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Based on observations, document review and interview, it was determined the facility failed to protect and promote the rights of patients within their care. The facility staff failed to document use of less restrictive interventions to protect the patient, failed to update the patient's plan of care to reflect use of restraint or seclusion (including drugs or medications used as restraint as well as physical restraint), failed to provide documentation of the condition of the patient while restrained or secluded by a physician, other licensed independent practitioner to protect the patient for one (1) of one (1) patients reviewed(Patient #18) and failed to specify physician and other licensed independent practitioner training requirements for use of restraint or seclusion. The facility also failed to treat Patient #3 in a respectful manner.

Based on interviews, observation and document review, it was determined the facility staff failed to ensure verbal orders were documented as such and were used infrequently, failed to ensure the staff members who administered medications signed the MAR (Medication Administration Record) for twenty (20) of twenty (20) patients (Patients #1 - #20) and failed to ensure the Nursing Care Plans for twenty (20) of twenty (20) patients were kept current by addressing current problems, documenting updates by a progress note, documenting evaluation dates, deleting or showing resolution for problems that were stable or no longer applicable and accurately noting the dates of care plan updates and that the physician was an active participate in the interdisciplinary care plan.


See Tags, 0396, 0405 and 0407 for further details.

Based on document review, interview and observations, it was determined the facility staff failed to ensure documentation of dialysis treatments contained potentially critical information for one (1)of three (3) patients (Patient #1), equipment and supplies used by the contracted dialysis agency were able to be cleaned and disinfected to prevent the potential spread of bloodborne infections for five (5) of five (5) machines and failed to use gloves and disinfect/clean hands when moving from a dirty surface to a clean surface for two (2) of three (3) patients observed (Patients #1 and #2).

See Tag 0749 for specific details.

Based on observations and interview, it was determined the facility staff failed to treat Patient #3 in a respectful manner.

The findings include:

On 10/29/15 at approximately 10:00 A.M., while observing wound care, Staff Member #22 entered the patient's room and attempted to pull the curtain back when Staff Member #9 stated, "We are doing a dressing change". Staff Member #22 stated, "Well could you just slap this on her while you have her on her side?" Staff Member #9 stated, "What is it?" Staff Member #22 stated, "It's her patch, just slap it on her." Staff Member #22 proceeded to demonstrate how to apply the patches. Staff Member #9 took the patches and applied them.

The surveyor asked Staff Member #22 how he/she knew Patient #3 interpreted the comment, "Just slap it on her". Staff Member #22 stated, "Oh she is with it, she knows what I mean" and walked out the door.

Staff Member #22 never addressed Patient #3 by name or explained why he/she was in the room or what was being requested of Staff Member #9.

Based on medical record review and interview, the facility failed to document use of less restrictive interventions to protect the patient for one (1) of one (1) patients reveiwed (Patient #18).

The findings include:

A medical record review for Patient #18 on October 26, 2015 between 11:45 a.m. and 12:30 p.m. revealed the following documentation on October 24, 2015:

0400 "Resident has made several attempts to climb out of bed over rails. Resident has pulled pulse ox lead off multiple times. Resident has pulled vent tubing apart."
0500 "Charge Nurse notified on call "physician" received orders for mitts bilateral, UA C&S CBC BMP Blood cultures ok to give extra dose of ativan. Also ordered low bed for patient safety. "
0600 "found with vent circuit in hand disconnected from vent. Alarm ringing. RT in room reattaching circuit. This confusion has increased since start of shift on October 23, 2015. Brother made aware via phone message."
0700 "bilateral mittens applied. Ativan and dilaudid given per peg."

An interview with Staff Member #8 revealed staff should document less restrictive interventions prior to applying restraints.

Based on medical record review, the facility failed to update the patient's plan of care to reflect use of restraint or seclusion (including drugs or medications used as restraint as well as physical restraint) for one (1) of one (1) patients reveiwed (Patient #18).

The findings include:

A medical record review for Patient #18 on October 26, 2015 between 11:45 a.m. and 12:30 p.m. revealed the plan of care was not updated to reflect the use of restraint or seclusion (including drugs or medications used as restraint as well as physical restraint).

Staff Members #12 and #13 were made aware of incomplete care plan on October 27, 2015 at 4:30 p.m.

Based on medical record review and interview, the facility failed document the condition of the patient while restrained or secluded by a physician, other licensed independent practitioner, to protect the patient for one (1) of one (1) patients reviewed (Patient #18).

The findings include:


A medical record review for Patient #18 on October 26, 2015, between 11:45 a.m. and 12:30 p.m., revealed Physician's Progress Notes, dated October 24, 2015, failed to document ongoing assessment and monitoring of patent's condition while restrained or secluded. The Physician's Progress Notes dated October 24, 2015 documented, "The plan of care has been reviewed at length with the patient at bedside. He voiced understanding and agreement; also with nursing staff." However the care plan was not updated to include the use of restraints.

Based on a review of the facility's Policy and Procedure titled, "Restraints (Hospital Level), the facility failed to specify physician and other licensed independent practitioner training requirements for use of restraint or seclusion.

The findings include:

The Policy and Procedure titled, "Restraints (Hospital Level), failed to specify the physician and other licensed independent practitioner training requirements in hospital policy. At a minimum, physicians and other licensed independent practitioners authorized to order restraint or seclusion by hospital policy in accordance with State law must have a working knowledge of hospital policy regarding the use of restraint or seclusion.

Based on interview and document review, it was determined the facility staff failed to ensure that adverse occurrences which had been investigated, were documented.

