/2014 for continued reason for restraints by the night shift.

7. No documentation on the Restraint Flow Sheet dated 07/18/2014 for the reason for the restraint use.

10. No data documented by registered nurse on the Restraint Flow Sheet dated 07/19/2014 for continued reason for restraints by the night shift.

11. No documentation on the Restraint Flow Sheet dated 07/20/2014 for the reason for the restraint use.

12. No data documented on the Restraint Flow Sheet by the night shift registered nurse on July 23, 2014 and July 24, 2014 pertaining to the reason for the continued use of restraints.

Patient #31's medical record was reviewed on July 30, 2014 at approximately 9:45 am.

1. Restraint Order and Flow Record dated 7/18/2014 had no physician signature on the form. Patient #31 remained in bilateral soft wrist and bilateral mitt restraints for a twenty four hour period without a physician order.

2. No documentation by night shift registered nurse on 07/27/2014 and 07/28/2014 of required assessment and documentation of the reason the patient continued to be restrained.

Review of Patient #32's medical record on July 30, 2014 at 10:20 am revealed the following information.

1. No documentation on 06/08/2014 by the day shift registered nurse of required reason for the continued use of restraints.

3. No documentation from 7:00 am to 4:59 pm by the day registered nurse for the required two hour assessments. No documentation of the restraints being discontinued by the medical doctor.

4. No documentation on 06/11/2014 by the night shift registered nurse of the required reason for the continued use of restraints.

5. No documentation on 06/13/2014, 06/14/2014, and 06/15/2014 by the night shift registered nurse on the Restraint Flow Record of the required reason for the continued use of restraints.

Patient #33's medical record was reviewed on July 30, 2014 at approximately 11:00 am.

1. The Restraint Order and Flow Record dated 07/27/2014 indicated the date of the initiation of restraints (no other restraint records found in hard copy of the patient's chart). Documentation on the form by the physician indicated the physician signed in the wrong area on the form (signed in discontinue restraints section at 8:00 am) The registered nurse documented Patient #33 was in restraints from 7:00 am to 2:00 pm. No order was found to place the Patient in restraints on 07/27/2014 at 8:00 am. On 07/29/2014 the physician discontinued the restraints at 7:00 am. No Restraint Order and Flow Record dated 07/28/2014 was found in Patient #33's medical record.

Staff #1 was present during the review of the restraint data on July 29, 2014 through July 30, 2014.

Based on document review and interview the facility failed to monitor the effectiveness and safety of services and include the patient safety data into the Quality Assessment and Performance Improvement Program.

The findings included:

Quality Assessment and Performance data was reviewed on July 30, 2014 at approximately 1:00 pm. The data reviewed was dated from 12/21/13 through July 2014. No current data pertaining to chart reviews was found. Medication errors, restraint data, and Vancomycin Therapeutic Monitoring are being addressed. The data on Vancomycin Therapeutic Monitoring has not changed for the months of April 2014 and May 2014. No specific data found as to how the facility is trying to improve either over dosing or under dosing Vancomycin.

No clear evidence found medication errors or omissions were being accurately tracked. Documentation found on the P & T Quarterly Summary stated "concern is that we are not capturing all medication errors because the numbers are pretty low." Documentation indicates dose omissions are not included in medication errors. The data reviewed suggested a spike of medication omissions of 14 during the month of April 2014. This surveyor found a total of 12 omitted doses of medications on current patients (Patients #21 and #23). This surveyor also found a total of seventeen (17) of twenty (20) discharged/closed medical records omitted doses of medications included in the survey sample (Patients #1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 13, 15, 16, 17, 18, 19, 20).

Restraint data was reviewed. No current data provided on the auditing of Restraint Order and Flow Record. The facility recognized in December of 2013 the "high rate of restraint usage." The current documented restraint usage has dropped very little. The target rate the facility is aiming for is 0.04 and the current rate is 0.08.

Staff #2 was interviewed on July 30, 2014 throughout the chart reviews. Staff #2 reported the results of chart audits pertaining to medication omissions would not be found in the Quality Assessment and Performance Data. Staff #2 volunteered the facility had a problem with medication omissions during the months of April 2014 and May 2014 due to the high use of agency staff. Staff #2 stated the facility has hired a lot of new staff.

Based on document review and interviews the facility failed to set priorities that focused on high-risk, high volume, or problem prone areas such as medication omissions and the late administration of Time Critical Medications.

The findings included:

Cross Reference Tags: 0273 and 0405.

Quality Assessment and Performance data was reviewed on July 30, 2014 at approximately 1:00 pm. The data reviewed was dated from 12/21/13 through July 2014. No current data pertaining to chart reviews was found that the facility had focused on medication omissions or the late administration of Time Critical Medications.

Staff #2 was interviewed on July 30, 2014 throughout the chart reviews. Staff #2 reported the results of chart audits pertaining to medication omissions would not be found in the Quality Assessment and Performance Data. Staff #2 volunteered the facility had a problem with medication omissions during the months of April 2014 and May 2014 due to the high use of agency staff. Staff #2 reported some agency staff do not have immediate access to the computer. Staff #2 stated the facility has hired a lot of new staff.

Based on document review and interview the facility failed to provide nursing care as ordered by the physician pertaining to restraints and the administration of medications for twelve of thirteen current patients (Patient #21 - #29, #31 - #33) and seventeen of twenty discharged/closed patients in the survey sample (Patient Records #1 - 6, #8 - #11, #13 and #15 - #20).

The findings included:

Cross Reference Tags: 0167, 0168, and 0405.

