HospitalInspections.org

Based on record review and interview the hospital failed to meet the Condition of Participation of Quality Assurance Performance Improvement as evidenced by:

1. Failing to ensure that a quality assurance system was implemented related to identifying all medication errors. The hospital failed to perform, as part of quality assurance, medical record chart reviews to identify medication errors rather than the hospital's system of relying on "self reporting". The failure of this QA system resulted in unidentified medication errors. (See findings at Tag A266);

2. Failing to ensure the data collected through the hospital's QA program was reported in measurable outcomes as evidenced by the failure to maintain supporting documentation that measurable improvements were made or sustained after problems were identified through QA with contracted agencies that provided laboratory, pharmacy and dietary (See findings in Tag A0291);

3. Failing to follow the hospital's Performance Improvement Plan by failing to ensure Dietary, Dialysis, Respiratory, Radiology, and Rehabilitation departments developed, monitored and tracked performance indicators in these departments which would identify problems with delivery of care and services and patient safety concerns (See findings at Tag A0275); and

4. Failing to ensure the Governing Body had ensured compliance with the hospital's Performance Improvement Plan as evidenced by the Performance Improvement Committee failing: to conduct QA/PI meetings monthly; to evaluate contracted services before the contract was renewed; to ensure contracted services providing direct patient care participated in the hospital-wide QA/PI program as evidenced by no documented evidence dialysis, radiology, ultrasound, rehabilitation or dietary were part of the OA/PI process; and to ensure a QA/PI Coordinator was hired after the Coordinator was promoted into the Assistant Director of Nursing position in April 2010. The position was delegated to the Director of Nursing which did not allow adequate time for performance of both the DON and QA Coordinator duties and responsibilities (See findings at Tag A0310).

Based on record review and interview the hospital failed to meet the Condition of Participation for Nursing Services as evidenced by:

1. Failing to ensure the Registered Nurse (RN) supervised and evaluated the nursing care for each patient by failing to:
a. ensure the RN assessed a patient with a change in condition for 2 of 8 patients sampled patients (#1, #3);
b. ensure the RN performed accurate wound/skin assessments that included measurement and/or staging of wounds and pressure ulcers for 3 of 5 patients reviewed with wounds (#1, #3, #4);
c. ensure vital signs were monitored as required for patients receiving blood pressure medications for 3 of 8 patients sampled (#1, #4, and #5) (See finding at Tag A0395);

2. Failing to ensure the nursing staff followed hospital policies and procedures for the development and implementation of each patient's plan of care. The plans of care failed to have measurable goals, measures to assess progress and goal attainment, ensure care plans identified all patient problems for which the patient was receiving medical treatment, and ensure care plans were updated when changes occurred in a patient's medical condition including diabetes complications, hypoglycemia, elevated blood pressures, tube feedings, wound care, and changes in weight (See findings at Tag A 0396); and

3. Failing to ensure medications were administered as ordered by the physician for 6 of 8 patients sampled (#1, #2, #3, #4, #5, #6). (See findings at Tag A0404).

Based on record review and interview, the hospital failed to meet the Condition of Participation for Food and Dietetic Services as evidenced by:

1) Failing to ensure there was a full-time employee who served as the director of the food and dietetic services. (see findings in tag A0620)

2) Failing to ensure the food and dietetic services were integrated into the hospital-wide QAPI (quality assurance performance improvement) program. (see findings in tag A0620) and

3) Failing to ensure the registered dietitian supervised the nutritional aspects of patient care as evidenced by:
a. failing to ensure the daily food intake had been monitored, assessed, and documented in each patients' chart for patients with diagnoses of anemia, pressure ulcers, malnutrition, diabetes mellitus, end stage renal disease;
b. failing to ensure weights had been re-assessed for accuracy for a patient with the diagnosis of malnutrition and a documented weight loss of 8.7 pounds in 19 days.

These failures were evident in 4 of 8 patients sampled (#4, #5, #7, #8) (see findings in tag A0621).

Based on record review and interview, the hospital failed to ensure a patient's representative was provided written notice of its decision regarding the investigation of 2 grievances for 1 of 1 patient reviewed for grievances from a total of 8 sampled patients (#3). Findings:

Grievance #1:
Review of the hospital's "Patient Family Complaint Log" revealed a complaint was filed on 08/09/10 by the spouse of Patient #3 regarding "poor food services". Further review of the log revealed the question "did complaint result in a grievance" with the answer of "yes". Review of the "Patient Complaint Form" revealed Director of Nursing (DON) S2 received the complaint from Patient #3's spouse on 08/09/10 with the complaint of "food service poor - food cold - pt (patient) not being feed diet not correct". Further review revealed the resolution was "spoke with Registered Dietitian (RD) S4 about food services. Request meeting with Facility A to resolve food service issues. Spoke with staff about preparing food & (and) service to pt (patient)". Further review of the form revealed the status was " unresolved complaint - requires further investigation". Further review revealed no documented evidence a written notice of the hospital's decision regarding the complaint had been sent to Patient #3's spouse at the completion of the investigation.

In a face-to-face interview on 09/08/10 at 4:20pm, DON S2 indicated he considered the complaint unresolved because Patient #3's spouse was not satisfied. He further indicated the complaint should have then been handled as a grievance, and this was not done.

Review of the hospital policy titled "Patient/Family Grievance", effective 04/09 and submitted by DON S2 as the hospital's current policy for grievances, revealed, in part, " ...Definitions ... Patient/Family Grievance - is defined as something that affords just cause for complaint or protest; and/or an issue unresolved following the normal complaint procedure that cannot be resolved promptly by staff present. ... 1. Complaints ... D. If resolution was not achieved by the actions taken by staff and the Charge Nurse, the DON will attempt to identify a solution acceptable to the patient, family member or representative. ... If patient, family member and/or family representative is still unsatisfied or if the verbal patient care complaint cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further action for resolution, then the complaint is considered a grievance ... ".

Grievance #2:
Review of the "Patient/Family Grievance Log" revealed a grievance was received on 08/20/10 from Patient #3's spouse, and written acknowledgement was sent to Patient #3's spouse on 08/24/10 by DON S2. Review of the "Patient Grievance Form" revealed LPN (licensed practical nurse) S11 took the complaint and documented " see attached letter ... ". Review of the letter dated 08/19/10, addressed to Medical Director S9, Patient #3's attending physician, from Patient #3's daughter revealed the following questions and/or complaints: status of brace for assistance in walking; dietary/food - "father does not seem to receive the proper dietary needs ... has on several occasions been given and asked to eat "cold" hot meals " ; caregivers (staff) - "are you all tired of caring for my father? Are you all tired of my Father demanding proper care?"; physical therapy - seemed to have been some unwillingness by staff to continue consistent physical therapy or disgust in treating". Review of the investigation revealed interviews were conducted with LPNs, the RN (registered nurse) Charge, certified nursing assistants, the occupational therapist, and the physical therapy technician. Further review revealed no documented evidence who had conducted and documented the interviews. Further review revealed no documented evidence that the Registered Dietitian and the physical therapist had been interviewed. There was no documented evidence that Administrator S1 had received the grievance as required by hospital policy.

Review of the letter submitted by DON S2 as the letter sent to Patient #3's spouse in answer to the grievance revealed it was dated 08/24/10 and had the typed name and title of DON S2. Further review revealed no documented evidence of DON S2's signature and documented evidence that the letter had been sent by mail, fax, or e-mail to Patient #3's spouse. Further review of the investigation and the contents of the letter revealed no documented evidence that the question concerning the brace for walking had been addressed.

Review of the e-mail sent to Administrator S1 from DON S2 on 08/24/10 at 9:09am and the e-mail response from Administrator S1 to DON S2 on 08/24/10 at 10:43am revealed the subject was "grievance letter for Patient #3's spouse" . There was no documented evidence Administrator S1 was included in the grievance process until the letter of response was ready to be reviewed.

In a face-to-face interview on 09/08/10 at 4:20pm, with Administrator S1, DON S2, and Corporate RN S10 present, DON S2 indicated he had conducted and documented the interviews. He further indicated he spoke with the occupational therapist (OT) rather than the physical therapist (PT), because the OT handled splints. When asked if it was not the OT's responsibility to address upper extremities and the PT to address lower extremities, DON S2 indicated the PT was not available at the time. DON S2 confirmed the investigation and the letter did not address the brace for walking of which Patient #3's daughter had asked. He further confirmed the PT had not been interviewed regarding attitudes toward treatment of Patient #3 as mentioned in the grievance. In the same interview, Administrator S1 indicated he was called about the grievance letter, and he had an e-mail that showed his involvement. After review of the e-mails, Administrator S1 confirmed the e-mails were in relation to the letter of response and did not show his involvement with the grievance process as required by hospital policy. S1 further indicated he gave the letter to his administrative secretary to mail, but he had no documented evidence to show that the letter was actually sent to Patient #3's spouse.

Review of the hospital policy titled "Patient/Family Grievance" , effective 04/09 and submitted by DON S2 as the hospital' s current policy for grievances, revealed, in part, " ...2. Formal Grievance ... B. The Director of Nurses, Case Manager or Administrative Representative receiving the grievance will initiate the Formal Grievance Form and take any steps available to resolve the grievance. ... Any grievance filed regarding quality of care is referred to the Administrator ... After documenting efforts to resolve the grievance, the Formal Grievance Form should immediately be given to the Administrator. E. Once the Committee and the Corporate Director of Quality/Risk Management make a final decision a written response will be provided the complainant within 5 working days ... K. The Governing Board has delegated the responsibility of handling patient grievances to Hospitals Administration and Corporate Risk Management who will respond, investigate, take appropriate action and communicate resolution, as appropriate, back to the patient or appropriate family member or representative ...".

Based on record review and interview, the hospital failed to have a process in place: 1) to ensure "An Important Message From Medicare" form was completed according to hospital policy for 2 of 3 patients reviewed for notification of "An Important Message From Medicare" from a total of 8 sampled patients (#2, #3); 2) to ensure the name of the person with the durable power of attorney was written on the "Consent for Treatment" form and a copy was obtained for the medical record for 3 of 3 patients reviewed who had a durable power of attorney from a total sample of 8 patients (#2, #4, #5); and 3) to ensure the hospital's policy and procedure for informed consents had been followed as evidenced by no documentation of the name of the physician authorized to perform the procedure or the signature of the physician for an "Excisional Wound Debridement" (#5) for 1 of 1 patients having a wound debridement performed out of 8 sampled medical records. Findings:

1) "An Important Message From Medicare":
Review of Patient #2 ' s and Patient #3's medical records revealed "An Important Message From Medicare" had been signed by the patient's representative. Further review revealed no documented evidence the following sections had been completed as required by hospital policy: patient name, patient ID# (identification number), attending physician, and date of notice. Further review revealed no documented evidence Patient #2's form included the date of the representative's signature.

In a face-to-face interview on 09/08/10 at 10:20am, Director of Nursing (DON) S2 confirmed the Medicare notice was incomplete. He offered no explanation for the form being incomplete.

Review of the hospital's "guideline for completion" of "The Important Message From Medicare", presented by DON S2 when the hospital's policy was requested for completion of "An Important Message From Medicare", revealed, in part, "...4. Patient Name: Fill in the beneficiary's full name. 5. Patient ID Number: Fill in an ID number that identifies this beneficiary. ... 6. Attending Physician: Fill in the beneficiary's attending physician ' s name. 7. Date of Notice: Fill in the date the notice is delivered to the beneficiary by the Hospital. ... 9. Date: Have the beneficiary or representative place the date he or she signed the notice ... Additional Recommendations: ... 2) Case Management review all admissions to ensure initial notification is documented in the medical record ...".

2) Durable power of attorney:
Review of Patient #2, #4 and #5's "Conditions of Admission Authorization For Medical Treatment" revealed Patient #2 and #5 had executed a Durable Power of Attorney (POA). Further review revealed no documented evidence the name of the individual who had been designated as the Durable POA was listed. Further review of the entire medical record for both patients revealed no documented evidence of a copy of the Durable POA.

Review of the Interdisciplinary Progress Notes for Patient #2, #4, #5 revealed no documented evidence any attempt had been made to obtain the Power of Attorney.

In a face-to-face interview on 09/08/10 at 10:20am, DON S2 confirmed the name of the Durable POA was not listed on the consent, and there was no copy of the POA in the medical record.

Review of the "Conditions of Admission Authorization For Medical Treatment" revealed, in part, "...4. I have executed a Durable Power of Attorney. (POA Name: ___) I understand that it is my responsibility to provide a copy of this document to this facility in order for it to be followed accordingly ...".

3) ensure the hospital's policy and procedure for informed consents
Patient #5
Review of the consent for " Excisional Wound Debridement " dated 08/05/10 for Patient #5 revealed no documented evidence of the name of the physician authorized to perform the procedure or the signature of the physician had been completed. Further review revealed in the space provided for the " relationship of the person consenting " " son - holds Power of Attorney (POA) to make medical decisions " . The consent was signed by the son of Patient #5 and witnessed by the son's wife; however there was no documented evidence which verified Patient #5 had given her POA to her son.

Review of the hospital policy titled "Witnessing Consents/Legal Documents", issued 04/09 and submitted by ADON (assistant director of nursing) S18 as one of two of the hospital's policies for consents, revealed, in part, "...It is the policy of this facility that the witnessing of legal documents while a patient is in the care of the facility be approved by the administrator. ... It is the policy of this facility that the witnessing of any consent for any and/or types of procedures must be done by a Registered Nurse. The procedure must be explained by the performing physician and all risk factors explained. The Registered Nurse is only witnessing that the patient or designated family member or guardian signs the consent. It is not a witness of the physicians reviewing the procedure and possible risk factors".

Review of the hospital policy titled "Consent To Treat/Photograph", issued 04/09 and submitted by ADON S18 as one of two of the hospital's policies for consents, revealed, in part, "... Each patient or family member/significant other will sign a Consent to Treat, which includes a Consent to Photograph, upon admission. Procedure: 1. Upon admit, the admitting nurse or Admission Coordinator will have the patient or family member sign a Consent to Treatment. 2. The consent will be placed in the medical record under the Admission section". Further review revealed no documented evidence that the policy addressed the completion of the form.

Based on record review and interview, the hospital failed to ensure the Registered Nurse (RN) supervised and evaluated the nursing care for each patient by failing to: 1) ensure the RN assessed a patient with a change in condition for 2 of 3 patients with a change in condition from a total of 8 sampled patients (#1, #3); 2) ensure the RN performed accurate wound/skin assessments that included measurement of wounds and staging and measurement of pressure ulcers for 3 of 5 patients reviewed with wounds from a total of 8 sampled patients (#1, #3, #4); 3) monitor vital signs which resulted in patients not being administered Clonidine as ordered for elevated systolic blood pressure for 2 of 3 patients reviewed for monitoring of vital signs from a total of 8 sampled patients (#1, #5) and Midodrine and Lopressor being administered without documented assessment of blood pressure to ensure the blood pressure was out of the ordered parameters (#4) for 1 of 1 patient with MD orders for Midodrine from 8 sampled medical records; 4) ensure medication orders without an indication for use were clarified by the physician for 2 of 2 patients reviewed for indication for use of medications from a total of 8 sampled patients (#1, #2, #4); 5) ensure the patients' daily food intake had been assessed and documented in the patients' charts for 5 of 5 patients reviewed for daily intake (#3, #4, #5, #7, #8) from a total of 8 sampled medical records; 6) ensure daily or weekly weights had been assessed as ordered for 4 of 8 sampled patients (#3, #4, #7, #8); and 7) ensure the RN assessed a patient and reported a patient's complaint of pain to the physician following a fall for 1 of 2 patients reviewed with a fall from a total of 8 sampled medical records (#1). Findings:

1) RN assessment with a change in condition:
Patient #1
Review of Patient #1's medical record revealed she was admitted on 08/19/10 at 8:00pm with diagnoses of Hyperkalemia, End Stage Renal Disease, and Sepsis. Review of the History and Physical (H&P) revealed additional diagnoses of Staph Epidermidis, Diabetes Mellitus, Major Depression, and Peripheral Neuropathy.