The findings include:

On 10/29/15 at approximately 12:30 P.M., Staff Members #1, #12 and #23 were interviewed regarding their investigation of an adverse occurrence regarding a J tube. They failed to document the investigation into the cause, the analysis of the investigation, the preventive actions and the reassessment of the preventative actions put into place.

Based on document review, interview and observations, it was determined the facility staff failed to ensure the Nursing Care Plans for twenty (20) of twenty (20) patients were kept current by addressing current problems, documenting updates by a progress note, documenting evaluation dates, deleting or showing resolved problems that were stable or no longer applicable and by accurately noting the dates of care plan updates and documenting that the physician was an active participate in the interdisciplinary care plan.

The findings include:


1. A. The medical record of Patient #2 was reviewed on 10/27/15 and revealed the following:
Patient #2 was a 68 year old admitted on 9/2/15 with the diagnoses of Sepsis, severe respiratory failure secondary to obstructive sleep apnea, ESRD (End Stage Renal Disease), morbid obesity, diabetes mellitus (DM) and pacemaker. Patient #2's Nursing Care Plan had the following problems inside the Care Plan Review/Assessment jacket:

Nursing Plan of Care - Safety Risk no dates of when this was initiated or evaluated
Nursing Plan of Care - Impaired Skin Integrity initiated 9/5/15 and dated as evaluated on 9/5/15 and 10/11/15. There were no progress notes indicating the evaluation of this problem.
Nursing Plan of Care - Renal Failure initiated on 9/5/15 and indicated as evaluated on 9/5/15 and 10/11/15. There were no progress notes indicating the evaluation of this problem.
Nursing Plan of Care - Impaired Mobility initiated on 9/5/15 and indicated as evaluated on 9/5/15 and 10/11/15. There were no progress notes indicating the evaluation of this problem.
Nursing Plan of Care-Anemia initiated on 9/5/15 and indicated as evaluated on 9/5/15 and 10/11/15. Two of Patient #2's measurable goals are "Sickle cell complications will be minimized", and "Patient will verbalize relief from sickle cell pain". There were no progress notes indicating the evaluation of this problem.
Nursing Plan of Care - Antibiotic Therapy initiated on 9/5/15 and indicated as evaluated on 9/5/15. There were no progress notes indicating the evaluation of this problem. Patient #2 was still receiving antibiotics on 9/25/15.
Nursing Plan of Care - Diabetes initiated on 9/5/15 and indicated as evaluated on 9/5/15 and 10/11/15. There were no progress notes indicating the evaluation of this problem.
There was no interdisciplinary plan of care. The Care Plan Review/Assessment jacket has a area for physician signature but not physician signature was present.

B. The medical record of Patient #3 was reviewed on 10/26 - 28/15 and revealed the following:
Patient #3 was a 70 year old admitted on 11/6/14 with the diagnoses of Chronic respiratory failure, pneumonia, diabetes mellitus, inclusion body myositis and status post sigmoid volvulus resection. Patient #3's Nursing Care Plan had the following problems inside the Care Plan Review/Assessment jacket:

Nursing Plan of Care - Antibiotic Therapy initiated on 11/6/14 and indicated as evaluated on 12/6/14. There were no progress notes indicating the evaluation of this problem.
There was no documented Nursing Plan of Care related to the surgical wound Patient #3 was admitted with on 11/6/14 nor a Nursing Plan of Care related to complaints of being unable to turn to the left side due to left should pain/injury.
The Care Plan Review/Assessment jacket has a area for physician signature but not physician signature was present.

C. The medical record of Patient #5 was reviewed on 10/27/15 and revealed the following: Patient #5 was a 57 year old admitted on 2/8/12 with the diagnoses of respiratory failure, S/P (status post) septicemia, lupus and ESRD. Patient #5's Nursing Care Plan had the following problems inside the Care Plan Review/Assessment jacket:

Nursing Plan of Care - Antibiotic Therapy initiated on 10/18/15 and indicated as evaluated on 10/19/15. There were no progress notes indicating the evaluation of this problem.
Nursing Plan of Care - Seizure Disorder with no initiation date and indicated as evaluated on 1/10/15,2/7/15, 3/8/15, 4/12/15, 5/9/15, 6/6/15, 7/11/15, 8/9/15, 9/5/15 and 10/19/15. There were no progress notes indicating the evaluation of this problem. The Plan of Care Summary dates were 8/11/15, 9/8/15 and 10/13/15. The Care Plan Review/Assessment jacket has a area for physician signature but not physician signature was present.

D. The medical record of Patient #6 was reviewed on 10/28/15 and revealed the following: Patient #6 was a 50 year old admitted on 10/28/14 with the diagnoses of DM, peripheral neuropathy, anxiety, respiratory failure. Patient #6's Nursing Care Plan had the following problems inside the Care Plan Review/Assessment jacket:

