HospitalInspections.org

Based on record review and interview the facility failed to:
A. Safely administer IV (intravenous) medication to a patient in renal failure (kidney failure) with a blood pressure of 84/45. Staff nurses #34 and #35 caring for patient #1, infused Levophed (a medication used to increase the blood pressure in critically ill patients with critically low blood pressures) and failed to follow the recommendations for dosing and monitoring of the patient receiving this medication. Nurses #34 and #35 infused Levophed to patient #1 with an incomplete physician's orders and failed to follow the accepted standard of practice of what constitutes a physician's order. The facility failed to provide policies and procedures to guide nurses for the infusion of Levophed. (Cross refer to findings at A0144, Care in a Safe Setting);

B. Ensure patient ' s safety by not providing proper monitoring of 4 of 4 (#3, 4, 8, and 9) patients in restraint. Nursing staff placed 4 of 4 patients in restraint without obtaining physician ' s orders. Physicians and nursing staff failed to follow the established restraint policy. (Cross refers to finding at A0167, A0168 and A0173, Restraint or Seclusion).



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C. Monitor documentation for 12 of 12 active medical records reviewed. Staff member # 9 pre-documented the effectiveness of medication on the patient's record on 1 of 12 (#3) charts. Staff members #9, 10, and 12 also pre-documented the Assessment and Routine Elements of Care on 12 of 12 (#1, #3, #4, #5, #6, #7, #8, #25, #26, #27, #28, and #29) charts. (Cross refer to findings A449-Content of Record)

D. Ensure written orders were dated in 18 of 21 (# 1, 2, 3, 4, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 22, and 23) charts. The facility also failed to ensure written orders were timed in 18 of 21 (#1, 2, 3, 4, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 22, and 23) charts. The facility also failed to ensure the ordering physician had signed the orders in 12 of 12 (#1, 2, 3, 4, 8, 9, 10, 11, 13, 14, 22, and 23) charts. The facility also failed to ensure physician's signature was the physician's original signature, on 3 of 6 restraint order forms for 1 of 21 (#3) patients. (Cross refer to findings A 454, Orders Dated and Signed)

Based on record review and interviews the facility failed to:

A. provide a safe setting for a critically ill patient by allowing nurses #34 and #35 to infuse Levophed (a medication used to increase the blood pressure in critically ill patients with critically low blood pressures) to 1 of 1(#1) patient. (Cross refer to findings at A0144, Care in a Safe Setting);

B. ensure patient ' s safety by not providing proper monitoring of 4 of 4 (# 3, #4, #8, and #9) patients in restraint. Nursing staff also placed 4 of 4 patients in restraint without obtaining physician ' s orders.(Cross refer to findings at A167, A0168 and A0173, Restraint or Seclusion)

These deficient practices were determined to pose an Immediate Jeopardy to patient health and safety due to nurses administering Levophed (norepinephrine bitartrate) (a medication used to increase the blood pressure in critically ill patients with critically low blood pressures) by intravenous drip to maintain a blood pressure without facility policy or a completed physician's order. Patients were being placed in restraints without physicians' orders and not being properly monitored.

C. ensure the registered nurse (RN) (#9, #10) assessed 9 of 9 patients , (#3, #6, #7, #8, #25, #26, #27, #28, #29) and supervised the licensed vocational nurse (LVN)(#12) providing care for 3 of 3 patients (#1, #4, #5). (Cross refer to findings at A0392, Staffing and Delivery of Care)

D. ensure physician's signature was the physician's original signature on 3 of 6 restraint order forms. (Cross refer to findings A 454, Orders Dated and Signed)

Based on observation, document review, and interview the facility failed to ensure nursing services was providing patient assessments, patient safety and proper administration of medications. The facility also failed to follow the facility policy on use of patient restraints.

The findings were:

A. provide a safe setting for a critically ill patient by allowing nurses #34 and #35 to infuse Levophed (a medication used to increase the blood pressure in critically ill patients with critically low blood pressures) to 1 of 1 patient. (Cross refer to findings at A0144, Care in a Safe Setting; and A0404, Administration of Drugs).

B. The facility failed to ensure patient's safety by not providing proper monitoring of 4 of 4 (# 3, #4, #8, and #9) patients in restraints. Nursing staff also placed 4 of 4 patients in restraint without obtaining physician's orders. (Cross refer to findings a A0167, Restraint or Seclusion)

These deficient practices were determined to pose an Immediate Jeopardy to patient health and safety due to nurses administering Levophed (norepinephrine bitartrate) (a medication used to increase the blood pressure in critically ill patients with critically low blood pressures) by intravenous drip to maintain a blood pressure without facility policy or a completed physician's order. Patients were being placed in restraints without physicians' orders.



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C. Based on observation, document review and interview the facility failed to ensure nursing staff provided assessment and supervision for 12 of 12 ( #1, #3, #4, #5, #6, #7, #8, #25, #26, #27, #28, #29)patients identified. The facility did not have a supervising RN who provided oversight for the nursing staff and the care that was provided to the patient identified. (Cross Refer to findings at A 0392 Staffing and Delivery of Care)

Based on record review, observation, and interview the facility failed to have an effective medical record service responsible for the completeness and accuracy of patient's medical records.

