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Based on observation, interview, medical record, staffing schedules and policy review, the facility failed to ensure nursing staff evaluated the nursing care needs for each patient in relation the actual weights, pressure sore care, incontinence care, toileting, providing nutritional supplementation and indwelling urinary catheter care and failed to staff the unit following the facility's staffing guidelines (A395). This affected six (Patients #1, #4, #6, #8, #9 and #10) of 10 patients whose medical records were reviewed.

Based on observation, medical record review, policy and procedure review, interview, and review of the facility's staffing guidelines and schedule, the facility nursing staff failed to evaluate the nursing care needs for each patient in relation to actual weights, pressure sore care, incontinence care, toileting, providing nutritional supplementation and urinary catheter care. The facility failed to staff the 3S unit per the facility's staffing guidelines. This affected six (Patients #1, #4, #6, #8, #9 and #10) of 10 patient medical records reviewed. The patient census was 61.

Findings include:

1. The medical record review for Patient #4 was completed on 05/16/13. This 19 year old patient was admitted to the facility from an acute care hospital on 01/25/13 after a motor vehicle collision. The admission diagnoses included a left fracture of the scapular body, traumatic displaced spondylioistheses of the sixth cervical vertebra with closed fracture of the cervical 6, cervical 7 and thoracic 1 vertebra., right pneumonia-thorax, left pulmonary contusion, facial laceration left peri-orbital of ear, quadriplegia cervical 6 complete, vertebral artery dissection, hypotension and fever.

The history and physical on admission by the physician included results an albumen level of 2.4 to 3.0 (normal 3.6 to 5.1) moderate malnutrition, acute anemia, bacterial pneumonia "will await culture results-no antibiotic", pain management, depression and stage 2 pressure sore. The patient was admitted to the unit and placed on a alternating air flow bed.

The pressure sore, on admission from the acute care hospital, was documented as a stage 2 pressure sore on the coccyx of 4 centimeters in length by 1.1 centimeters in width and 0.01 centimeters in depth. The wound care documentation in the medical record on 2/7/13 noted the wound had changed from a stage 2 to a stage 3 with dimensions of length of 3 centimeters, 2.2 centimeters in width and 0.01 centimeters in depth. This was verified on interview with Staff E, Staff F, and Staff A at 5/16/13 at 1:00 PM.

The facility policy #PC300-201003 stated "hourly rounding at Drake Center is structured around scheduled times whereby the nursing associates will address patient care needs. The primary focus is based on 4 "P"s which include: Potty (toileting needs), Positioning, Pain and Peace of Mind." Interview with Staff A on 05/15/13 at 1:30 PM revealed the patients are expected to be turned every 2 hours and is a standard set ordered by the physician.

The rounding check for the patient in the medical record was reviewed. The patient was admitted to the unit on 1/25/13 at 6:55 PM with no documentation of re-positioning until 3:55 AM on 1/26/13. The next documentation of re-positioning was at 7:00 AM. Further review of the medical record revealed the following re-positioning documentation:
- 1/26/13 was at 4:46 PM with the next documentation of re-positioning was 9:54 PM.
- 1/27/13 at 2:00 AM revealed the patient was positioned and not documented as re-positioned until 1/27/13 at 6:41 AM, then at 9:00 AM and not again until 8:46 PM.
- 1/28/13 revealed at 6:46 AM the patient was re-positioned and not again until 8:00 PM.
- 1/31/13 at 3:00 PM and not again until 9:00 PM.
- 2/1/13 at 5:00 AM and not again until 11:47 PM.
- 2/2/13 at 7:00 PM, and then not repositioned again until 11:00 PM.
- 2/3/13 at 3:00 AM was the first documentation of re-positioning, the patient refused positioning at 4:46 AM, repositioned at 5:20 AM, 9:00 AM and not again until 11:00 PM.
- 2/4/13, the only documentation of repositioning was recorded at 1:00 AM.
- 2/5/13 other then safety checks, the only documentation of positioning was recorded on 9:00 PM and 11:00 PM.
- 2/6/13 the patient was documented as repositioned at 3:00 AM and then repositioned at 6:00 AM. The documentation revealed the patient was repositioned every 2 hours until 5:00 PM and not documented as repositioned until 7:00 AM on 2/7/13.

