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Based on record review and interview the hospital failed to ensure the complainant (patient or patient's representative) was provided a written notice of the hospital's decision; in response to filed grievances, that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for 2 of 2 grievances reviewed (Patients #R1, #R2). Findings:

Review of the hospital policy titled, "Patient Complaint/Grievance Process #H-PC 05-007 (12/2008)" presented by the hospital as their current policy revealed in part, "The hospital CEO(Chief Executive Officer)/Administrator or designee: sends a written response to the complainant within 7 days. The letter shall include a. The name of the Hospital contact person, b. Steps taken on behalf of the patient to investigate the grievance, c. The results of the grievance process, d. The dates of completion, and e. Is signed by the CEO/Administrator"

A "Patient & (and) Family Grievance Report Form" filed on 8/28/2011 was reviewed for Patient # R1. Review of the section titled "Summarize Grievance" revealed that a friend of the patient found her lying in loose stool and complained of a delayed response by staff in providing hygiene care. Documentation revealed an investigation was conducted by the hospital. Further review revealed no documented evidence that the patient/representative was provided a written response to the grievance which included the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

A "Patient & (and) Family Grievance Report Form" filed on 7/30/2011 was reviewed for Patient # R2. Review of the section titled "Summarize Grievance" revealed that the patient had complained of repeated neglect in staff response to his call bell requests. Documentation revealed an investigation was conducted by the hospital. Further review revealed no documented evidence that the patient was provided a written response to the grievance which included the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

This finding was confirmed in a face to face interview on 9/02/2011 at 10:15 a.m. with Quality Director S2. S2 indicated she (S2) had not understood that all grievances required a written response letter. S2 indicated that although she had investigated grievances and implemented corrective action as indicated, she (S2) had provided verbal responses to grievances rather than written responses.

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Based on record review and interview the hospital failed to ensure a Registered Nurse (RN) supervised (oversee) and evaluated (careful appraisal to determine the significance of) the nursing care for each patient by failing:
1) to ensure a complete and accurate nursing assessment of patients was provided, upon admission to the hospital, to include an assessment of the patients wounds for 7 of 10 sampled patients (#1, #3, #5, #7, #8, #9, #10);
2) to ensure a Registered Nurse assessed a significant variation in patients' weights to determine if the weight fluctuation was obtained in error or if the patient's physician needed to be notified for 4 of 10 sampled patients (#4, #5, #6, #10);
3) to ensure vital signs were assessed prior to the administration of medications (Metoprolol) per physician's orders for parameters governing the administration of the medication for 1 of 10 sampled patients (#8);
4) to ensure a Registered Nurse assessed a patient with a drop or increase in blood pressure and notified the physician when indicated for 2 of 2 patients reviewed with changes in vital signs from a total of 10 sampled patients (#3, #9); and
5) to ensure an accurate wound assessment was performed weekly as required by policy for 1 of 4 patients' records reviewed with wounds from a total sample of 10 patients (#3). Findings:

1) Ensure a complete and accurate nursing assessment of patients was provided, upon admission to the hospital, to include an assessment of the patients wounds:
Patient #1: Patient #1 was admitted to the hospital on 8/17/2011 with diagnoses that included Infected Right Heel Wound, Diabetes Mellitus, and Peripheral Vascular Disease.
Patient #1
Review of Patient #1's "Initial Wound Assessment" dated 8/17/2011 at 1810 (6:10 p.m.) revealed in part, "R (right) heel wound - drsgs intact". Review of Patient #1's "Skin Abnormality" documentation dated 8/18/2011 at 1400 (2:00 p.m./19 hours and 50 minutes after Patient #1 was admitted to the hospital) revealed in part, "Rt (right) heel 5.5 x 5 x 1.25 (centimeters) Stage IV (four) beefy red (with) bone exposed." This finding (no complete Registered Nurse assessment of Patient #1's wound upon admission to the hospital) was confirmed in a face to face interview on 8/31/2011 at 1530 (3:30 p.m.). by Wound Care Nurse S9.