Staffing sheets were requested and received on July 30, 2014 at 9:00 am. Staff #2 reported the facility had been using a lot of "agency staff" in April and May. Staff #2 reported the facility is using less agency staff and has hired more professional nurses.

Staff #8 was interviewed on July 29, 2014 at approximately 10:00 am. Staff #8 reported sometimes when someone calls in sick the staff is not replaced. Staff #8 reported the staffing ratio is one staff to five or six patients.

Based on document review and interview the facility failed to develop an individualized interdisciplinary plan of care and failed to update the plan of care to reflect current needs for five (5) of twenty (20) discharged/closed medical records included in the survey sample (Patients #4, 5, 6, 9 and 13).

The findings included:

Twenty (20) closed/discharged medical records (#1-20) were reviewed on 07/28/2014 through 07/30/2014 beginning at 8:45 a.m.

An interview was conducted on 07/28/2014 at approximately 11:00 a.m. with Staff #1 and Staff #2. A request was made for the facility's policy and procedure for plan of care. Review of the facility's policy titled "Assessment and Reassessment" read in part: "The patient's assessment/reassessment process includes consideration of biophysical, psychosocial, cultural, spiritual, environmental, self-care, educational, and discharge planning factors. Pain is assessed in all patients and, if present, a more comprehensive assessment is performed when warranted by the patient's condition. The plan of care is a system for defining care goals for each patient based on the assessment process. An Interdisciplinary Plan of Care will be initiated by the RN (registered nurse) within 24 hours of the patient's admission. The Interdisciplinary team of licensed professionals adds to and updates the plan of care as needed. Needs should be prioritized. Care priorities are also updated, established and discussed in Interdisciplinary Team Conference (ITC). Each discipline will document changes in the care plan as appropriate."

1. Patient #4 was admitted to the facility on 04/11/2014 and discharged home with a home health agency on 05/20/2014.

Review of Patient #4's electronic medical record (EMR) on 07/28/2014 did not include a plan of care on admission by the Registered Nurse (RN). A request was made to review Patient #4's plan of care. Staff #2 stated, "[Patient #4's name]'s plan of care was not done on admission. A care plan was done by a RN for pain management on 04/22/2014.

An interview was conducted on 07/28/2014 at approximately 11:00 a.m. with Staff #2. Staff #2 reported the documentation on the "Interdisciplinary Plan of Care" and "Treatment Interventions" had not been updated and did not provide an accurate picture of what Patient #4 needed. Staff #2 acknowledged Patient #4's "Interdisciplinary Plan of Care" and "Treatment Interventions" did not reflect an ongoing assessment of the patient's needs or response to interventions as per the facilities policy and procedure requirements.

2. Patient #5 was admitted to the facility on 04/14/2014 and discharged to a long term care facility on 05/08/2014.

Review of Patient #5's EMR on 07/28/2014 did not include a plan of care on admission by the RN. A request was made to review Patient #5's plan of care. Staff #2 stated, "[Patient #5's name]'s plan of care was not done by the RN.

An interview was conducted on 07/28/2014 at approximately 1:00 p.m. with Staff #2. Staff #2 reported the documentation on the "Interdisciplinary Plan of Care" and "Treatment Interventions" had not been updated and did not provide an accurate picture of what Patient #5 needed. Staff #2 acknowledged Patient #5's "Interdisciplinary Plan of Care" and "Treatment Interventions" did not reflect an ongoing assessment of the patient's needs or response to interventions.

3. Patient #6 was admitted to the facility on 04/14/2014 and discharged home to a home health agency on 05/16/2014.

Review of Patient #6's EMR on 07/29/2014 did not include a plan of care on admission by the RN. A request was made to review Patient #6's plan of care. Staff #2 stated, "[Patient #6's name]'s plan of care was not done by the RN.

An interview was conducted on 07/29/2014 at approximately 11:00 a.m. with Staff #2. Staff #2 reported the documentation on the "Interdisciplinary Plan of Care" and "Treatment Interventions" had not been updated and did not provide an accurate picture of what Patient #6 needed. Staff #2 acknowledged Patient #6's "Interdisciplinary Plan of Care" and "Treatment Interventions" did not reflect an ongoing assessment of the patient's needs or response to interventions.

4. Patient #9 was admitted to the facility on 04/19/2014 and discharged home on 05/19/2014.

Review of Patient #9's EMR on 07/29/2014 did not include a plan of care on admission by the RN. A request was made to review Patient #9's plan of care. Staff #2 stated, "[Patient #9's name]'s plan of care was not done by the RN.

An interview was conducted on 07/29/2014 at approximately 11:00 a.m. with Staff #2. Staff #2 reported the documentation on the "Interdisciplinary Plan of Care" and "Treatment Interventions" had not been updated and did not provide an accurate picture of what Patient #9 needed. Staff #2 acknowledged Patient #9's "Interdisciplinary Plan of Care" and "Treatment Interventions" did not reflect an ongoing assessment of the patient's needs or response to interventions.

5. Patient #13 was admitted to the facility on 04/24/2014 and expired on 05/16/2014.

Review of Patient #13's EMR on 07/29/2014 did not include a plan of care on admission by the RN. A request was made to review Patient #13's plan of care. Staff #2 stated, "[Patient #13's name]'s plan of care was not done by the RN.

An interview was conducted on 07/29/2014 at approximately 2:00 p.m. with Staff #2. Staff #2 reported the documentation on the "Interdisciplinary Plan of Care" and "Treatment Interventions" had not been updated and did not provide an accurate picture of what Patient #13 needed. Staff #2 acknowledged Patient #13's "Interdisciplinary Plan of Care" and "Treatment Interventions" did not reflect an ongoing assessment of the patient's needs or response to interventions.