Review of Patient #1's "Physician Sliding Scale Insulin Orders" dated 08/19/10 at 10:10pm revealed she was to have capillary blood glucose (CBG) checks AC and HS (before meals and at bedtime). Further review of the order revealed the "Hypoglycemic Protocol" included the following: accucheck 60-69 - 4 oz (ounces) OJ (orange juice) or 15 ml (milliliters) D50 (50% dextrose) IV (intravenous) (if unable to swallow or Signs or symptoms); accucheck 50-59 - 20 ml D50 IV; accucheck less than 50 - 25 ml D50 IV - draw stat BMP (basic metabolic profile); always check CBG 30 minutes after interventions & notify physician. Further review revealed if the accucheck was above 400, 14 units of Regular insulin was to be administered and the physician notified.

Review of Patient #1's "Daily Nursing Assessment" for 08/29/10 revealed an entry by RN S3 at 9:00pm of "accu (check mark) 475, 14 units of R (regular) insulin given SQ (subcutaneous) to abd (abdomen)". Further review revealed at 9:30pm RN S3 documented that RN S12, Charge Nurse, notified Medical Director S9, and no new orders were obtained. Further review revealed at 10:00pm RN S3 documented the accucheck was 430, and at 11:15pm it was 273. Further review revealed no documented evidence Medical Director S9 was notified of the CBG greater than 400 at 10:00pm.

In a face-to-face interview on 09/08/10 at 8:20am, RN S3 confirmed she did not report Patient #1's repeat CBG of 430 to his physician.

Review of Patient #1's "Daily Nursing Assessment" for 09/06/10 revealed the following entries by LPN (licensed practical nurse) S5:
8:00pm - patient stated feels nauseated; Phenergan given as ordered; CBG down to 40; RN charge nurse notified; patient awake and alert oriented times 3; gave Ensure (patient refused juice);
8:30pm - rechecked CBG 66; patient given Nepro, celery, carrots, and peanut butter (patient ' s usual evening snack); reports feeling better;
9:00pm - recheck CBG 83; awake, alert, oriented times 3; RN charge nurse notified.
Review revealed no documented evidence the RN assessed Patient #1 when her blood glucose dropped to 40.

In a face-to-face interview on 09/08/10 at 9:55am, LPN S5 indicated Patient #1's roommate was receiving blood at the time of Patient #1's drop in blood glucose, so there was a RN in the room throughout the time she was caring for the patient. After S5 reviewed the physician's orders for the hypoglycemic protocol, she indicated she did not follow the physician's orders. LPN S5 indicated she didn't call the physician, because she leaves that to the RN.

In a face-to-face interview on 09/08/10 at 9:55am, DON S2, who was present during the interview with LPN S5, indicated the RN should have assessed Patient #1 during her hypoglycemic episode, assured the physician's orders were followed, and the physician was notified of the event.

Review of Patient #1's physician orders revealed an order on 08/25/10 at 8:50pm for Clonidine 0.1 mg (milligrams) by mouth every 6 hours as needed for systolic blood pressure greater than 160.

Review of Patient #1's "Vital Signs and Intake & Output Records" revealed the following dates and times of documented blood pressures:
08/30/10 at 6:00am - 64/31; at 6:00pm - 163/77;
09/04/10 at 6:00pm - 166/80.

Review of Patient #1's "Daily Nursing Assessment" for 08/30/10 revealed no documented evidence LPN S17 reported the blood pressure of 64/31 to the RN and physician, an intervention was implemented, and a reassessment of the blood pressure was performed.

Review of the "Daily Nursing Assessment" for 09/04/10 revealed the following documentation by LPN 6: 7:15pm - blood pressure (BP) 192/86 per certified nursing assistant; manual BP 188/98; Clonidine 0.1 mg and Ultram (2) given orally; 8:15pm - BP 166/80, resting without distress; 11:45pm - BP 179/81, Xanax 0.25 mg given orally. Further review revealed no documented evidence LPN S6 notified the RN of the change in condition, and there was no further reassessment of the BP of 179/81 at 11:45pm.

In a face-to-face interview on 09/08/10 at 10:20am, DON S2 indicated LPN S6 was not available for interview. After reviewing the medical record of Patient #1, DON S2 confirmed the LPN should have notified the RN when the patient's condition changed, LPN S17 should have notified the RN and physician when the BP of 64/31 was obtained.

Patient #3
Review of Patient #3's medical record revealed he was admitted on 08/02/10 at 5:00pm with diagnoses of Sepsis, Fever, Chronic Kidney Disease, Hemodialysis, and Prostate Cancer. Review of the H&P revealed additional diagnoses of Abdominal distention with constipation, anorexia, and a history of a colostomy; Diabetes Mellitus, insulin requiring; Metastatic prostate cancer with particularly metastases to his back; History of stroke with moderate right hemiparesis; Left foot drop which is severe; Generalized debility; Stage 2 sacral decubitus; Diabetic neuropathy, Scrotal and penile edema; Recent left lower lobe pneumonia with bronchospasm, ongoing; and Anorexia, at risk for malnutrition.

Review of Patient #3's physician's orders revealed the admit orders included accuchecks before meals and bedtime. Further review revealed an order for management of patient with low blood sugar to include if "60" appears in display or blood glucose below 60, retest, notify physician, and obtain blood glucose to send to laboratory for confirmatory test results. Further review revealed a "Physician Sliding Scale Insulin Orders" received by telephone order from Medical Director S9 on 08/02/10 with no documented evidence of the time the order was received. Further review revealed for a CBG of 50-59, 20 ml D50 IV was to be administered, always recheck CBG 30 minutes after interventions, and notify the physician.

Review of Patient #3's "Diabetic Record" revealed his blood glucose was 50 at 7:30am on 08/03/10. Review of the "Daily Nursing Assessment" for 08/03/10 revealed no documented evidence LPN S11 had reported the blood glucose of 50 to the RN, the blood glucose was rechecked, the physician was notified, blood glucose was sent to the lab for confirmatory test results, and 20 ml D50 IV was administered, all required by physician orders.

In a face-to-face interview on 09/08/10 at 10:20am, DON S2 confirmed Patient #3's physician's orders were not implemented on 08/03/10.

Review of the hospital policy titled "Nursing Documentation Guidelines", effective 04/09 and submitted by DON S2 as the hospital's current policy for RN assessment with a change in condition, revealed, in part, "... For changes in patient condition, the RN must be notified for assessment, physician notification (if applicable), and evaluation of interventions. This is to be documented in patient's daily record and communicated to the other disciplines involved in the patient's care ...".

Review of the hospital policy titled "Patient Care Documentation (Nursing)", last revised 04/09 and presented by DON S2 as their current policy for RN assessment with a change in condition, revealed, in part, "...Whenever the patient's condition changes, a reassessment will be documented. ... The LPN must notify the RN of abnormal findings and deterioration in the patient's condition for assessment, physician notification (if applicable), and evaluation of interventions. The RN will direct and coordinate patient care team members through direct assessment and through reviewing and updating the problem list and plan of care on a daily basis ...".

2) Wound/skin assessments by the RN:
Patient #1
Review of Patient #1's medical record revealed she was admitted on 08/19/10 with diagnoses of Hyperkalemia, End Stage Renal Disease, and Sepsis.

Review of the "Initial Nursing Assessment" performed by RN S13 on 08/19/10 at 9:00pm revealed the following "wound description": type P (pressure); Location - buttocks; Color - pink; Odor - none; Drainage - none; Description of dressing & surrounding tissue - healthy tissue; Type S (surgical); Location - right foot 3rd toe amputated; Description of dressing & surrounding tissue - healthy. Further review revealed no documented evidence of the measurement and stage of the pressure ulcer to the buttocks.

Review of Patient #1's "Wound Care Notes" dated 08/20/10 at 2:20pm by LPN S14 revealed the following: "new admit assessment done. No open areas noted. Patient has an old scar to left buttock from a wound. No redness noted. Scab noted to first toe & second toe on right foot. Mild redness noted to bilateral heels". Further review of Patient #1's daily wound assessment revealed she had no wounds.

Patient #3
Review of Patient #3's medical record revealed he was admitted on 08/02/10 at 5:00pm with diagnoses of Sepsis, Fever, Chronic Kidney Disease, Hemodialysis, and Prostate Cancer. Review of the H&P revealed additional diagnoses of Abdominal distention with constipation, anorexia, and a history of a colostomy; Diabetes Mellitus, insulin requiring; Metastatic prostate cancer with particularly metastases to his back; History of stroke with moderate right hemiparesis; Left foot drop which is severe; Generalized debility; Stage 2 sacral decubitus; Diabetic neuropathy, Scrotal and penile edema; Recent left lower lobe pneumonia with bronchospasm, ongoing; and Anorexia, at risk for malnutrition.

Review of the "LTAC (long term acute care) Admit Physician Orders" of 08/02/10 at 5:00pm revealed an order for the wound care nurse to evaluate and treat.

Review of the "History And Physical" performed by Medical Director S9 on 08/03/10 at 8:52pm revealed, in part, "Sacrum: His sacral area shows a small round, perhaps 1 cm (centimeter) in diameter, stage 2 sacral decubitus. ...Assessment/Diagnosis: ... Stage 2 sacral decubitus ...".

Review of the "Initial Nursing Assessment" completed on 08/02/10 by RN S15 revealed the following "wound description": 1) Type - (P) (pressure); Location - coccyx; Color - red; Odor - (a line indicating none); Drainage - (a line indicating none); Description of dressing & surrounding tissue - WNL (within normal limits); 2) Type - S (surgical); Location - left thigh; Color - blank; Odor - (a line indicating none); Drainage - (a line indicating none); Description of dressing & surrounding tissue - graft site dressing clean, dry, intact WNL; 3) Type - (P) (V) (venous); Location - right pinky toe medial aspect, small dime-sized area; skin intact, dressing clean, dry, intact; 4) Type - (P) (V); Location - left heel; Color - dark brown skin intact, dressing clean, dry, intact. Further review " wound assessment " form revealed, in part, "...Document in Wound Descriptions below what is observed. Describe each wound and/or dressing (if covered and dressing not to be removed), including location, size, color of wound and surrounding tissue, drainage, odor and other characteristics ...". Further review of Patient #3's wound assessment revealed no documented evidence of the measurement and staging of the pressure ulcers and the condition of the surrounding tissue. There was no documented evidence of a graft site to the right thigh and a wound to the right Achilles as assessed on 08/03/10 by RN S16, the wound care RN.

Review of the "Admit/Weekly Photographic Wound Documentation Sheet" revealed an assessment on 08/03/10 at 9:23am by LPN S14 of the sacrum. Further review revealed no documented evidence of the length, width, depth, stage, color and temperature of the peri-wound skin, presence or absence of tunneling or undermining, and the date of the last CMP (complete medical profile), albumin, and protein. Further review revealed no documented evidence of an assessment performed by the RN wound care nurse.
Review of the "Admit/Weekly Photographic Wound Documentation Sheet" revealed an assessment on 08/03/10 at 9:23am by LPN S14 and RN S16 of the wounds to the left heel and the right 5th metatarsal head. Further review revealed no documented evidence of the length, width, depth, stage, presence or absence of tunneling or undermining, and the color and temperature of the peri-wound skin of the right 5th metatarsal head.
Review of the "Admit/Weekly Photographic Wound Documentation Sheet" revealed an assessment on 08/03/10 at 9:23am by LPN S14 and RN S16 of the wound to the right Achilles. Further review revealed no documented evidence of the length, width, depth, and the color and temperature of the peri-wound skin was documented as WNL.
Review of the "Admit/Weekly Photographic Wound Documentation Sheet" dated 08/12/10 at 2:41pm and signed by LPN S14 and RN Wound Care S16 revealed a picture of the sacrum with a note of "sacral update". Further review revealed no documented evidence of the length, width, depth, stage, presence or absence of drainage and odor, wound bed color, presence or absence of slough and eschar, color and temperature of the peri-wound skin, and presence or absence of tunneling or undermining. Further review revealed no documented evidence of the weekly assessment with photographs of the wounds as required by hospital policy.

Review of Patient #3's entire medical record revealed no documented evidence of a measurement and staging of the pressure ulcers by a RN.

Patient #4
Review of the medical record for Patient #4 revealed she was admitted to the hospital with diagnoses of Sepsis, ESRD (End Stage Renal Disease) requiring dialysis, DM (Diabetes Mellitus), Malnutrition, Pressure ulcers and Anemia.

Review of the "Admit/Weekly Photographic Wound Documentation Sheet" for Patient #4 dated/timed 08/09/10 for the wound located on the left thigh, left groin, and right heel revealed no documented evidence the assessment, including measurements had been assessed by the RN. Further review revealed no documented evidence the RN had assessed the wound to the left thigh and right thigh on 08/30/10 as evidenced by a blank on the line indication RN signature.

In a face-to-face interview on 09/08/10 at 10:20am, DON S2 indicated RN S16, Wound Care Nurse, was unavailable to interview due to a family emergency. S2 indicated the RN wound care specialist would assess the wounds if she was at the hospital. He further indicated she came to the hospital on Monday, Wednesday, and Friday, and she would come at any time if the staff nurse felt there was a wound that needed her expertise. S2 indicated he did not want the RNs to stage and measure the wounds on admit, because he wanted the assessment done by the RN wound care specialist. He further indicated the wound care specialist had 72 hours to perform the assessment (there was no documented evidence of this time allowance in any hospital policy presented by DON S2). After reviewing the medical record of Patient #1, DON S2 confirmed there was a discrepancy in the assessment and documentation of the wounds. He further confirmed there was no documented evidence the wounds/pressure ulcers of Patient #3 had been assessed by the RN wound care nurse after the initial assessment on 08/03/10. S2 further confirmed there was no documented evidence the RN wound care nurse had assessed Patient #3's sacral decubitus.

Review of the hospital policy titled "Pressure Ulcer Prevention", effective 04/09 and presented by DON S2 as their policy for pressure ulcer assessment, revealed, in part, "...Purpose: To provide guidelines for the prediction and prevention of pressure ulcers. ... A general skin assessment will be performed by the TN (treatment nurse) or LPN ... on every shift ...". Further review of the policy revealed the description of the pressure ulcer stages revised by the National Pressure Ulcer Advisory Panel. Further review revealed no documented evidence of the policy addressing the measurement and staging of the pressure ulcers by the RN.

Review of the hospital policy titled "Skin Care Protocol", effective 04/09 and presented by DON S2 as the hospital ' s current policy for skin assessments, revealed, in part, "...Policy: All patients have an integumentary assessment completed upon admission and daily for their risk of developing breakdown ... Notification to the MD for wound care intervention is made if there is a wound present and a consult to a dietician and for a Wound Care Nurse may be requested to assist (if applicable) with the management of patients found to be at risk according to the Braden Scale. Procedure: Braden Scale is completed at time of admission and daily. ...". Review of the entire policy revealed no documented evidence that the admit skin assessment must be performed by a RN.

Review of the hospital policy titled "Patient Care Documentation (Nursing)", last revised 02/10 and presented by DON S2 as their policy for documentation of wounds and pressure ulcers, revealed, in part, "...Wound care - explain type of wound, specific care (including supplies and equipment used) and assessment of wound condition in notes/intervention section of shift assessment page. ... Integumentary - indicate site of wound beside the word "wound". Describe wound condition in Notes/Interventions section. In addition, the Weekly Photographic Wound Documentation Flow Sheet will be completed each week. Photos will be taken on admission, and retaken weekly and PRN (as needed) ...".

3) Monitor vital signs:
Patient #1
Review of Patient #1's medical record revealed she was admitted on 08/19/10 with diagnoses of Hyperkalemia, End Stage Renal Disease, and Sepsis.

Review of Patient #1's physician orders revealed an order on 08/25/10 at 8:50pm for Clonidine 0.1 mg (milligrams) by mouth every 6 hours as needed for systolic blood pressure greater than 160.

Review of Patient #1's "Vital Signs and Intake & Output Records" revealed the following dates and times of documented blood pressures:
08/26/10 at 6:00pm - 179/76;
08/27/10 at 6:00pm - no documented evidence of a blood pressure assessment;
08/28/10 at 6:00pm - 180/81;
08/29/10 at 6:00am - 169/74;
08/30/10 at 6:00am - 64/31; at 6:00pm - 163/77;
08/31/10 at 6:00pm - 180/82;
09/02/10 at 6:00pm - 161/72;
09/04/10 at 6:00pm - 166/80;
09/05/10 at 6:00pm - 172/72;
09/06/10 at 6:00am - 187/71.

Review of Patient #1's "Daily Nursing Assessment" for 08/30/10 revealed no documented evidence LPN S17 reported the blood pressure of 64/31 to the RN and physician, an intervention was implemented, and a reassessment of the blood pressure was performed.