Nursing Plan of Care - Hypertension initiated on 10/28/14 and indicated as evaluated on 11/16/14, 12/14/14/, 1/18/15, 2/15/15, 3/15/15, 4/19/15, 5/15/15, 6/12/15, 7/19/15, 8/16/15, 9/13/15 and 10/19/15. There were no progress notes indicating the evaluation of this problem.
Nursing Plan of Care - Antibiotic Therapy with an initiation date of 12/2/14 and indicated as evaluated on 12/14/14. There were no progress notes indicating the evaluation of this problem.
Nursing Plan of Care - Diabetes initiated on 10/28/14 and indicated as evaluated on 11/16/14, 12/14/14/, 1/18/15, 2/15/15, 3/15/15, 4/19/15, 5/15/15, 6/12/15, 7/19/15, 8/16/15, 9/13/15 and 10/19/15. There were no progress notes indicating the evaluation of this problem.
Interdisciplinary Plan of Care - Tracheostomy initiated on 10/28/14 and has no dates of evaluation There were no progress notes indicating the evaluation of this problem.
Interdisciplinary Plan of Care - Tracheostomy (second page dated 10/28/14 as initiated). Indicates the problems were continued on 11/4/14, 11/18/14, 12/16/14, 1/20/15 and 2/17/15. The notations indicate there was an evaluation of the problem documented on 11/4/14, 11/18/14, 12/16/14, 1/20/15 and 2/17/15. There were no progress notes indicating the evaluation of this problem after 2/17/15.
Interdisciplinary Plan of Care - Ventilator initiated on 10/28/14 and indicated as continued 11/4/14, 11/18/14, 12/16/14, 1/20/15, 2/17/15, 3/17/15, 4/21/15, 5/19/15, 7/21/15, 8/18/15 evaluated on 11/4/14, 11/18/14, 12/16/14, 1/20/15, 2/17/15, 3/17/15, 4/21/15 and 5/19/15. There were no evaluations of this problem noted on the review form from May 2015 to August 2015.

E. The medical record of Patient #7 was reviewed on 10/28/15 and revealed the following: Patient #73 was a 36 year old admitted on 1/7/15 with the diagnoses of Chronic respiratory failure, pneumonia, pressure sores seizure disorder cardiac arrest and sepsis. Patient #7's Nursing Care Plan had the following problems inside the Care Plan Review/Assessment jacket:

Nursing Plan of Care - Antibiotic Therapy initiated on 10/18/15 for elevated temperature. There is no documentation beyond temperature. The Nursing Care Plan indicated it evaluated on 10/19/15. There were no progress notes indicating the evaluation of this problem.
Nursing Plan of Care - Antibiotic Therapy (second listing) initiated on 1/7/15 for positive sputum and ingrown toenail. There additional dates of problems of 1/23 (no year), 3/3 (no year), 4/15 (no year), and 9/14/15. The Nursing Care Plan indicated it was evaluated on 1/31/15, 2/1/15, 3/6/15, 4/12/15, 5/10/15, 6/7/15, 7/5/15, and 8/2/15. There were no progress notes indicating the evaluation of this problem and no dates beyond 8/2/15 indicating an evaluation of the problem listed on 9/14/15.
Nursing Plan of Care - Seizure Disorder initiated on 1/7/15 and indicated as evaluated on 1/31/15, 2/1/15, 3/7/15, 4/12/15, 5/10/15, 6/7/15, 7/5/15, 8/2/15, and 10/3/15. There were no progress notes indicating the evaluation of this problem and no dates for September showing an evaluation. The Plan of Care Summary dates were 8/4/15, 9/8/15 and 10/6/15. The Care Plan Review/Assessment jacket has a area for physician signature but not physician signature was present.

The Policy titled, Care Planning 8.25, updated 1/15 Section II A states, "All departments will assess the patient within 72 hours of admission. These assessments will be used to develop the plan of care for the interdisciplinary team to use as a guide toward discharge, if the patient is able to discharge."
Section B states, "An initial nursing care plan will be developed within 48 hours of admission. A comprehensive Care Plan will be developed by the interdisciplinary Care Planning Team and reviewed after completion of the comprehensive admission assessment within 7 working days of admission for the Hospital levels of care."
Section C states, "The Interdisciplinary Care Planning Team consists of, and be contributed to by: 1. The patient, Patients family, and/or the patients's representative. 2. Staff from the following departments: Nursing, Dietary, Recreation, Social Services, Rehabilitation, if indicated, Respiratory, if indicated, and SECEP (for Hospital level children).

The Care Planning policy does not include the physician as a part of the interdisciplinary team. The section titled Process: Section B states, "Interdisciplinary team will also seek information regarding the patients plan of care by soliciting information from family members, physicians and other hospital staff."






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2. F. The medical record of Patient #1 was reviewed on 10/27/15 and revealed the following: Patient #1 was a 78 year old admitted on 9/24/15 with the diagnoses of chronic respiratory failure, diabetes mellitus, end stage renal disease, tracheotomy, and ventilator dependent. Patient#1 was first admitted was 09/10/15, patient went to the hospital and was re-admitted on 09/24/15. Care plans are dated 09/17/15 with a review date of 10/22/15. There was no review or care plan update upon re-admission. The Care Plan Review/Assessment jacket has an area for physician signature but no physician signature was present.

G. The medical record of Patient #4 was reviewed on 10/26/15 and revealed the following: Patient #4 was a 63 year old admitted on 9/17/15 with the diagnoses of chronic respiratory failure, ventilator dependent, and amyotrophic lateral sclerosis. Patient #4 was a readmit from the hospital on 9/17/15 with no update to care plans. The first care plan meeting after readmission was 10/15/15. The Care Plan Review/Assessment jacket has an area for physician signature but no physician signature was present.

H. The medical record of Patient #8 was reviewed on 10/28/15 and revealed the following: Patient #8 was a 77 year old admitted on 4/23/15 with the diagnoses of chronic respiratory failure, pressure ulcer right lower back, ventilator dependent and tracheotomy. The initial care plan meeting was on 5/1/15. There is no documentation of a care plan meeting for June or July. The patient was moved on 10/27/15 to another room due to positive c-diff culture. The care plan was updated and is to be reviewed in 30 days however the antibiotic therapy is only ordered for 14 days. The Care Plan Review/Assessment jacket has an area for physician signature but no physician signature was present.

