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Based upon review of 1 of 6 medical records, policy and procedure, and staff interview, the Registered Nurse failed to 1) evaluate the nursing care of patient #1 as evidenced by failure to document an evaluation of the patient from 7:15 AM to 10:45 AM on 03/09/13 after the patient became unresponsive due to an asystole episode, and 2) failure to assess patient #1 related to ensuring the touch pad call bell was within reach at all times in order to notify the nursing staff for assistance. Findings:

Review of the nursing notes for patient #1 revealed on 03/09/13, 6:12 AM, the patient experienced aystole per the cardiac monitor along with a blood pressure of 64/47. The nursing staff were present and noted the patient was experiencing bilateral upper extremity shaking and facial twitching. Epinephrine was given intravenously with a pulse noted though heart rate was irregular. Respiratory Therapy was present and after physician notification, the patient was given medication for the seizure activity along with ventilator settings. At 6:40 AM, a Dopamine drip was started for hypotension (69/36) and the patient stabilized. Review of the initial nursing shift assessment documented by S3RN dated 03/09/13, 7:15 AM, revealed "Unresponsive to verbal, pain, tactile stimuli. On Dopamine at 1.25mcg/kg/min for BP (Blood Pressure) support. VSS (Vital Signs Stable). No distress. Will cont (continue) to monitor." The next entry by S3RN was at 10:00 AM and revealed "Patient now alert and answering questions appropriately. States 'I was getting a bath' when asked what was the last thing she remembered..." Review of the nursing flow sheet revealed S3RN documented the patient's vital signs were monitored every 30 minutes; however, there failed to be further documentation the patient's condition was monitored for 2 hours and 45 minutes (7:15 AM to 10:00 AM).

Interview with S3RN on 04/15/13 at 11:50 AM, revealed when asked about patient #1's condition during his initial shift assessment on 03/09/13, S3RN replied the patient was unconscious due to the code event that occurred during the early morning prior to his shift beginning. There was no other response from S3RN regarding the missing assessment of patient #1 from 7:15 AM to 10:00 AM on 03/09/13.

Review of policy #201-21-025.7 titled "Nursing Assessment, Daily" revealed "Policy: Nursing care will be based upon the nursing process of assessment, planning, intervention, and evaluation. Patients will be assessed upon admission and reassessed every shift and upon a change in patient condition at a minimum. A RN must perform at least one of the shift reassessments in a 24 hour period..." "Procedure: A. Assessment: #3. A complete physical assessment will be conducted and documented every shift thereafter. In addition, reassessments will be conducted as warranted by the patient's condition."

Observation of patient #1 on 04/12/13 at 11:05 AM and 1:30 PM revealed the patient was a quadriplegic and could only move her head and the touch pad call bell was lying on the bedside table out of the patient's reach. If the patient required nursing assistance, the call system could not be activated unless touched by the patient's sister who was present in the room. The Registered Nurse failed to document safety issues and conduct ongoing assessments of patient #1 to ensure the touch pad call system was readily available.

Based upon review of 3 of 6 medical records and staff interview, the hospital failed to ensure the nursing staff developed and keep current a nursing care plan for patients #1, 3, and 6 as evidenced by: 1) failure to identify communication issues for patient #1 due to the patient having a tracheostomy, being a paraplegic, and unable to use the push button call system, 2) failure to update patient #3's plan of care to include infection control issues related to Methicillin Resistant Staph Aureus in the urine, and 3) failure to identify functional mobility deficits related to patient #6's hip fracture. Findings:

Review of the medical record for patient #1 revealed the patient had a cervical 4-5 fracture resulting in quadriplegia and a tracheostomy with ventilator assistance. Review of the plan of care revealed a problem with communication was identified on 04/09/13 by the speech therapist; however, the Registered Nurse failed to identify the patient could not use a push button call system and alternative measures required implementation. Observation of patient #1 on 04/12/13 revealed a touch pad call system was present but not within reach of the patient.

Review of the medical record for patient #3 revealed the patient had a Methicillin Resistant Staph Aureus (MRSA) urinary tract infection. Review of the plan of care revealed the MRSA infection failed to be identified.

Review of medical record for patient #6 revealed the patient was admitted for a hip fracture. Review of the plan of care revealed functional mobility related to the hip fracture failed to be identified.

Based upon review of 1 of 6 medical records, policies and procedures and staff interviews, the Registered Nurse failed to follow policy and procedure related to intravenous fluids as evidenced by failing to change the Normal Saline Infusion on patient #1 every 24 hours and change the Glucerna tube feeding bottle every 48 hours. Findings:

Observations of patient #1 on 04/12/13 at 11:05 AM, revealed a plastic bottle of Glucerna, used for tube feedings, had a date on the label of 04/08/13. Interview with S1DON on 04/12/13 at 1:30 PM, revealed the Glucerna bottle was to be changed every 48 hours. There was also a 250cc Normal Saline infusion bag hanging on the intravenous pole with no label affixed identifying when the infusion was initiated. Interview with S1DON revealed the normal saline bag was to be changed every 24 hours. Review of the pharmacy printout for medications removed from the pixis system for patient #1 revealed there failed to be evidence the normal saline solution was changed from 03/26/13, 10:24 PM to 03/29/13, 3:57 AM, 04/01/03, 8:36 PM to 04/03/13, 9:00 PM, 04/05/13, 9:02 PM to 04/07/13, 9:12 PM. Review of the Medication Administration Record (MAR) revealed there failed to be documented evidence the Registered Nurse changed the Normal Saline infusion bag from 04/10/13 to 04/14/13. Further review of the MAR revealed the Glucerna Tube Feeding was identified; however, the Registered Nurse failed to document when a new bottle of Glucerna was initiated.

Review of patient #1's medical record revealed the physician ordered the normal saline infusion to infuse at a TKO (To Keep Open) rate (10cc/hr).

Review of policy #201-21-004.8 titled "Intravascular Devices-Initiation and Management of Intravenous Therapy" revealed "General Guidelines for All Lines: D. Replacement of Administration Sets and Intravenous Fluids, 2. All intravenous fluid containers (bags and bottles) are to be replaced and/or changed every 24 hours." Interview with S1DON revealed the hospital did not have a policy for the time limits for changing the bottles of tube feedings.