Review of the "Daily Nursing Assessment" for 09/04/10 revealed the following documentation by LPN 6: 7:15pm - blood pressure (BP) 192/86 per certified nursing assistant; manual BP 188/98; Clonidine 0.1 mg and Ultram (2) given orally; 8:15pm - BP 166/80, resting without distress; 11:45pm - BP 179/81, Xanax 0.25 mg given orally. Further review revealed no documented evidence LPN S6 notified the RN of the change in condition, and there was no further reassessment of the BP of 179/81 at 11:45pm.

In a face-to-face interview on 09/08/10 at 10:20am, DON S2 indicated LPN S6 was not available for interview. After reviewing the medical record of Patient #1, DON S2 confirmed the LPN should have notified the RN when the patient's condition changed, LPN S17 should have notified the RN and physician when the BP of 64/31 was obtained.

Review of the entire medical record of Patient #1 revealed no documented evidence the Clonidine was administered as ordered for systolic blood pressure greater than 160 on the above listed dates and that the blood pressures were reassessed.

In a face-to-face interview on 09/08/10 at 8:20am, RN S3 indicated the blood pressures documented on the graphic sheet were not actually the time the blood pressure was taken by the nursing assistant.

In a face-to-face interview on 09/08/10 at 9:55am, LPN S5 indicated there was no way the blood pressures documented on the graphic sheet at 6:00pm were actually taken at that time, because the nursing assistants start their shift at 5:30pm. She further indicated the nursing assistants take the vital signs between 7:45pm and 8:30pm.

In a face-to-face interview on 09/08/10 at 12:50pm with Medical Director S9, Administrator S1, and DON S2 present, Medical Director S9 indicated she was aware of the problem with the documentation of vital signs on the graphic sheet. She then asked DON S2 "what are you going to do to correct the problem?". Administrator S1 indicated he was planning to hire a QA (quality assurance) nurse to audit the medical records.

Patient #4
Review of the medical record for Patient #4 revealed she was admitted to the hospital with the diagnoses of sepsis, malnutrition, anemia, hepatic encephalopathy, End Stage Renal Disease (ESRD) requiring dialysis, DM (Diabetes Mellitus) and pressure ulcers.

Review of the Physician's Orders for Patient #4 dated 08/24/10 revealed an order for Lopressor 25mg one tablet by mouth twice a day and to hold for a heart rate < 55 or a Systolic Blood Pressure (SBP) of < 110. Review of the Medication Administration Record (MAR) revealed no documented evidence the blood pressure and heart rate had been assessed before Lopressor 25mg had been administered on the following dates and times: 08/24/10 @0900 (9:00am); 08/25/10 @ 0900, 2100 (9:00pm); 08/26/10 @ 9:00am; 08/27/10 @ 9:00am; 09/03/10 @ 0900 (9:00am);

Review of the Physician ' s Orders for Patient #4 dated 07/29/10 revealed an order for Midodrine 10mg by mouth three times a day hold for a SBP (Systolic Blood Pressure)> 110. Review of the Medication Administration Record (MAR) revealed no documented evidence the blood pressure had been assessed before Midodrine 10mg had been administered on the following dates and times: 07/29/10 @ 2100 (9:00pm); 07/30/10 @ 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm); 07/31/10 @ 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm); 08/03/10 @ 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm); 08/04/10 @ 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm); 08/05/10 @ 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm); 08/07/10 @ 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm); 08/08/10 @ 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm); 08/09/10 @ 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm); 08/10/10 @ 0900 (9:00am); 08/11/10 @ 0900 (9:00am), 1500 (3:00pm); 08/12/10 @ 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm); 08/20/10 @ 1500 (3:00pm), 2100 (9:00pm); 08/27/10 @ (9:00pm), 1500 (300pm); and 09/03/10 @ 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm).

In a face to face interview on 09/08/10 at 4:20pm S2 RN DON indicated blood pressures should be assessed by the nurse administering the medication.

Patient #5
Review of the medical record for Patient #5 revealed she was admitted to the hospital with the diagnoses of Diabetes Mellitus (DM), Wound Infection and Hypertension (HTN).

Review of the Physicians' Orders for Patient #5 dated 08/03/10 revealed an order for Clonidine 0.1mg twice a day at 0900 (9:00am) and 2100 (9:00pm) and Clonidine 0.1mg by mouth prn (as needed) for a SBP (Systolic Blood Pressure) of >170 or a Diastolic Blood Pressure >100.

Review of the "Vital Signs and Intake & Output Record" revealed the following: 08/07/10 0600 (6:00am) Blood Pressure (BP) 180/88; 08/09/10 1800 (3:00pm) BP 173/81; 08/11/10 0600 (6:00am) BP 184/96; 08/13/10 0600 (6:00am) BP 173/87; and 08/14/10 0600 (6:00am) 175/94, 1800 (3:00pm) 177/94.

Review of the MAR for Patient #5 revealed no documented evidence a prn dosage of Clonidine had been administered even though the systolic blood pressures were not within the parameters ordered by the physician.

In a face to face interview on 09/08/10 at 8:45am LPN S5 indicated she did not administer the Clonidine 0.1mg prn because she attributed the elevated blood pressure with the patient's complaint of pain. Further she felt that because the patient was elderly it was not wise to give both. S5 indicated she always re-assessed the blood pressure; however she did not document the re-assessment in the chart. Further S5 indicated she did not report this to the charge nurse.

4) Clarification orders:
Patient #1
Review of Patient #1's medical record revealed she was admitted on 08/19/10 with diagnoses of Hyperkalemia, End Stage Renal Disease, and Sepsis.

Review of Patient #1's physician admit orders on 08/19/10 at 8:00pm revealed orders for Xanax 0.25mg (milligrams) by mouth prn (as needed) BID (twice a day) and Ultram 100mg by mouth prn every 8 hours. Further review revealed no documented evidence of the indication for use and clarification by the physician whether the Xanax was to be administered BID or prn and whether the Ultram was to be administered every 8 hours or prn.

Patient #2
Review of Patient #2's medical record revealed he was admitted on 09/04/10 at 6:15pm with diagnoses of Aspiration pneumonia, Hypertension, and Diabetes Mellitus.

Review of the physician admit orders revealed an order for Colace 100mg by mouth BID prn. Further review revealed no documented evidence of the indication for use and clarification by the physician whether the Colace was to be administered prn or BID.

In a face-to-face interview on 09/08/10 at 10:20am, DON S2 indicated the pharmacist would send a note requesting the indication for use if it was not included in the orders, but a clarification order was not written. He could offer no explanation for this not being done and for not clarifying an order when a medication was ordered prn and every 8 hours or BID.

Patient #4
Review of the medical record for Patient #4 revealed she was admitted to the hospital with the diagnoses of sepsis, malnutrition, anemia, hepatic encephalopathy, End Stage Renal Disease (ESRD) requiring dialysis, DM (Diabetes Mellitus) and pressure ulcers.

Review of the Physician's Order dated 08/18/10 for Patient #4 revealed, "Ativan 0.5mg U/D Tablet take one tablet by mouth every 8 hours as needed". Review of the Physicians' Orders, Nursing Progress Notes and MAR (Medication Administration Record) dated 08/18/10 through 09/03/10 revealed no documented evidence the order had been clarified by the nursing staff or the pharmacist.

Review of the policy titled "Medication Management", effective 04/09 and submitted by DON S2 as their current medication administration policy, revealed, in part, "...Each medication ordered has a documented diagnosis, condition, or indication-for-use. ... Elements of a complete order includes the following necessary information regarding the medication itself: a. Drug name b. Strength c. Dosage form ... d. Route of administration e. Frequency of administration f. Special instructions ... g. Designated administration time to be assigned by the MD or by nurse using hospital established scheduled frequency of administration times. ... If an order is incomplete, is not legible, or if there is a question as to the dosage, route of administration, or the time, the nurse is to contact the physician for a "clarification order". The pharmacist will fax clarification order to be placed in medical record. If pharmacy is unsuccessful in contacting the physician to get clarification, the charge nurse will be notified and asked to attempt to get the order clarified. The charge nurse will document any clarification on the physician order form and fax to pharmacy ...".

5) ensure the patients' daily food intake had been assessed and documented in the patients' charts
Patent #3
Review of Patient #3's medical record revealed he was admitted on 08/02/10 at 5:00pm with diagnoses of Sepsis, Fever, Chronic Kidney Disease, Hemodialysis, and Prostate Cancer. Review of the H&P revealed additional diagnoses of Abdominal distention with constipation, anorexia, and a history of a colostomy; Diabetes Mellitus, insulin requiring; Metastatic prostate cancer with particularly metastases to his back; History of stroke with moderate right hemiparesis; Left foot drop which is severe; Generalized debility; Stage 2 sacral decubitus; Diabetic neuropathy, Scrotal and penile edema; Recent left lower lobe pneumonia with bronchospasm, ongoing; and Anorexia, at risk for malnutrition.

Review of the "Vital Signs and Intake and Output Record" for Patient #3 revealed no documented evidence the dietary intake had been assessed and recorded in the chart as follows: 08/03/10 dinner, 08/04/10 dinner, 08/05/10 dinner, 08/06/10 dinner, 08/07/10 dinner, 08/10/10 dinner, 08/15/10 dinner, 08/16/10 dinner, and 08/17/10 dinner.

Patient #4
Review of the medical record for Patient #4 revealed she was admitted to the hospital with the diagnoses of Sepsis, ESRD (End Stage Renal Disease) requiring dialysis, Malnutrition, Anemia and Pressure Ulcers.

Review of the "Vital Signs and Intake and Output Record" for Patient #4 revealed no documented evidence the dietary intake had been assessed and recorded in the chart as follows: 07/29/10, 07/30/10, 08/10/10 (dinner), 08/11/10 (dinner), 08/24/10 (dinner), 08/25/10 (dinner), 0826/10 (dinner),and 08/30/10 (dinner).

Patient #5
Review of the medical record for Patient #5 revealed she had been admitted to the hospital on 08/04/10 with the diagnoses of Stage III to the coccyx, DM (Diabetes Mellitus), and HTN (Hypertension). Review of the Nutritional Consult (per physician ' s order) dated 08/05/10 revealed Patient #5 weighed 77.3 pounds upon admit with an IBW (Ideal Body Weight) of 110 pounds (32.7 pounds below IBW). Further review revealed Patient #5 had moderate malnutrition with the dietetic recommendations to continue the 1800 calorie ADA (American Diabetes Association) diet mechanical soft, multivitamins daily, Vitamin C and the dietitian to follow-up and monitor.

Review of the " Vital Signs and Intake & Output Record " for Patient #5 revealed she had been weighed on 08/04/10 (77.3 pounds); 08/09/10 (74.5 pounds); and 08/23/10 (68.9 pounds). Further review revealed Patient #5 had not been assessed for nutritional intake as follows: 08/07/10; 08/08/10; 08/10/10 dinner; 08/11/10 dinner; 08/16/10 dinner; 08/18/10; 08/19/10 dinner, 08/23/10 dinner, 08/24/10 dinner, 08/27/10, 08/28/10 dinner, 09/01/10 dinner, 09/02/10 dinner, 09/03/10; 09/04/10 and 09/05/10. (Patient assessed approximately 70% of the time).

Patient #7
Review of the medical record for Patient #7 revealed he was admitted to the hospital on 06/25/10 with the diagnoses of renal failure (on dialysis which was started three months ago), DM (Diabetes Mellitus), HTN (Hypertension), and morbid obesity.

Review of the "Vital Signs and Intake and Output Record" for Patient #7 revealed no documented evidence the dietary intake had been assessed and recorded in the chart as follows: 06/25/10, 07/01/10, 07/05/10 (dinner), 07/06/10, 07/07/10 (dinner), 07/08/10, 07/10/10 (breakfast, lun

Based on record review and interviews, the hospital failed to: 1) ensure the nursing staff followed hospital policies and procedures for the individual plan of care as evidenced by patient care plans without measurable goals, objective measures used to assess progress and goal attainment, and identification of the staff member responsible for the interventions (#1, #2, #3), care plans that did not identify and address patient's skin integrity (#1), and care plans that were not updated with changes in condition of high and low blood glucose levels (#1, #3), falls (#1), and elevated blood pressures (#1); 2) follow physician orders for 7 of 8 sampled patients for: a) insulin administration (#1), b) implementation of the hypoglycemic protocol (#1, #3), c) administration of Clonidine for elevated blood pressure (#1, #5), d) obtaining labs (#1, #2), e) weights (#3, #4, #7, #8), f) calorie counts (#3); g) administration of Flagyl (#2), h) administration of tube feedings as ordered and according to hospital policy (#2), and i) assessment of blood pressures before administration of blood pressure medication (#4), and 3) obtain physician orders for wound care provided by the nursing staff for 1 of 8 sampled patients (#3). Findings:

1) Ensure the nursing staff followed hospital policies and procedures for the individual plan of care:
Patient #1
Review of Patient #1's medical record revealed she was admitted on 08/19/10 at 8:00pm with diagnoses of Hyperkalemia, End Stage Renal Disease, and Sepsis. Review of the History and Physical (H&P) revealed additional diagnoses of Staph Epidermidis, Diabetes Mellitus, Major Depression, and Peripheral Neuropathy.

Review of Patient #1's "LTAC (long term acute care) Interdisciplinary Plan of Care", initiated 08/19/10, revealed the nursing diagnosis of impaired mobility with interventions of assist with transfer as needed, active or passive range of motion (ROM) QID (four times a day), consult Rehab, and consult PT (physical therapy). There was no documented evidence of who was responsible for each intervention. Further review revealed the goals included return to prior level of functioning, and free from contractures, with no documented evidence how these would be measured. Further review revealed a nursing diagnosis of decline in ADLs (activities of daily living). Review of the interventions revealed staff would assist with ADLs and consult OT (occupational therapy). There was no documented evidence as to who was responsible for each intervention. Further review revealed the goals included return to prior level of function for bathing, grooming, eating, and dressing, with no documented evidence how these would be measured. Review of Patient #1's care plan revealed a nursing diagnosis of altered comfort/pain with the goal of patient will report pain level of no more than ___ with or without interventions. Further review revealed no documented evidence of the level of pain that was acceptable to Patient #1. Further review revealed a nursing diagnosis of ineffective coping (anxiety), with goals of patient report of less anxiety, demonstrates effective decision making, and demonstrate effective coping skills. Further review revealed no documented evidence how the level of anxiety, decision making, and coping skills would be measured. Review of the care plan revealed Patient #1 was a high risk for injury (fall) with the goal of patient will be free from falls during hospitalization. Review of Patient #1's medical record revealed she had a fall on 08/24/10 with no documented evidence the care plan had been updated to reflect the fall. Further review revealed Patient #1 was assessed by RN S13 upon admit with a pressure ulcer to buttocks with no documented evidence of impaired skin integrity selected as a nursing diagnosis and care planned with interventions and goals. Further review of the medical record revealed Patient #1 had episodes of hypoglycemia, hyperglycemia, and elevated blood pressures with orders to administer Clonidine for systolic blood pressures greater than 160 with no documented evidence the care plan was updated with these changes in condition. Further review revealed no documented evidence the plan of care was reviewed weekly as required by hospital policy, as the only documented review date was 09/01/10 which was 13 days after it had been initiated.

Patient #2
Review of Patient #2's medical record revealed he was admitted on 09/04/10 at 6:15pm with diagnoses of Aspiration pneumonia, Hypertension, and Diabetes Mellitus.

Review of Patient #2's "LTAC Interdisciplinary Plan of Care", initiated 09/04/10, revealed the nursing diagnosis of impaired mobility with interventions of assist with transfer as needed, active or passive ROM QID, consult Rehab, and consult PT. There was no documented evidence of who was responsible for each intervention. Further review revealed the goals included return to prior level of functioning, and free from contractures, with no documented evidence how these would be measured. Further review revealed a nursing diagnosis of decline in ADLs. Review of the interventions revealed staff would assist with ADLs and consult OT. There was no documented evidence as to who was responsible for each intervention. Further review revealed the goals included return to prior level of function for bathing, grooming, eating, and dressing, with no documented evidence how these would be measured. Further review revealed no documented evidence of a target date for meeting the goals for impaired mobility, decline in ADLs, impaired airway clearance, ineffective breathing pattern, impaired gas exchange, fluid volume deficit, fluid volume excess, altered nutrition, altered urine elimination, high risk for injury/fall, knowledge deficit, cognitive deficit, and discharge planning needs related to dialysis and diabetes and which staff was responsible for each intervention.