I. The medical record of Patient #9 was reviewed on 10/28/15 and revealed the following: Patient #9 was a 79 year old admitted on 8/21/12 with the diagnoses of chronic respiratory failure, myasthenia gravis, ventilator dependent, tracheotomy, diabetes mellitus and hypertension. The Care Plan Review/Assessment jacket has an area for physician signature but no physician signature was present.

J. The medical record of Patient #10 was reviewed on 10/28/15 and revealed the following: Patient #10 was a 48 year old admitted on 11/6/05 with the diagnoses of chronic respiratory failure, quadriplegia, pressure ulcer, tracheotomy and ventilator dependent. The Care Plan Review/Assessment jacket has an area for physician signature but no physician signature was present.

K. The medical record of Patient #11 was reviewed on 10/28/15 and revealed the following: Patient #11 was a 54 year old admitted on 5/22/15 with the diagnoses of chronic respiratory failure, quadriplegia, pressure ulcer sacrum, tracheotomy and ventilator dependent. The Care Plan Review/Assessment jacket has an area for physician signature but no physician signature was present.

L. The medical record of Patient #12 was reviewed on 10/28/15 and revealed the following: Patient #12 was a 37 year old admitted on 7/31/15 with the diagnoses of chronic respiratory failure, quadriplegia, tracheotomy and ventilator dependent. The Care Plan Review/Assessment jacket has an area for physician signature but no physician signature was present.

M. The medical record of Patient #13 was reviewed on 10/28/15 and revealed the following: Patient #13 was a 52 year old admitted on 9/21/15 with the diagnoses of chronic respiratory failure, pressure ulcer sacrum, quadriplegia, ventilator dependent and tracheotomy. The Care Plan Review/Assessment jacket has an area for physician signature but no physician signature was present.

N. The medical record of Patient #14 was reviewed on 10/28/15 and revealed the following: Patient #14 was a 54 year old admitted on 7/10/14 with the diagnoses of chronic respiratory failure, encephalopathy, tracheotomy and hypertension. The Care Plan Review/Assessment jacket has an area for physician signature but no physician signature was present.

O. The medical record of Patient #15 was reviewed on 10/27/2015 and revealed the following: Patient #15 was a 90 year old admitted on 10/22/15 with the diagnoses of chronic respiratory failure and chronic kidney disease. Patient was admitted on 9/23/15 with a re-admit date of 10/22/15. The care plan is date 10/1/15 with no update for the readmission. The Care Plan Review/Assessment jacket has an area for physician signature but no physician signature was present.

P. The medical record of Patient #16 was reviewed on 10/28/15 and revealed the following: Patient #16 was an 85 year old admitted on 10/22/15 with the diagnoses of right total knee replacement, respiratory failure, pneumonia, congestive heart failure and left lung hematoma.
The Care Plan Review/Assessment jacket has an area for physician signature but no physician signature was present.

Q. The medical record of Patient #17 was reviewed on 10/27/15 and revealed the following: Patient #17 was an 84 year old admitted on 10/1/15 with diagnoses of chronic respiratory failure, ventilator dependent, diabetes mellitus and pressure ulcer. Patient was readmitted on 10/1/15 and care plan was not updated. The Care Plan Review/Assessment jacket has an area for physician signature but no physician signature was present.

R. The medical record of Patient #18 was reviewed on 10/27/15 and revealed the following: Patient #18 was a 52 year old admitted on 10/21/15 with diagnoses of pneumonia, ventilator dependent, alcohol abuse and right upper lobe non small cell carcinoma with chest wall invasion. An order was written for mitten and they were applied on 10/24/2015 with no update to the care plan. The Care Plan Review/Assessment jacket has an area for physician signature but no physician signature was present.

S. The medical record of Patient #19 was reviewed on 10/27/15 and revealed the following: Patient #19 was a 35 year old admitted on 10/9/15 with diagnoses of respiratory failure, alcohol induced pancreatitis, diabetes mellitus, asthma, hypertension, obesity and anxiety. The first care plan review date is 10/29/15. The Care Plan Review/Assessment jacket has an area for physician signature but no physician signature was present.

T. The medical record of Patient #20 was reviewed on 10/27/15 and revealed the following: Patient #20 was a 61 year old admitted on 8/6/15 with diagnoses of respiratory failure, end stage renal disease, tracheotomy, hypertension and anemia. The Care Plan Review/Assessment jacket has an area for physician signature but no physician signature was present.

Based on observations, document and interview, it was determined the facility staff failed to ensure medications prepared by a nurse were administered by the same nurse for one (1) of one (1) patients (Patient #3). The facility also failed to ensure the staff members who administered medications signed the MAR (Medication Administration Record) for twenty (20) of twenty (20) patients (Patients #1 - #20). Facility staff aslo failed to ensure medication administration orders follow the standard of practice for one (1) of twenty (20) records reviewed (Patient #18).


The findings include:

1. On 10/29/15 at approximately 10:00 A.M. ,while observing wound care,Staff Member #22 entered the room and attempted to pull the curtain back when Staff Member #9 stated, "We are doing a dressing change." Staff Member #22 stated, "Well could you just slap this on her while you have her on her side?" Staff Member #9 stated, "What is it?" Staff Member #22 stated, "It's her patch, just slap it on her." The patches were not in any type of wrapper or container designatingwhat the name and dose of the medication was. Staff Member #22 proceeded to demonstrate how to apply the patches. Staff Member #9 took the patches and applied them.

The MARs had initials indicating who administered the medications but the MARs had no legend indicating the name of the persons who initial the MAR. Staff Member #4 was asked whose initials were on the MAR for various days. Staff Member #4 stated, "I don't know whose initials those are."