Patient #4 was admitted to the facility with an indwelling urinary catheter. Review of the hourly rounding schedule in the medical record revealed peri/incontinence care was not consistently documented on the hourly rounding schedules from the patient's admission date of 1/25/13, 1/27 through 1/31/13, and 2/1 through 2/7/13. Urinary catheter care was not documented as provided on 1/29, 1/30, 1/31, and 2/1, 2/3, 2/4, 2/5, 2/6, 2/8, 2/9, and 2/10/13. The Foley catheter care, per interview with staff A, on 5/7/13 at 1:15 PM, is expected to be performed every day.

Additionally, review of the medical record for the Patient #4 revealed the admission weight on 1/25/13 was documented as 165# (pounds) with a usual stated weight of 162#. The next recorded weight was 159# on 1/31/13, 148 # on 2/4/13, 165# on 2/6/13 and 2/10/13 a weight of 149# and 6.4 oz.

The patient's physician order for nutrition was continuous tube feeding from 8:00 PM to 6:00 AM with Fibersource HN 80 ml/hr and a bolus tube feeding of Fibersource HN 240 ml/he at meal times when the patient would consume less than 25 % of a meal. The oral intake was documented by the nutritionist as poor with swallowing difficulties. There was no documentation in the medical record of any bolus feeding provided to the patient on 2/1/13, 2/2/13 and 2/3/13 when the morning meal was only 120 cc and no documentation of any intake for lunch and dinner. On 2/4/13 the was no documentation a bolus feeding was provided to the patient when there was less than 25 % consumed at breakfast, lunch and dinner.

Recorded temperatures for Patient #4 on 1/26 T (temperature) - 100.1 (o) orally (normal 98.6) at 5:00 AM, T-100.7 (o) at 7:10 AM, T- 99.3 (a) and at 1:35 PM, T 99.5 (o), at 8:30 PM. Recorded temperatures on 1/27/13 had increased to T-101.8 (a) at 7:30 AM, There was no documented evidence in the medical record to indicate the nursing staff had notified the physician of this increase in temperature. This finding was verified with staff A on 5/16/13 at 11:00 AM when she/he further stated it would have been expected the nurse contact the physician.

Review of the medical record for Patient #4 revealed the PICC line (Peripheral Intravenous Central Catheter) was inserted on 2/1/13 and the site assessment was documented as checked every shift for redness, swelling or drainage; however, there was no documentation in the medical record a description of the site by observation. Interview with staff I (nurse responsible for PICC lines) stated on 5/13/13 at 11:45 AM, all PICC lines dressings are changed weekly and as needed.

2. Review of the medical record for Patient #8 was completed the afternoon of 5/16/13. The medical record revealed Patient #8 was admitted on 4/26/13 from another hospital. The admission weight was documented as 215 pounds and 6.2 ounces on the bed scales. The admitting diagnoses was a neck fracture, vent weaning, volume overload, pulmonary collapse, tracheostomy status, gastrostomy tube (G-tube) and a dialysis patient. The admission orders were to weigh the patient weekly and provide continuous tube feeding at 64/cc per hour. On 5/1/13 orders were received to bolus tube feed 200 milliters as needed if the patient ate less than 75 percent at each meal and continuous tube feeding from 8:00 PM to 6:00 AM at 60 milliters per hour.

The medical record for Patient #8 revealed on 4/28/13 a weight of 205 pounds via bed scales and documentation revealed the bed scales were not working and the patient was weighed with a Hoyer lift but did not reveal the Hoyer weight. On 5/5/13 documentation revealed a weight of 261 pounds via bed scale. Documentation revealed the bed weight may not be accurate as the bed weight will need to be zeroed when the patient is out of bed. On 5/9/13, the weight was documented as 287 pounds but did not document how the patient was weighed. On 5/10/13 the weight was documented as 172 pounds and 4.8 ounces but did not document how patient #8 was weighed. On 5/12/13 documentation revealed patient #8 weighed 165 pounds and 4.8 ounces but there was no documentation how the patient was weighed. The medical record revealed, on 5/14/13, Patient #8 was weighed on the bed scales and was 126 pounds.

Review of the dialysis flow sheets for Patient #8 revealed the following weights pre dialysis; 4/30/13 (121.8 kilograms) 267.96 pounds, 5/2/13 (120.8 kilograms) 265.76 pounds, 5/4/13 (117.6 kilograms) 258.72 pounds, 5/7/13 (119 kilograms) 261.8 pounds, 5/9/13 (122.8 kilograms) 270.16 pounds, 5/11/13 (121.9 kilograms) 268.18 pounds, and on 5/14/13 (120.4 kilograms) 264.88 pounds.