A. The facility failed to monitor the documentation for 12 of 12 active medical records reviewed. Staff member # 9 pre-documented the effectiveness of medication on the patient's record on 1 (#3) of 12 charts. Staff members #9, 10, and 12 also pre-documented the Assessment and Routine Elements of Care on 12 (#1, 3, 4, 5, 6, 7, 8, 25, 26, 27, 28, and 29) of 12 charts. (Cross refer to findings at A449, Content of Record);

B. The facility failed to ensure written orders were dated in 18 of 21 charts (# 1, 2, 3, 4, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 22, and 23) and written orders were timed in 18 of 21 charts (#1, 2, 3, 4, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 22, and 23). The facility also failed to ensure the ordering physician had signed the orders in 12 of 13 charts (#1, 2, 3, 4, 8, 9, 10, 11, 13, 14, 22, and 23). Also the facility failed to ensure physician's signature was the physician's original signature on 3 of 6 restraint order forms in 1 of 12 (#3) Charts. (Cross refer to findings A 454, Orders Dated and Signed)

Based on record review and interview the facility failed to safely administer IV medication to 1 of 1 (#1)patients in renal failure (kidney failure) with a blood pressure of 84/45.
A. Nurses #34 and #35 caring for patient #1, infused Levophed (a medication used to increase the blood pressure in critically ill patients with critically low blood pressures) and failed to follow the recommendations for dosing and monitoring of the patient receiving this medication.
B. Nurses #34 and #35 infused Levophed to patient #1 with an incomplete physician ' s orders and failed to follow the accepted standard of practice of what constitutes a physician ' s order.
C.The facility failed to provide policies and procedures to guide nurses for the infusion of Levophed.
These deficient practices were determined to pose Immediate Jeopardy to patient health and
safety due to nurses infused Levophed (norepinephrine bitartrate) (a medication used to
increase the blood pressure in critically ill patients with critically low blood pressures) was being administered by intravenous drip using titration method to maintain a blood pressure without facility policy or physician order.

A.During the record review on 06/19/2012, revealed the patient was admitted to the facility on 05/25/2012 with a diagnosis of Decubitus Ulcer- E.Coli (bacteria)Wound. The document titled " Physician Progress Notes " dated 06/06/22012 revealed a diagnosis of Septic Shock, Acute Renal Failure, Anemia.

During the review of patient #1 chart on 06/19/2012 the document titled, " Nurses Notes " revealed the following entries by staff #34:
1. 2445,Levophed 4mg in 250 D5W started @ 6 mcg/min. will continue to monitor.
2. 0100 BP 82/28 increased Levophed to 10 mcg/min.
3. 0200 BP99/41 Levophed remained @ 10 mcg/min.

Review of the document titled " Vital Signs Record " revealed the following enteries:
Staff #34 recorded :
1. 06/07/12, Time 0045, Blood pressure 84/45, Notes Levophed @ 6 mcg/min
2. 06/07/12, Time 0130, Blood pressure 82/28, Notes increased to 10 mcg/min
3. 06/07/12, Time 0230, Blood pressure 99/41, Notes Levophed @ 10 mcg/min
4. 06/07/12, Time 0330, Blood pressure 101/44, Notes Same Rate
5. 06/07/12, Time 0430, Blood pressure 98/45, Notes Same Rate
6. 06/07/12, Time 0530, Blood pressure 143/68, Notes Decreased rate to 2 mcg/min
7. 06/07/12, Time 0 630, Blood pressure 128/55, Notes Same Rate
Staff #35 recorded:
1. 06/07/12, Time 0800, Blood pressure 103/53, Notes Levophed @ 2 mcg/min
2. 06/07/12, Time 0900, Blood pressure 102/52, Notes Levophed @ 2 mcg/min
3. 06/07/12, Time 1000, Blood pressure 104/55, Notes Levophed @ 6 mcg/min
4. 06/07/12, Time 1100, Blood pressure 103/58, Notes Levophed @ 2 mcg/min
5. 06/07/12, Time 1200, Blood pressure 125/53, Notes Levophed gtt. Off

Review of the FDA information in regards to Levaphed precautions revealed:Avoid Hypertension: Because of the potency of LEVOPHED and because of varying response to pressor substances, the possibility always exists that dangerously high blood pressure may be produced with overdoses of this pressor agent. It is desirable, therefore, to record the blood pressure every two minutes from the time administration is started until the desired blood pressure is obtained, then every five minutes if administration is to be continued.
A review of the medication insert provided by the manufacture, CIBA Pharmaceuticals Company, revealed, "Avoid Hypertension: Because of the potency of LEVOPHED and because of varying response to pressor substances, the possibility always exists that dangerously high blood pressure may be produced with overdoses of this pressor agent. It is desirable, therefore, to record the blood pressure every two minutes from the time administration is started until the desired blood pressure is obtained, then every five minutes if administration is to be continued. The rate of flow must be watched constantly, and the patient should never be left unattended while receiving LEVOPHED.
An interview with Staff # 35 on 07/02/2012 at 10:20AM revealed, patient #1 was placed on an automatic blood pressure machine. The blood pressure machine was set to cycle every hour. Interview revealed there was no continuous monitoring being done by staff while the patient was receiving the continuous medication. When staff #34 was asked what guidance was relied on to infuse the medication, the reply was " my personal notes and personal experience. Staff was asked if the facility or it ' s pharmacy provided policies or guidance for infusing the medication, response was, " no " .


B.During review of patient #1 ' s medical record, a document titled " Physician ' s Orders " revealed, " Keep SBP >100 (systolic blood pressure(the top number) greater than 100), may need to start levophed to maintain SBP. No other order for Levophed was in the chart for review.

A review of the following resource for acceptable element of a physician ' s orders, Encyclopedia of Nursing & Allied Health, ?2002 Gale Cengage, revealed, "Universally accepted safe clinical practice guidelines and state laws govern the components of medication orders in order to ensure consistency and patient safety. All orders should contain the patient's name, the date and time when the order is written, and the signature of the ordering clinician. Caregivers administering medication are responsible for checking that these components are present and clear. The name of the medication is accompanied by the dosage, or how much of the drug should be given; the route of administration, or how the medication should be given (ie, intramuscular injection); and frequency, or how often the drug is to be given. "



C.A request was made to Staff #1, Staff #7, Staff #14 and Staff #30 for a Policy and Procedure as it relates to the medication, Levophed. No policy was made available to the survey team.