Patient #3
Review of Patient #3's medical record revealed he was admitted on 08/02/10 at 5:00pm with diagnoses of Sepsis, Fever, Chronic Kidney Disease, Hemodialysis, and Prostate Cancer. Review of the H&P revealed additional diagnoses of Abdominal distention with constipation, anorexia, and a history of a colostomy; Diabetes Mellitus, insulin requiring; Metastatic prostate cancer with particularly metastases to his back; History of stroke with moderate right hemiparesis; Left foot drop which is severe; Generalized debility; Stage 2 sacral decubitus; Diabetic neuropathy, Scrotal and penile edema; Recent left lower lobe pneumonia with bronchospasm, ongoing; and Anorexia, at risk for malnutrition.

Review of Patient #3's "LTAC Interdisciplinary Plan of Care", initiated 08/02/10, revealed the nursing diagnosis of impaired mobility with interventions of assist with transfer as needed, active or passive ROM QID, consult Rehab, and consult PT. There was no documented evidence of who was responsible for each intervention. Further review revealed the goals included return to prior level of functioning, and free from contractures, with no documented evidence how these would be measured. Further review revealed a nursing diagnosis of decline in ADLs. Review of the interventions revealed staff would assist with ADLs and consult OT. There was no documented evidence as to who was responsible for each intervention. Further review revealed the goals included return to prior level of function for bathing, grooming, eating, and dressing, with no documented evidence how these would be measured. Further review revealed the nursing diagnosis of cognitive deficit was identified with no documented evidence of specific, measurable goals for this diagnosis. Review of Patient #3's medical record revealed he had episodes of hyperglycemia and hypoglycemia with no documented evidence the care plan was updated to address these changes in condition. Review of Patient #3's plan of care revealed no documented evidence which staff was responsible for the interventions identified.

In a face-to-face interview on 09/08/10 at 10:20am, Director of Nursing (DON) S2 confirmed the nursing care plans for each patient were not individualized and did not include measurable goals, which staff was responsible for the interventions, and a target date for the goal to be met.

Review of the hospital policy titled "Individual Plan of Care", effective 04/09 and submitted by DON S2 as their current policy for plan of care, revealed, in part, "...All patients will have an individualized plan of care that is individually tailored, integrated and coordinated by competent professionals ... Procedure: 2. The individual treatment plan includes the following information presently behavioral: ... c. The type of treatment and/or services to be provided, and revised when appropriate. D. Measurable goals with the anticipated time frames of accomplishing these goals. E. Objective measures to be used to assess progress and goal attainment. G. Any barrier to learning or treatment. ... 5. The progress of the individual toward the specified goals are reviewed weekly and communicated to the individual patient, the patient's family (as appropriate), team members, ... by the Case Manager or Designee ... 6. The individual treatment plan may be in the form of a Care Plan, care map or Critical path in conjunction with the weekly team conference note".

2) Follow physician orders for:
a) Insulin administration
Patient #1
Review of Patient #1's medical record revealed she was admitted on 08/19/10 at 8:00pm with diagnoses of Hyperkalemia, End Stage Renal Disease, and Sepsis. Review of the History and Physical (H&P) revealed additional diagnoses of Staph Epidermidis, Diabetes Mellitus, Major Depression, and Peripheral Neuropathy.

Review of Patient #1's "Physician Sliding Scale Insulin Orders" dated 08/19/10 at 10:10pm revealed she was to have capillary blood glucose (CBG) checks AC and HS (before meals and at bedtime). Further review revealed Patient #1 was to receive 2 units Regular Insulin for a CBG of 140. Review of the "Diabetic Record" for 08/20/10 at 9:00pm revealed her CBG was 159 with a note of "pt (patient) refused" by RN (registered nurse) S13. Further review revealed another entry for 9:00pm on 08/20/10 by LPN (licensed practical nurse) S5 of a CBG of 140. Further review of the entire medical record revealed no documented evidence that Patient #1's physician was notified of her refusal to have the insulin administered.

In a face-to-face interview on 09/08/10 at 9:55am, LPN S5 indicated she usually reported to the charge RN if a patient refused insulin and would leave it to the discretion of the RN to report to the physician. LPN S5 indicated there was no documented evidence in the medical record of Patient #1 that she had reported the patient ' s refusal of insulin to the RN.

b) Implementation of the hypoglycemic protocol:
Patient #1
Review of Patient #1's medical record revealed she was admitted on 08/19/10 at 8:00pm with diagnoses of Hyperkalemia, End Stage Renal Disease, and Sepsis. Review of the H&P revealed additional diagnoses of Staph Epidermidis, Diabetes Mellitus, Major Depression, and Peripheral Neuropathy.

Review of Patient #1's "Physician Sliding Scale Insulin Orders" dated 08/19/10 at 10:10pm revealed she was to have CBG checks AC and HS. Further review of the order revealed the "Hypoglycemic Protocol" included the following: accucheck 60-69 - 4 oz (ounces) OJ (orange juice) or 15 ml (milliliters) D50 (50% dextrose) IV (intravenous) (if unable to swallow or Signs or symptoms); accucheck 50-59 - 20 ml D50 IV; accucheck less than 50 - 25 ml D50 IV - draw stat BMP (basic metabolic profile); always check CBG 30 minutes after interventions & notify physician. Further review revealed if the accucheck was above 400, 14 units of Regular insulin was to be administered and the physician notified.

Review of Patient #1's "Daily Nursing Assessment" for 08/29/10 revealed an entry by RN S3 at 9:00pm that the blood glucose was 475, and 14 units of R (regular) insulin was given SQ (subcutaneous). Further review revealed at 9:30pm RN S3 documented that RN S12, Charge Nurse, notified Medical Director S9, and no new orders were obtained. Further review revealed at 10:00pm RN S3 documented the accucheck was 430, and at 11:15pm it was 273. Further review revealed no documented evidence Medical Director S9 was notified of the CBG greater than 400 at 10:00pm.

In a face-to-face interview on 09/08/10 at 8:20am, RN S3 confirmed she did not report Patient #1's repeat CBG of 430 to his physician, and thus she did not follow the physician's orders.

Review of Patient #1's "Daily Nursing Assessment" for 09/06/10 at 8:00pm revealed the
CBG was 40, the RN charge nurse was notified, and Ensure (patient refused juice) was given. Further review revealed at 8:30pm the CBG was rechecked and was 66. Patient #1 was given Nepro, celery, carrots, and peanut butter (patient ' s usual evening snack). Further review revealed no documented evidence the physician was notified of the blood glucose results of 40 and 66.

In a face-to-face interview on 09/08/10 at 9:55am, LPN S5 indicated she did not follow the physician's orders. LPN S5 indicated she didn't call the physician, because she leaves that to the RN.

In a face-to-face interview on 09/08/10 at 9:55am, DON S2, who was present during the interview with LPN S5, indicated the RN should have assessed Patient #1 during her hypoglycemic episode, assured the physician's orders were followed, and the physician was notified of the event.

Patient #3
Review of Patient #3's medical record revealed he was admitted on 08/02/10 at 5:00pm with diagnoses of Sepsis, Fever, Chronic Kidney Disease, Hemodialysis, and Prostate Cancer. Review of the H&P revealed additional diagnoses of Abdominal distention with constipation, anorexia, and a history of a colostomy; Diabetes Mellitus, insulin requiring; Metastatic prostate cancer with particularly metastases to his back; History of stroke with moderate right hemiparesis; Left foot drop which is severe; Generalized debility; Stage 2 sacral decubitus; Diabetic neuropathy, Scrotal and penile edema; Recent left lower lobe pneumonia with bronchospasm, ongoing; and Anorexia, at risk for malnutrition.

Review of Patient #3's physician's orders revealed the admit orders included accuchecks before meals and bedtime. Further review revealed an order for management of patient with low blood sugar to include if "60" appears in display or blood glucose below 60, retest, notify physician, and obtain blood glucose to send to laboratory for confirmatory test results. Further review revealed a "Physician Sliding Scale Insulin Orders" received by telephone order from Medical Director S9 on 08/02/10 with no documented evidence of the time the order was received. Further review revealed for a CBG of 50-59, 20 ml D50 IV was to be administered, always recheck CBG 30 minutes after interventions, and notify the physician.

Review of Patient #3's "Diabetic Record" revealed his blood glucose was 50 at 7:30am on 08/03/10. Review of the "Daily Nursing Assessment" for 08/03/10 revealed no documented evidence LPN S11 had reported the blood glucose of 50 to the RN, the blood glucose was rechecked, the physician was notified, blood glucose was sent to the lab for confirmatory test results, and 20 ml D50 IV was administered, all required by physician orders.

In a face-to-face interview on 09/08/10 at 10:20am, DON S2 confirmed Patient #3's physician's orders were not implemented on 08/03/10.

c) Administration of Clonidine for elevated blood pressure
Patient #1
Review of Patient #1's physician orders revealed an order on 08/25/10 at 8:50pm for Clonidine 0.1 mg (milligrams) by mouth every 6 hours as needed for systolic blood pressure greater than 160.

Review of Patient #1's "Vital Signs and Intake & Output Records" revealed the following dates and times of documented blood pressures:
08/26/10 at 6:00pm - 179/76;
08/27/10 at 6:00pm - no documented evidence of a blood pressure assessment;
08/28/10 at 6:00pm - 180/81;
08/29/10 at 6:00am - 169/74;
08/30/10 at 6:00pm - 163/77;
08/31/10 at 6:00pm - 180/82;
09/02/10 at 6:00pm - 161/72;
09/04/10 at 6:00pm - 166/80;
09/05/10 at 6:00pm - 172/72;
09/06/10 at 6:00am - 187/71.

Review of the entire medical record of Patient #1 revealed no documented evidence the Clonidine was administered as ordered for systolic blood pressure greater than 160 on the above listed dates and that the blood pressures were reassessed.

Review of the "Daily Nursing Assessment" for 09/04/10 revealed the following documentation by LPN 6: 7:15pm - blood pressure (BP) 192/86 per certified nursing assistant; manual BP 188/98; Clonidine 0.1 mg and Ultram (2) given orally; 8:15pm - BP 166/80, resting without distress; 11:45pm - BP 179/81, Xanax 0.25 mg given orally. Further review revealed no documented evidence LPN S6 notified the RN of the change in condition, and there was no further reassessment of the BP of 179/81 at 11:45pm.

In a face-to-face interview on 09/08/10 at 8:20am, RN S3 indicated the blood pressures documented on the graphic sheet were not actually the time the blood pressure was taken by the nursing assistant.

In a face-to-face interview on 09/08/10 at 9:55am, LPN S5 indicated there was no way the blood pressures documented on the graphic sheet at 6:00pm were actually taken at that time, because the nursing assistants start their shift at 5:30pm. She further indicated the nursing assistants take the vital signs between 7:45pm and 8:30pm.

In a face-to-face interview on 09/08/10 at 10:20am, DON S2 indicated LPN S6 was not available for interview. After reviewing the medical record of Patient #1, DON S2 confirmed the LPN should have notified the RN of the blood pressures of 192/86, 166/80, and 179/81 for assessment and notification of the physician. He further confirmed there was no documented evidence Patient #1 had received Clonidine as ordered. He indicated that although one couldn't tell by the documentation due to the incorrect times documented for the blood pressures, he felt that Clonidine was not given because the nurse was planning to administer to scheduled antihypertensive medication at 9:00pm and would not administer the Clonidine. He indicated there was no documented evidence in the medical record that the nurse had reported the blood pressure to the physician and obtained an order to hold the Clonidine and to administer the scheduled antihypertensive instead.

In a face-to-face interview on 09/08/10 at 12:50pm with Medical Director S9, Administrator S1, and DON S2 present, Medical Director S9 indicated she was aware of the problem with the documentation of vital signs on the graphic sheet. She then asked DON S2 "what are you going to do to correct the problem?". Administrator S1 indicated he was planning to hire a QA (quality assurance) nurse to audit the medical records.

Patient #5
Review of the medical record for Patient #5 revealed she was admitted to the hospital with the diagnoses of Diabetes Mellitus (DM), Wound Infection and Hypertension (HTN).

Review of the Physicians' Orders for Patient #5 dated 08/03/10 revealed an order for Clonidine 0.1mg twice a day at 0900 (9:00am) and 2100 (9:00pm) and Clonidine 0.1mg by mouth prn (as needed) for a SBP (Systolic Blood Pressure) of >170 or a Diastolic Blood Pressure >100.

Review of the "Vital Signs and Intake & Output Record" revealed the following: 08/07/10 0600 (6:00am) Blood Pressure (BP) 180/88; 08/09/10 1800 (3:00pm) BP 173/81; 08/11/10 0600 (6:00am) BP 184/96; 08/13/10 0600 (6:00am) BP 173/87; and 08/14/10 0600 (6:00am) 175/94, 1800 (3:00pm) 177/94.

Review of the MAR for Patient #5 revealed no documented evidence a prn dosage of Clonidine had been administered even though the systolic blood pressures were not within the parameters ordered by the physician.

In a face to face interview on 09/08/10 at 8:45am LPN S5 indicated she did not administer the Clonidine 0.1mg prn because she attributed the elevated blood pressure with the patient's complaint of pain. Further she felt that because the patient was elderly it was not wise to give both. S5 indicated she always re-assessed the blood pressure; however she did not document the re-assessment inthe chart. Further S5 indicated she did not report this to the charge nurse.

d) Obtaining labs
Patient #1
Review of Patient #1's medical record revealed she was admitted on 08/19/10 at 8:00pm with diagnoses of Hyperkalemia, End Stage Renal Disease, and Sepsis. Review of the H&P revealed additional diagnoses of Staph Epidermidis, Diabetes Mellitus, Major Depression, and Peripheral Neuropathy.

Review of Patient #1's "LTAC (long term acute care) Admit Physician Orders" of 08/19/10 at 8:00pm revealed an order for PT/INR (protime/International Normalized Ratio) daily. Review of the entire medical record revealed no documented evidence the PT/INR was drawn or results had been received for 08/20/10.

Patient #2
Review of Patient #2's medical record revealed he was admitted on 09/04/10 at 6:15pm with diagnoses of Aspiration pneumonia, Hypertension, and Diabetes Mellitus.

Review of Patient #2's "LTAC Admit Physician Orders" of 09/04/10 at 6:15pm revealed an order for a urinalysis in the morning. Review of the entire medical record revealed no documented evidence of urinalysis results in the record.

In a face-to-face interview on 09/08/10 at 10:20am, DON S2 confirmed there was no evidence in the medical records of Patient #1 of a PT/INR for 08/20/10 and a urinalysis for Patient #2 that should have been collected on 09/05/10.

e) Weights
Patient #3
Review of Patient #3's medical record revealed he was admitted on 08/02/10 at 5:00pm with diagnoses of Sepsis, Fever, Chronic Kidney Disease, Hemodialysis, and Prostate Cancer. Review of the H&P revealed additional diagnoses of Abdominal distention with constipation, anorexia, and a history of a colostomy; Diabetes Mellitus, insulin requiring; Metastatic prostate cancer with particularly metastases to his back; History of stroke with moderate right hemiparesis; Left foot drop which is severe; Generalized debility; Stage 2 sacral decubitus; Diabetic neuropathy, Scrotal and penile edema; Recent left lower lobe pneumonia with bronchospasm, ongoing; and Anorexia, at risk for malnutrition.

Review of Patient #3's "LTAC Admit Physician Orders" of 08/02/10 at 5:00pm revealed an order to weigh the patient daily. Review of the entire medical record revealed no documented evidence that Patient #3 was weighed on 08/12/10 and 08/18/10 as ordered.

Patient #4
Review of the medical record revealed Patient #4 was admitted to the hospital with diagnoses of Sepsis, ESRD (End Stage Renal Disease) requiring dialysis, DM (Diabetes Mellitus), Malnutrition and Anemia.

Review of the Physician's Orders dated 07/29/10 revealed an order to weigh the patient daily.

Review of the "Vital Signs and Intake & Output Record" for Patient #4 revealed no documented evidence a weight had been obtained on the following days: 07/29/10, 07/30/10, 08/12/10, 08/22/10, and 08/31/10.