The medical record revealed up until 5/1/13 the patient was receiving continuous tube feeding at 64 cubic centimeters per hour vial G-tube. On 5/1/13 the G-tube feeding orders were changed to bolus tube feedings, 200 milliliters at each meal if the patient eats less than 75 percent and continuous tube feedings at 60 milliliters per hour from 8:00 PM to 6:00 AM.
The medical record revealed, from 5/1/13 through 5/15/13, most of the documented
evidence revealed the patient had no oral nutritional intake. There was no documentation the bolus tube feedings were given as ordered for each meal.

Review of the policy and procedure for weights and heights for LTACH and SNF patients, policy number: FANSJ2011, effective 5/2008, revealed the patients weights are obtained to provide initial assessment information about the patient's size, to identify weight loss or gain, and to provide accurate information for staff to use to identify and monitor the patient's care needs on an ongoing basis. The policy revealed if necessary, refer to operating manual for specific scale types used, zero scale, scale calibration per maintenance policy, document type of scale used, document identified reasons for significant weight gain or loss and indicate any changes or unusual conditions.

Further review of the medical record for Patient #8 lacked documentation the physician was made aware of the weight discrepancies from week to week, nor that a work order had been sent to maintenance for the bed scales regarding possible inaccurate weights.

Interview with Staff A, registered nurse, Clinical Manager on 5/16/13 at 3:00 PM revealed the physician should have been notified in regard to the weight discrepancies, and a work order should have been submitted to maintenance in regard to the bed scales and the weight discrepancies.

The turn schedule in the medical record for Patient #8 lacked documentation from admission on 4/26/13, through 5/6/13, the patient was turned every two hours. On 4/29/13 documentation revealed patient #8 was not turned at 5:00 AM. On 5/1/13 documentation revealed patient #8 was turned at 3:30 AM and 8:00 AM, on 5/3/13 documentation revealed the patient was last turned at 1:00 PM and then not again until 9:45 PM, on 5/5/13, documentation revealed patient #8 was last turned at 5:00 PM and then not again until 11:00 PM.

Interview with Staff A, registered nurse, clinical manager on 5/16/13 at 10:30 AM revealed patients should be turned every two hours.

Review of the policy and procedure "Nursing Services-Hourly Rounding" policy number Drake-Nsg-PC-300-201003, revealed hourly rounding at this facility is structured around scheduled times whereby the nursing associates will check in to address patient care needs and the primary focus is based on 4 "P's", which include: potty (toileting needs), positioning, pain and peace of mind.

This finding was confirmed with Staff E, Director of Regulatory Compliance and Safety, Emergency Management and Staff F, Operations Manager Regulatory Compliance and Safety, Emergency Management on 5/15/13 at 1:30 PM.

3. Review of the medical record for Patient #9 was completed the afternoon of 5/16/13. The medical record revealed patient #9 was admitted on 5/2/13 with diagnoses including hypertensive urgency, gastroenteritis, chest pain, chronic kidney disease, non ST elevated myocardial infarction, solitary left sided kidney, sepsis secondary to urinary tract infection, sepsis secondary to clostridium difficle, episode of acute respiratory failure, obstructive sleep apnea, hyperventilation syndrome.

The physician's orders, upon admission, revealed Patient #9 was to to be weighed daily. On 5/3/13, 5/6/13, 5/8/13, 5/14/13, and 5/15/13 the weight was documented but lacked description of how the weight was obtained. On 5/11/13, 5/14/13 and 5/16/13, the medical record lacked documentation a weight was obtained.

The medical record lacked documentation on 5/8/12, the patient had been turned and repositioned between 8:40 PM to 5/9/13 at 6:00 AM.

Further review of the medical record revealed on 5/9/13 Patient #9 had a physician order for a bolus tube feeding of 200 cubic centimeter of diabeta source (feeding) if the patient ate less than 75 percent at each meal and for a continuous tube feeding to be given from 8:00 PM to 6:00 AM at 70 milliters per hour. On 5/9/13, the medical record lacked documentation of the patient's oral intake at supper or if the bolus tube feed had been given. On 5/10/13, 5/12/13, 5/13/13, and 5/15/13 the medical record lacked documentation of the percentage of oral intake for each meal but there was documentation Patient #9 had received the bolus tube feed as ordered for each meal time.