An interview on 06/21/2012 at approximately 1130 in the family room with staff #1 revealed, he had no knowledge of the medication Levophed being give in the facility. Staff #1 revealed there was not a policy or guidance to the nursing staff for giving the medication Levophed.

An interview was conducted on 06/21/2012 at approximately 1130 in the family room with staff #7. Staff #7 reported a lot of their staff had Intensive Care experience and had knowledge of the medication Levophed. Staff #7 revealed there was no policy or guidance to the nursing staff for giving the medication Levophed.

An interview was conducted on 06/21/2012 at approximately 1130 in the family room with staff #14 who reported there was no policy or guidance to the nursing staff for giving the medication Levophed.

An interview was conducted on 06/22/2012 at approximately 1130 with staff #30. Staff #30 revealed he had no knowledge of the medication Levophed being given in the facility.

Based on record review and interviews the facility failed to ensure patient ' s safety by not providing proper monitoring 4 of 4 (#3, #4, #8, and # 9) patients in restraint. Nursing staff also placed 4 of 4 patients in restraint without obtaining physician ' s orders.

A review of the document titled " Restraints, ID.TX.7400 CDHS, C# Policy Date 12-2010", revealed, " Physician/LIP issues the order for use of restraint. RN may initiate restraint in response to a change in patient condition considered an emergency. Nurse notifies the physician/LIP immediately and requests a verbal or written order. Physician/LIP will evaluate the patient in person within 24 hours and complete a written order for restraint. Continued use of restraint beyond 24 hours is based on patient examination by the ordering physician/LIP and a written order each calendar day."

A review of patient #3 ' s medical record revealed, for the dates of 06/15/2012, and 06/17/2012 the nursing staff documented the patient was placed in restraints. The document titled " Restraint Order Form " for the above mentioned dates were dated and signed by the physician on 06/17/2012. . There was no evidence documented in the chart the physician evaluated the patient for the need of restraints. Patient #3 diagnoses were Back Surgery, Methicillin-resistant Staphylococcus aureus (MRSA) spinal fluid, and Acute Delirium. Soft wrist restraints were placed to prevent patient from removing Endo tracheal tube, Nasal gastric tube, foley catheter, and right internal jugular.

A review of staff #9 ' s notes and the document titled " Patient Monitoring Form " on 06/21/2012 at 4:00 PM revealed patient #3 was in restraints. At 4:00 PM, upon inspection of the document, staff #9 had pre-document patient #3 ' s assessment, hydration/ nutrition, release of the restraints and range of motion through the hour of 6:00 PM.

A review of patient #4 ' s medical record revealed the patient was in restraints and was not being monitored. A review of the document titled " Patient Monitoring Form " revealed on 06/15/2012 between the hours of 6:00 AM and 8:30 PM, no entries was made by nursing staff. A review of the document titled " Patient Monitoring Form " On 06/16/2012 between the hours 12:00 AM and 8:00 AM, no entries were made by nursing staff. A review of the document titled " Patient Monitoring Form " for the date of 06/18/2012 revealed the patient was removed from restraint at 10:00 AM. At 3:00 PM the document showed the patient was placed back into restraints, no documentation of a physician ' s order or communication with the physician by the nurse to place the patient in restraints or to remove the restraints. There was no evidence documented in the chart the physician evaluated the patient for the need of restraints. Patient #4 diagnoses were Gastro esophageal Cancer Peptic Ulcer, Hypertension, Diabetes, Lumbar Surgery, and Subdural Hematoma. Soft wrist restraints were placed to prevent patient from removing Peripheral inserted central catheter (PICC), Oxygen, and foley catheter.

A review of patient #8 ' s medical record revealed, for the dates of 06/4/2012, 06/5/2012, 06/6/2012, 06/7/2012,and 06/08/2012 the nursing staff documented the patient was in restraints. The document titled " Restraint Order Form " for the above mentioned dates were dated and signed by the physician on 06/11/2012. . There was no evidence documented in the chart the physician evaluated the patient for the need of restraints. Patient #8 diagnoses was Respiratory Failure, status/ post Motor vehicle accident, Tracheotomy, Cervical spine injury, Left elbow and Right hip fracture. Soft wrist restraints were placed to prevent patient from removing tracheotomy tube, peg tube, and flexiseal (rectal tube).

A review of patient #9 ' s medical record revealed, for the dates of 06/12/2012, 06/13/2012, 06/14/2012 the nursing staff documented the patient was placed in restraints. The document titled " Restraint Order Form " for the above mentioned dates were dated and signed by the physician on 06/16/2012. There was no evidence documented in the chart the physician evaluated the patient for the need of restraints. Patient #9 diagnoses was Respiratory Failure and soft wrist restraints were placed due to patient trying to remove tracheotomy tube, chest tube, peg tube, and foley catheter.

A review of patient ' s #9 medical record titled " Patient Monitoring Form" for the date of 06/19/2012 revealed the patient was removed from restraint at 8:00 AM and 4:00 PM the document showed the patient was placed back into restraints. A review of patient's #9 medical records revealed no documentation of a physician's order or communication with the physician by the nurse to place the patient in restraints or to remove the restraints.

During an interview with Administrator on 06/22/2012 at approximately 2:00 PM in the patient gym confirmed, the findings in regards to the lack of monitoring and documentation by both nursing staff and medical staff on 4 of 4 patients placed in restraints.