Patient #7
Review of the medical record for Patient #7 revealed he was admitted to the hospital on 06/30/10 with the diagnoses of renal failure (on dialysis which was started three months ago), DM (Diabetes Mellitus), HTN (Hypertension), and morbid obesity.

Review of the "Vital Signs and Intake & Output Record revealed no documentation Patient #7 had been weighed on the following dates: 06/26/10, 06/27/10, 06/29/10, 06/30/10, 07/01/10, 07/02/10, 07/03/10, 07/04/10, 07/06/10, 07/07/10,07/08/10, 07/09/10, 07/10/10, 07/11/10, 07/13/10, and 07/20/10. Review of the documented weights for Patient #7 revealed the following: 06/25/10 (213.7); 06/28/10 (220.5 with two question marks); 07/05/10 (222.7); 07/12/10 (218.3); and 07/14/10 214.3 with a note that patient weighed 207.6 in dialysis).

Patient #8
Review of the medical record for Patient #8 revealed she was admitted to the hospital on 08/25/10 with the diagnoses of a non-healing Stage IV Decubitus of the Left Hip, DM (Diabetes Mellitus) and Malnutrition.

Review of the "Vital Signs and Intake and Output Record" for Patient #8 revealed no documented evidence weights had been assessed weekly as ordered by the MD as evidenced by the documented weights on admit 08/25/10 and 09/06/10 (12 days after admission).

In a face to face interview on 09/08/10 at 4:20pm S2, RN Director of Nursing (DON) indicated weights not being performed should have been identified through the 24 hour chart check.

In a face to face interview on 09/08/10 at 4:30pm S1 Administrator indicated chart audits are not being performed because the hospital does not have a QA person at the present time and the new DON has taken on that role as well as Infection Control.

f) Calorie counts #3
Review of Patient #3's physician orders for 08/03/10 at 2:45pm revealed an order for calorie counts.

Review of the entire medical record revealed no documented evidence that calorie counts were done.

In a face-to-face interview on 09/08/10 at 10:20am, DON S2 confirmed there was no documented evidence in the medical record of Patient #3 that calorie counts were performed. He indicated they should remain in the record.

In a face-to-face interview on 09/08/10 at 2:30pm, RD S4 indicated she remembered doing calorie counts for Patient #3, but she didn't see them documented in the medical record. She further indicated she couldn't remember if the staff documented every meal. RD S4 confirmed that her documentation in Patient #3's medical record did not include an assessment of calorie counts.

g) Administration of Flagyl
Review of Patient #2's medical record revealed he was admitted on 09/04/10 at 6:15pm with diagnoses of Aspiration pneumonia, Hypertension, and Diabetes Mellitus.

Review of Patient #2's admit physician orders revealed an order for Flagyl 500mg IVPB (intravenous piggyback) every 6 hours.

Review of the "Daily Nursing Assessment" for 09/04/10 revealed a note at 6:15am (on 09/05/10) by RN (registered nurse) S13 of "late entry Flagyl 500mg IVPB not given. Pharmacy did not send medication. None in Omnicell". There was no documented evidence the physician was notified that Flagyl was not administered as ordered, and there was no medication variance completed for this occurrence.

h) Administration of tube feedings
Review of Patient #2's medical record revealed he was admitted on 09/04/10 at 6:15pm with diagnoses of Aspiration pneumonia, Hypertension, and Diabetes Mellitus.

Review of Patient #2's "LTAC Admit Physician Orders" for 09/04/10 at 6:15pm revealed an order for PEG (percutaneous esophageal gastrostomy) tube feeding Nepro at 50 ml/hr (milliliters per hour). Further review revealed the following orders for Patient #2:
09/05/10, with no documented evidence of the time the order was received, whether the order was verbal or by telephone, and who received the order - ok to hold TF (tube feedings);
09/05/10 at 10:10pm - consult Nutrition; Procal at 40 cc/hr (cubic centimeters per hour);
09/07/10 at 11:20am - increase Nepro to 50ml/hr as tolerated; decrease Procalamine to 25 ml/hr, discontinue after this bag; discontinue Juven;
09/07/10 at 1:00pm - increase Procal at 40 ml/hr; restart Nepro at 20 ml/hr when n/v (nausea/vomiting) subsides, increase 5 ml every 6 hours as tolerated to 50 ml/hr.

Review of Patient #2's "Daily Nursing Assessment" for 09/05/10 at 9:30am revealed Patient #2 had vomited, and the tube feeding was off. Further review revealed the tube feeding was restarted on 09/05/10 at 12:00pm at 20 cc/hr, with no documented evidence of what tube feeding was in progress. Further review revealed no documented evidence of a physician's order to restart the tube feeding and for the Nepro to be at 20 cc/hr (originally ordered at 50 ml/hr). Further review revealed at 5:00pm the Nepro was increased to 30 cc/hr with "no residuals since 1200 (12:00pm) today". Review of the nutrition assessment for the 6:00pm to 6:00am shift on 09/05/10 revealed the Nepro was at "30 cc/hr with goal of 50 cc/hr".

Review of Patient #2's "Daily Nursing Assessment" for 09/06/10 revealed the Nepro was at 30 cc/hr (originally ordered at 50 ml/hr) and Procal was at 40 cc/hr. Further review revealed at 4:00pm the residual was documented as > (greater than) 100 cc, and the tube feeding was turned off. There was no documented evidence of a reassessment of residual 2 hours later and whether the tube feeding was begun. Review of the nutrition assessment for the 6:00pm to 6:00am shift on 09/06/10, with no documented evidence of the time this assessment was done, revealed the residual was 10 cc and Nepro was infusing at 30 cc/hr.

Review of the "Daily Nursing Assessment" for 09/07/10 at 6:10am revealed Nepro was increased to 40 cc/hr with no documented evidence of an order for a rate other than 50 ml/hr as given at admit. Further review revealed at 12:30pm the residual was > 100 cc, the tube feeding was turned off, and the dietitian was at the bedside. Further review revealed the nurse documented he/she (unable to decipher handwriting) received orders from the dietitian to increase Procal to 40 cc/hr and decrease tube feeding to 20 cc/hr when residuals decrease.

Review of Patient #2's entire medical record revealed no documented evidence the nursing staff was checking tube placement and residual every 4 hours as required by hospital policy.

In a face-to-face interview on 09/08/10 at 2:30pm, RD S4 confirmed the nursing actions for Patient #2 on 09/07/10 at 12:30pm were performed prior to the order from the physician. S4 further indicated when she performed a nutritional consult, she wrote the physician's order, and the physician later signed it. When asked by the surveyor if the orders she documented as telephone orders were actually orders received by the physician by telephone, S4 indicated she was not calling the physician but only writing the order for the physician to later sign. S4 confirmed, after reviewing Patient #2's medical record, that physician orders and/or hospital policy was not followed for the tube feedings administered by the nursing staff. She also confirmed there was no documented evidence the physician was notified of the times the Nepro was not at a 50 ml/hr rate as ordered.

Review of the hospital policy titled "Tube Feeding", effective 04/09 and submitted by DON S2 as their current policy for tube feeding, revealed, in part, "... Continuous feeding with enteral pump: ...vi. Check tube placement every four hours. Vii. Check residual a minimum of once every 4 hours. If residual is >100cc or >2x (2 times) rate of infusion, stop feeding for two hours. Viii. Recheck residual after two hours and resume tube feeding unless residual remains over 100cc. Then notify the physician. ... e. Notify the physician of the following: i. Residual feeding of 100 ml or greater aspirated prior to feeding. ii. Signs and symptoms of intolerance. ... f. Documentation: i. Date and time, proper tube placement, patient tolerance, and insertion site appearance in Patient Care Flow Sheet. ii. Type, strength, amount, time hung, rate of feeding, and time down on the Nursing Flow Sheet under the Diet and Intake and Output section. ... vi. Physician notification of intolerance or complications ...".

i) Assessment of blood pressures before administration of blood pressure medication
Review of the medical record for Patient #4 revealed she was admitted to the hospital with the diagnoses of sepsis, malnutrition, anemia, hepatic encephalopathy, End Stage Renal Disease (ESRD) requiring dialysis, DM (Diabetes Mellitus) and pressure ulcers.

Review of the Physician's Orders for Patient #4 dated 08/24/10 revealed an order for Lopressor 25mg one tablet by mouth twice a day and to hold for a heart rate < 55 or a Systolic Blood Pressure (SBP) of < 110. Review of the Medication Administration Record (MAR) revealed no documented evidence the blood pressure and heart rate had been assessed before Lopressor 25mg had been administered on the following dates and times: 08/24/10 @0900 (9:00am); 08/25/10 @ 0900, 2100 (9:00pm); 08/26/10 @ 9:00am; 08/27/10 @ 9:00am; 09/03/10 @ 0900 (9:00am);

Review of the Physician ' s Orders for Patient #4 dated 07/29/10 revealed an order for Midodrine 10mg by mouth three times a day hold for a SBP (Systolic Blood Pressure)> 110. Review of the Medication Administration Record (MAR) revealed no documented evidence the blood pressure had been assessed before Midodrine 10mg had been administered on the following

Based on record review and interview the hospital failed to: 1) follow their policy and procedure for administering medication without a usage as evidenced by failing to clarify an order for Xanax and Ultram (Patient #1); Colace (Patient #2); and Ativan (Patient #4) for 3 of 8 sampled medical records and 2) ensure medications were administered as ordered for 4 of 8 sampled medical records (#1, #3, #5, #6). Findings:

1) Follow their policy and procedure for administering medication without a usage:
Patient #1
Review of Patient #1's medical record revealed she was admitted on 08/19/10 with diagnoses of Hyperkalemia, End Stage Renal Disease, and Sepsis.

Review of Patient #1's physician admit orders on 08/19/10 at 8:00pm revealed orders for Xanax 0.25mg (milligrams) by mouth prn (as needed) BID (twice a day) and Ultram 100mg by mouth prn every 8 hours. Further review revealed no documented evidence of the indication for use and clarification by the physician whether the Xanax was to be administered BID or prn and whether the Ultram was to be administered every 8 hours or prn.

Patient #2
Review of Patient #2's medical record revealed he was admitted on 09/04/10 at 6:15pm with diagnoses of Aspiration pneumonia, Hypertension, and Diabetes Mellitus.

Review of the physician admit orders revealed an order for Colace 100mg by mouth BID prn. Further review revealed no documented evidence of the indication for use and clarification by the physician whether the Colace was to be administered prn or BID.

Patient #4
Review of the medical record for Patient #4 revealed she was admitted to the hospital with the diagnoses of sepsis, malnutrition, anemia, hepatic encephalopathy, End Stage Renal Disease (ESRD) requiring dialysis, DM (Diabetes Mellitus) and pressure ulcers.

Review of the Physician's Order dated 08/18/10 for Patient #4 revealed, "Ativan 0.5mg U/D Tablet take one tablet by mouth every 8 hours as needed". Review of the Physicians' Orders, Nursing Progress Notes and MAR (Medication Administration Record) dated 08/18/10 through 09/03/10 revealed no documented evidence the order had been clarified by the nursing staff or the pharmacist.

In a face-to-face interview on 09/08/10 at 10:20am, DON S2 indicated the pharmacist would send a note requesting the indication for use if it was not included in the orders, but a clarification order was not written. He could offer no explanation for this not being done and for not clarifying an order when a medication was ordered prn and every 8 hours or BID.

Review of the policy titled "Medication Management", effective 04/09 and submitted by DON S2 as their current medication administration policy, revealed, in part, "...Each medication ordered has a documented diagnosis, condition, or indication-for-use. ... Elements of a complete order includes the following necessary information regarding the medication itself: a. Drug name b. Strength c. Dosage form ... d. Route of administration e. Frequency of administration f. Special instructions ... g. Designated administration time to be assigned by the MD or by nurse using hospital established scheduled frequency of administration times. ... If an order is incomplete, is not legible, or if there is a question as to the dosage, route of administration, or the time, the nurse is to contact the physician for a "clarification order". The pharmacist will fax clarification order to be placed in medical record. If pharmacy is unsuccessful in contacting the physician to get clarification, the charge nurse will be notified and asked to attempt to get the order clarified. The charge nurse will document any clarification on the physician order form and fax to pharmacy ...".

2) Ensure medications were administered as ordered:
Patient #1
Review of Patient #1's medical record revealed she was admitted on 08/19/10 at 8:00pm with diagnoses of Hyperkalemia, End Stage Renal Disease, and Sepsis. Review of the History and Physical (H&P) revealed additional diagnoses of Staph Epidermidis, Diabetes Mellitus, Major Depression, and Peripheral Neuropathy.

Review of Patient #1's "Physician Sliding Scale Insulin Orders" dated 08/19/10 at 10:10pm revealed she was to have capillary blood glucose (CBG) checks AC and HS (before meals and at bedtime). Further review of the order revealed the "Hypoglycemic Protocol" included the following: accucheck 60-69 - 4 oz (ounces) OJ (orange juice) or 15 ml (milliliters) D50 (50% dextrose) IV (intravenous) (if unable to swallow or Signs or symptoms); accucheck 50-59 - 20 ml D50 IV; accucheck less than 50 - 25 ml D50 IV - draw stat BMP (basic metabolic profile); always check CBG 30 minutes after interventions & notify physician. Further review revealed if the accucheck was above 400, 14 units of Regular insulin was to be administered and the physician notified.

Review of Patient #1's "Daily Nursing Assessment" for 08/29/10 revealed an entry by RN S3 at 9:00pm of an accucheck of 475, and 14 units of R (regular) insulin was given SQ (subcutaneous). Further review revealed RN S12, Charge Nurse, notified Medical Director S9, and no new orders were obtained. Further review revealed at 10:00pm RN S3 documented the accucheck was 430, and at 11:15pm it was 273. Further review revealed no documented evidence Medical Director S9 was notified of the CBG greater than 400 at 10:00pm.
In a face-to-face interview on 09/08/10 at 8:20am, RN S3 confirmed she did not report Patient #1's repeat CBG of 430 to his physician.

Review of Patient #1's "Daily Nursing Assessment" for 09/06/10 at 8:00pm by LPN (licensed practical nurse) S5 revealed the CBG was 40, the RN charge nurse was notified, and Patient #1 was given Ensure (patient refused juice). Further review revealed the CBG at 8:30pm was 66, and Patient#1 was given Nepro, celery, carrots, and peanut butter (patient ' s usual evening snack). Further review revealed at 9:00pm the CBG was 83. Review revealed no documented evidence the RN assessed Patient #1 when her blood glucose dropped to 40.

In a face-to-face interview on 09/08/10 at 9:55am, LPN S5 indicated she did not follow the physician's orders. LPN S5 indicated she didn't call the physician, because she leaves that to the RN.

Patient #3
Review of Patient #3's medical record revealed he was admitted on 08/02/10 at 5:00pm with diagnoses of Sepsis, Fever, Chronic Kidney Disease, Hemodialysis, and Prostate Cancer. Review of the H&P revealed additional diagnoses of Abdominal distention with constipation, anorexia, and a history of a colostomy; Diabetes Mellitus, insulin requiring; Metastatic prostate cancer with particularly metastases to his back; History of stroke with moderate right hemiparesis; Left foot drop which is severe; Generalized debility; Stage 2 sacral decubitus; Diabetic neuropathy, Scrotal and penile edema; Recent left lower lobe pneumonia with bronchospasm, ongoing; and Anorexia, at risk for malnutrition.

Review of Patient #3's physician's orders revealed the admit orders included accuchecks before meals and bedtime. Further review revealed an order for management of patient with low blood sugar to include if "60" appears in display or blood glucose below 60, retest, notify physician, and obtain blood glucose to send to laboratory for confirmatory test results. Further review revealed a "Physician Sliding Scale Insulin Orders" received by telephone order from Medical Director S9 on 08/02/10 with no documented evidence of the time the order was received. Further review revealed for a CBG of 50-59, 20 ml D50 IV was to be administered, always recheck CBG 30 minutes after interventions, and notify the physician.

Review of Patient #3's "Diabetic Record" revealed his blood glucose was 50 at 7:30am on 08/03/10. Review of the "Daily Nursing Assessment" for 08/03/10 revealed no documented evidence 20 ml D50 IV was administered as required by physician orders.

In a face-to-face interview on 09/08/10 at 10:20am, DON S2 confirmed Patient #3's physician's orders were not implemented on 08/03/10.

