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Based on medical record reviews, staff interviews, and review of policies and procedures, the facility failed to ensure that registered nurses evaluated and supervised the nursing care of 4 of 22 sampled patients (Patients #7, #17, #18,#20). The total census during this visit was 17 patients.

Findings include:

Review of the medical record for Patient #7 was completed on 05/19/11 and 05/20/11. This patient was admitted from 04/01/11 with a diagnosis of cerebral vascular accident (CVA) and left sided weakness and paralysis. The patient was admitted for therapy services which included physical, occupational, and speech therapies. The patient was assessed by nursing on 04/01/11 as being a high risk for falls. This assessment scored the patient at 110 according to the Morse Fall Risk Assessment. A score greater than 45 on the assessment indicated the patient was at high risk. The assessment documented the patient as having impaired situational term memory, having a history of falls, using a cane/crutches, walker, being on fall risk medications, having weak or impaired gait/transferring skills, and forgetful to limits. A mobility assessment completed on 04/02/11 documented the patient's gait pattern was uneven step length, and patient leaned and falls to the left constantly as left knee buckled. This assessment also stated the patient's trunk is shifted left.

The medical record documented the patient experienced the following falls:
a) A fall occurred on 04/01/11 at 6:50 PM. The post fall assessment documented night shift staff came in and found the patient sitting beside the bed on the floor. This assessment was silent to safeguards in place before the fall. No injuries were documented on the post fall assessment.

b) On 04/02/11 at 3:00 AM, a post fall assessment (PFA) revealed a fall resulting in a 3 centimeter abrasion on the patient's left elbow. The medical record was silent to nursing documentation on how the fall occurred, and of notification of the patient's interested party (friend), who was listed as the person to notify in an emergency. Safeguards in place before this fall was a chair alarm and a low bed. The PSA was silent to a yellow wrist band (used on all high risk fall patients to identify being at risk).

c) On 04/06/11 at 3:45 PM, a post fall assessment revealed a personal alarm, yellow band, and low bed were in place. The nursing note, at 4:00 PM on 04/06/11, stated the patient's personal alarm went off, and a patient care technician found the patient on their knees on the floor. This resulted in a small abrasion on the patient's left knee. The medical record was silent to notification of the patient's interested party.

d) On 04/16/11 at 4:15 AM, the post fall assessment revealed the patient experienced a fall; however, the nursing notes were silent to the incident. The PFA stated the only safeguards in place before the fall were a yellow band and low bed. The medical record was silent to a bed or chair alarm. The physical assessment on the PFA documented the patient's left arm appeared that it may be dislocated or out of alignment in some way. The patient was alert and oriented but confused regarding his/her physical limitations regarding mobility. There was no documentation by nursing as to what occurred as the nursing progress notes were silent to this fall.

A review of Policy NSG 129 titled: Fall Prevention stated nursing staff should investigate and assess circumstances surrounding a fall via a Post Fall Assessment. This policy included interventions which stated "Initiate fall risk plan of care which may include on or more of the following strategies (not limited to):
Place a yellow arm band on the patient, use of bed/chair alarms, use protective devices for patients unable to follow instructions, bed in lowest position while in bed, and monitor patient and environment for safety every hour.

Interviews conducted with Staff C and F on 05/20/11 between 11:15 AM and 11:25 AM verified the aforementioned concern regarding lack of nursing assessments, documentation, and notification of the interest party related to Patient #7's falls. These staff verified Policy NSG 129 did not include specific measures that should be implemented for patients at high risk for falls, verifying the policy only stated suggestions that may be put into place. Staff F stated all high risk fall patients, at a minimum, should include moving the patient close to the nursing station, placing a yellow wristband on the patients, using a low bed, education to the risk of falls, and personal/bed alarms if appropriate.

On 05/19/11 and 05/20/11, medical record review for Patient #17 revealed the patient was admitted to the facility on 04/22/11 from a long term care acute hospital, for therapy services. The patient had an admitting diagnoses of CVA with left sided paralysis. At the time of admission, the patient was identified at high risk for falls with a score of 70 (greater than 45 was high risk). Medical orders stated the bed alarm and bed in low position was discontinued on 04/25/11.
A post fall assessment dated 04/25/11 at 3:10 PM stated staff observed patient lying on their left side on the floor in doorway of room with wheelchair on its side next to the patient. The patient was observed with blood on their right hand. After washing the patient's hand, the skin was noted intact; however, and abrasion was observed on the patient's forehead. The physician gave orders at 3:30 PM for a bed and chair alarm, every one hour checks, and leave the door open. The physician assessed the patient at 3:50 PM that same date.
Nursing progress notes, dated 04/25/11 at 4:20 PM, revealed staff heard the patient's personal alarm and entered the room, observing the patient sitting on the floor in front of the wheelchair. The post fall assessment stated a chair alarm was in place. This assessment was silent to a call light and yellow wrist band.
After these two falls, the medical record was silent to safeguards in place after identifying the patient at high risk for falls, and prior to the fall experienced by the patient on 04/25/11 at 3:10 PM.
A CT scan was done for Patient #17 on 04/29/11. The resulting report stated this was done due to cognitive decline and 3 falls that week.
Staff C and F verified the aforementioned concerns for Patient #17 on 05/20/11 between 11:15 AM and 11:25 AM.