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2.A medical record review for Patient #18 revealed an order dated 10/24/2015 at 0610 reads in part "give another dose of ativan now". This orders fails to include dose and route for administration.

Staff Member #12 acknowledge the order was incomplete during an interview on October 27, 2015 at 4:30 p.m.

In accordance with standard practice, all practitioner orders for the administration of drugs and biologicals must include at least the following:

o Name of the patient;
o Age and weight of the patient, to facilitate dose calculation when applicable. Policies and procedures must address weight-based dosing for pediatric patients as well as in other circumstances identified in the hospital's policies. (Note that dose calculations are based on metric weight (kg, or g for newborns). If a hospital permits practitioners to record weight in either pounds or using metric weight, the opportunity for error increases, since some orders would require conversion while others would not. Accordingly, hospitals must specify a uniform approach to be used by prescribing practitioners. For example, a hospital could require all prescribers to use pounds or ounces and have the electronic ordering system or the pharmacy convert to metric);
o Date and time of the order;
o Drug name;
o Dose, frequency, and route;
o Dose calculation requirements, when applicable
o Exact strength or concentration, when applicable;
o Quantity and/or duration, when applicable;
o Specific instructions for use, when applicable; and
o Name of the prescriber.

Based on interview, observations and document review, it was determined the facility staff failed to ensure verbal orders were documented as such and were used infrequently.


The findings include:

On 10/27 and 28/15 the medical record of Patient #5 was reviewed. The record contained a Consultation Report from the pharmacist, dated May 29 2015 through June 1, 2015, with a recommendation date of 5/29/15. The physician underlined the recommendation and signed the page. There was no date or time of the physician's signature. Staff Member #10 then wrote what the physician had underlined as a TORB (telephone order read back) order on 6/2/15. The physician signed the order written by Staff Member #10 on 6/2/15.

Staff Member #10 was interviewed on 10/28/15 at 2:25 P.M. regarding the order date and time. Staff Member #10 stated, "I did not call the physician and get the order. The physician was standing next to me when I wrote the order. We were told to not write an order as a verbal order so we have been writing them as TORB and the physician signs them. The physicians write some of their orders but not all of them."

Patient #7's record was reviewed on 10/28/15 at approximately 2:00 P.M. From October 1, 2015 to October 28, 2015 there were approximately 37 physician orders; 21 of the orders were documented as TORB orders.

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Based on medical record review and interview, the facility failed to ensure all medical record entries are legible, complete, dated, timed and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures.

Seven (7) of twenty (20) Patients failed to have physician notes with date, time and authenticating signature.(Patient # 4, 9, 10, 11, 17, 18 and 19).
Twenty (20) of twenty (20) Patients failed to have Nursing Weekly Summaries accurate and/or completed according to facility policy and procedure. (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20)
Twelve (12) of twenty (20) Patients failed to have documented weekly skin assessments including measurements and description of pressure sores according to facility policy and procedure. (Patients #1, 2, 3, 4, 5, 6, 7, 8, 11, 13, 17, and 20)


The findings include:

1. Medical record reviews revealed seven (7) of twenty (20) records containing physician note with no authenticating signature, date and time for the following patients:

Patient #4 notes dated 9/20, 10/9 and 10/10
Patient #9 notes dated 10/2, 10/5 and 10/9
Patient #10 notes dated 10/2, 10/5 and 10/9
Patient #11 notes dated 10/2, 10/5 and 10/9
Patient #17 notes dated 10/2, 10/6 and 10/9
Patient #18 note dated 10/22
Patient #19 note dated 10/13

Medical record reviews revealed twenty (20) of twenty (20) Nursing Weekly Summaries failed to be accurate and/or completed according to the policy and procedure. (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20)
Patients #1, 2, 3, 5, 6, 7, 8, 9, 11, 13, 14, 15, 16, 17, and 18 failed to be be accurate for the care, treatment and services of the patient.
Patients #4, 10, 12, 19 and 20 failed to be completed weekly and to be accurate for the care, treatment and services of the patient.

Medical record reviews revealed ten (10) of twenty (20) Patients failed to have documented weekly skin assessments including measurements and description of pressure sores according to facility policy and procedure. (Patients #2, 3, 4, 5, 6, 7, 8, 11, 13, and 17)
Patient #4 has a skin assessment with wound location "top R foot" dated 9/18/2015 with no other skin assessment documented. A second skin assessment with wound location "bottom L foot" dated 9/18/2015 with the next assessment dated 10/2/2014. A third skin assessment with wound location "R ear" dated 9/18/2015 with the next assessment dated 10/2/2015.
Patient #8 has a skin assesment with wound location "sacral" dated 9/18/2015 with the next assessment date 10/2/2015.
Patient #11 has a skin assessment with wound location "L isch" dated 9/18/2015 with the next assessment date 10/2/2015.
Patient #13 has a skin assessment with wound location "sacrum" dated 9/21/2015 with the next assessment is dated 10/2/2015. A second skin assessment with wound location "rt heel" dated 9/21/2015 with no other skin assessment documented.
Patient #17 has a skin assessment with wound location "L buttock" dated 10/14/2015 with no other skin assessment is documented. A second skin assessment with wound location "R ankle" is dated 10/2/2015 with no other skin assessment is documented. A third skin assesment with wound location "R thigh (cluster of 3)" is dated 10/2/2015 with no other skin assessment documented.
Patient #19 has a skin assessment with wound location "R upper back outer" dated 10/9/2015 with no other skin assessment documented.