Based on record review and interviews the facility failed to ensure patient's safety by not providing proper monitoring 4 of 4 (#3,# 4, #8, and #9) patients in restraint. Nursing staff also placed 4 of 4 patients in restraint without obtaining physician ' s orders.

A review of the document titled " Restraints, ID.TX.7400 CDHS, C# Policy Date 12-2010", revealed, " Physician/LIP issues the order for use of restraint. RN may initiate restraint in response to a change in patient condition considered an emergency. Nurse notifies the physician/LIP immediately and requests a verbal or written order. Physician/LIP will evaluate the patient in person within 24 hours and complete a written order for restraint. Continued use of restraint beyond 24 hours is based on patient examination by the ordering physician/LIP and a written order each calendar day."

A review of patient #3's medical record revealed, for the dates of 06/15/2012, and 06/17/2012 the nursing staff documented the patient was placed in restraints. The document titled " Restraint Order Form" for the above mentioned dates were not dated and signed by the physician till 06/17/2012. There was no evidence documented in the chart by the physician the patient had been evaluated for the need of restraints. Patient #3 diagnoses were Back Surgery, Methicillin-resistant Staphylococcus aureus (MRSA) spinal fluid, and Acute Delirium. Soft wrist restraints were placed to prevent patient from removing Endo-tracheal tube, Nasal gastric tube, foley catheter, and right internal jugular.

A review of staff #9's notes and the document titled " Patient Monitoring Form " on 06/21/2012 at 4:00 PM revealed patient #3 was in restraints. At 4:00 PM, upon inspection of the document, staff #9 had pre-document patient #3 ' s assessment, hydration/ nutrition, release of the restraints and range of motion through the hour of 6:00 PM.

A review of patient #4 ' s medical record revealed the patient was in restraints and was not being monitored. A review of the document titled " Patient Monitoring Form " revealed on 06/15/2012 between the hours of 6:00 AM and 8:30 PM, no entries was made by nursing staff. A review of the document titled " Patient Monitoring Form " On 06/16/2012 between the hours 12:00 AM and 8:00 AM, no entries were made by nursing staff. A review of the document titled " Patient Monitoring Form " for the date of 06/18/2012 revealed the patient was removed from restraint at 10:00AM. At 3:00 PM the document showed the patient was placed back into restraints, no documentation of a physician ' s order or communication with the physician by the nurse to place the patient in restraints or to remove the restraints. There was no evidence documented in the chart the physician evaluated the patient for the need of restraints. Patient #4 diagnoses were Gastro esophageal Cancer Peptic Ulcer, Hypertension, Diabetes, Lumbar Surgery, and Subdural Hematoma. Soft wrist restraints were placed to prevent patient from removing Peripheral inserted central catheter (PICC), Oxygen, and foley catheter.

A review of patient #8 ' s medical record revealed, for the dates of 06/4/2012, 06/5/2012, 06/6/2012, 06/7/2012,and 06/08/2012 the nursing staff documented the patient was in restraints. The document titled " Restraint Order Form " for the above mentioned dates were dated and signed by the physician on 06/11/2012. . There was no evidence documented in the chart the physician evaluated the patient for the need of restraints. Patient #8 diagnoses was Respiratory Failure, status/ post Motor vehicle accident, Tracheostomy, Cervical spine injury, Left elbow and Right hip fracture. Soft wrist restraints were placed to prevent patient from removing tracheostomy tube, peg tube, and flexiseal (rectal tube).

A review of patient #9 ' s medical record revealed, for the dates of 06/12/2012, 06/13/2012, 06/14/2012 the nursing staff documented the patient was placed in restraints. The document titled " Restraint Order Form " for the above mentioned dates were dated and signed by the physician on 06/16/2012. There was no evidence documented in the chart the physician evaluated the patient for the need of restraints. Patient #9 diagnoses was Respiratory Failure and soft wrist restraints were placed due to patient trying to remove tracheostomy tube, chest tube, peg tube, and foley catheter.

A review of patient ' s #9 medical record titled " Patient Monitoring Form " for the date of 06/19/2012 revealed the patient was removed from restraint at 8:00AM and 4:00 PM the document showed the patient was placed back into restraints. A review of patient's #9 medical records revealed no documentation of a physician ' s order or communication with the physician by the nurse to place the patient in restraints or to remove the restraints.

During an interview with Administrator on 06/22/2012 at approximately 2:00PM in the patient gym confirmed, the findings in regards to the lack of monitoring and documentation by both nursing staff and medical staff on 4 of 4 patients placed in restraints.

Based on record review and interviews the facility failed to ensure patient ' s safety by not providing proper monitoring 4 (#3, 4, 8, and 9) of 4 patients in restraint. Nursing staff also placed 4 of 4 patients in restraint without obtaining physician ' s orders.

A review of the document titled " Restraints, ID.TX.7400 CDHS, C# Policy Date 12-2010", revealed, " Physician/LIP issues the order for use of restraint. RN may initiate restraint in response to a change in patient condition considered an emergency. Nurse notifies the physician/LIP immediately and requests a verbal or written order. Physician/LIP will evaluate the patient in person within 24 hours and complete a written order for restraint. Continued use of restraint beyond 24 hours is based on patient examination by the ordering physician/LIP and a written order each calendar day."

A review of patient #3 ' s medical record revealed, for the dates of 06/15/2012, and 06/17/2012 the nursing staff documented the patient was placed in restraints. The document titled " Restraint Order Form " for the above mentioned dates were dated and signed by the physician on 06/17/2012. . There was no evidence documented in the chart the physician evaluated the patient for the need of restraints. Patient #3 diagnoses were Back Surgery, Methicillin-resistant Staphylococcus aureus (MRSA) spinal fluid, and Acute Delirium. Soft wrist restraints were placed to prevent patient from removing Endo tracheal tube, Nasal gastric tube, foley catheter, and right internal jugular.