Per medical record review, Patient #20 was admitted to the facility 05/03/11 with a reddened coccyx and buttocks. On 05/18/11, this patient was discovered with an open area on the left outer ankle with measured 1/2 by 3/4 centimeter opening that was 100% white slough. The open area was surrounded by a 3 centimeter reddened area. This documentation was silent to staging of the open area. A review of the patient's medical record on 05/19/11, and an interview with the patient on 05/20/11 at 8:50 AM, revealed the patient has uncontrolled spastic movements of both lower extremities, and had difficulty keeping pressure off the left outer ankle.

An interview was conducted with registered nursing staff C on 05/19/11 at 4:30 PM. This employee stated the facility standard for assessing, staging, and documentation of pressure sores was the Lippincott Manual of Nursing Practice, 9th edition. This employee verified the section used in this manual for pressure ulcers was pages 186-188. An actual review of this section revealed the assessment of the open pressure sore should include staging of the wound. The manual was silent to reassessing the open area. This was verified with Staff C at that time.



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The medical record review for Patient #18 was completed on 05/19/11. The Patient was admitted for rehabilitative services of the hospital on 04/19/11 with admission diagnosis of cerebral vascular accident. The patient was identified by nursing as a high fall risk with indicators of secondary diagnoses of neuropathy, dementia and depression, use of cane, impaired gait and transfer and mental deficit of forgetting limits.

The nursing services instituted precautionary measures of the use of a personal alarm while in the wheelchair. According to the documentation in the nursing progress notes of 04/21/11 at 10:10 AM, "observed patient on the floor next to her wheelchair. She had removed her personal alarm. No injury noted, vital signs stable, doctor was called no new orders. Patient went down to therapy new intervention:put bed alarm in wheel chair so she will be sitting on the alarm. "

The medical record review revealed a post -fall assessment dated 04/21/11. The physical assessment portion of the assessment stated "patient takes her alarm off, it is pinned to her clothing, new intervention is to put the bed alarm in her wheel chair when she is in it so she will be sitting on the alarm." There was no documentation in the physical assessment to determine the physical status at the time of the fall. Interview with Staff F (registered nurse manager) on 05/10/11 at 10:30 AM revealed the physical assessment portion of the post fall assessment should include a head to toe assessment with range of motion and a neurological assessment if head injury." Documention in the nursing progress notes stated "therapy tech informed nursing the patient is now complaining of left hip pain only when weight bearing. Paged doctor again at 11:55 AM." A stat (emergent ) X-ray was ordered which revealed "slightly impacted basocervical fracture of the left hip." The Patient was then transferred to an acute care hospital on 04/21/11 at 3:30 PM.

Based on medical record reviews, and staff interviews, and policy reviews, the facility failed to maintain a complete medical record related to falls for 1 of 22 sampled patients (Patient #7). The total census during this visit was 17 patients.

Findings include:

Review of the medical record for Patient #7 was completed on 05/19/11 and 05/20/11. This patient was admitted from 04/01/11 with a diagnosis of cerebral vascular accident (CVA) and left sided weakness and paralysis. The patient was admitted for therapy services which included physical, occupational, and speech therapies. The patient was assessed by nursing on 04/01/11 as being a high risk for falls.

The medical record documented the patient experienced the following falls:

a) On 04/02/11 at 3:00 AM, a post fall assessment (PFA) revealed a fall resulting in a 3 centimeter abrasion on the patient's left elbow. The medical record was silent to nursing documentation on how the fall occurred, and of notification of the patient's interested party (friend), who was listed as the person to notify in an emergency). Safeguards in place before this fall was a chair alarm and a low bed. The PSA was silent to a yellow wrist band (used on all high risk fall patients to identify being at risk).

d) On 04/16/11 at 4:15 AM, the post fall assessment revealed the patient experienced a fall; however, the nursing notes were silent to the incident. The physical assessment on the PFA documented the patient's left arm appeared that it may be dislocated or out of alignment in some way. The patient was alert and oriented but confused regarding his/her physical limitations regarding mobility. There was no documentation by nursing as to what occurred as the nursing progress notes were silent to this fall.

Interviews conducted with Staff C and F on 05/20/11 between 11:15 AM and 11:25 AM. These employees verified the medical record documentation for Patient #7 related to these falls.

Based on review of job descriptions of the food service supervisor and director of facilities management, policy for food storage, observation of the dietary department and staff interview, the hospital failed to ensure the dietary supervisor and director of facilities management maintained ongoing monitoring of the food safety related to food stored in frozen storage. The total patient census was 17.