This finding was confirmed by Staff E, the director of regulatory compliance and safety, emergency management and Staff F, the operations manager of regulatory compliance and safety, emergency management on 5/15/13 at 1:30 PM.

4. Review of the medical record for Patient #10 was completed the afternoon of 5/16/13. The patient was admitted on 2/5/13 with diagnoses including coronary artery disease, chronic obstructive pulmonary disease, hypertension, pneumonia, obesity, hyperemia, and atrial fibrillation.

The medical record lacked documentation patient #10 had been turned and repositioned every two hours, on 2/7/13, for the ten hours between 8:00 AM to 6:00 PM, on 2/8/13, for the twenty-three hours between 8:00 AM to 6:00 PM and between 6:00 PM to 7:00 AM,
on 2/10/13, for the 16 hours between 8:00 AM to midnight, and on 2/11/13, the same day the patient was discharged, the medical record lacked documentation the patient had been turned and repositioned every two hours.

These findings were confirmed by Staff E, the director of regulatory compliance and safety, emergency management and Staff F, the operations manager of regulatory compliance and safety, emergency management on 5/15/13 at 1:30 PM.


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5. Patient #1, a 77 year old female, was admitted to the facility on 04/05/13 after a prolonged stay at an outside hospital. According to the physician's history & physical the patient had diagnoses of aspiration pneumonia, severe malnutrition, and pulmonary collapse.
The patient was assessed as weighing 275 pounds on 04/05/13. On 04/07/13 the patient's weight was identified as 276 pounds. The patient weighed 265 pounds on 04/12/13, 10 pounds less than on 04/05/13. The medical record lacked documentation that a physician was notified of this weight loss. Two days later, on 04/14/13, the patient weighed 247 pounds, 18 pounds lighter than two days prior.

On 04/22/13 the patient's weekly weight was documented as 266 pounds, 19 pounds heavier than the previous weight. On Sunday, 04/28/13, the bed scale weight was documented as 261 pounds, five pounds lighter than on 04/22/13. The following Sunday, 05/05/13, the patient's documented weight was 249 pounds. The last documented weight occurred on 05/13/13. The weight was 251 pounds.

The facility policy entitled Weights and Heights for LTACH was reviewed on 05/16/13. According to the policy, staff are instructed to monitor weights for accuracy and request that patients be weighed again if there is a significant discrepancy between the current weight and previous weight. A discrepancy is defined, for patients greater than 100 pounds, as a five pound or greater difference. The policy instructs staff to document identified reasons for significant weight gain or loss.

Staff A, Clinical Manager of 3 South, was interviewed on 05/16/13 at 04:00 PM, and confirmed that the medical record lacked documentation of any reason (s) for the significant weight gains and losses.

6. Patient #6, an 87 year old male, was admitted to the facility on 04/26/13. The patient had a history of a fall resulting in a left subdural hematoma which required two craniotomies. It was reported that the patient had a decline in mental status after the second craniotomy. According to the Admission Assessment the patient was ordered to have nothing by mouth (NPO) and was to be given tube feedings.

Review of the Positioning Flowsheet indicated the patient was in a supine position with "pillow support" on 04/29/13 at 09:20 AM. The medical record lacked documentation of a position change until 09:00 PM. The position change documented the patient was in a supine position, the same position that was documented at 09:20 AM. At 11:00 PM the patient's position was changed to "semi-fowlers." On 05/16/13 at 02:00 PM, Staff A confirmed that in a semi-fowlers position the patient would still be considered to be on the back.
On 04/29/13 at 03:00 PM, the patient was noted to be positioned on his right side. The medical record lacked documentation the patient's position was changed until 09:00 PM. But again, the patient was identified as on the right side. On 05/01/13 at 07:00 AM, the documentation identified the patient was positioned by staff in a supine position with pillow support. The medical record lacked documentation the patient was repositioned again until 7:00 PM and identified the patient was positioned on the right side. On 05/04/13 at 01:14 PM, documentation identified the patient was positioned to the right side. The next time the documentation identified the patient was repositioned was at 07:00 PM. On 05/05/13 at 03:00 PM the documentation identified the patient was in a supine position. The documentation at 8:01 PM identified the patient was repositioned in a semi-fowlers. Staff A confirmed the patient in a semi-fowlers position is still positioned on the back. On 05/08/13 at 05:00 PM the patient was lying on the right side. The medical record lacked documentation of the repositioning of the patient until 04:00 AM on 05/09/13, when the patient was identified as positioned on the left side.