Patient #4
Review of the medical record for Patient #4 revealed she was admitted to the hospital with the diagnoses of sepsis, malnutrition, anemia, hepatic encephalopathy, End Stage Renal Disease (ESRD) requiring dialysis, DM (Diabetes Mellitus) and pressure ulcers.

Review of the Physician's Orders for Patient #4 dated 08/24/10 revealed an order for Lopressor 25mg one tablet by mouth twice a day and to hold for a heart rate < 55 or a Systolic Blood Pressure (SBP) of < 110. Review of the Medication Administration Record (MAR) revealed no documented evidence why the medication had not been administered on the following dates/times: 08/28/10 @0900 (9:00am)and 09/02/10 @ 0900 (9:00am). Review of the Physician' Orders dated 08/20/10 revealed an order for Mododrine 10mg by mouth three times a day and to hold for a Systolic Blood Pressure > 110. Review of the MAR revealed no documented evidence why the medication had not been administered on the following dates/times: 08/20/10 @1500 (3:00pm); 08/21/10 @ 2100 (9:00pm); and 08/24/10 @1500 (3:00pm).

Patient #5
Review of the medical record for Patient #5 revealed she was admitted to the hospital with the diagnoses of Diabetes Mellitus (DM), Wound Infection and Hypertension (HTN).

Review of the Physicians' Orders for Patient #5 dated 08/03/10 revealed an order for Clonidine 0.1mg twice a day at 0900 (9:00am) and 2100 (9:00pm) and Clonidine 0.1mg by mouth prn (as needed) for a SBP (Systolic Blood Pressure) of >170 or a Diastolic Blood Pressure >100.

Review of the "Vital Signs and Intake & Output Record" revealed the following: 08/07/10 0600 (6:00am) Blood Pressure (BP) 180/88; 08/09/10 1800 (3:00pm) BP 173/81; 08/11/10 0600 (6:00am) BP 184/96; 08/13/10 0600 (6:00am) BP 173/87; and 08/14/10 0600 (6:00am) 175/94, 1800 (3:00pm) 177/94.

Review of the MAR for Patient #5 revealed no documented evidence a prn dosage of Clonidine had been administered even though the systolic blood pressures were not within the parameters ordered by the physician.

In a face to face interview on 09/08/10 at 8:45am LPN S5 indicated she did not administer the Clonidine 0.1mg prn because she associated the elevated blood pressure with the patient's complaint of pain. Further she felt that because the patient was elderly it was to wise to give both. S5 indicated she always re-assessed the blood pressure; however she did not document the re-assessment in the chart. Further S5 indicated she did not report this to the charge nurse.

Patient #6
Review of the medical record for Patient #6 revealed he was admitted to the hospital on 08/14/10 for a diabetic foot ulcer with osteomyelitis, DM (Diabetes Mellitus) and ESRD (End Stage Renal Disease) on dialysis.

Review of the Physician ' s Orders for Patient #6 dated 08/14/10 revealed ... .... " Management of patient with low blood sugar: Nurse to obtain glucose checks as ordered if 60 appears in display or blood glucose below 60, retest, notify physician, and obtain blood glucose to send to laboratory for confirmatory test results " .

Review of the Nursing Notes for Patient #6 dated/times 1235 (12:35pm) revealed ... " Called to room by wife - laying in bed with head leaning to left - diaphoretic - unable to eyes open or remain alert - blood sugar 26. 2 amps (ampoule) D50 to right peripheral IV-flushed with 10cc NS (Normal Saline)."

Review of Policy # II-C.3.32.1 titled "Management of the Patient with Low Blood Sugar (Below 60) revealed...... "If patient is unable to swallow give 1/2 of D50 IVP (Intravenous Push) or one IM (Intramuscular) dose of Glucogan and recheck in 15 minutes and repeat every hour if needed".

In a face to face interview on 09/08/10 at 11:40am RN S7 indicated she was the nurse assigned to Patient #6 on 08/22/10 at 1235 (12:35pm) when his blood sugar dropped to 26.
Further S7 verified the patient was becoming non-responsive so she administered 2 ampoules of D50 IVP. After reviewing the policy and procedure for management of a low blood sugar S7 indicated she did not administer the correct dosage of D50 to Patient #7.

Review of the policy titled "Medication Management", effective 04/09 and submitted by DON S2 as their current medication administration policy, revealed, in part, "... Administration ...Report a variance in medication immediately to the nurse in charge. Medication variances are reported on the occurrence report. ... The drug regimen of all patients is reviewed by the pharmacist upon admission and with any medication order change and at least weekly with production of MAR's (medication admission record). Any irregularities detected must be reported to the attending physician, Director of Nursing or both, and these reports must be acted upon...".

Review of the "Pharmacy Services Agreement", effective 05/09, revealed, in part, "... Pharmacy agrees to perform the following pharmaceutical services, including but not limited to: ... Screening each new medication order for an appropriate indication or diagnoses; ... If diagnoses or indication is not available, notifying the nursing staff of the need to obtain the information from the prescriber prior to administering the drug. ...Assist with the development and oversight of medication error reporting...".





25065

Based on record review and interview, the pharmacist failed to ensure medications ordered by the physician were available for administration for the next scheduled dose by having medications not available and having nursing staff obtain physician orders to hold medications until they were received from the pharmacy for 4 of 8 sampled patients (#1, #2, #4, #6). Findings:

Patient #1
Review of Patient #1's medical record revealed a physician order on 08/24/10 at 8:20pm for Naprosyn 500mg (milligrams) by mouth with food BID (twice a day) for 5 days. Further review revealed a physician's order on 08/25/10 at 9:40am to hold Naprosyn "until arrives from pharmacy". Further review revealed a physician's order on 08/25/10 at 3:00pm to give Naprosyn as ordered.

Review of the MAR (medication administration record) for Patient #1 for 08/25/10 revealed a note, with no documented evidence of the author of the note, "100 awaiting from pharmacy". Review of the nursing notes for 08/25/10 revealed no documented evidence Naprosyn was administered on 08/25/10. Further review revealed the first dose of Naprosyn was administered on 08/26/10 at 9:00am, more than 36 hours after it was initially ordered by the physician. There was no documented evidence the physician was notified that Naprosyn was not administered as ordered, and there was no medication variance completed for this occurrence.

Patient #2
Review of Patient #2's medical record revealed he was admitted on 09/04/10 at 6:15pm with diagnoses of Aspiration pneumonia, Hypertension, and Diabetes Mellitus.

Review of Patient #2's admit physician orders revealed an order for Flagyl 500mg IVPB (intravenous piggyback) every 6 hours.

Review of the "Daily Nursing Assessment" for 09/04/10 revealed a note at 6:15am (on 09/05/10) by RN (registered nurse) S13 of "late entry Flagyl 500mg IVPB not given. Pharmacy did not send medication. None in Omnicell". There was no documented evidence the physician was notified that Flagyl was not administered as ordered, and there was no medication variance completed for this occurrence.

Patient #4
Review of the medical record for Patient #4 revealed she had been admitted 07/29/10 with the diagnoses of Sepsis, Pressure Ulcers, End Stage Renal Disease (ESRD) requiring dialysis and Diabetes Mellitus (DM).

Review of the Physicians' Orders dated 07/29/10 revealed an order for Oxycodone HCL 5mg U/D take 1/2 tablet by mouth every 12 hours. Further review revealed an order for Percocet 5/325mg 1/2 tablet by mouth every 12 hours until the oxycodone arrives 07/30/10.
There was no documented evidence a medication variance was completed for this occurrence.

In a face-to-face interview on 09/08/10 at 10:20am, DON (Director of Nursing) S2 indicated Facility B was their contracted pharmacy. He further indicated Facility B delivered twice a day Monday through Friday about 3:00pm and 9:00pm and once in the evening on weekends. DON S2 further indicated most of their patients were admitted after 7:00pm, the nursing staff had to fax the physician orders to the pharmacy, and the next delivery time wasn't until 3:00pm the next afternoon.

Patient #6
Review of the medical record for Patient #6 revealed he was admitted to the hospital with the diagnoses of DM (Diabetes Mellitus), ESRD (End Stage Renal Disease) requiring dialysis, Anemia and chronic skin necrosis.

Review of the Physicians' Admit Orders for Patient #6 dated 08/14/10 revealed an order for Novolog 70/30 22 units sq (subcutaneously) every AM. Further review revealed a physician's order dated 08/14/10, "to use Novolin 70/30 until Novolog 70/30 arrives".

Review of the MAR (Medication Administration Record) revealed Novolin 70/30 had been administered to Patient #6 as follows: 08/15/10 at 0730 (7:30am); 08/16/10 at 7:30am; 08/17/10 at 0900 (9:00am); and 08/18/10 at 9:00am. Further review revealed the Novolog 70/30 had not arrived from the pharmacy until after the 08/18/10 9:00am dose had been administered (five days after the medication had been ordered by the MD).

Review of the medical record for Patient #6 revealed no documented evidence the unavailability of the medication had been reported to the charge nurse, Director of Nursing or the Pharmacist. There was no documented evidence the physician was notified of the delay of the pharmacy obtaining the Novolog 70/30 and no medication variance completed for this occurrence.

In a face-to-face interview on 09/08/10 at 12:50pm with Medical Director S9, Administrator S1, and Director of Nursing S2, Medical Director S9 indicated the hospital continued to have problems with the delivery of medications from pharmacy. DON S2 indicated the nurses were not completing medication variance reports for medications that were missed due to late delivery from pharmacy.

Review of the "Pharmacy Services Agreement "between LTAC of Slidell and Facility B revealed, in part, "...Appendix A Pharmacy agrees to perform the following pharmaceutical services, including but not limited to: ...Providing routine and timely pharmacy service for the Facility in-patients 24 hours per day, 7 days per week and as necessary to meet patient needs ...".

Based on record review and interview the hospital failed: 1) to ensure there was a full-time employee who served as the director of the food and dietetic services as evidenced by having a dietitian whose hours were dependent on patient census and 2) to ensure the food and dietetic services were integrated into the hospital-wide QAPI (quality assurance performance improvement) program as evidenced by no documented quality indicators were developed and monitored for the identified problems related to dietary and by the lack of attendance by the Dietitian/Department Head for Food and Dietary Services at QA/PI meetings. Findings:

1) to ensure there was a full-time employee who served as the director of the food and dietetic services as evidenced by having a dietitian whose hours were dependent on patient census
In a face-to-face interview on 09/07/10 at 10:10am, Administrator S1 indicated the dietary manager was employed in their off-site location, and Registered Dietitian (RD) S4 was at the hospital 40 hours per week and had oversight of the dietary department.

In a face-to-face interview on 09/08/10 at 8:55am, RD S4 indicated she was supposed to be full-time, but she flexed her day according to the patient census, because she was a salaried employee. She further indicated she worked 3 or 4 days per week, usually Monday, Wednesday, and Friday from 9:00am to about 3:30pm or 4:00pm. RD S4 indicated the ward clerk did the food temperature checks and the nursing assistants checked the diets when she wasn't present. She confirmed that she did not work 40 hours per week which was considered full-time.

The hospital was not able to submit any documentation of the hours worked for the salaried dietitian.

2) to ensure the food and dietetic services were integrated into the hospital-wide QAPI (quality assurance performance improvement) program
Review of the Performance Improvement Committee meeting minutes dated 08/30/10 revealed no documented evidence quality indicators had been developed for the identified problems of accurate assessment of weights, performance of calorie counts, and nutritional assessments. Further review revealed no documented evidence the dietitian S4 who also serves as department head was part of the QA/PI Committee.

In a face to face interview on 09/0810 at 8:55am RD S4 indicated she was not involved in the QA/PI program.

Review of Policy # I-E.5.00 titled "Performance Improvement Plan " submitted a the one currently in use revealed... "All departments shall participate in the systematic monitoring and evaluation of the quality and safety of care/services they provide".

Based on record review and interviews, the hospital failed to ensure the registered dietitian supervised the nutritional aspects of patient care by: 1) failing to ensure the daily food intake had been assessed and documented in the patients' charts for 4 of 8 sampled patients (#4, #5, #7, #8); 2) failing to obtain a physician's order for the nutritional needs of the patient identified through the nutritional assessment prior to implementing patient care necessary to meet the nutritional needs for 1 of 8 sampled patients (#2); 3) failing to ensure the nutritional consults included a patient's height to determine BMI (body mass index) in order to obtain an accurate assessment of the patient's nutritional status for 1 of 8 sampled patients (#3); and 4) failing to ensure calorie counts ordered by the physician were documented and evaluated by the dietitian for 1 of 2 patient with an order for calorie counts from a total of 8 sampled patients (#3). Findings:

1) Assessment of daily food intake:
Patient #4
Review of the medical record for Patient #4 revealed she was admitted to the hospital with the diagnoses of Sepsis, ESRD (End Stage Renal Disease) requiring dialysis, Malnutrition, Anemia and Pressure Ulcers.

Review of the "Vital Signs and Intake and Output Record" for Patient #4 revealed no documented evidence the dietary intake had been assessed and recorded in the chart as follows: 07/29/10, 07/30/10, 08/10/10 (dinner), 08/11/10 (dinner), 08/24/10 (dinner), 08/25/10 (dinner), 0826/10 (dinner),and 08/30/10 (dinner).

Patient #5
Review of the medical record for Patient #5 revealed she had been admitted to the hospital on 08/04/10 with the diagnoses of Stage III to the coccyx, DM (Diabetes Mellitus), and HTN (Hypertension). Review of the Nutritional Consult (per physician ' s order) dated 08/05/10 revealed Patient #5 weighed 77.3 pounds upon admit with an IBW (Ideal Body Weight) of 110 pounds (32.7 pounds below IBW). Further review revealed Patient #5 had moderate malnutrition with the dietetic recommendations to continue the 1800 calorie ADA (American Diabetes Association) diet mechanical soft, multivitamins daily, Vitamin C and the dietitian to follow-up and monitor.

Review of the "Vital Signs and Intake & Output Record" for Patient #5 revealed she had been weighed on 08/04/10 (77.3 pounds); 08/09/10 (74.5 pounds); and 08/23/10 (68.9 pounds). Further review revealed Patient #5 had not been assessed for nutritional intake as follows: 08/07/10; 08/08/10; 08/10/10 dinner; 08/11/10 dinner; 08/16/10 dinner; 08/18/10; 08/19/10 dinner, 08/23/10 dinner, 08/24/10 dinner, 08/27/10, 08/28/10 dinner, 09/01/10 dinner, 09/02/10 dinner, 09/03/10; 09/04/10 and 09/05/10. (Patient assessed approximately 70% of the time).

Patient #7
Review of the medical record for Patient #7 revealed he was admitted to the hospital on 06/25/10 with the diagnoses of renal failure (on dialysis which was started three months ago), DM (Diabetes Mellitus), HTN (Hypertension), and morbid obesity.

Review of the "Vital Signs and Intake and Output Record" for Patient #7 revealed no documented evidence the dietary intake had been assessed and recorded in the chart as follows: 06/25/10, 07/01/10, 07/05/10 (dinner), 07/06/10, 07/07/10 (dinner), 07/08/10, 07/10/10 (breakfast, lunch), 07/11/10 (dinner), 07/12/10 (dinner), 07/13/10 (dinner), 07/18/10 (dinner), and 07/19/10.

Patient #8
Review of the medical record for Patient #8 revealed she was admitted to the hospital on 08/25/10 with the diagnoses of a non-healing Stage IV Decubitus of the Left Hip, DM (Diabetes Mellitus) and Malnutrition.

Review of the "Vital Signs and Intake and Output Record" for Patient #8 revealed no documented evidence the dietary intake had been assessed and recorded in the chart as follows: 08/25/10 (dinner), 08/26/10 (dinner), 08/27/10, 08/28/10 (dinner), 08/29/10, 09/03/10 (dinner), 09/07/10 and 09/08/10 (breakfast) (60% of the time).

In a face to face interview on 09/08/10 at 4:20pm S1 RN Director of Nursing (DON)indicated the CNAs (Certified Nursing Assistants) have the primary responsibility for picking up the trays and documenting the percentage of the meals eaten; however any nursing staff member who picks up the trays should document in the patient's record how much was eaten. Further S2 indicated the charge nurse is responsible for making sure this is done.

In a face to face interview on 09/08/10 at 8:55am RD S4 indicated she basis her assessment of nutritional intake for her patients on on the percentage of the nutritional intake document in the patients' charts. S4 could not explain how this is calculated when the CNAs fail to assess meal intake.