Patient #3
Review of Patient #3's medical record revealed she was admitted on 06/23/11 with diagnoses of Pneumonia, MRSA (methicillin-resistant staph aureus), rule out Sepsis, and endocarditis. Further review revealed Patient #3 had a history of HIV (human immunodeficiency virus), Anemia, Malnutrition, Dementia, Diabetes Mellitus, and multiple Stage II wounds.

Review of Patient #3's "Admission Database" revealed RN S8 performed the admission assessment on 06/23/11 at 2040 (8:40pm). Further review revealed the "initial wound assessment" documented by RN S8 included a skin tear to the right wrist (as indicated on the drawing), a left "buttock Stage II" (no documented evidence of the type of wound), a right buttock Stage II pressure ulcer, a left ischial unstageable (no documented evidence of the type of wound). Further review revealed no documented evidence of the measurement of any of the wounds.

Review of the "Wound Care Initial Skin Assessment & (and) Weekly Update" revealed the first documentation of the measurement of the wounds, and the assessment of depth, appearance, odor, and condition of surrounding tissue was performed on 06/24/11 at 1:00pm, more than 16 hours after admission. Further review of the medical record revealed the first wound pictures were taken on 06/24/11.

In a face-to-face interview on 09/02/11 at 2:30pm, when informed by the surveyor that chart reviews revealed that the admit nurse was not assessing the skin and wounds at the time of the admission assessment, Medical Director S12 indicated she did not agree with that practice.

Patient #5:
Review of the medical record for Patient #5 revealed a 60 year old female admitted to the hospital on 02/16/11 for respiratory failure, CVA (Cerebral Vascular Accident) and a Pontine hemorrhage. Further review revealed Patient #4 had a long history with hypertension non-compliance.

Review of the Nursing Admission Assessment for Patient #5 dated/timed 02/16/11 at 1630 (4:30pm) revealed the following: (1) Right buttock - blisters X 3; measurement 2cm X 0.5cm; exudate none; color/tissue - no documentation noted and (2) Left buttock (healed).

Review of the Wound Care Initial Skin Care Assessment dated 02/17/11 at 10:40am-10:45am by the RN assigned to wound care revealed the following assessment for Patient #5: Blisters BIL (bilateral) buttock checks. According to the Skin Assessment Key blisters were classified as a Stage II pressure ulcer. Further review of the assessment revealed no documented evidence size, appearance, drainage, condition of surrounding tissue or presence of odor was assessed.

Patient #7:
Patient #7 was admitted to the hospital on 8/19/2011 with diagnoses that included Pyogenic Brain Abscess and Chronic Obstructive Pulmonary Disease.

Patient #7 was admitted to the hospital as a transfer from Acute Care Hospital A. Review of Patient #7's "Wound Care Note" from Hospital A dated 8/18/2011 at 10:15 a.m. revealed in part, "Patient remain(s) (with) sacral Stg (Stage) II (two) (with) 100% non granular tissue. area measures 1.0 x 1.0 cm (centimeters). Periwound intact. Min (minimal) amt (amount) serous drainage. . ."

Review of Patient #7's "Admission Database, Initial Wound Assessment" at Louisiana Specialty Hospital as performed by Registered Nurse S10 dated 8/19/2011 at 2020 (8:20 p.m./30 hours after Wound Care Note from Hospital A indicated the wound was Stage II measuring 1.0 x 1.0 centimeters) revealed in part, "3" to contain a dot located over sacral area on body chart with check marks indicating "reddened area". Further review revealed no documented evidence of physician's admission orders for providing wound care to patient #7's sacral wound.

Review of Patient #7's "Skin Abnormality" Documentation by Wound Care Nurse S9 on 8/22/2011 at 9:00 a.m. revealed in part, "gluteal fold Stage II 3.5 x 1 (centimeter)" (increase in size since last assessed at Hospital A on 8/18/2011 at 8:20 p.m. from 1.0 x 1.0 to 3.5 x 1.0).