Based on document review and interview the facility nursing staff failed to administer drugs per the hospital policy for nine of thirteen current patients (Patients #21 - #29). It was also determined that based on document review and interviews the staff failed to administer time critical medications and in accordance with the approved medical staff policies and procedures to prevent harm or result in substantial sub-optimal therapy or pharmacological effect for seventeen (17) of twenty (20) discharged/closed medical records included in the survey sample (Patients #1 - 6, 8 - 11, 13 and 15 -20).

The findings included:

A review of thirteen current electronic medical records was conducted on July 28, 2014 through July 30, 2014 (Patient Records #21-#33).

According to The Institute for Safe Medication Practices (ISMP) "time critical medications are those where early or delayed administration of maintenance doses of greater than thirty (30) minutes before or after the scheduled dose may cause harm or result in substantial sub-optimal therapy or pharmacological effect."

Patient Record #21's EMR (electronic medical record) revealed the patient had been admitted to the facility on 06/13/2014 for advanced Multiple Sclerosis (immune system attacks the protective sheath that covers the nerves). Multiple doses of Time Critical Medications administered late. Multiple missing doses of medication administration.

1. Neurontin 300 mg ordered every six hours. According to drugs.com Neurontin is used to treat seizures and nerve pain. On 07/02/2014 the 12:00 pm dose of Neurontin was given as a late dose at 3:03 pm. The 6:00 pm dose was documented as given at 6:30 pm. On 07/04/2014 no documentation of 12:00 pm dose of Neurontin being administered. On 07/07/2014 Neurontin 300 mg 12:00 pm dose documented as given at 2:54 pm. The reason documented for the late dose is "other patient care."

2. No documentation on the medication administration record (MAR) of Neurontin 300 mg being administered on the following dates 12:00 am on 07/07/2014, 12:00 am on 07/11/2014, 12:00 pm on 07/12/2014, 12:00 am on 07/13/2014 and 07/15/2014 at 12:00 am.

3. Avonex 30 mcg (micrograms) intramuscularly (injection into the muscle) was ordered on 07/14/2014. Documentation on the MAR indicates the medication was not given due to "medication not available." According to drugs.com Avonex reduces the frequency of relapses in people who have multiple sclerosis (a disorder that affects the brain and spinal cord).

4. Vancomycin (antibiotic) 1 gram intravenous (by vein) daily documented as given at 8:38 am on 07/23/2014. Documentation on the MAR indicates the medication was due at 10:00 am. This is a Time Critical Medication per the facility's policy which allows an hour window for administration.

5. Merrem (antibiotic) 500 mg intravenous every eight hours was administered at 11:39 pm on 07/26/2014. The dose was due at 10:00 pm. This medication is a Time Critical Medication.

6. Vancomycin 1 gram intravenous was given at 11:31 am on 07/28/2014. The medication was due at 10:00 am. This is a Time Critical Medication. The documentation indicates the medication was administered late due to "other patient care."

Patient #22's EMR revealed the patient had been admitted to the facility on 07/02/2014 with paraplegia (paralysis) and multiple pressure sores. Documentation revealed multiple late doses of Time Critical Medications.

1. Heparin 5,000 units subcutaneous every twelve hours was documented as administered at 11:23 pm on 07/07/2014. The dose was due at 9:00 pm. Documentation indicates the drug was administered late due to "other patient care." According to drugs.com Heparin is an anticoagulant (blood thinner). A subcutaneous injection according to drugs.com is an injection given into the fat layer between the skin and the muscle. This medication is a Time Critical Medication.

2. Documentation on 07/08/2014 indicates Heparin dose due at 9:00 am. The 9:00 am dose is documented as administered at 10:54 am. The documentation indicates the Time Critical Medication was administered late due to "other patient care."

3. Vancomycin (antibiotic) 1 gram every 12 hours due at 9:00 pm on 07/07/2014 documented as given at 10:24 pm. No reason documented for the late administration. Vancomycin dose due at 9:00 pm on 07/19/2014 administered at 10:53 pm. Documented reason for late administration of Time Critical Medication is "other patient care."

4. Regular Insulin Sliding Scale documentation on 07/10/2014 at 11:30 am and 07/24/2014 at 5:30 pm indicates no dose verification with a second registered nurse was obtained.

The hospital medication administration policy mandates this second verification by a registered nurse. Staff #1 was interviewed during the EMR reviews and confirmed the facility requires a second nurse verify the type of insulin and the dosage.

Patient #23's EMR revealed the patient had been admitted to the facility on 06/30/2014 following a scooter accident. The patient has multiple open wounds. Missed doses of Sliding Scale Regular Insulin (short acting protein hormone that lowers the blood sugar) every six hours according to blood sugar:

1. Blood sugar 158 at 5:23 am on 07/02/2014 no Insulin documented as given to Patient #23. According to the physician order Patient #23 should have received 2 units of Regular Insulin.

2. Blood sugar 154 at 12:20 pm on 07/02/2014 no Insulin documented as given to Patient #23. According to the physician order Patient #23 should have received 2 units of Regular Insulin.

3. Blood sugar 153 at 11:17 pm on 07/09/2014 no Insulin documented as given to Patient #23. According to the physician order Patient #23 should have received 2 units of Regular Insulin.

4. Blood sugar 151 at 11:35 pm on 07/11/2014 no Insulin documented as given to Patient #23. According to the physician order Patient #23 should have received 2 units of Regular Insulin.

5. Blood sugar 171 at 11:57 am on 07/21/2014 no Insulin documented as given to Patient #23. According to the physician order Patient #23 should have received 2 units of Regular Insulin.