Staff A was interviewed on 05/16/13 at 03:00 PM. According to Staff A, staff are required to turn patients every 2 hours to prevent skin breakdown. Staff A confirmed Patient #6 had not been turned per facility protocol.

7. Staffing and Census records for 3 South for the month of January and February 1-15 as well as the facility staffing guidelines were reviewed on 05/16/13 at 03:00 PM. Staff A, the Clinical Manager of 3 South was interviewed on 05/17/13 at 10:40 AM, regarding the findings of the staffing review. The facility's inability to follow their staffing guidelines as identified during the review of facility's staff schedules, although not inclusive, are as follows:

On 01/01/13 and 01/02/13 from 07:00 AM to 07:00 PM the census was noted to be 32 patients. The staffing review revealed 6 registered nurses (RN), and 4 state tested nurses aides (STNA), 1 Health Unit Coordinator/Monitor Watcher (HUC) that worked from 07:00 AM to 03:00 PM and 2 HUCs worked from 03:00 PM to 07:00 PM. The staffing guidelines for 32 patients required 7 RNs, 1 Charge RN without an assignment, 4 STNAs, and 2 HUCs providing care during this shift. Staff A confirmed the staffing for the unit was short 1 RN, 1 Charge Nurse without an assignment, and 1 HUC/Monitor Watcher (from 07:00 AM to 03:00 PM) on these days.

On 01/03/13 from 07:00 AM to 07:00 PM the census was also noted to be 32 patients.
The staffing review revealed 6 RNs, 3 STNAs, and 2 HUCs working on this date and time.
On 01/03/13 from 11:00 PM to 07:00 AM the census was 33 patients. The staffing review revealed 6 RNs, 5 STNAs, and 1 HUC. The staffing guidelines for that census required 7 RNs, 1 Charge RN without an assignment, 4 STNAs, and 2 HUCs from 07:00 AM to 07:00 PM. From 11:00 PM to 07:00 AM, when the census was 33 patients, the facility guidelines required there to be 7 RNs, 5 STNAs, and 1 HUC. Staff A confirmed for 01/03/13, the unit was short 1 RN, 1 Charge Nurse without an assignment, and 1 STNA from 07:00 AM to 07:00 PM. From 11:00 PM to 7:00 AM, the unit was short 1 RN and 1 Charge Nurse without an assignment.

On 01/06/13 from 07:00 AM to 07:00 PM the census was 34 patients. The staffing review revealed 6 RNs, 3 STNAs, and 2 HUCs working. The staffing guidelines for 34 patients required 7 RNs, 5 STNAs, and 2 HUCs. Staff A confirmed the unit was short 1 RN, 1 Charge Nurse without an assignment, and 2 STNAs.

On 01/13/13 the unit census was 31 patients. The staffing review revealed from 07:00 AM to 07:00 PM there were 6 RNs, 4 STNAs, and 2 HUCs. Staff A confirmed the unit was short 1 RN and 1 Charge Nurse without an assignment. From 07:00 PM to 11:00 PM, with a census of 31, the staffing review revealed 5 RNs, 4 STNAs, and 1 HUC. Staff A confirmed, for this four hour period of time, the unit was short 2 RNs and 1 Charge Nurse without an assignment.

On 01/14/13 the unit census was 31 patients. From 07:00 AM to 03:00 PM, The staffing review revealed 6 RNs, 4 STNAs, and 2 HUCs working. Staff A confirmed the unit was short 1 RN and 1 Charge Nurse without an assignment. From 03:00 PM to 07:00 PM, the census dropped to 30 patients. The staffing review revealed 5 RNs, 2 STNAs, and 2 HUCs, were working. Staff A confirmed the unit was short 1 RN, 1 Charge Nurse without an assignment, and 2 STNAs.

The facility staffing guidelines were also not met on 1/15, 1/16, 1/17, 1/20, 1/22, 1/28, 1/31, 2/4, 2/5, 2/7, and 2/14/13. This finding was confirmed by Staff A during an interview.