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Based on record review and interview the facility failed to ensure that ancillary nursing staff are supervised and meet patient care needs in 6 of 10 patients (#1, 2, 3, 4, 5, 10). This has the potential to affect all 34 patients receiving care at this facility at the time of the survey.


Findings:

The facility's "Patient Care Guidelines and Protocols", reviewed 2/12/2015 at 4:00 p.m., outlines minimum frequency for "nursing routines, guidelines, and protocols of patient care." The guidelines define the minimum frequency for the following: Assessment, every 12 hours and recorded on flowsheet within 4 hours; Hygiene, patient bathed daily; Foley catheter care, peri-care every 12 hours.

Pt. #1's MR, reviewed 2/12/2015 at 10:40 a.m., contains an order for dressing changes to saccral wound 4 times daily beginning on 1/30/2015. Pt. #1's wound treatment record reveals the dressing change was not done on 7 of 12 prescribed times from 1/31/2015 to 2/2/2015. Pt. #1's daily flow sheet did not contain a documented AM nursing assessment as of 2/12/2015 at 12:40 p.m.

During an interview with Pt. #2 on 2/12/2015 at 10:00 a.m., Pt. #2 stated the facility is frequently "short staffed." Pt. #2 stated "scheduled things get pushed back" such as medications and wound dressing changes. Pt. #2 stated staff told Pt. #2 "there is a wait time for a call light." During Pt. #2's hospitalization, Pt. #2 states the wait time for a response to a call light can vary anywhere from "a few minutes" to over an hour. Pt. #2 stated that staff reports working short "daily" and sometimes there is not enough staff to assist with bathing. Pt. #2 stated "I like to get washed up everyday, but there are at least 4 times in the last 2 weeks that I didn't get a bath." Pt. #2's MR, reviewed 2/12/2015 at 11:05 a.m., does not contain documentation of personal cares being administered on 2/4/2015, 2/7/2015 and 2/10/2015. Pt. #2's daily flow sheet did not contain a documented AM nursing assessment as of 2/12/2015 at 12:35 p.m.

Pt. #3's MR, reviewed 2/12/2015 at 1:35 p.m., reveals Pt. #3 did not receive a bath on 12/27/2014 or 1/11/2015. There are no personal cares documented on 1/9/2015. Pt. #3's wound treatment record reveals staff did not administer 9 of 46 prescribed doses of ointment to bilateral heels from 12/31/2014 to 1/22/2015.

Per Pt. #4's MR, reviewed 2/12/2015 at 1:05 p.m., Pt. #4 did not receive any type of personal cares on 12/23/2014.

Pt. #5's MR, reviewed 2/12/2015 at 1:55 p.m., reveals urinary catheter peri-care was not completed twice daily on 2/2/2014 and 2/4/2014; Pt. #5's bath was not completed on 1/20/2015, 1/31/2015 and 2/7/2015. Pt. #5's wound treatment record reveals staff did not administer 15 of 54 prescribed does of Aloe Vesta antifungal cream between 12/27/2014 and 1/22/2015.

Pt. #10's MR, reviewed 2/12/2015 at 12:10 a.m., contains a critical care nursing flow sheet that did not contain a documented AM nursing assessment from 07:00 a.m. to time of review at 12:10 a.m.

Per interview with CNA H on 2/12/2015 at 02:50 p.m., CNA H states, "when we don't have enough staff, call lights are not being answered, our manager understands this, it's not the staff that's the problem, it's the acuity of the patients, when you have bariatric patients, they take more than one person to do cares". CNA H also stated that they have a constant turnover in staff and feels they are constantly working short or with people not yet trained.

Per interview with RN G on 2/12/2015 at 03:15 p.m., RN G stated G felt staffing to be inadequate, noting constant turnover with at least 2-3 people leaving each month. RN G states that management is aware and shortages do happen, there are miscommunications between case management staff and nurse management as to how many patients one RN can handle safely and do new admissions. At times it is impossible to answer all the call lights and do cares.

During an interview with CNO C on 2/12/2015 at 3:00 p.m., CNO C confirms being aware of patients not getting cares as prescribed, including hygiene, wound care and activity. Regarding the facility staff working with less than the recommended staff to patient ratio, CNO C stated "sometimes we do, sometimes we don't." CNO C stated "I'm not concerned with staffing" in regards to patients not receiving cares, but was unable to offer potential reasons why staff was unable to perform patient cares as expected.