6. Intravenous (given by vein) Levaquin (antibiotic) scheduled for 10:00 am on 07/07/2014 documentation indicates given at 8:00 am. The policy titled Timely Administration of Medications was requested and received on July 29, 2014 at 4:00 pm. The policy states medications which should be included on "Time-Critical Drug List include antibiotics." The policy states all antibiotics have a one (1) hour time window.

7. Intravenous Vancomycin 1 gram daily (antibiotic) scheduled for 10:00 am on 07/10/2014 given at 6:45 pm. Reason for late dose documented as "other patient care." No documentation found a physician was notified of the late dose. No documentation found pharmacy notified of the late dose.

8. Intravenous Vancomycin 1 gram daily (antibiotic) scheduled for 10:00 am on 07/11/2014 documented as given at 4:19 pm. Reason for late dose documented as "other patient care." No documentation found a physician was notified of the late dose.

9. Zosyn (antibiotic) 3.375 grams intravenous every six (6) hours scheduled for 6:00 pm on 07/11/2014 documented as given on 9:44 pm. No documentation found a physician or pharmacy notified of the late dose.

10. Zosyn 3.375 grams intravenous scheduled for 12:00 am given at 12:56 am (see above Zosyn dose given). Previous dose given at 9:44 pm. Dose is ordered every six hours. Documentation indicates dose given after 3 hours and approximately 10 minutes. No documentation found a physician notified or pharmacy contacted.

11. Zosyn 3.375 grams intravenous scheduled for 12:00 pm on 07/14/2014 documented as given at 2:00 pm. Reason for late dose documented as "other patient care." No documentation a physician was notified of the late dose.

12. No documentation of 9:00 pm dose of Keppra 500 mg found on the MAR of Patient #23 for the date of 07/15/2014. According to Drugs.com Keppra is an anti seizure medication. Staff #1 was present during the medical record review on July 28, 2014 at approximately 11:00 am and was unable to explain why the Keppra was not documented.

Patient #24's EMR revealed the patient had been admitted to the facility on 04/29/2014 after sustaining multiple skeletal injuries due to a motor vehicle accident. The injuries included multiple fractures, fractured skull, and spleen laceration. The patient developed a urinary tract infection during recovery. Multiple documented doses of late administration of Time Critical Medications.

1. Heparin 5,000 units subcutaneous injection every eight hours documented late administration due to "other patient care" on 05/04/2014 and 05/13/2014. The medication was due at 10:00 pm on 05/04/14 and administered at 11:26 pm. Documentation on 05/13/2014 indicates the 10:00 pm dose was administered at 12:06 am. The 2:00 pm dose on 05/13/2014 was given at 6:15 pm. The documented reason on the MAR is "non-time critical medication." According to the facility's policy titled Timely Administration of Medications Heparin is a Time Critical Medication.

Patient #25's EMR revealed the patient had been admitted to the facility on 04/01/2014 for encephalopathy (affects the function of the brain), ventilator dependent (breathes with aid of machine), and acute respiratory failure. Multiple doses of late administration of Time Critical Medications.

1. Lovenox (anticoagulant) 40 subcutaneous was given at 12:10 pm on 04/20/2014. The dose was due at 10:00 am. The reason for the late administration is documented as "other patient care."

2. On 04/20/2014 the 12 noon sliding scale regular insulin was given at 3:06 pm. According to the facility's policy titled Timely Administration of Medications Insulin is a Time Critical Medication.

3. On 04/21/2014 the Lovenox 10:00 am dose was documented as given at 11:35 am. No reason was documented for the late administration.

Patient #26's EMR revealed the patient had been admitted on 07/13/2014 for diabetes, atrial fibrillation (abnormal heart rate which can predispose the patient to blood clots), Methicillin Resistant pneumonia (resistant bacteria which can cause a lung infection). The patient later developed C-Diff (Clostridium Difficile gram positive spore forming bacteria which can cause diarrhea). Multiple doses of Time Critical Medications administered late according to documentation on the MAR.

1. Heparin 5,000 units subcutaneous every eight hours dose due at 2:00 pm on 07/15/2014 documented as given at 4:41 pm. Documentation on the MAR indicates "other reason for late dose."

2. Flagyl (antibiotic) 500 mg by mouth every eight hours due at 2:00 pm on 07/15/2014 was administered at 4:42 pm. Documentation on the MAR indicates the reason for the late dose as "other reason for late dose." No documentation of Patient #26 being off the unit at the time the medication was due.

3. Vancomycin (antibiotic) 500 mg intravenous ordered every Monday, Wednesday, and Friday (dialysis patient). Dose ordered to be given at 6:00 pm. Documentation indicates the dose was administered at 7:40 pm. The documentation states the reason for the late dose as "other reason for late dose." Of note the nursing staff have the option of selecting "patient off the unit" for a reason for the late administration of medications. Nowhere on the MAR was it found the patient was off the unit.

Patient #27's EMR revealed the patient had been admitted to the facility on 07/26/2014 for a large decubitus ulcer. The patient later developed a urinary tract infection. Time Critical Medication administered late per the documentation on the MAR.

1. Vancomycin (antibiotic) 125 mg by mouth ordered four times a day (QID). Vancomycin dose due at 12:00 pm on 07/27/2014 administered at 2:30 pm. Documented reason for late administration is "other patient care."

Patient #28's EMR revealed the patient had been admitted to the facility on 07/18/2014 for insulin dependent diabetes and calcaneous osteomyelitis (infection in the bone). Multiple doses of documented late administration of Time Critical Medications.

1. Lantus Insulin (long acting) 6 units subcutaneous due at 7:30 am on 07/22/2014 has no documentation of a second registered nurse verifying the dose per the hospital policy.