A review of staff #9 ' s notes and the document titled " Patient Monitoring Form " on 06/21/2012 at 4:00 PM revealed patient #3 was in restraints. At 4:00 PM, upon inspection of the document, staff #9 had pre-document patient #3 ' s assessment, hydration/ nutrition, release of the restraints and range of motion through the hour of 6:00 PM.

A review of patient #4 ' s medical record revealed the patient was in restraints and was not being monitored. A review of the document titled " Patient Monitoring Form " revealed on 06/15/2012 between the hours of 6:00 AM and 8:30 PM, no entries was made by nursing staff. A review of the document titled " Patient Monitoring Form " On 06/16/2012 between the hours 12:00 AM and 8:00 AM, no entries were made by nursing staff. A review of the document titled " Patient Monitoring Form " for the date of 06/18/2012 revealed the patient was removed from restraint at 10:00AM. At 3:00 PM the document showed the patient was placed back into restraints, no documentation of a physician ' s order or communication with the physician by the nurse to place the patient in restraints or to remove the restraints. There was no evidence documented in the chart the physician evaluated the patient for the need of restraints. Patient #4 diagnoses were Gastro esophageal Cancer Peptic Ulcer, Hypertension, Diabetes, Lumbar Surgery, and Subdural Hematoma. Soft wrist restraints were placed to prevent patient from removing Peripheral inserted central catheter (PICC), Oxygen, and foley catheter.

A review of patient #8 ' s medical record revealed, for the dates of 06/4/2012, 06/5/2012, 06/6/2012, 06/7/2012,and 06/08/2012 the nursing staff documented the patient was in restraints. The document titled " Restraint Order Form " for the above mentioned dates were dated and signed by the physician on 06/11/2012. . There was no evidence documented in the chart the physician evaluated the patient for the need of restraints. Patient #8 diagnoses was Respiratory Failure, status/ post Motor vehicle accident, Tracheostomy, Cervical spine injury, Left elbow and Right hip fracture. Soft wrist restraints were placed to prevent patient from removing tracheostomy tube, peg tube, and flexiseal (rectal tube).

A review of patient #9 ' s medical record revealed, for the dates of 06/12/2012, 06/13/2012, 06/14/2012 the nursing staff documented the patient was placed in restraints. The document titled " Restraint Order Form " for the above mentioned dates were dated and signed by the physician on 06/16/2012. There was no evidence documented in the chart the physician evaluated the patient for the need of restraints. Patient #9 diagnoses was Respiratory Failure and soft wrist restraints were placed due to patient trying to remove tracheostomy tube, chest tube, peg tube, and foley catheter.

A review of patient ' s #9 medical record titled " Patient Monitoring Form " for the date of 06/19/2012 revealed the patient was removed from restraint at 8:00AM and 4:00 PM the document showed the patient was placed back into restraints. A review of patient's #9 medical records revealed no documentation of a physician ' s order or communication with the physician by the nurse to place the patient in restraints or to remove the restraints.

During an interview with Administrator on 06/22/2012 at approximately 2:00PM in the patient gym confirmed, the findings in regards to the lack of monitoring and documentation by both nursing staff and medical staff on 4 of 4 patients placed in restraints.

Based on observation, document review and interview the facility failed to insure nursing staff (#9, #10) provided assessment and supervision for 12/12 ( #1, #3, #4, #5, #6, #7, #8, #25, #26, #27, #28, #29) patient's identified. . The facility did not have a supervising RN who provided oversight for the nursing staff and the care that was provided to the patient identified.

Review of open record # 3 revealed staff #9 documented on 06/21/2012 Ativan 2 mg IV was given at 1600 (4:00 PM) and medication was " Not Effective " at 1700 (5:00 PM). Review of the patient record took place at 4:05 PM on 06/21/2012, which was 55 minutes prior to the time the medication was documented as not effective.

Further review of all active patient records on 06/21/2012 revealed documents titled "Assessment and Routine Elements of Care " was observed for patients #1, #3, #4, #5, #6, #7, #8, #25, #26, #27, #28, and #29. These records had been pre-documented through the 6:00 PM hour. The afore mentioned patients were assigned to two RNs (#9,#10) and an LVN (#12). Observation of this documentation occurred on 06/21/2012 at 4:15 PM at the nurses' station by the surveyors.
On 6/21/2012 at 4:10 PM the Director of Nurses was interviewed and was not aware nurse #9 had pre-charted the results of the medications and was not aware that RN's #9, #10 and LVN #12 had pre-charted patient assessments.
On 6/21/2012 at 4:10 PM the Director of Nurses, Administrator and Corporate Consultant were shown the documentation from RN #9 and confirmed RN #9, had falsified the documentation by pre-documenting the effectiveness of the PRN medication. During the following audit of 100% of the active patient records they also confirmed staff #10 and #12 had pre-documented the "Assessment and Routine Elements of Care " through the 6:00 hr for patients #1, #3, #4, #5, #6, #7, #8, #25, #26, #27, #28, and #29.

Based on record review and interview the facility failed to safely administer an IV medication to a patient (#1) in renal failure (kidney failure) with a blood pressure of 84/45.
A. Nurses #34 and #35 caring for patient #1, infused Levophed (a medication used to increase the blood pressure in critically ill patients with critically low blood pressures) and failed to follow the recommendations for dosing and monitoring of the patient receiving this medication.
B. Nurses #34 and #35 infused Levophed to patient #1 with an incomplete physician ' s orders and failed to follow the accepted standard of practice of what constitutes a physician's order.
C.The facility failed to provide policies and procedures to guide nurses for the infusion of Levophed.
These deficient practices were determined to pose Immediate Jeopardy to patient health and
safety due to nurses infused Levophed (norepinephrine bitartrate) (a medication used to
increase the blood pressure in critically ill patients with critically low blood pressures) was being administered by intravenous drip using titration method to maintain a blood pressure without facility policy or physician order.