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Based on record review and interview, the facility failed to maintain and update plans of care in 8 of 10 patients (#1, 2, 3, 4, 5, 6, 7, 10).

Findings:

Facility policy "Transdisciplinary Care Planning" dated 1/2014, reviewed on 2/12/2015 at 4:00 p.m., states in part: "C. As indicated by the screening of data, involved disciplines will perform clinical evaluations...and will contribute to further developing the Transdisciplinary Plan of Care. ...G. At every subsequent team meeting specific goals and target dates will be addressed and progress toward goals will be measured and documented...H. New goals and target dates and interventions for those goals will be set as appropriate. Identified problems/goals and interventions may be "completed" during these intervals as well."

Pt. #1's MR, reviewed on 2/12/2015 at 10:40 a.m., reveals Pt. #1 was admitted to the facility for wound care and ventilator weaning. Pt. #1's MR contains a POC with 5 of 18 potential problems activated. Pain Management, Infection and Swallowing are identified as "Significant Problems/Barriers to Discharge." The POC does not include the significant problems or barriers to discharge or documentation of evaluation or patient progress toward goals that were initiated. Team conference notes document "POC updated" on 2/4/2015 and 2/10/2015. There is no documentation within the POC to reflect updates related to the team conference identified problems.

Pt. #2's MR, reviewed on 2/12/2015 at 11:05 a.m., reveals Pt. #2 was admitted to the facility for wound care. Pt. #2's MR contains a POC with 12 of 18 potential problems initiated. 8 of the 12 initiated problems are not updated since 12/18/2014. There is no evidence of patient progression toward goals. The POC lacks evaluation and intervention based on assessment. Pt. #2's has POC initiated for Infection and Bowel & Bladder Function. While an inpatient, Pt. #2 was diagnosed with a urinary tract infection, there are no updates to reflect this change in status on either POC. Per team conference notes, "POC updated" is documented as occurring on 12/23/2014, 12/30/2014, 1/7/2015, 1/21/2015, 2/4/2015 and 2/10/2015. There is no documentation within the POC to reflect updates to the identified problems.

Pt. #3's MR, reviewed on 2/12/2015 at 1:35 p.m., revealed Pt. #3 received inpatient services from 12/24/2014 through 1/23/2015 due to respiratory failure. Pt. #3's MR contains a POC with 9 of 18 potential problems initiated. The POC for Psychosocial Adjustment, initiated on 12/26/2014 does not include documentation of interventions, evaluation or patient progress toward meeting outcomes. The POC for Skin Integrity, and Safety do not include any documentation after the date of initiation on 12/24/2014. There is no resolution of any initiated POC at the time of discharge. The POC for Respiratory, initiated on 12/24/2014, was updated as "active" on 12/26/2014. There is no documentation of Pt. #3's progress toward goal of "improve pulmonary function" from the time of initiation to the time of Pt. #3's discharge on 1/23/2015.

Per review of Pt. #4's MR on 2/12/2015 at 1:05 p.m., Pt. #4 received inpatient services from 12/5/2014 through 1/2/2015 for respiratory failure. Pt. #4's MR contains a POC with 6 of 18 potential problems initiated. The POC for Functional Mobility, Self-Care, Swallowing and Psychosocial Adjustment indicate "active" interventions during the hospitalization. There are no updates to the interventions, evaluation or goals. Pt. #4's Respiratory POC contains no documentation of progress made toward goal of "improve pulmonary function" or "maintain and improve respiratory status and wean from vent to decannulation." There is no resolution of any initiated POC at the time of discharge.

Per review of Pt. #5's MR on 2/12/2015 at 1:55 p.m., Pt. #5 received inpatient services from 12/26/2014 through 2/9/2015 for respiratory failure. Pt. #5's MR contains a POC with 12 of 18 potential problems initiated. 8 of the 12 initiated problems do not contain any documentation after the date of initiation on 12/26/2014. There is no documentation regarding the patient's progress toward goals, there is no resolution to any problems identified in the POC upon discharge. The POC for Respiratory, initiated on 12/26/2014, was updated as "active" on 12/26/2014. There is no documentation of Pt. #5's progress toward goal of "improve pulmonary function" or "maintain pulmonary function" from the time of initiation to the time of Pt. #5's discharge on 2/9/2015.