2. Lantus Insulin 3 units subcutaneous due at 7:30 am on 07/24/2014 documented as administered at 9:24 am. Documented reason for the late administration is "other patient care."

3. Lantus Insulin 3 units subcutaneous due at 7:30 am on 07/26/2014 documented as administered at 11:04 am. Documented reason for the late administration on the MAR is "other patient care."

4. Naficillin (antibiotic) 1 gram intravenous every eight hours due at 8:00 pm on 07/23/2014 documented as administered at 10:52 pm. The reason for the late administration documented on the MAR is "other patient care."

5. Naficillin 1 gram intravenous due at 2:00 pm on 07/26/2014 documented as given at 4:00 pm. The reason for the late administration documented on the MAR is "other patient care."

6. Naficillin 1 gram intravenous due at 2:00 am on 07/27/2014 documented as administered at 3:44 am. No reason documented for late administration.

7. Naficillin 1 gram intravenous due at 2:00 pm on 07/28/2014 documented as administered at 3:56 pm. The reason for the late administration documented on the MAR is "other patient care."

Patient Record #29's EMR revealed the patient had been admitted to the facility on 07/25/2014 with a history of renal transplant (kidney transplant), sacral decubitus, and chronic urinary tract infection.

1. Regular insulin (fast acting) 2 units subcutaneous documented at 5:56 pm. No documentation found on the MAR a second registered nurse verified the drug and dosage.

Patient #23's medical record was reviewed on July 28, 2014 and July 29, 2014. Staff #1 was asked to locate a Vancomycin level (blood test to determine the level of drug in the body to aid in dosing of medication) ordered on Patient #23 on 07/10/2014. Staff #1 was unable to locate the test results in the electronic medical record due to the system capabilities (data unavailable after four days).

An interview was conducted with Staff #7 on July 29, 2014 between 9:00 am and 11:00 am. Staff #7 reported the Vancomycin level was ordered on 07/10/2014. The laboratory never received the specimen. Staff #7 reported the pharmacy was waiting on the results from the laboratory but the specimen was not received. The test was reordered on 07/12/2014 at 11:00 am. Patient #23 had already received his/her Vancomycin. The specimen was obtained on 07/13/2014 and the Vancomycin level (trough) was low. The physician increased the Vancomycin from 1.5 grams a day to 1 gram every eight hours. Staff #7 confirmed Patient #23 was under dosed on the antibiotic due to the delay in the Vancomycin trough blood test being obtained. Staff #7 confirmed the under dosing occurred from 07/10/2014 the date the test was ordered until 07/13/2014 when the results were obtained.

The review of discharged/closed medical records revealed the following:

Twenty (20) closed/discharged medical records (#1-#20) were reviewed on 07/28/2014 through 07/30/2014 beginning at 8:45 a.m.

An interview was conducted on 07/29/2014 at approximately 9:00 a.m. with Staff #1 and Staff #2. A request was made for the facility's policy and procedure for medication administration. Review of the facility's policy titled "Timely Administration of Medications" read in part: "Medications will be administered in a timely manner. Medications that are deemed "time-critical" medications will be given within a 1-hour window (30 minutes before or after the scheduled due time). Time-critical medications are defined as those where early or delayed administration of maintenance doses of greater than 30 minutes before or after the scheduled dose may cause harm or result in substantial sub-optimal therapy or pharmacological effect. At the end of each shift, the licensed nurse and respiratory therapist verifies all medications due were administered. The physician is notified of all missed medications identified at that time. The physician shall be notified of missed or late time-critical scheduled medications. New "stat" and "now" medication orders will be administered within one hour."

Patient #1's electronic medical record (EMR) revealed the patient had been admitted to the facility on 12/13/2013 for acute respiratory failure. Patient Record #1's medication administration record (MAR) from 04/26/2014 through 04/30/2014 revealed a time-critical medication administered late.

1. Heparin Sodium 5000 units subcutaneous (SQ) injection every 8 hours scheduled for 04/28/2014 at 14:00 failed to be administered until 17:37. Documentation in the MAR by the licensed nurse revealed the late dose reason was documented as, "other reason for late dose." According to drugs.com Heparin is an anticoagulant (blood thinner). A subcutaneous injection according to drugs.com is an injection given into the fat layer between the skin and the muscle. Patient #1's EMR and MAR did not reveal the physician was notified of a late time-critical scheduled medication.

Patient #2's EMR revealed the patient had been admitted to the facility on 04/01/2014 for systolic heart failure. Review of Patient #2's MAR from 04/26/2014 through 04/30/2014 revealed time-critical medications administered late.

1. Vancomycin 750 mg intravenous (by vein) piggy back (IVPB) scheduled for 04/28/2014 at 16:00 failed to be administered until 17:48.
2. Vancomycin 750 mg IVPB scheduled for 04/29/2014 at 16:00 failed to be administered until 17:44. Documentation in the MAR by the licensed nurse revealed the late dose reason was documented as, "other patient care." Patient #2's EMR and MAR did not reveal the physician was notified of a late time-critical scheduled medication. According to drugs.com Vancomycin is an antibiotic. An intravenous piggy back according to drugs.com refers to giving medications or fluids through a needle or tube inserted into a vein.

Patient #3's EMR revealed the patient had been admitted to the facility on 04/09/2014 for abdominal and sacral wounds. Review of Patient #3's MAR from 04/22/2014 through 04/30/2014 revealed time-critical medications administered late.

1. Regular Insulin (short acting protein hormone that lowers the blood sugar) sliding scale SQ every 6 hours scheduled for 04/22/2014 at 12:00 failed to be administered until 13:10.