A.During the record review on 06/19/2012, revealed the patient was admitted to the facility on 05/25/2012 with a diagnosis of Decubitus Ulcer- E.Coli (bacteria)Wound. The document titled " Physician Progress Notes" dated 06/06/22012 revealed a diagnosis of Septic Shock, Acute Renal Failure, Anemia.

During the review of patient #1 chart on 06/19/2012 the document titled, "Nurses Notes" revealed the following entries by staff #34:
1. 2445,Levophed 4mg in 250 D5W started @ 6 mcg/min. will continue to monitor.
2. 0100 BP 82/28 increased Levophed to 10 mcg/min.
3. 0200 BP99/41 Levophed remained @ 10 mcg/min.

Review of the document titled " Vital Signs Record " revealed the following enteries:
Staff #34 recorded :
1. 06/07/12, Time 0045, Blood pressure 84/45, Notes Levophed @ 6 mcg/min
2. 06/07/12, Time 0130, Blood pressure 82/28, Notes increased to 10 mcg/min
3. 06/07/12, Time 0230, Blood pressure 99/41, Notes Levophed @ 10 mcg/min
4. 06/07/12, Time 0330, Blood pressure 101/44, Notes Same Rate
5. 06/07/12, Time 0430, Blood pressure 98/45, Notes Same Rate
6. 06/07/12, Time 0530, Blood pressure 143/68, Notes Decreased rate to 2 mcg/min
7. 06/07/12, Time 0 630, Blood pressure 128/55, Notes Same Rate
Staff #35 recorded:
1. 06/07/12, Time 0800, Blood pressure 103/53, Notes Levophed @ 2 mcg/min
2. 06/07/12, Time 0900, Blood pressure 102/52, Notes Levophed @ 2 mcg/min
3. 06/07/12, Time 1000, Blood pressure 104/55, Notes Levophed @ 6 mcg/min
4. 06/07/12, Time 1100, Blood pressure 103/58, Notes Levophed @ 2 mcg/min
5. 06/07/12, Time 1200, Blood pressure 125/53, Notes Levophed gtt. Off

Review of the FDA information in regards to Levaphed precautions revealed:Avoid Hypertension: Because of the potency of LEVOPHED and because of varying response to pressor substances, the possibility always exists that dangerously high blood pressure may be produced with overdoses of this pressor agent. It is desirable, therefore, to record the blood pressure every two minutes from the time administration is started until the desired blood pressure is obtained, then every five minutes if administration is to be continued.
A review of the medication insert provided by the manufacture, CIBA Pharmaceuticals Company, revealed, "Avoid Hypertension: Because of the potency of LEVOPHED and because of varying response to pressor substances, the possibility always exists that dangerously high blood pressure may be produced with overdoses of this pressor agent. It is desirable, therefore, to record the blood pressure every two minutes from the time administration is started until the desired blood pressure is obtained, then every five minutes if administration is to be continued. The rate of flow must be watched constantly, and the patient should never be left unattended while receiving LEVOPHED.
An interview with Staff # 35 on 07/02/2012 at 10:20AM revealed, patient #1 was placed on an automatic blood pressure machine. The blood pressure machine was set to cycle every hour. Interview revealed there was no continuous monitoring being done by staff while the patient was receiving the continuous medication. When staff #34 was asked what guidance was relied on to infuse the medication, the reply was " my personal notes and personal experience. Staff was asked if the facility or it's pharmacy provided policies or guidance for infusing the medication, response was "no".

B.During review of patient #1 ' s medical record, a document titled " Physician ' s Orders " revealed, " Keep SBP >100 (systolic blood pressure(the top number) greater than 100), may need to start levophed to maintain SBP". No other orders for Levophed was in the chart for review.

A review of the following resource for acceptable element of a physician's orders, Encyclopedia of Nursing & Allied Health, ?2002 Gale Cengage, revealed, "Universally accepted safe clinical practice guidelines and state laws govern the components of medication orders in order to ensure consistency and patient safety. All orders should contain the patient's name, the date and time when the order is written, and the signature of the ordering clinician. Caregivers administering medication are responsible for checking that these components are present and clear. The name of the medication is accompanied by the dosage, or how much of the drug should be given; the route of administration, or how the medication should be given (ie, intramuscular injection); and frequency, or how often the drug is to be given. "

C.A request was made to Staff #1, Staff #7, Staff #14 and Staff #30 for a Policy and Procedure as it relates to the medication, Levophed. No policy was made available to the survey team.

An interview was conducted on 06/21/2012 at approximately 1130 in the family room with staff #1 Staff #1 reported he had no knowledge of the medication Levophed being give in the facility. Staff #1 reported there was not a policy or guidance to the nursing staff for giving the medication Levophed.

An interviewwas conducted on 06/21/2012 at approximately 1130 in the family room with staff #7. Staff #7 reported a lot of their staff had Intensive Care experience and had knowledge of the medication Levophed. Staff #7 reported there was no policy or guidance to the nursing staff for giving the medication Levophed.

An interview was conducted on 06/21/2012 at approximately 1130 in the family room with staff #14. Staff #14 reported there was no policy or guidance to the nursing staff for giving the medication Levophed.

An interview was conducted on 06/22/2012 at approximately 1130 with staff #30. Staff #30 reported he had no knowledge of the medication Levophed being given in the facility.