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02/12/2015 at 09:30 a.m. the care plan for Pt #6, admitted 01/19/2015 for a broken hip and fractured vertebra, revealed 4 significant problems identified for patient on admission. Of the 4 problems identified on the care plan, none of the 4 had any documentation of progression toward goals, nor did they resolve, revise or reevaluate interventions as needed during patient's stay. Plan of care was reevaluated on 01/28/15, 02/04/2015 and 02/11/2015 at Team Conference Meeting, yet no evaluation notes are documented on care plan.

02/12/2015 at 02:15 p.m. the care plan for Pt #7, admitted 12/19/2014 for multiple falls with trauma and ESRD (End Stage Renal Disease), revealed 5 significant problems identified for patient on admission. Of the 5 problems identified on the care plan, Pain Management had no care plan initiated. Infection Control care plan initiated on 12/15/2015 with no further documentation or updates, no progression towards goals. Psychosocial Adjustment care plan initiated 12/22/2015 documents the plan was evaluated on 01/01/2014 Active; 01/07/2015 Active; 01/14/2015 Active. No other documentation or revisions or progress towards goals are included on any other care plan.

02/12/2015 at 10:00 a.m. the care plan for Pt #10, admitted 01/23/2015 with respiratory failure and malnutrition, revealed 6 significant problems identified for patient on admission. Of the 6 problems identified on the care plan, none of the 6 had any documentation of progression toward goals, nor did they resolve or revise interventions as needed during patient's stay. Plan of care was reevaluated on 02/04/2015 at Team Conference Meeting, yet no evaluation notes are documented on the care plan.

The above findings were verified with CNO C at the time of review. During an interview with CNO C on 2/12/2015 at 3:00 p.m., CNO C stated all components of the care plan, including progress toward goals and evaluation, should be documented in the POC.

Based on record review and interview, the nursing staff failed to follow hospital policy when documenting nursing assessment and personal cares in 8 of 10 patients (#1, 2, 3, 4, 5, 6, 7, 10) and medication administration records failed to provide an accurate time for each medication administration in 10 of 10 patients (#1-10). This has the potential to affect all 34 patients receiving care at this facility at the time of the survey.

Findings:

The facility's "Patient Care Guidelines and Protocols", reviewed 2/12/2015 at 4:00 p.m., outlines minimum frequency for "nursing routines, guidelines, and protocols of patient care." The guidelines state the minimum frequency for signatures as "Every shift by all staff who provide care for the patient; on all pages with documentation by the staff member."

02/12/2015 at 03:50 p.m., review of facility Policy #130-28-002.7 titled: Administration of Drugs, last reviewed 09/2014 states under C: Standard Drug Administration Times 2) Doses are considered "on time" if administered within one hour before or one hour after the scheduled time, 5a) Certain time critical medications (ie; insulin) require administration within one-half hour before or after the scheduled administration time have been identified.

Pt. #1's MR, reviewed 2/12/2015 at 12:40 p.m., lacks documentation of a nursing assessment, personal cares or patient activities on 2/12/2015. Pt. #1's MAR contains standard, pre-populated medication administration times, the exact time of medication administration is not documented.

Pt. #2's MR, reviewed 2/12/2015 at 11:05 a.m., contains an unsigned nursing assessment in the med-surg flow sheet on 2/11/2015. There is no documentation on the 2/12/2015 flowsheet of an assessment, personal cares or activities on 2/12/2015 at 12:35 p.m. Pt. #2's MAR contains standard, pre-populated medication administration times, the exact time of medication administration is not documented.

Pt. #3's MR, reviewed 2/12/2015 at 1:35 p.m., contains unsigned nursing assessments in the med-surg flow sheet on 1/4/2015, 1/10/2015, 1/11/2015, 1/15/2015, 1/17/2015, 1/18/2015, 1/20/2015, 1/21/2015 and 1/22/2015. Pt. #3's MAR contains standard, pre-populated medication administration times, the exact time of medication administration is not documented.