2) Obtaining a physician's order for nutritional needs of the patient:
Review of Patient #2's medical record revealed he was admitted on 09/04/10 at 6:15pm with diagnoses of Aspiration pneumonia, Hypertension, and Diabetes Mellitus.

Review of Patient #2's physician's orders revealed telephone orders for nutrition therapy on 09/07/10 at 11:20am and 1:00pm received from Physician S21 by RD (registered dietitian) S4.

In a face-to-face interview on 09/08/10 at 2:30pm, RD S4 indicated when she performed a nutritional consult, she wrote the physician's order, and the physician later signed it. When asked by the surveyor if the orders she documented as telephone orders for Patient #2 on 09/07/10 were actually orders received by the physician by telephone, S4 confirmed that the physician orders were written by her without calling the physician for orders, and thus, they were not actually telephone orders as documented.

3) Nutritional consults with documentation of height:
Review of Patient #3's medical record revealed he was admitted on 08/02/10 at 5:00pm with diagnoses of Sepsis, Fever, Chronic Kidney Disease, Hemodialysis, and Prostate Cancer. Review of the H&P revealed additional diagnoses of abdominal distention with constipation, anorexia, and a history of a colostomy; Diabetes Mellitus, insulin requiring; metastatic prostate cancer with particularly metastases to his back; history of stroke with moderate right hemiparesis; left foot drop which is severe; generalized debility; stage 2 sacral decubitus; diabetic neuropathy, scrotal and penile edema; recent left lower lobe pneumonia with bronchospasm, ongoing; and anorexia, at risk for malnutrition.

Review of Patient #3's "LTAC (long term acute care) Admit Physician Orders" of 08/02/10 at 5:00pm revealed a dietary assessment was ordered by Medical Director S9.

Review of RD (registered dietitian) S4's "Nutritional Assessment Summary" performed 08/04/10 at 11:20am revealed no documented evidence of a height and BMI (body mass index). Further review revealed comments of "need ht (height) for further assessment, mod. (moderate) malnutrition 2 (secondary to) diagnosis, med hx. (medical history) & (and) alb (albumin) ...".

In a face-to-face interview on 09/08/10 at 2:30pm, RD S4, after reviewing Patient #3's nutritional assessment, could offer no explanation for not obtaining his height in order to ensure an assessment of his BMI and an accurate assessment of his nutritional status.

Review of the 2 policies presented by Director of Nursing S2 upon request of their nutritional assessment policies, "Nutritional Screening" and "Nutritional Services" revealed no documented evidence of the documentation required for a nutritional assessment by the dietitian.

4) Calorie counts:
Review of Patient #3's physician orders for 08/03/10 at 2:45pm revealed an order for calorie counts.

Review of the entire medical record revealed no documented evidence that calorie counts were done.

In a face-to-face interview on 09/08/10 at 10:20am, DON S2 confirmed there was no documented evidence in the medical record of Patient #3 that calorie counts were performed. He indicated they should remain in the record.

In a face-to-face interview on 09/08/10 at 2:30pm, RD S4 indicated she remembered doing calorie counts for Patient #3, but she didn't see them documented in the medical record. She further indicated she couldn't remember if the staff documented every meal. RD S4 confirmed that her documentation in Patient #3's medical record did not include an assessment of calorie counts.

Based on observation and interview, the hospital failed to ensure the maintenance of a sanitary physical environment by having lemon glycerin swabsticks in the freezer of the patient's nourishment refrigerator and not having daily checks of temperature of the refrigerator and freezer used to store patient nourishments. Findings:

Observation on 09/07/10 at 4:00pm with Director of Nursing (DON) S2 present revealed a box containing 23 Lemon Glycerin Swabsticks in the freezer located in the patient nourishment room. Further review revealed no documented evidence the temperature of the freezer and refrigerator had been checked on 09/01/10, 09/04/10, 09/05/10, and 09/06/10.

In a face-to-face interview on 09/07/10 at 4:00pm, DON S2 indicated the lemon glycerin swabsticks should not be in the freezer used to store patient nourishments. He further indicated the freezer and refrigerator temperatures should be checked daily.

In a face-to-face interview on 09/08/10 at 4:20pm, DON S2 indicated he could not find a hospital policy that addressed that the temperatures being taken for the freezer and refrigerator storing patient nourishments or for the storage of non-food items in freezers/refrigerators used for patient nourishments.

Based on observation ad review the hospital failed to ensure medication variances had been identified by relying on self reporting for identification of medication variances as evidenced by 57 medication variances not reported related to: failure to clarify MD orders before administration of drugs (#1, #2, #4); failure to administer medications as ordered and document the reasons ordered medications were not administered (Patient #1, #2, #3, #4, #5); failure by the pharmacy to send ordered medications by the next dose (#1, #2, #4, #6); blood pressure medications not administered when the patients' blood pressures were not within the parameters ordered by the physician (#4, #5); and the protocol for Management of Hypoglycemia not followed resulting in a patient receiving 2 ampoules of D50 IVP (Intravenous Push) instead of the ordered 1/2 ampoule of D50 (Patient #6) (See findings in Tag A0500, A0501, A0395 and A0396) ;

Based on record review and interview the hospital failed to follow their Performance Improvement Plan by failing: 1) to ensure Dietary, Respiratory, Radiology, Physical, Occupational and Speech Therapies developed standards of care and criteria to measure and monitor processes that affect patient safety and quality of care and 2) to ensure twenty-four hour chart checks had been performed by the nursing staff as evidenced by identified problems in the plan of care related to medication administration, weights, assessments, labs, tube feedings, skin integrity, falls, calorie counts, wound care, hypoglycemia and physician orders (Patient #1, #2, #3, #4, #5, #6, #7, #8) for 8 of 8 sampled patients. Findings:

1) to ensure Dietary, Respiratory, Radiology, Physical, Occupational and Speech Therapies developed standards of care and criteria to measure and monitor processes that affect patient safety and quality of care
Review of the meeting minutes for the Performance Improvement Committee dated 08/30/10 revealed no documented evidence Dietary, Respiratory, Radiology, Physical, Occupational or Speech Therapies had participated in performance improvement activities as evidenced by no documentation of criteria and indicators were developed and implemented to monitor patient care.

Review of the Performance Improvement Plan, Policy #I-E.5.00, revealed under the section "Hospital Departments"....... "The DON (Director of Nursing) and department leaders will monitor the processes in their areas that affect patient care safety, outcomes and satisfaction.

In a face to face interview on 09/08/10 at 4:20pm S18 RN Assistant Director of Nursing indicated she was the WA/PI Coordinator before becoming the ADON and the hospital used to have indicators for all services. Further she indicated several staff members had been put in the QA/PI position; however none had worked out. During this time some of the indicators were dropped.

2) to ensure twenty-four hour chart checks had been performed by the nursing staff as evidenced by identified problems in the plan of care related to medication administration, weights, assessments, labs, tube feedings, skin integrity, falls, calorie counts, wound care, hypoglycemia and physician orders (See findings at Tag A0395).

Based on record review and interview the hospital failed to follow their Performance Improvement Plan as evidenced by failure to include the identified high volume/problem-prone population of diabetes and hypertensive patients admitted to the hospital resulting in patients not receiving medication as ordered and patient assessments not performed to monitor the effectiveness of the medications for diabetes and/or hypertension (#1, #3, #4, #5, #6) for 5 of 8 sampled patients. Findings:

Review of the medical records for sampled patient (#1, #2, #3, #4, #5, #6, #7, #8) revealed all had been admitted to the hospital with the diagnosis of Diabetes Mellitus and were insulin dependent. Review of the medical records for patient (#1, #2, #3, #4, #5) had been admitted to the hospital with a diagnosis of HTN (Hypertension) and hypertensive medication(s) were ordered. (See findings in Tag A0500)

Based on record review and interview the hospital failed to ensure the data collected for performance improvement was documented and reported in measurable outcomes as evidenced by no documentation improvements had been made and/or sustained for identified problems related to: 1) poor performance of the laboratory Facility "C" resulting in a change in the laboratory contract (#1, #2); 2) poor performance by the pharmacy related to delivery of medication in a timely manner resulting in 4 of 8 patients (#1, #2, #4, #6) out of 8 sampled patients not receiving their MD ordered medications; and 3) poor performance by the contracted dietary services related to the quality of the food served to the patients resulting in poor patient satisfaction surveys. Findings:


1) poor performance of the laboratory Facility "C" resulting in a change in the laboratory contract
Patient #1
Review of Patient #1's medical record revealed she was admitted on 08/19/10 at 8:00pm with diagnoses of Hyperkalemia, End Stage Renal Disease, and Sepsis. Review of the H&P revealed additional diagnoses of Staph Epidermidis, Diabetes Mellitus, Major Depression, and Peripheral Neuropathy. Review of Patient #1's "LTAC (long term acute care) Admit Physician Orders" of 08/19/10 at 8:00pm revealed an order for PT/INR (protime/International Normalized Ratio) daily. Review of the entire medical record revealed no documented evidence the PT/INR was drawn or results had been received for 08/20/10.

Patient #2
Review of Patient #2's medical record revealed he was admitted on 09/04/10 at 6:15pm with diagnoses of Aspiration pneumonia, Hypertension, and Diabetes Mellitus. Review of Patient #2's "LTAC Admit Physician Orders" of 09/04/10 at 6:15pm revealed an order for a urinalysis in the morning. Review of the entire medical record revealed no documented evidence of urinalysis results in the record.

Review of the Quality Assurance/Performance Improvement Committee meeting minutes dated 08/30/10 revealed no documented evidence obtaining of labs and lab results had been identified as a problem.

In a face to face interview on 09/08/10 at 12:30 S2 DON indicated the hospital had problems with the services of Facility"C" because the route of the pick-up courier was so long, many times the specimen was no longer of acceptable quality by the time it actually reached the lab to be processed. S2 indicated the hospital attempted to find another lab here in town and finally got a contract signed with Facility "D". S2 confirmed there were no indicators developed for the identified problem of the timeliness for lab pick-up or results, no statistics documented and nn monitoring in place at the present time.
indicator
2) poor performance by the pharmacy related to delivery of medication in a timely manner
Patient #1
Review of Patient #1's medical record revealed a physician order on 08/24/10 at 8:20pm for Naprosyn 500mg (milligrams) by mouth with food BID (twice a day) for 5 days. Further review revealed a physician's order on 08/25/10 at 9:40am to hold Naprosyn "until arrives from pharmacy". Further review revealed a physician's order on 08/25/10 at 3:00pm to give Naprosyn as ordered. Review of the MAR (medication administration record) for Patient #1 for 08/25/10 revealed a note, with no documented evidence of the author of the note, "100 awaiting from pharmacy". Review of the nursing notes for 08/25/10 revealed no documented evidence Naprosyn was administered on 08/25/10. Further review revealed the first dose of Naprosyn was administered on 08/26/10 at 9:00am, more than 36 hours after it was initially ordered by the physician.

Patient #2
Review of Patient #2's medical record revealed he was admitted on 09/04/10 at 6:15pm with diagnoses of Aspiration pneumonia, Hypertension, and Diabetes Mellitus. Review of Patient #2's admit physician orders revealed an order for Flagyl 500mg IVPB (intravenous piggyback) every 6 hours. Review of the "Daily Nursing Assessment" for 09/04/10 revealed a note at 6:15am (on 09/05/10) by RN (registered nurse) S13 of "late entry Flagyl 500mg IVPB not given. Pharmacy did not send medication. None in Omnicell".

Patient #4
Review of the medical record for Patient #4 revealed she had been admitted 07/29/10 with the diagnoses of Sepsis, Pressure Ulcers, End Stage Renal Disease (ESRD) requiring dialysis and Diabetes Mellitus (DM). Review of the Physicians' Orders dated 07/29/10 revealed an order for Oxycodone HCL 5mg U/D take 1/2 tablet by mouth every 12 hours. Further review revealed an order for Percocet 5/325mg 1/2 tablet by mouth every 12 hours until the oxycodone arrives 07/30/10.

Patient #6
Review of the medical record for Patient #6 revealed he was admitted to the hospital with the diagnoses of DM (Diabetes Mellitus), ESRD (End Stage Renal Disease) requiring dialysis, Anemia and chronic skin necrosis. Review of the Physicians' Admit Orders for Patient #6 dated 08/14/10 revealed an order for Novolog 70/30 22 units sq (subcutaneously) every AM. Further review revealed a physician's order dated 08/14/10, "to use Novolin 70/30 until Novolog 70/30 arrives". Review of the MAR (Medication Administration Record) revealed Novolin 70/30 had been administered to Patient #6 as follows: 08/15/10 at 0730 (7:30am); 08/16/10 at 7:30am; 08/17/10 at 0900 (9:00am); and 08/18/10 at 9:00am. Further review revealed the Novolog 70/30 had not arrived from the pharmacy until after the 08/18/10 9:00am dose had been administered (five days after the medication had been ordered by the MD).

Review of the "Pharmacy Services Agreement "between LTAC of Slidell and Facility B revealed, in part, "...Appendix A Pharmacy agrees to perform the following pharmaceutical services, including but not limited to: ...Providing routine and timely pharmacy service for the Facility in-patients 24 hours per day, 7 days per week and as necessary to meet patient needs ...".

Review of the Pharmacy and Therapeutics (P&T) Committee meeting minutes for 06/25/10 and the Quality Assurance/Performance Improvement Committee meeting minutes dated 08/30/10 revealed no documented evidence the availability of medication had been identified as a problem.

In a face to face interview on 09/08/10 at 12:20 S1 Administrator indicated he had had a meeting with Facility "B" concerning the issues of medications not being available. Further S1 indicated at that time he informed the pharmacy either to improve the services provided to the hospital or the contract would be terminated. S1 verified there were no indicators developed for the identified problem of medication availability, no statistics documented and no monitoring in place at the present time.


3) poor performance by the contracted dietary services related to the quality of the food served to the patients
Review of the Safety Function Report dated 08/30/10 which was reported to the Quality Assurance/Performance Improvement Committee revealed no documented evidence the Dietary department participates on the PI Committee.

In a face to face interview on 09/08/10 at 12:50pm S1 Administrator indicated problems had been identified with the service provided by (Facility "A" ) involving food temperatures, availability of snacks especially on the weekends and the menu of cold sandwiches and soup for the evening meal. Further he indicted the corporate office looked into other possibilities for obtaining services form another facility, but nothing worked out.

In a face to face interview on 09/08/10 at 12:30pm S9 Medical Director indicated administration meets from time to time to discuss the problems. Further S9 indicated things will improve for about a month and then go right back to the same service and complaints by the patients concerning the food.

In a face to face interview on 09/08/10 at 2:30pm S4 Dietitian indicated she has no input into the diet of the patients at the hospital because the menus served at Facility "A" where the food is obtained has pre-printed menus on a cycle of 4 weeks. In the past we attempted to get the dinner menu changed; however the changes did not last long because some of our patients were requesting sandwiches at night so "Facility "A" wet back to serving the sandwiches and soup. S9 confirmed at the present time there are no performance improvement activities to monitor this identified problem, other than food temperatures.

Based on record review and interview the Governing Body failed to follow the Performance Improvement Plan as evidenced by: 1) failing to conduct QA/PI meetings monthly; 2) to ensure contracted services had been evaluated for performance before being renewed; 3) to ensure contracted services providing direct patient care participated in the hospital-wide QA/PI program as evidenced by no documented evidence dialysis, radiology, ultrasound, or dietary were part of the OA/PI process; 3) to ensure the duties of QA/PI Coordinator which were delegated to staff due to the vacancy in the QA/PI position were being performed. Findings:

1) to follow the Performance Improvement Plan as evidenced by failing to conduct QA/PI meetings monthly
Review of the QA/PI Meeting Minutes submitted by the hospital revealed a meeting was conducted on 02/03/2010, 06/25/10 and 08/30/10.

Review of the Performance Improvement Plan, Policy # I-E.5.00 revealed.... "Performance Improvement Committee will meet monthly".

2) to ensure contracted services had been evaluated for performance before being renewed
Review of the meeting minutes of the Governing Body dated 09/01/10 revealed the following contracts for patient services were renewed: dialysis, linen, medical record management, eye bank, radiology and ultrasound. Further review revealed no documented evidence the quality of the services provided to the patients at the hospital had been evaluated before being renewed.

