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Based on clinical record review and interview it was determined a Registered Nurse failed to supervise and evaluate the care of two (#7 and #14) of three (#7, #9 and #14) patients with a PEG (percutaneous endoscopic gastrostomy) tube did not receive daily dressing changes as ordered; two (#9 and #14) of two patients with PEG tubes did not receive Prostat supplement as ordered; two (#9 and #14) of two patients with PEG tubes did not receive QID (four times a day) bolus feedings as ordered; and one (#7) of one patient was not weighed every other day as ordered by the physician. Failure to perform daily dressing changes as ordered did not allow staff to observe, monitor and prevent infection of the the site. Failure to ensure patients received the supplements and bolus feedings as ordered did not ensure patient received adequate nutritional intake for healing. Failure to weigh patient every other day did not ensure the physician had information necessary to make informed medical decisions. The failed practices affected Patients #7, #9 and #14. Findings follow:

A. Review of Patient #7's clinical record revealed a physician's order on 03/09/17 to weigh the patient every other day. Review of the clinical record revealed Patient #7 was weighed on 03/10/17. There was no documentation Patient #7 was weighed on 03/12/17 and 03/14/17. Review of Patient #7's clinical record revealed physician's orders dated 03/10/17 for PEG site care/dressings to be performed daily. Review of the clinical record revealed no documentation the dressing was changed four (03/10/17 through 03/12/17 and 03/15/17) of six (03/10/17 through 03/15/17) days. The above findings for Patient #7 were verified in an interview with the Second Floor Unit Supervisor at 1056 on 03/16/17.
B. Review of Patient #9's clinical record revealed a physician's order dated and timed 03/06/17 at 1451 for Prostat one packet per PEG BID (twice a day). Review of the clinical record revealed no documentation the Prostat was given as ordered for two (03/06/17 and 03/07/17) of four days (03/06/17 through 03/09/17). Review of Patient #9's clinical record revealed a physician's order dated 03/07/17 for Osmolite 1.5 200 mls (milliliters) QID. Review of Patient #9's clinical record revealed no documentation Patient #9 received the Osmolite QID three( 03/07/17, 03/08/17 and 03/09/17) of three days. The Osmolite was discontinued on 03/10/17. The above findings for Patient #9 were verified in an interview with the Second Floor Unit Supervisor at 1023 on 03/16/17.
C. Review of Patient #14's clinical record revealed a physician's order dated 03/09/17 for Osmolite 1.5 bolus QID. Review of the clinical record revealed no documentation Patient #14 received the Osmolite QID on three (03/10/17, 03/11/7, and 03/12/17) of six (03/09/17 through 03/14/17) days. Review of Patient #14's clinical record revealed a physician's order for Prostat one packet at 2100. Review of Patient #14's clinical record revealed Prostat was given twice on 03/10/17 and twice on 03/11/17. The above findings for Patient #14 were verified in an interview with the Second Floor Unit Supervisor at 1305 on 03/15/17.


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Based on clinical record review and interview, it was determined the facility failed to ensure nutritional supplement intake was documented for five of five (#5, #9, #12, #19, and #25) patients for which nutrition supplements were ordered. Failure to document supplement intake did not ensure staff was aware as to whether the patient was getting adequate nutrients and had the likelihood to affect any patient for whom nutritional supplements were ordered. Findings follow.

A. Review of clinical records revealed the following:
1) Patient #5-order for Ensure Enlive with breakfast and dinner beginning on 03/06/17 at 1351. There was no documentation as to whether the patient received and/or consumed the supplement 19 out of a possible 20 times (from dinner on 03/06/17 through dinner on 03/15/17).
2) Patient #9-order for Ensure Enlive with breakfast, lunch, and dinner beginning on 03/13/17 at 0848. There was no documentation as to whether the patient received and/or consumed the supplement 7 out of a possible 9 times (from lunch on 03/13/17 through lunch on 03/15/17).
3) Patient #12-order for Nepro with breakfast and dinner beginning on 03/02/17 at 1436. There was no documentation as to whether the patient received and/or consumed the supplement 29 out of a possible 29 times (from dinner on 03/02/17 through lunch on 03/15/17).
4) Patient #19-order for Ensure Enlive with breakfast, lunch, and dinner beginning on 03/08/17 at 1530. There was no documentation as to whether the patient received and/or consumed the supplement 23 out of a possible 23 times (from dinner on 03/08/17 through lunch on 03/15/17).
5) Patient #25-order for Ensure Enlive with breakfast, lunch, and dinner beginning on 03/11/17 at 1436. There was no documentation as to whether the patient received and/or consumed the supplement 14 out of a possible 14 times (from dinner on 03/11/17 through breakfast on 03/16/17).
B. During an interview on 03/16/17 at 1014, the Second Floor Unit Supervisor confirmed the lack of supplement documentation for Patient #9. The Second Floor Unit Supervisor confirmed the lack of documentation for Patient #12 during an interview on 03/15/17 at 1459 .
C. During an interview on 03/16/17 at 0959, the Director of Nursing confirmed the lack of supplement documentation for Patient #5. The Director of Nursing confirmed the lack of documentation for Patient #19 during an interview on 03/15/17 at 1245, and Patient #25 on 03/16/17 at 0818.

Based on observation and interview, it was determined the facility failed to ensure a medication room was locked to ensure prescription only medications were not available to non-licensed personnel in one (22B) of four (22A, 22B, 33A, 33B) medication rooms toured. By not controlling prescription only medications, the facility could not assure the safety, integrity or efficacy of the uncontrolled medications. The failed practice had the potential to affect all patients that were admitted into the facility. Findings follow:

A. A tour of Rehabilitation Floors was conducted on 03/13/17 between 1335 and 1440, observation revealed the locking mechanism to medication room 22B was not working properly and therefore not locking the door once someone walked through it. It was determined one would have to jiggle the handle long enough until you felt the locking mechanism engage.
B. During an interview on 03/13/2017 at 1356, Second Floor Supervisor verified the 22B medication room door did not automatically lock once opened and shut again.

Based on observation, review of policy and interview, the Infection Control Officer failed to identify the likelihood for infection control negative outcomes in that the facility failed to maintain therapy equipment in a manner that prevented thorough cleaning between patients in Rehabilitation for four of four (#1-4) walkers with multiple paper stickers on them (not able to disinfect) and one of one padded stand-up piece of equipment with medical tape holding pieces of foam in place (not able to disinfect), in the Rehabilitation Gym equipment room. By not maintaining therapy equipment in a way that allowed them to be thoroughly cleaned, the facility could not assure the sanitary environment when patients used these items. The failed practice had the likelihood to affect all patients that receive therapy services using the therapy equipment. Findings follow:

A. During a tour of Rehabilitation Gym on 03/13/17 from 1300 until 1340, observation revealed four patient walkers stored in a Rehabilitation Gym equipment room. The walkers had paper stickers in multiple places on them. Also observation revealed one padded stand-up piece of equipment that had medical tape holding pieces of foam in place.
B. Review of Rehabilitation Therapy Policy titled Infection Control stated "All transport equipment and therapy items will be cleaned with approved disinfectant by personnel wearing gloves immediately following patient use."
C. The Director of Rehabilitation verified the findings at the time of observation.