2. A. The medical record of Patient #2 was reviewed on 10/27/15 and revealed the following:
Patient #2 was a 68 year old admitted on 9/2/15 with the diagnoses of Sepsis, severe respiratory failure secondary to obstructive sleep apnea, ESRD (End Stage Renal Disease), morbid obesity, diabetes mellitus (DM) and pacemaker. Patient #2's Nursing Care Plan had the following problems inside the Care Plan Review/Assessment jacket:

Nursing Plan of Care - Safety Risk no dates of when this was initiated or evaluated
Nursing Plan of Care - Impaired Skin Integrity initiated 9/5/15 and dated as evaluated on 9/5/15 and 10/11/15. There were no progress notes indicating the evaluation of this problem.
Nursing Plan of Care - Renal Failure initiated on 9/5/15 and indicated as evaluated on 9/5/15 and 10/11/15. There were no progress notes indicating the evaluation of this problem.
Nursing Plan of Care - Impaired Mobility initiated on 9/5/15 and indicated as evaluated on 9/5/15 and 10/11/15. There were no progress notes indicating the evaluation of this problem.
Nursing Plan of Care-Anemia initiated on 9/5/15 and indicated as evaluated on 9/5/15 and 10/11/15. Two of Patient #2's measurable goals are "Sickle cell complications will be minimized", and "Patient will verbalize relief from sickle cell pain". There were no progress notes indicating the evaluation of this problem.
Nursing Plan of Care - Antibiotic Therapy initiated on 9/5/15 and indicated as evaluated on 9/5/15. There were no progress notes indicating the evaluation of this problem. Patient #2 was still receiving antibiotics on 9/25/15.
Nursing Plan of Care - Diabetes initiated on 9/5/15 and indicated as evaluated on 9/5/15 and 10/11/15. There were no progress notes indicating the evaluation of this problem.
There was no interdisciplinary plan of care. The Care Plan Review/Assessment jacket has a area for physician signature but not physician signature was present.

Patient #2's 24 Hour Patient Care Record was reviewed for the dates of September 10 through 17, 2015. There are 3 to 5 sets of vital signs for each day. Staff Member #4 stated, "The vital signs are done by the CNA who gives them to the Charge nurse who documents them on the Vital Signs Record and the nurse gets the vital signs off the form and documents them on the 24 Hour Patient Care Record." Patient #2's respirations were as follows for the indicated dates:
9/10/15 at 8:30 A.M., 4:00 P.M. and 9:00 P.M. were 10
9/11/15 at 8:30 A.M., 4:00 P.M. and 8:00 P.M. were 10
9/12/15 at 8:00 A.M., 4:00 P.M. and 8:45 P.M. were 10
9/13/15 at 8:30 A.M., 4:00 P.M. and 9:00 P.M. were 10
9/14/15 at 8:00 A.M., 5:00 P.M. and midnight were 10
9/15/15 at 8:00 A.M. and midnight and 4:00 A.M. were 10
9/16/15 at 8:00 A.M. and 5:00 P.M. were 10
9/17/15 at 8:00 A.M. and 7:00 P.M. were 10
Patient #2 was on a ventilator set at 10 breaths per minute as support should Patient #2 not breath on their own. Staff Member #15 was interviewed regarding the respirations of Patient #2. Staff Member #15 stated, "In my professional opinion the respirations were not counted but they just documented the number set on the ventilator." There was no indication in Patient #2's medical record that the rate of 10 breaths per minute was rechecked by the Charge Nurse who is a Registered Nurse or by the Licensed Practical Nurse who was assigned to care for Patient #2.
Cleveland Clinic Healthy Living notes the following: Respiratory rate: A person's respiratory rate is the number of breaths you take per minute. The normal respiration rate for an adult at rest is 12 to 20 breaths per minute. A respiration rate under 12 or over 25 breaths per minute while resting is considered abnormal.

B. The medical record of Patient #3 was reviewed on 10/26 - 28/15 and revealed the following:
Patient #3 was a 70 year old admitted on 11/6/14 with the diagnoses of Chronic respiratory failure, pneumonia, diabetes mellitus, inclusion body myositis and status post sigmoid volvulus resection. Patient #3's Nursing Care Plan had the following problems inside the Care Plan Review/Assessment jacket:

Nursing Plan of Care - Antibiotic Therapy initiated on 11/6/14 and indicated as evaluated on 12/6/14. There were no progress notes indicating the evaluation of this problem.
There was no documented Nursing Plan of Care related to the surgical wound Patient #3 was admitted with on 11/6/14 nor a Nursing Plan of Care related to complaints of being unable to turn to the left side due to left should pain/injury.
The Care Plan Review/Assessment jacket has a area for physician signature but not physician signature was present.

Patient #3's Nursing Admission Assessment dated 11/6/14 made note of an abdominal incision with 14 staples and a Stage II pressure sore on the sacrum. The physician's admission noted dated 11/6/14 makes a note under Review of Systems: Skin: No itching, no rashes and under Physical Examination: Abdomen: Abdominal wound with staples in place. There is no mention of the Stage II pressure sore on the sacrum.

C. The medical record of Patient #5 was reviewed on 10/27/15 and revealed the following: Patient #5 was a 57 year old admitted on 2/8/12 with the diagnoses of respiratory failure, S/P (status post) septicemia, lupus and ESRD. Patient #5's Nursing Care Plan had the following problems inside the Care Plan Review/Assessment jacket:

Nursing Plan of Care - Antibiotic Therapy initiated on 10/18/15 and indicated as evaluated on 10/19/15. There were no progress notes indicating the evaluation of this problem.
Nursing Plan of Care - Seizure Disorder with no initiation date and indicated as evaluated on 1/10/15,2/7/15, 3/8/15, 4/12/15, 5/9/15, 6/6/15, 7/11/15, 8/9/15, 9/5/15 and 10/19/15. There were no progress notes indicating the evaluation of this problem. The Plan of Care Summary dates were 8/11/15, 9/8/15 and 10/13/15. The Care Plan Review/Assessment jacket has a area for physician signature but not physician signature was present.