Based on record review and interview the facility failed to monitor documentation for 12 of 12 active medical records reviewed. Staff member # 9 pre-documented the effectiveness of medication on the patient's record on 1 of 12 (#3) charts. Staff members #9, #10, and #12 also pre-documented the Assessment and Routine Elements of Care on 12 of 12 (#1, #3, #4, #5, #6, #7, #8, #25, #26, #27, #28, and #29) charts.
Review of open record # 3 revealed staff #9 documented on 06/21/2012 Ativan 2 mg IV given at 1600 (4:00 PM) and medication " Not Effective " at 1700 (5:00 PM). Review of the patient record took place at 4:05 PM on 06/21/2012, which was 55 minutes prior to the time documented medication not effective.
An interview on 06/21/2012 at 4:15 PM with the Administrator, Director of Patient Care, and Regional Director of Quality confirmed the nurse #9 had falsified the timing of the effectiveness of the prn (means when medication needed) medication.
During a face to face interview by the Administrator with staff #9 on 06/21/2012 at 4:20 PM, the administrator confirmed the nurse #9 had pre-documented the effectiveness of the medication.
Review of open records ( #1, #3, #4, #5, #6, #7, #8, #25, #26, #27, #28, and #29) on 06/21/2012 at 4:15 PM titled " Assessment and Routine Elements of Care " it was observed staff # 9, #10, and #12 had pre-documented through the 6:00 PM hour. Observation of this documentation occurred on 06/21/2012 at 4:15 PM at the nurses' station by the surveyors. This was 45 minutes prior to the time the nurses should have been evaluating the activities and safety of patient care. Three nurses pre-charted on 12 patients on the activities and safety checks before the patients had been evaluated by a face to face evaluation by the nurse caring for the patient.
During a face to face interview by the Administrator with staff #9, #10, and #12 on 06/21/2012 at 4:20 PM, the administrator confirmed with the nurses they had pre- documented on the "Assessment and Routine Elements of Care."

Based on record review, observation, and interview the facility failed to ensure written orders were dated in 18 of 21 charts (# 1, 2, 3, 4, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 22, and 23). The facility also failed to ensure written orders were timed in 18 of 21 charts (#1, 2, 3, 4, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 22, and 23). The facility also failed to ensure the ordering physician had signed the orders in 12 of 12 charts (#1, 2, 3, 4, 8, 9, 10, 11, 13, 14, 22, and 23). The facility failed to ensure physician's signature was the physician's original signature on 3 of 6 restraint order forms for 1 of 21 (#3) patients.


Findings include:

Review of medical records revealed the following 18 charts with undated written orders, as follows (Chart# x number of orders lacking date):

Chart #1 x 7
Chart #2 x 16
Chart #3 x 19
Chart #4 x 13
Chart #8 x 48
Chart #9 x 24
Chart #10 x 3
Chart #11 x 3
Chart #12 x 6
Chart #13 x 40
Chart #14 x 9
Chart #15 x 13
Chart #16 x 1
Chart #17 x 10
Chart #19 x 1
Chart #20 x 8
Chart #22 x 6
Chart #23 x 11

Review of medical records revealed the following 18 charts with written orders lacking time ordered, as follows (Chart# x number of orders lacking time of order):

Chart #1 x 9
Chart #2 x 17
Chart #3 x 19
Chart #4 x 13
Chart #8 x 48
Chart #9 x 26
Chart #10 x 16
Chart #11 x 8
Chart #12 x 6
Chart #13 x 41
Chart #14 x 17
Chart # 15 x 13
Chart #16 x 1
Chart #17 x 9
Chart #19 x 1
Chart #20 x 8
Chart #22 x 8
Chart #23 x 13

Review of medical records revealed 12 charts where orders were not signed, as follows (Chart# x number of orders not signed):

Chart #1 x 1
Chart #2 x 4
Chart #3 x 18
Chart #4 x 9
Chart #8 x 41
Chart #9 x 19
Chart #10x 6
Chart #12 x 1
Chart #13 x 40
Chart #14 x 18
Chart #22 x 1
Chart #23 x 6

An interview with staff #1 and # 7 on 06/21/2012, at approximately 3:30 PM in the family room, confirmed patients' charts were missing dates, times, and physicians' signatures.

Review of form titled " restraint order form " in open record #3 dated 06/15/2012 through 06/21/2012 it was observed the signature, date, and time of the physician's documentation did not appear to be in the same hand writing.
An interview with physician # 34 on 06/22/2012 at 11:30, confirmed only 3 of 6 signatures on the restraint order form were his original signature. Questioned physician #34 if the signatures were from another caring giver of the patient? He reported he had no idea who had tried to sign his signature on the restraint order form.
An interview with staff #24, #13 and #28 on 6/22/2012 at 12:00 PM at the nurses station, revealed no staff could accurately identify the remaining 3 physician's signature. All three staff accredited the signature to Physician #34 (who identified only the first three of the signatures as his).

An interview with staff #24 on 06/22/2012 at 12:30 PM in medical record office, confirmed no signature card produced a matching signature for the last three signed physician's orders for the restraint order form.

The facility failed to provide a legitimately signed physician order on three occasions that a patient was restrained.

Based on record review and interview the facility failed to provide a safe setting for the care of a patient in renal failure (kidney failure) with a blood pressure of 84/45.
A. Nurses #34 and #35 caring for patient #1, infused Levophed (a medication used to increase the blood pressure in critically ill patients with critically low blood pressures) and failed to follow the recommendations for dosing and monitoring of the patient receiving this medication.
B. Nurses #34 and #35 infused Levophed to patient #1 with an incomplete physician ' s orders and failed to follow the accepted standard of practice of what constitutes a physician ' s order.
C.The facility failed to provide policies and procedures to guide nurses for the infusion of Levophed.
These deficient practices were determined to pose Immediate Jeopardy to patient health and
safety due to nurses infused Levophed (norepinephrine bitartrate) (a medication used to
increase the blood pressure in critically ill patients with critically low blood pressures) was being administered by intravenous drip using titration method to maintain a blood pressure without facility policy or physician order.