In a face to face interview on 09/08/10 at 4:20pm S1 Administrator indicated the contracted services were reviewed and discussed in the Governing Body Meetings; however he could not submit any documented evidence an evaluation had been performed. Further he verified the meeting minutes were abbreviated due to the RHIT typing the minutes.

3) to ensure contracted services providing direct patient care participated in the hospital-wide QA/PI program
Review of the QA meeting minutes dated 08/30/10 revealed no documented evidence dialysis, ultrasound or radiology services, providing direct patient care, were included in the quality assurance/performance improvement process for the hospital.

In a face to face interview on 09/08/10 at 4:20pm S18 RN Assistant Director of Nursing indicated she was the QA/PI Coordinator before becoming the ADON and the hospital used to have indicators for all services. Further she indicated several staff members had been put in the QA/PI position; however none had worked out. During this time some of the indicators were dropped.

4) to ensure the duties of QA/PI Coordinator which were delegated to staff due to the vacancy in the QA/PI position were being performed.

In a face to face interview on 09/08/10 at 4:20pm S1 Administrator indicated the hospital had been trying to find a person who was knowledgeable about quality assurance. At the present time this duty has been delegated to the new DON as well as Infection Control. S1 indicated he is aware that chart audits are not being performed and because of this problems are not being identified.

Based on record review and interviews, the hospital failed to ensure medications were administered as ordered by the physician for 5 patients from a total of 8 sampled patients (#1, #2, #3, #4, #5). Findings:

Patient #1
Review of Patient #1's medical record revealed she was admitted on 08/19/10 at 8:00pm with diagnoses of Hyperkalemia, End Stage Renal Disease, and Sepsis. Review of the History and Physical (H&P) revealed additional diagnoses of Staph Epidermidis, Diabetes Mellitus, Major Depression, and Peripheral Neuropathy.

Review of Patient #1's "Physician Sliding Scale Insulin Orders" dated 08/19/10 at 10:10pm revealed she was to have capillary blood glucose (CBG) checks AC and HS (before meals and at bedtime). Further review revealed Patient #1 was to receive 2 units Regular Insulin for a CBG of 140. Further review of the order revealed the "Hypoglycemic Protocol" included the following: accucheck 60-69 - 4 oz (ounces) OJ (orange juice) or 15 ml (milliliters) D50 (50% dextrose) IV (intravenous) (if unable to swallow or Signs or symptoms); accucheck 50-59 - 20 ml D50 IV; accucheck less than 50 - 25 ml D50 IV - draw stat BMP (basic metabolic profile); always check CBG 30 minutes after interventions & notify physician. Further review revealed if the accucheck was above 400, 14 units of Regular insulin was to be administered and the physician notified.
Review of Patient #1's physician orders revealed an order on 08/25/10 at 8:50pm for Clonidine 0.1 mg (milligrams) by mouth every 6 hours as needed for systolic blood pressure greater than 160.

Review of the "Diabetic Record" for 08/20/10 at 9:00pm revealed her CBG was 159 with a note of "pt (patient) refused" by RN (registered nurse) S13. Further review revealed another entry for 9:00pm on 08/20/10 by LPN (licensed practical nurse) S5 of a CBG of 140. Further review of the entire medical record revealed no documented evidence that Patient #1's physician was notified of her refusal to have the insulin administered.

In a face-to-face interview on 09/08/10 at 9:55am, LPN S5 indicated she usually reported to the charge RN if a patient refused insulin and would leave it to the discretion of the RN to report to the physician. LPN S5 confirmed there was no documented evidence in the medical record of Patient #1 that she had reported the patient's refusal of insulin to the RN.

Review of Patient #1's "Daily Nursing Assessment" for 08/29/10 revealed an entry by RN S3 at 9:00pm that the blood glucose was 475, and 14 units of R (regular) insulin was given SQ (subcutaneous). Further review revealed at 9:30pm RN S3 documented that RN S12, Charge Nurse, notified Medical Director S9, and no new orders were obtained. Further review revealed at 10:00pm RN S3 documented the accucheck was 430, and at 11:15pm it was 273. Further review revealed no documented evidence Medical Director S9 was notified of the CBG greater than 400 at 10:00pm.

In a face-to-face interview on 09/08/10 at 8:20am, RN S3 confirmed she did not report Patient #1's repeat CBG of 430 to his physician, and thus she did not follow the physician's orders.

Review of Patient #1's "Daily Nursing Assessment" for 09/06/10 at 8:00pm revealed LPN S5 documented the CBG was 40, the RN charge nurse was notified, and Ensure (patient refused juice) was given. Further review revealed at 8:30pm the CBG was rechecked and was 66. Patient #1 was given Nepro, celery, carrots, and peanut butter (patient ' s usual evening snack). Further review revealed no documented evidence the physician was notified of the blood glucose results of 40 and 66.

In a face-to-face interview on 09/08/10 at 9:55am, LPN S5 confirmed she did not follow the physician's orders for the hypoglycemic protocol. LPN S5 indicated she didn't call the physician, because she leaves that to the RN.

In a face-to-face interview on 09/08/10 at 9:55am, DON S2, who was present during the interview with LPN S5, indicated the RN should have assessed Patient #1 during her hypoglycemic episode, assured the physician's orders were followed, and ensured the physician was notified of the event.

Review of Patient #1's "Vital Signs and Intake & Output Records" revealed the following dates and times of documented blood pressures:
08/26/10 at 6:00pm - 179/76;
08/27/10 at 6:00pm - no documented evidence of a blood pressure assessment;
08/28/10 at 6:00pm - 180/81;
08/29/10 at 6:00am - 169/74;
08/30/10 at 6:00pm - 163/77;
08/31/10 at 6:00pm - 180/82;
09/02/10 at 6:00pm - 161/72;
09/04/10 at 6:00pm - 166/80;
09/05/10 at 6:00pm - 172/72;
09/06/10 at 6:00am - 187/71.

Review of the entire medical record of Patient #1 revealed no documented evidence the Clonidine was administered as ordered for systolic blood pressure greater than 160 on the above listed dates and that the blood pressures were reassessed.

Review of the "Daily Nursing Assessment" for 09/04/10 revealed the following documentation by LPN 6: 7:15pm - blood pressure (BP) 192/86 per certified nursing assistant; manual BP 188/98; Clonidine 0.1 mg and Ultram (2) given orally; 8:15pm - BP 166/80, resting without distress; 11:45pm - BP 179/81, Xanax 0.25 mg given orally. Further review revealed no documented evidence LPN S6 notified the RN of the change in condition, and there was no further reassessment of the BP of 179/81 at 11:45pm.

In a face-to-face interview on 09/08/10 at 8:20am, RN S3 indicated the blood pressures documented on the graphic sheet were not actually the time the blood pressure was taken by the nursing assistant.

In a face-to-face interview on 09/08/10 at 9:55am, LPN S5 indicated there was no way the blood pressures documented on the graphic sheet at 6:00pm were actually taken at that time, because the nursing assistants start their shift at 5:30pm. She further indicated the nursing assistants take the vital signs between 7:45pm and 8:30pm.

In a face-to-face interview on 09/08/10 at 10:20am, DON S2 indicated LPN S6 was not available for interview. After reviewing the medical record of Patient #1, DON S2 confirmed the LPN should have notified the RN of the blood pressures of 192/86, 166/80, and 179/81 for assessment and notification of the physician. He further confirmed there was no documented evidence Patient #1 had received Clonidine as ordered for systolic blood pressures above 160. He indicated that although one couldn't tell by the documentation, due to the incorrect times documented for the blood pressures, he felt that Clonidine was not given because the nurse was planning to administer the scheduled antihypertensive medication at 9:00pm and would not administer the Clonidine. He indicated there was no documented evidence in the medical record that the nurse had reported the blood pressure to the physician and obtained an order to hold the Clonidine and to administer the scheduled antihypertensive instead.

In a face-to-face interview on 09/08/10 at 12:50pm with Medical Director S9, Administrator S1, and DON S2 present, Medical Director S9 indicated she was aware of the problem with the documentation of vital signs on the graphic sheet. She then asked DON S2 "what are you going to do to correct the problem?". Administrator S1 indicated he was planning to hire a QA (quality assurance) nurse to audit the medical records.

Patient #2
Review of Patient #2's medical record revealed he was admitted on 09/04/10 at 6:15pm with diagnoses of Aspiration pneumonia, Hypertension, and Diabetes Mellitus.

Review of Patient #2's admit physician orders revealed an order for Flagyl 500mg IVPB (intravenous piggyback) every 6 hours.

Review of the "Daily Nursing Assessment" for 09/04/10 revealed a note at 6:15am (on 09/05/10) by RN (registered nurse) S13 of "late entry Flagyl 500mg IVPB not given. Pharmacy did not send medication. None in Omnicell". There was no documented evidence the physician was notified that Flagyl was not administered as ordered, and there was no medication variance completed for this occurrence.

Patient #3
Review of Patient #3's medical record revealed he was admitted on 08/02/10 at 5:00pm with diagnoses of Sepsis, Fever, Chronic Kidney Disease, Hemodialysis, and Prostate Cancer. Review of the H&P revealed additional diagnoses of Abdominal distention with constipation, anorexia, and a history of a colostomy; Diabetes Mellitus, insulin requiring; Metastatic prostate cancer with particularly metastases to his back; History of stroke with moderate right hemiparesis; Left foot drop which is severe; Generalized debility; Stage 2 sacral decubitus; Diabetic neuropathy, Scrotal and penile edema; Recent left lower lobe pneumonia with bronchospasm, ongoing; and Anorexia, at risk for malnutrition.

Review of Patient #3's physician's orders revealed the admit orders included accuchecks before meals and bedtime. Further review revealed an order for management of patient with low blood sugar to include if "60" appears in display or blood glucose below 60, retest, notify physician, and obtain blood glucose to send to laboratory for confirmatory test results. Further review revealed a "Physician Sliding Scale Insulin Orders" received by telephone order from Medical Director S9 on 08/02/10 with no documented evidence of the time the order was received. Further review revealed for a CBG of 50-59, 20 ml D50 IV was to be administered, always recheck CBG 30 minutes after interventions, and notify the physician.

Review of Patient #3's "Diabetic Record" revealed his blood glucose was 50 at 7:30am on 08/03/10. Review of the "Daily Nursing Assessment" for 08/03/10 revealed no documented evidence LPN S11 had reported the blood glucose of 50 to the RN, the blood glucose was rechecked, the physician was notified, blood glucose was sent to the lab for confirmatory test results, and 20 ml D50 IV was administered, all required by physician orders.

In a face-to-face interview on 09/08/10 at 10:20am, DON S2 confirmed Patient #3's physician's orders were not implemented on 08/03/10.

Patient #4
Review of the medical record for Patient #4 revealed she was admitted to the hospital with the diagnoses of sepsis, malnutrition, anemia, hepatic encephalopathy, End Stage Renal Disease (ESRD) requiring dialysis, DM (Diabetes Mellitus) and pressure ulcers.

Review of the Physician's Orders for Patient #4 dated 08/24/10 revealed an order for Lopressor 25mg one tablet by mouth twice a day and to hold for a heart rate < 55 or a Systolic Blood Pressure (SBP) of < 110. Review of the Medication Administration Record (MAR) revealed no documented evidence the blood pressure and heart rate had been assessed before Lopressor 25mg had been administered on the following dates and times: 08/24/10 @0900 (9:00am); 08/25/10 @ 0900, 2100 (9:00pm); 08/26/10 @ 9:00am; 08/27/10 @ 9:00am; 09/03/10 @ 0900 (9:00am);

Review of the Physician's Orders for Patient #4 dated 07/29/10 revealed an order for Midodrine 10mg by mouth three times a day hold for a SBP (Systolic Blood Pressure)> 110. Review of the Medication Administration Record (MAR) revealed no documented evidence the blood pressure had been assessed before Midodrine 10mg had been administered on the following dates and times: 07/29/10 @ 2100 (9:00pm); 07/30/10 @ 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm); 07/31/10 @ 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm); 08/03/10 @ 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm); 08/04/10 @ 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm); 08/05/10 @ 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm); 08/07/10 @ 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm); 08/08/10 @ 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm); 08/09/10 @ 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm); 08/10/10 @ 0900 (9:00am); 08/11/10 @ 0900 (9:00am), 1500 (3:00pm); 08/12/10 @ 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm); 08/20/10 @ 1500 (3:00pm), 2100 (9:00pm); 08/27/10 @ (9:00pm), 1500 (300pm); and 09/03/10 @ 0900 (9:00am), 1500 (3:00pm), 2100 (9:00pm).

In a face to face interview on 09/08/10 at 4:20pm S2 RN DON indicated blood pressures should be assessed by the nurse administering the medication.

Patient #5
Review of the medical record for Patient #5 revealed she was admitted to the hospital with the diagnoses of Diabetes Mellitus (DM), Wound Infection and Hypertension (HTN).

Review of the Physicians' Orders for Patient #5 dated 08/03/10 revealed an order for Clonidine 0.1mg twice a day at 0900 (9:00am) and 2100 (9:00pm) and Clonidine 0.1mg by mouth prn (as needed) for a SBP (Systolic Blood Pressure) of >170 or a Diastolic Blood Pressure >100.

Review of the "Vital Signs and Intake & Output Record" revealed the following: 08/07/10 0600 (6:00am) Blood Pressure (BP) 180/88; 08/09/10 1800 (3:00pm) BP 173/81; 08/11/10 0600 (6:00am) BP 184/96; 08/13/10 0600 (6:00am) BP 173/87; and 08/14/10 0600 (6:00am) 175/94, 1800 (3:00pm) 177/94.

Review of the MAR for Patient #5 revealed no documented evidence a prn dosage of Clonidine had been administered even though the systolic blood pressures were not within the parameters ordered by the physician.

In a face to face interview on 09/08/10 at 8:45am LPN S5 indicated she did not administer the Clonidine 0.1mg prn because she attributed the elevated blood pressure with the patient's complaint of pain. Further she felt that because the patient was elderly it was not wise to give both. S5 indicated she always re-assessed the blood pressure; however she did not document the re-assessment in the chart. Further S5 indicated she did not report this to the charge nurse.

Patient #6
Review of the medical record for Patient #6 revealed he was admitted to the hospital on 08/14/10 for a diabetic foot ulcer with osteomylitis, DM (Diabetes Mellitus) and ESRD (End Stage Renal Disease) on dialysis. Review of the Plan of Care dated 08/14/10 revealed the problems of impaired mobility, decline in ADLs (Activities of Daily Living), altered comfort/pain, fluid volume excess, altered nutrition, impaired skin integrity, and sleep pattern disturbance; however there was no documented evidence goals and interventions had been identified and implemented. Further review revealed the Care Plan had not been reviewed for the entire hospital stay of 08/14/10 through 08/27/10.

Review of the Physician's Orders for Patient #6 dated 08/14/10 revealed ... .... " Management of patient with low blood sugar: Nurse to obtain glucose checks as ordered if 60 appears in display or blood glucose below 60, retest, notify physician, and obtain blood glucose to send to laboratory for confirmatory test results" .

Review of the Nursing Notes for Patient #6 dated/times 1235 (12:35pm) revealed ... " Called to room by wife - laying in bed with head leaning to left - diaphoretic - unable to eyes open or remain alert - blood sugar 26. 2 amps (ampoule) D50 to right peripheral IV-flushed with 10cc NS (Normal Saline).

In face to face interview on 09/08/10 at 11:40am RN S7 who was assigned to the care of Patient #6 and who administered the 2 ampoules of D50 for a blood sugar of 26 indicated she was not aware of the Management of Hypoglycemia Protocol at the time and listened to the charge nurse and administered double the ordered dose.

Review of the hospital policy titled "Medication Management", effective 04/09 and submitted by DON S2 as their current medication administration policy, revealed, in part, "... F. Administration ... Report a variance in medication immediately to the nurse in charge. Medication variances are reported on the occurrence report. ... Each Patient has an individual medication record and the dose of the drug administered is properly recorded after administration in that record by the person whom administered the drug. ... The drug regimen of all Patients is reviewed by the pharmacist upon admission and with any medication order change and at least weekly with production of MAR's (medication administration record). Any irregularities detected must be reported to the attending physician, Director of Nursing or both, and these reports must be acted upon...". Review of the entire policy revealed no documented evidence of what would be considered a medication variance and would require reporting.