D. The medical record of Patient #6 was reviewed on 10/28/15 and revealed the following: Patient #6 was a 50 year old admitted on 10/28/14 with the diagnoses of DM, peripheral neuropathy, anxiety, respiratory failure. Patient #6's Nursing Care Plan had the following problems inside the Care Plan Review/Assessment jacket:

Nursing Plan of Care - Hypertension initiated on 10/28/14 and indicated as evaluated on 11/16/14, 12/14/14/, 1/18/15, 2/15/15, 3/15/15, 4/19/15, 5/15/15, 6/12/15, 7/19/15, 8/16/15, 9/13/15 and 10/19/15. There were no progress notes indicating the evaluation of this problem.
Nursing Plan of Care - Antibiotic Therapy with an initiation date of 12/2/14 and indicated as evaluated on 12/14/14. There were no progress notes indicating the evaluation of this problem.
Nursing Plan of Care - Diabetes initiated on 10/28/14 and indicated as evaluated on 11/16/14, 12/14/14/, 1/18/15, 2/15/15, 3/15/15, 4/19/15, 5/15/15, 6/12/15, 7/19/15, 8/16/15, 9/13/15 and 10/19/15. There were no progress notes indicating the evaluation of this problem.
Interdisciplinary Plan of Care - Tracheostomy initiated on 10/28/14 and has no dates of evaluation There were no progress notes indicating the evaluation of this problem.
Interdisciplinary Plan of Care - Tracheostomy (second page dated 10/28/14 as initiated). Indicates the problems were continued on 11/4/14, 11/18/14, 12/16/14, 1/20/15 and 2/17/15. The notations indicate there was an evaluation of the problem documented on 11/4/14, 11/18/14, 12/16/14, 1/20/15 and 2/17/15. There were no progress notes indicating the evaluation of this problem after 2/17/15.
Interdisciplinary Plan of Care - Ventilator initiated on 10/28/14 and indicated as continued 11/4/14, 11/18/14, 12/16/14, 1/20/15, 2/17/15, 3/17/15, 4/21/15, 5/19/15, 7/21/15, 8/18/15 evaluated on 11/4/14, 11/18/14, 12/16/14, 1/20/15, 2/17/15, 3/17/15, 4/21/15 and 5/19/15. There were no evaluations of this problem noted on the review form from May 2015 to August 2015.

E. The medical record of Patient #7 was reviewed on 10/28/15 and revealed the following: Patient #73 was a 36 year old admitted on 1/7/15 with the diagnoses of Chronic respiratory failure, pneumonia, pressure sores seizure disorder cardiac arrest and sepsis. Patient #7's Nursing Care Plan had the following problems inside the Care Plan Review/Assessment jacket:

Nursing Plan of Care - Antibiotic Therapy initiated on 10/18/15 for elevated temperature. There is no documentation beyond temperature. The Nursing Care Plan indicated it evaluated on 10/19/15. There were no progress notes indicating the evaluation of this problem.
Nursing Plan of Care - Antibiotic Therapy (second listing) initiated on 1/7/15 for positive sputum and ingrown toenail. There additional dates of problems of 1/23 (no year), 3/3 (no year), 4/15 (no year), and 9/14/15. The Nursing Care Plan indicated it was evaluated on 1/31/15, 2/1/15, 3/6/15, 4/12/15, 5/10/15, 6/7/15, 7/5/15, and 8/2/15. There were no progress notes indicating the evaluation of this problem and no dates beyond 8/2/15 indicating an evaluation of the problem listed on 9/14/15.
Nursing Plan of Care - Seizure Disorder initiated on 1/7/15 and indicated as evaluated on 1/31/15, 2/1/15, 3/7/15, 4/12/15, 5/10/15, 6/7/15, 7/5/15, 8/2/15, and 10/3/15. There were no progress notes indicating the evaluation of this problem and no dates for September showing an evaluation. The Plan of Care Summary dates were 8/4/15, 9/8/15 and 10/6/15. The Care Plan Review/Assessment jacket has a area for physician signature but not physician signature was present.

The facility Policy titled, Care Planning 8.25 updated 1/15 Section II A states, "All departments will assess the patient within 72 hours of admission. These assessments will be used to develop the plan of care for the interdisciplinary team to use as a guide toward discharge, if the patient is able to discharge."
Section B states, "An initial nursing care plan will be developed within 48 hours of admission. A comprehensive Care Plan will be developed by the interdisciplinary Care Planning Team and reviewed after completion of the comprehensive admission assessment within 7 working days of admission for the Hospital levels of care."
Section C states, "The Interdisciplinary Care Planning Team consists of, and be contributed to by: 1. The patient, Patients family, and/or the patients's representative. 2. Staff from the following departments: Nursing, Dietary, Recreation, Social Services, Rehabilitation, if indicated, Respiratory, if indicated, and SECEP (for Hospital level children).

The Care Planning policy does not include the physician as a part of the interdisciplinary team. The section titled, Process: Section B states, "Interdisciplinary team will also seek information regarding the patients plan of care by soliciting information from family members, physicians and other hospital staff."