2. Regular Insulin sliding scale SQ every 6 hours scheduled for 04/24/2014 at 12:00 failed to be administered until 14:45.

3. Novolin Insulin (fast-acting form of insulin that works by lowering levels of sugar in the blood) 9 units SQ twice per day scheduled for 04/25/2014 at 08:00 failed to be administered until 09:24 and the next dose scheduled at 17:00 failed to be administered until 18:10.

4. Regular Insulin sliding scale SQ every 6 hours scheduled for 04/28/2014 at 12:00 failed to be administered until 13:32 and Novolin Insulin 9 units SQ twice per day scheduled at 17:00 failed to be administered until 18:02.

5. Novolin Insulin 9 units SQ twice per day scheduled for 04/29/2014 at 08:00 failed to be administered until 10:35. Documentation in the MAR by the licensed nurse revealed the late dose reasons were documented as, "other patient care." Patient #3's EMR and MAR did not reveal the physician was notified of the late time-critical scheduled medications.

Patient #4's EMR revealed the patient had been admitted to the facility on 04/11/2014 for septic right knee. Review of Patient #4's MAR from 04/25/2014 through 04/30/2014 revealed time-critical medications administered late and multiple missing doses of medication administration.
1. Prednisone (corticosteroid that prevents the release of substances in the body that cause inflammation) 5 mg tablet by mouth (PO) every 12 hours scheduled for 04/25/2014 at 20:00 failed to be administered; Betapace (beta-blocker that affects the heart and blood flow through arteries and veins) 120 mg tablet PO every 12 hours scheduled at 20:00 failed to be administered.
2. Teflaro (antibiotic) 600 mg IVPB every 12 hours scheduled for 04/26/2014 at 05:15 failed to be administered and Normal Saline (sterile solution of sodium chloride) 0.9% 100 ml IVPB every 12 hours scheduled at 05:15 failed to be administered.
3. Teflaro 600 mg IVPB every 12 hours scheduled for 04/27/2014 at 18:00 failed to be administered; Normal Saline 0.9% 100 ml IVPB every 12 hours scheduled at 18:00 failed to be administered and Levothyroxine (replacement for a hormone normally produced by low thyroid hormone) 75 mcg tablet PO every day scheduled at 06:00 failed to be administered.
4. Prednisone 5 mg tablet PO every 12 hours scheduled for 04/29/2014 at 20:00 failed to be administered. Documentation in the MAR by the licensed nurse revealed no documentation for the missed doses of medication. Patient #4's EMR and MAR did not reveal the physician was notified of any missed time-critical scheduled medications.
Patient #5's EMR revealed the patient had been admitted to the facility on 04/14/2014 for respiratory failure. Review of Patient #5's MAR from 04/25/2014 through 04/30/2014 revealed time-critical medications administered late or multiple missing doses of medication administration.

1. Lantus Insulin (long-acting form of insulin that works by lowering levels of sugar in the blood) 5 units SQ daily scheduled for 04/25/2014 at 10:00 was administered at 08:32 and Cardizem (calcium channel blockers working to relax the muscles of the heart and blood vessels to lover blood pressure) 60 mg tablet PO every 6 hours scheduled at 10:00 was administered at 08:41.

2. Lantus Insulin 5 units SQ every day scheduled for 04/26/2014 at 10:00 was administered at 08:32.

3. Cardizem 60 mg tablet PO every 6 hours scheduled for 04/27/2014 at 04:00 failed to be administered until 07:00 and the scheduled doses at 13:00 and 19:00 are not documented as being administered.

4. Regular Insulin sliding scale SQ before meals and at bedtime scheduled for 04/28/2014 at 11:30 failed to be administered until 13:31 and the scheduled dose at bedtime failed to be administered.

5. Regular Insulin sliding scale SQ before meals and at bedtime dose scheduled for 04/29/2014 at 17:00 failed to be administered until 18:54 and the scheduled at bedtime dose failed to be administered. Documentation in the MAR by the licensed nurse revealed no documentation for the missed doses of medication and revealed the late dose reasons were documented as, "other patient care." Patient #5's EMR and MAR did not reveal the physician was notified of any missed or late administration for time-critical scheduled medications.

Patient #6's EMR revealed the patient had been admitted to the facility on 04/14/2014 for osteomyelitis from a left hip wound. Review of Patient #6's MAR from 04/26/2014 through 04/30/2014 revealed time-critical medications administered early, late and multiple missing doses of medication administration.

1. Merrem (antibiotic) 500 mg IVPB every 8 hours scheduled for 04/26/2014 at 20:00 failed to be administered until 22:05.
2. Kayexolate (treat high potassium levels in the blood) 15 gm now dose scheduled for 04/28/2014 at 13:08 hours failed to be administered until 17:23 and Bacitracin (antibiotic) 1 oz Ointment daily scheduled at 10:00 failed to be administered until 17:25.
3. Lovenox (anticoagulant helps prevent the formation of blood clots) 40 mg SQ injection daily scheduled for 04/29/2014 at 10:00 failed to be administered until 13:33. Documentation in the MAR by the licensed nurse revealed no documentation for the missed doses of medication and revealed the late dose reasons were documented as, "other patient care." Patient #6's EMR and MAR did not reveal the physician was notified of any early, missed or late administration of the time-critical scheduled medications.

Patient #8's EMR revealed the patient had been admitted to the facility on 04/08/2014 for decubital ulcers and paraplegia. Review of Patient #8's MAR from 04/25/2014 through 04/30/2014 revealed time-critical medications administered early and late.