Findings include:

Review of the hospital's job descriptions for the food service supervisor and director of facilities management and hospital policy for food storage was completed on 05/19/11 in the afternoon hours. The hospital policy for food storage (policy number Nutri-122) stated the purpose was to "assure safe food, supply, and chemical storage facilities within the department, as well as safe storage techniques are utilized." The section #16 (c) Frozen Foods stated "Foods should be covered, labeled and dated." Staff D (plant operations manager) stated on interview it was standard practice of the dietary supervisor for pork to be frozen for two months, poultry for four months and lunch meat for four months and then removed and discarded.

The job description of the Food Services Supervisor was reviewed on 05/19/11 in the afternoon hours. The position purpose included but not limited to : "assists in planning, directing, and coordinating the activities of the Food Services Department to provide dietetic services to patients as well as employees and guests". Position Specific Duties included :'(1) performs and documents all purchasing receiving and inventory control of food and supplies, (2) performs any and all duties in the kitchen tray line, cafeteria, and dish room as requires, (3) checks routine maintenance, (4) responsible for all aspects of cafeteria food service, (5) develops systems and provides for dietary services according to accepted standards of care and (6) maintains sanitation and proper temperature as well as correct food handling techniques in cafeteria."

The job description of the Director of Facilities Management was reviewed on 05/19/11 in the afternoon hours. The position purpose included but not limited to : daily direction of the kitchen/dietary functions." The Position Specific Duties included :"establishes and maintains a high standard of sanitation. "

Observations were made of the dietary department while on tour with Staff C (Chief Nursing Officer) and Staff D (plant operations manager) on 05/19/11 at 9:10 AM. The frozen food was stored in two upright freezers. The following observations were made of food storage in the upright freezer located to the left of the first upright freezer: (1) there were multiple plastic bags of frozen meat that were identified by Staff D as sausage patties. These bags had no label to identify what was stored in the bag or date of expiration. There were dates on the bags, however, Staff D and Staff G (dietary aide) were unable to explain if indicated for expiration or date of arrival. A case of sausage patties was stored in an opened box with a date marked of 03/23/11. Another case of sausage was dated 12/10/10. A third case of sausage was dated 05/03/11. In addition, there were 19 smaller freezer bags of sausage ranging in dates from 04/01/11 to 05/04/11. A case of bacon was dated 05/02/11 and Staff D was unable to verify the expiration date or what the date of 05/02/11 referred to. A bag of ham stored in the freezer and for patient use was labeled "use by 05/08/11." There were 4 packages of meatballs that were not dated or labeled. Three large gallon bags of chicken patties were stored in this freezer that had been opened, not resealed and not labeled nor dated. There were 2 pork shoulder roasts that were not dated. All of the items were removed by Staff D and he/she instructed the dietary aide (Staff G) to discard the items.

The above findings were confirmed on interview with Staff C and Staff D on 05/19/11 in the afternoon hours.

Based on observation of medication administration, record review, and staff interview, it was determined the facility failed to ensure blood pressure medications were administered to Patient #8 in accordance with the physician ordered blood pressure parameters. In addition, the medication nurse failed to administer blood pressure medication to Patient #21 in accordance with the physician orders. Medication administration was observed on six patients (Patients #1, 3, 4, 10, 20, and 21). The facility census was 17.

Findings include:

On 05/18/11 between 8:45 AM and 9:20 AM Staff E (Registered Nurse) was observed administering medications. At 8:45 AM Staff E was observed to administer medications to Patient #21. Staff E administered one tablet of Lopressor 25 milligrams (blood pressure control medication). Review of Patient #21's medical record on 05/18/11 revealed a written physician order dated 05/17/11 to administer one and 1/2 tablets of Lopressor 25 milligrams twice a day. Interview with Staff C on 05/18/11 at 4:00 PM confirmed only one tablet of Lopressor 25 milligrams had been administered.

The medical record for Patient #8 was reviewed on 05/18/11 with Staff F. There was a physician written order dated 05/12/11 at 7:00 PM that called for blood pressure medications of Toprol and Cardizem to be held if the systolic blood pressure was less than 120. Review of the medication administration record and review of the nursing notes/vital signs revealed on 05/13/11 the patient's blood pressure was 117/70 and 109/69 prior to the administration of the Cardizem and Toprol. The medications of Toprol and Cardizem were documented as administered. The medications were not held as per the physician order and in accordance with the blood pressure parameters established. In addition, on 05/16/11 the patient's blood pressure was recorded as 116/50 at 6:00 AM. There were no further blood pressure readings documented prior to the administration of Toprol and Cardizem. The medications (Toprol and Cardizem) were administered outside the physician ordered parameters. On 05/17/11 the patient's blood pressure was 118/65 at 6:00 AM. There were no further blood pressure readings documented prior to the administration of Toprol and Cardizem. The blood pressure medications were documented as administered outside of the physician ordered parameters. These findings were confirmed with Staff F on 05/18/11 at 11:00 AM.