The MARs had initials indicating who administered the medications but the MARs had no legend indicating the name of the persons who initial the MAR. Staff Member 4 was asked whose initials were on the MAR for various days. Staff Member #4 stated, "I don't know whose initials those are."

On 10/27 and 28/15 the medical record of Patient #5 was reviewed. The record contained a Consultation Report from the pharmacist, dated May 29 2015 through June 1, 2015, with a recommendation date of 5/29/15. The physician underlined the recommendation and signed the page. There was no date or time of the physician's signature. Staff Member #10 then wrote what the physician had underlined as a TORB (telephone order read back) order on 6/2/15. The physician signed the order written by Staff Member #10 on 6/2/15.

Staff Member #10 was interviewed on 10/28/15 at 2:25 P.M. regarding the order date and time. Staff Member #10 stated, "I did not call the physician and get the order. The physician was standing next to me when I wrote the order. We were told to not write an order as a verbal order so we have been writing them as TORB and the physician signs them. The physicians write some of their orders but not all of them."

Patient #7's record was reviewed on 10/28/15 at approximately 2:00 P.M. From October 1, 2015 to October 28, 2015 there were approximately 37 physician orders; 21 of the orders were documented as TORB orders.

Based on medical record review and interview, the facility failed to have all orders, including verbal orders, dated, timed and authenticated promptly by the ordering practitioner who is responsible for the care of the patient for one (1) of twenty (20) patients reviewed (Patient #15).

The finding include:

A medical record review on October 27, 2015 between 10:30 and 10:45 a.m. for Patient # 15 revealed the following:

10/26/2015 at 10:00 a.m. order written as "Amikacin trough at 10/26/2015 per phone recommendation continue current dose of amikacin. TORB (physician name) noted by nurse. The order failed to have an authenticating signature, date or time by the ordering physician.

10/26/2015 at 3:37 p.m. order written as "Recommend: 1 PMV eval and tx as indicated. 2 Blue dye eval and tx a indicated. 3 Skilled ST 5x/wk for 4 wks to address expressive communication via PMV, cognition, dysphagia, pt/caregiver ed, d/c planning. Speech therapist signature. The order failed to have an authenticating signature, date or time by the ordering physician.

Based on document review and observations, it was determined the facility staff failed to ensure documentation of dialysis treatments contained potentially critical information for one (1) of three (3) patients (Patient #1), equipment and supplies used by the contracted dialysis agency were able to be cleaned and disinfected to prevent the potential spread of blood borne infections for five (5) of five (5) machines and failed to use gloves and disinfect/clean hands when moving from a dirty surface to a clean surface for two (2) of three (3) patients observed (Patients #1 and #2).

The findings include:

On 10/26/15 at approximately 11:20 A.M. during the initial tour of the facility, Patient #1 was observed receiving dialysis treatment on Machine #18. The dialysis machine was observed to have blood in the transducer line and had a syringe with approximately 7 cc (Cubic centimeters) of blood in it. The Contracted Staff Member (#2), a Licensed Practical Nurse (LPN), who was administering the dialysis treatment stated, "Oh yes the transducer became wet and I changed it. That is an AOR (adverse occurrence event) event but I don't have any of the forms to fill out." A review of the dialysis documentation for 10/26/15 had no notations that the transducer had become wet. Staff Member #2 was asked what would happen if something happened and a Registered Nurse (RN) was needed for the dialysis. Staff Member #2 stated, "The RN is downstairs with her patient."

Contracted Staff Member #3 who was an RN stated, "I would have to stop my patient's treatment and run their blood back to them in a dialysis emergency to assess the patient on another floor, that has always bothered me." Staff Member #3 was asked what should be done regarding the wet transducer. Staff Member #3 stated, "After the treatment the machine should be pulled, bio-med notified and the machine taken apart to see if the blood crossed over to the machine. If it crossed over and we didn't know the next patient could get that patient's blood."

Staff Member #2 had a green canvas bag sitting on the dialysis cart behind the dialysis machine. Staff Member #2 stated, "I put extra supplies in the bag in case I need something because I can't leave the patient to get something I might need." The bad had a porous surface which could not be disinfected between patient use.

Staff Member #2 and #3 and were observed between 11:20 A.M. and 12 Noon touching the blood line on Patient # 1 and #2, as they were receiving dialysis, without gloves and then picking up the Acute Hemodialysis Flow Sheets from on top of the dialysis machines and writing on them. No hand hygiene was performed. The Acute Hemodialysis Flow Sheets were placed in the Patients' medical records.

Also, during the initial tour, a total of three (3) dialysis machines were observed in use and two (2) back up machines were observed in the dialysis work area. All of the machines were transported on a metal rolling cart. All of the carts had areas where rust and peeling paint were observed. This would make the carts unable to be cleaned and disinfected properly between patient use.

The End Stage Renal Disease CMS Regulations, dated October 3, 2008 state, "If the external transducer protector becomes wet, replace immediately and inspect the protector. If fluid is visible on the side of the transducer protector that faces the machine, have qualified personnel open the machine after the treatment is completed and check for contamination. This includes inspection for possible blood contamination of the internal pressure tubing set and pressure sensing port. If contamination has occurred, the machine must be taken out of service and disinfected using either 1:100 dilution of bleach (300-600 mg/L free chlorine) or a commercially available, EPA-registered tuberculocidal germicide before reuse."

Staff Member #1 stated, "We have nine (9) patients currently receiving dialysis but we have had as many as fifteen (15)."

Staff Member #16 stated, "The machine was never reported to me by the nurse to be pulled and assessed. I would not have know about it if you had not asked about it."

Staff Member #13 stated, "We would not have even known there was problems with dialysis if you had not pointed them out."