A.During the record review on 06/19/2012, revealed the patient was admitted to the facility on 05/25/2012 with a diagnosis of Decubitus Ulcer- E.Coli (bacteria)Wound. The document titled " Physician Progress Notes " dated 06/06/22012 revealed a diagnosis of Septic Shock, Acute Renal Failure, Anemia.

During the review of patient #1 chart on 06/19/2012 the document titled, " Nurses Notes " revealed the following entries by staff #34:
1. 2445,Levophed 4mg in 250 D5W started @ 6 mcg/min. will continue to monitor.
2. 0100 BP 82/28 increased Levophed to 10 mcg/min.
3. 0200 BP99/41 Levophed remained @ 10 mcg/min.

Review of the document titled " Vital Signs Record " revealed the following enteries:
Staff #34 recorded :
1. 06/07/12, Time 0045, Blood pressure 84/45, Notes Levophed @ 6 mcg/min
2. 06/07/12, Time 0130, Blood pressure 82/28, Notes increased to 10 mcg/min
3. 06/07/12, Time 0230, Blood pressure 99/41, Notes Levophed @ 10 mcg/min
4. 06/07/12, Time 0330, Blood pressure 101/44, Notes Same Rate
5. 06/07/12, Time 0430, Blood pressure 98/45, Notes Same Rate
6. 06/07/12, Time 0530, Blood pressure 143/68, Notes Decreased rate to 2 mcg/min
7. 06/07/12, Time 0 630, Blood pressure 128/55, Notes Same Rate
Staff #35 recorded:
1. 06/07/12, Time 0800, Blood pressure 103/53, Notes Levophed @ 2 mcg/min
2. 06/07/12, Time 0900, Blood pressure 102/52, Notes Levophed @ 2 mcg/min
3. 06/07/12, Time 1000, Blood pressure 104/55, Notes Levophed @ 6 mcg/min
4. 06/07/12, Time 1100, Blood pressure 103/58, Notes Levophed @ 2 mcg/min
5. 06/07/12, Time 1200, Blood pressure 125/53, Notes Levophed gtt. Off

Review of the FDA information in regards to Levaphed precautions revealed:Avoid Hypertension: Because of the potency of LEVOPHED and because of varying response to pressor substances, the possibility always exists that dangerously high blood pressure may be produced with overdoses of this pressor agent. It is desirable, therefore, to record the blood pressure every two minutes from the time administration is started until the desired blood pressure is obtained, then every five minutes if administration is to be continued.
A review of the medication insert provided by the manufacture, CIBA Pharmaceuticals Company, revealed, "Avoid Hypertension: Because of the potency of LEVOPHED and because of varying response to pressor substances, the possibility always exists that dangerously high blood pressure may be produced with overdoses of this pressor agent. It is desirable, therefore, to record the blood pressure every two minutes from the time administration is started until the desired blood pressure is obtained, then every five minutes if administration is to be continued. The rate of flow must be watched constantly, and the patient should never be left unattended while receiving LEVOPHED.
An interview with Staff # 35 on 07/02/2012 at 10:20AM revealed, patient #1 was placed on an automatic blood pressure machine. The blood pressure machine was set to cycle every hour. Interview revealed there was no continuous monitoring being done by staff while the patient was receiving the continuous medication. When staff #34 was asked what guidance was relied on to infuse the medication, the reply was " my personal notes and personal experience. Staff was asked if the facility or it ' s pharmacy provided policies or guidance for infusing the medication, response was, " no " .


B.During review of patient #1 ' s medical record, a document titled " Physician ' s Orders " revealed, " Keep SBP >100 (systolic blood pressure(the top number) greater than 100), may need to start levophed to maintain SBP". No other orders for Levophed was in the chart for review.

A review of the following resource for acceptable element of a physician ' s orders, Encyclopedia of Nursing & Allied Health, ?2002 Gale Cengage, revealed, "Universally accepted safe clinical practice guidelines and state laws govern the components of medication orders in order to ensure consistency and patient safety. All orders should contain the patient's name, the date and time when the order is written, and the signature of the ordering clinician. Caregivers administering medication are responsible for checking that these components are present and clear. The name of the medication is accompanied by the dosage, or how much of the drug should be given; the route of administration, or how the medication should be given (ie, intramuscular injection); and frequency, or how often the drug is to be given. "



C.A request was made to Staff #1, Staff #7, Staff #14 and Staff #30 for a Policy and Procedure as it relates to the medication, Levophed. No policy was made available to the survey team.


An interview was conducted on 06/21/2012 at approximately 1130 in the family room with staff #1 Staff #1 reported he had no knowledge of the medication Levophed being give in the facility. Staff #1 reported there was not a policy or guidance to the nursing staff for giving the medication Levophed.

An interviewwas conducted on 06/21/2012 at approximately 1130 in the family room with staff #7. Staff #7 reported a lot of their staff had Intensive Care experience and had knowledge of the medication Levophed. Staff #7 reported there was no policy or guidance to the nursing staff for giving the medication Levophed.

An interview was conducted on 06/21/2012 at approximately 1130 in the family room with staff #14. Staff #14 reported there was no policy or guidance to the nursing staff for giving the medication Levophed.

An interview was conducted on 06/22/2012 at approximately 1130 with staff #30. Staff #30 reported he had no knowledge of the medication Levophed being given in the facility.