1. Zosyn (antibiotic) 3.375 gm IVPB every 6 hours scheduled for 04/25/2014 at 24:00 was administered at 22:23 and Teflaro 600 mg IVPB every 12 hours scheduled at 18:00 failed to be administered until 04/26/2014 at 06:25.

2. Lovenox 40 mg SQ daily scheduled for 04/26/2014 at 10:00 was administered at 08:35.

3. Lovenox 40 mg SQ daily scheduled for 04/27/2014 at 10:00 was administered at 08:17.

4. Lovenox 40 mg SQ daily scheduled for 04/28/2014 at 10:00 failed to be administered until 11:26; Zosyn 3.375 gm IVPB every 6 hours scheduled at 06:00 failed to be administered until 11:27 and the dose scheduled at 17:00 failed to be administered until 18:10.

5. Regular Insulin sliding scale SQ every 6 hours scheduled for 04/28/2014 at 12:00 failed to be administered until 13:32; Novolin Insulin 9 units SQ twice per day scheduled at 17:00 failed to be administered until 18:02; Zosyn 3.375 gm IVPB every 6 hours scheduled at 24:00 failed to be administered until 01:34.

6. Zosyn 3.375 gm IVPB every 6 hours scheduled for 04/29/2014 at 06:00 was administered at 04:35.

7. Zosyn 3.375 gm IVPB every 6 hours scheduled for 04/30/2014 at 06:00 was administered at 04:52; Teflaro 600 mg IVPB every 12 hours scheduled at 06:00 failed to be administered until 07:42; Lovenox 40 mg SQ daily scheduled at 10:00 failed to be administered until 12:04. Documentation in the MAR by the licensed nurse revealed the late dose reasons were documented as, "other patient care," "other reason for late dose," and "patient off unit." Patient #8's EMR and MAR did not reveal the physician was notified of the early and late time-critical scheduled medications.

Patient #9's EMR revealed the patient had been admitted to the facility on 04/19/2014 for tricuspid valve endocarditis. Review of Patient #9's MAR from 04/25/2014 through 04/30/2014 revealed time-critical medications administered early, late or multiple missing doses of medication administration.
1. Oxycodone (opioid pain medication) 15 mg tablet PO every 6 hours scheduled for 04/27/2014 at 18:00 failed to be administered; Advair Diskus (steroid used to relax muscles in the airway to improve breathing) 250 mcg/50 mcg Inhaler twice a day scheduled at 20:00 failed to be administered; Lioresal (muscle relaxer and an antispastic agent) 10 mg tablet PO three times a day scheduled at 09:00 failed to be administered until 10:45; and Lovenox 40 mg SQ daily scheduled at 10:00 failed to be administered until 14:02.
2. Oxycodone 5 mg tablet PO every 6 hours scheduled for 04/28/2014 at 12:00 failed to be administered until 13:17 and Cathflo (restoring function to central venous access devices that have become clogged with clotted blood) 2 mg IVPB now dose scheduled at 11:03 failed to be administered until 13:17.
3. Lioresal 10 mg tablet PO three times per day scheduled for 04/29/2014 at 21:00 failed to be administered.
4. Lovenox 40 mg SQ daily scheduled for 04/30/2014 at 10:00 was administered at 08:41. Documentation in the MAR by the licensed nurse revealed no documentation for the missed doses of medication and revealed the late dose reasons were documented as, "other patient care," and ""other reason for late dose." Patient #9's EMR and MAR did not reveal the physician was notified of any missed, early or late administration of the time-critical scheduled medications.
Patient #10's EMR revealed the patient had been admitted to the facility on 04/05/2014 for progressive refractory Hodgkin lymphoma and multi-organ dysfunction syndrome. Review of Patient #10's MAR from 04/25/2014 through 04/30/2014 revealed time-critical medications administered late or multiple missing doses of medication administration.
1. Keppra (anti-epileptic drug, used to treat partial onset seizures) 2000 mg twice a day scheduled for 04/27/2014 at 21:00 failed to be administered; Xenaderm (increases blood flow to a wound area, and also helps fight bacteria) Ointment twice per day scheduled at 21:00 failed to be administered; Protonix (proton pump inhibitors used to decrease the amount of acid produced in the stomach) 40 mg IVPB twice per day scheduled at 21:00 failed to be administered; Vancomycin Hydrochloride 1 gm IVPB every 12 hours scheduled at 21:00 failed to be administered; Maxipime (antibiotic) 1 gm IVPB every 12 hours scheduled at 22:00 failed to be administered; Carafate (anti-ulcer medication) 1 gm four times per day only administered at 12:00, no other doses were documented as being administered; and Lopressor (treat high blood pressure) 5 mg IVPB every 6 hours scheduled at 20:00 failed to be administered.
2. Maxipime 1 gm IVPB every 12 hours scheduled for 04/29/2014 at 10:00 failed to be administered until 12:24. Documentation in the MAR by the licensed nurse revealed no documentation for the missed doses of medication and revealed the late dose reasons were documented as, "other patient care." Patient #10's EMR and MAR did not reveal the physician was notified of any missed or late administration for time-critical scheduled medications.
Patient #11's EMR revealed the patient had been admitted to the facility on 04/04/2014 for cellulitis and renal failure. Review of Patient #11's MAR from 04/25/2014 through 04/30/2014 revealed a time-critical medications administered late.

1. Lantus Insulin 40 units SQ scheduled for 04/28/2014 at 21:00 failed to be administered until 22:37.
2. Lasix (treats fluid retention) 20 mg tablet PO twice per day scheduled for 04/29/2014 at 09:00 failed to be administered until 11:00. Documentation in the MAR by the licensed nurse revealed the late dose reasons were documented as, "other patient care," and "patient off unit." Patient #11's EMR and MAR did not reveal the physician was notified of late administration for time-critical scheduled medications.
Patient #13's EMR revealed the patient had been admitted to the facility on 04/24/2014 for right hip ulceration. Review of Patient #13's MAR from 04/25/2014 through 04/30/2014 revealed time-critical medications administered late.