Pt. #4's MR, reviewed 2/12/2015 at 1:05 p.m., contains unsigned nursing assessments in the med-surg flow sheet on 12/13/2014, 12/14/2014 and 12/24/2014. The nursing assessment on 12/16/2014 is untimed. Pt. #4's MAR contains standard, pre-populated medication administration times, the exact time of medication administration is not documented.

Pt. #5's MR, reviewed 2/12/2015 at 1:55 p.m., contains unsigned nursing assessments in the med-surg flow sheet on 1/27/2015, 1/31/2015, 2/1/2015, 2/2/2015, 2/3/2015, 2/6/2015 and 2/8/2015. The nursing assessments are both untimed and without RN signature on 1/26/2015 and 1/29/2015. Pt. #5's MAR contains standard, pre-populated medication administration times, the exact time of medication administration is not documented.

02/12/2015 at 12:10 p.m., review of MR critical care flow sheet dated 02/10/2015 for Pt # 6, CC flow sheet documents an illegible and incomplete vital sign measurement at 8:00 p.m. Wound care documentation on PM shift did not document time of evaluation. No discussion of POC with family or patient documented on AM RN assessment, no POC discussion on PM RN assessment. Pt. #6's MAR contains standard, pre-populated medication administration times, the exact time of medication administration is not documented.

02/12/2015 at 02:00 p.m., review of MR crtical care flow sheet dated 12/26/2014 for Pt #7, CC flow sheet shows no documentation of discussion of POC with patient or family on AM RN and PM RN assessment. No signiture or date on document as to who performed PM RN physical assessment. Pt. #7's MAR contains standard, pre-populated medication administration times, the exact time of medication administration is not documented.

Pt. #8's MAR, reviewed 2/12/2014 at 1:45 p.m., contains standard, pre-populated medication administration times, the exact time of medication administration is not documented.

Pt. #9's MAR, reviewed 2/12/2014 at 1:15 p.m., contains standard, pre-populated medication administration times, the exact time of medication administration is not documented.

02/12/2015 at 10:00 a.m., review of MR critical care flow sheet for Pt #10, pain assessment documented on 02/10/2015 does not reflect evaluation of measures used to reduce pain in 2 of 3 documented pain assessments, at 3:00 p.m. evaluation complete, at 9:35 p.m. no evaluation, at 12:15 a.m., no evaluation completed. CC flow sheet from 02/10/2015 does not address POC discussion with family or patient on AM RN assessment. CC flow sheet dated 02/12/2015 has no documentation of any RN assessment, flow sheet blank other than one set of vital signs from 7:00 a.m. to time of review at 12:20 p.m. Pt. #10's MAR contains standard, pre-populated medication administration times, the exact time of medication administration is not documented.


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Per interview on 02/12/2015 at 4:00 p.m., CNO C stated "I recognized these things a few weeks ago, I haven't talked with staff yet. I talked to the pharmacy director to take off the prepopulated times and I was told we couldn't do that. I have to schedule a training with the nurses to document exact times given [on the MAR]."

Based on observation, record review and interview the facility failed to ensure that staff followed facility policy concerning Contact Precautions for one of one patient on Contact Precautions in a sample of 1 patient.


Findings:

Facility policy "Isolation Precautions" #051-39-052.3 dated 8/2009, reviewed on 2/12/2015 at 3:35 p.m., states in part: "3. Contact Precautions: ...d. Gown 2. ...wear a clean, non-steril gown when entering the room..."

On 2/12/2015 at 8:40 a.m., CNA E entered Pt. #11's room to obtain vital signs. Pt. #11 was in contact precautions requiring all staff to don gown and gloves upon patient contact. CNA E provided patient care without donning a gown.
During an interview with CNA E on 2/12/2015 at 8:45 a.m., CNA E stated that gowns and gloves are stored outside patient rooms and that there were no gowns available outside Pt. #11's room at the time CNA E entered to provide patient cares.
On 2/12/2015 at 8:50 a.m. CNA E entered Pt. 11's room donning a protective gown. CNA E failed to secure the ties of the gown prior to or while giving cares to Pt. #11.
During an interview with CNO C at 9:00 a.m., CNO C stated all staff entering an isolation room "should" be wearing a protective gown tied securely in the back.