1. D5 NS (sterile solution of dextrose in sodium chloride) 1000 ml IV scheduled for 04/27/2014 at 19:14 failed to be administered until 04/29/2014 at 10:55; NS (sterile solution in sodium chloride) 0.9% 10 ml flush syringe IVPB every 12 hours scheduled at 21:00 failed to be administered until 04/30/2014 at 07:39.

2. Dakin's 0.125% Solution 60 ml daily scheduled for 04/30/2014 at 10:00 failed to be administered until 16:09. Documentation in the MAR by the licensed nurse revealed no documentation for the missed doses of medication and revealed the late dose reasons were documented as, "other patient care," and "other reason for late dose." Patient #13's EMR and MAR did not reveal the physician was notified of missed or late administration for time-critical scheduled medications.

Patient #15's EMR revealed the patient had been admitted to the facility on 04/09/2014 for catastrophic trauma and brain injury. Review of Patient #15's MAR from 04/25/2014 through 04/30/2014 revealed time-critical medications administered late.
1. Zoloft (antidepressant used to treat depression, panic, anxiety, or obsessive-compulsive symptoms) 50 mg PO before breakfast scheduled for 04/26/2014 at 07:30 failed to be administered until 11:49; Heparin Sodium 5000 units SQ every 8 hours scheduled at 14:00 failed to be administered until 15:55; Bacitracin 1 oz Ointment daily scheduled at 10:00 failed to be administered until 15:59.
2. Heparin Sodium 5000 units SQ every 8 hours scheduled for 04/28/2014 at 22:00 failed to be administered until 23:16.
3. Heparin Sodium 5000 units SQ every 8 hours scheduled for 04/29/2014 at 14:00 failed to be administered until 18:29.
4. Bacitracin 10 oz Ointment daily scheduled for 04/30/2014 at 10:00 failed to be administered until 14:49. Documentation in the MAR by the licensed nurse revealed the late dose reason was documented as, "other patient care." Patient #15's EMR and MAR did not reveal the physician was notified of late administration for time-critical scheduled medications.
Patient #16's EMR revealed the patient had been admitted to the facility on 04/17/2014 for severe rhabdomyolysis and acute renal failure. Review of Patient #15's MAR from 04/25/2014 through 04/30/2014 revealed time-critical medications administered earl

Based on observations, interviews, and document review the facility staff failed to follow infection control policies during three of three observations of patient care (Staff #8 and Staff #9).

The findings included:

Staff #8 was observed in a patient's isolation room (contact isolation) on the second floor of the above named facility at approximately 10:00 am on July 29, 2014. Staff #8 was observed crossing the designated clean zone (red tape to designate the area) gowned and gloved after being in contact with the patient. Staff #8 was observed touching the container of Sani Wipes mounted on the wall in the designated clean zone while gloved after being in contact with the patient. After obtaining a Sani Wipe Staff #8 crossed back over from the designated clean area back into the patient care area.

A medication pass was observed on July 29, 2014 at approximately 10:10 am. Staff #8 was observed in a second patient's room. Staff #8 was gowned and gloved due to contact isolation. Staff #8 was observed crossing over gowned after coming in contact with the patient into the designated clean area. Prior to crossing from the patient care area into the designated clean area Staff #8 removed his/her gloves. No hand hygiene was observed prior to Staff #8 donning another pair of gloves.

Trachesostomy (surgically created hole in the trachea to assist with breathing) care was observed (2nd floor) on a contact isolation patient on July 29, 2014 at approximately 10:15 am to 10:30 am. Staff #9 was observed multiple times (approximately (3) three) crossing from the patient care area into the designated clean area gowned after coming into contact with the patient. Staff #9 removed his/her gloves three times. Staff #3 was observed once doing hand hygiene prior to donning a new pair of gloves.

Emergency Medical Technicians (county employees) were observed on July 28, 2014 on the second floor at approximately 10:45 am in a contact isolation room without gowns. Two emergency medical technicians were observed gloved leaving the room and placing the stretcher in the hall way. No observation was made of the emergency medical technicians cleaning the stretcher prior to removing it from the room. Staff #4 approached the surveyors and stated the facility staff had requested the emergency medical technicians to gown and glove.

The facility's policy titled Initiation of Transmission Based Precautions was requested and obtained on July 30, 2014 at approximately 4:00 pm. The policy states under the subtitle Transporting the Patient on Transmission Based Precautions "transporter wears isolation gown, gloves, and mask as indicated if necessary to enter the patient's room and assist the patient to chair or stretcher." This policy is not specific to outside transporters nor does it exclude them from the policy.

Staff #7 was interviewed on July 30, 2014 at approximately 1:30 pm and reported the designated clean area (red tape on the floor) in patient's rooms is a visual reminder to staff. Staff #7 confirmed this area should not be crossed over after being in contact with a patient unless the staff removed their gown and gloves. Staff #7 reported he/she could not control what the emergency medical technicians did while transporting patients.

Staff #14 was interviewed on July 30, 2014 at 3:00 pm (with Staff #15). Staff #14 reported he/she was taught the designated clean area should not be crossed into after being in contact with an isolation patient.

Staff #15 was interviewed on July 30, 2014 at 3:00 pm. Staff #15 reported he/she does not cross into the designated clean area once he/she has had contact with an isolation patient. Staff #15 confirmed this practice was taught to him/her by the above named facility.