During a face to face interview on 9/01/2011 at 10:50 a.m., Registered Nurse S10 indicated he had been the nurse that had performed the initial Registered Nurse Assessment for Patient #7 on 8/19/2011 at 8:20 p.m. when he (S10) had documented the wound to be a reddened area. S10 indicated he (S10) had never measured any wounds on any patient at the time of admission. S10 indicated it would require too much time for him(S10) to complete a detailed wound assessment. S10 indicated the hospital had a wound care nurse that would perform wound assessments on patients. S10 confirmed there was no wound care nurse present at the hospital 24 hours a day/7 days a week.

Patient #8
Patient #8 was admitted to the hospital on 8/19/2011 with diagnoses that included Acute Pulmonary Syndrome, Cerebral Vascular Accident, Malnutrition, and Dementia.

Review of Patient #8's "Initial Wound Assessment" dated 8/19/2011 at 2215 (10:15 p.m.) revealed in part, "Rt (right) foot dressing" and "dressing to Rt (right) foot intact". Review of Patient #8's entire medical record revealed the first assessment of Patient #8's right foot wound to be dated 8/22/2011 at 6:45 a.m. (3 days after the patient had been admitted to the hospital). Review of the 8/22/2011, 6:45 a.m. assessment by Wound Care Nurse S9 revealed Patient #8 had a Stage IV (four) Pressure Ulcer to her right fifth toe 2 x 3 x 0.5 (centimeters) with necrotic foul odored drainage. This finding (no complete Registered Nurse assessment of Patient #8's wound upon admission to the hospital) was confirmed in a face to face interview on 9/01/2011 at 10:10 a.m. by Wound Care Nurse S9.

Patient #9: Review of the medical record for Patient #9 revealed a 62 year old female admitted to the hospital on 08/15/11 with the diagnoses of Left AKA (Above Knee Amputation), sacral decubitus and a history of DM (Diabetes Mellitus), ESRD (End Stage Renal Disease), Anemia, Lupus, Hypertension and CHF (Congestive Heart Failure).

Review of Patient #9's "Initial Wound Assessment" dated 08/15/11 at 2010 (8:10pm) revealed in part.... "1) Left AV shunt necrotic area with pus drainage; 2) Right Subclavian IJ Quinton Catheter; 3) Left AKA (Above Knee Amputation) with dressing; 4) Right AKA with dressing; 5) Right buttock dressing; 6) Bilateral thigh blisters; 7) Bilateral posterior thigh sloughing off". Further review revealed 7)documented in the notes was not illustrated in the diagram provided.

Review of the entire medical record for Patient #9 revealed the first assessment of Patient #9's wounds was documented on 08/16/11 at 0915 (9:15am). Review of the assessment performed on 08/16/11 at 9:15am by Wound Care Nurse S9 revealed the following: abdominal wound 1 X 1.5 (type of measurement not documented), 100% pink, scant SSD (serous sanguineous drainage), no odor; right lateral stump 25cm x 9cm, 100% P (pink), scant SSD, no odor; Right AKA (Above Knee Amputation) stump 13cm with staples intact small amount of drainage, no odor; right AKA inner thigh 20cm X 14cm, 100% P, scant SSD, no odor; right anterior stump 5 X 8cm, 100% P, scant SSD, no odor; left inner stump 8 X 5cm, 100% P, scant SSD, no odor; left posterior thigh 17 X 9, 100% P, scant SSD, no odor; and sacrum 25 X 28cm hard eschar without drainage. This finding (no complete Registered Nurse assessment of Patient #9's wound upon admission to the hospital) was confirmed in a face to face interview on 9/01/2011 at 10:10 a.m. by Wound Care Nurse S9.

Patient #10
Review of the medical record for Patient #10 revealed a 67 year old female admitted to the hospital on 06/28/11 for treatment of an infected stage IV wound with a history of Diabetes Mellitus, Hypertension and DJD (degenerative joint disease).

Review of the Admission Assessment dated 06/28/11 at 1815 (6:15pm) revealed Patient #10 had a sacral Stage III-IV wound which was checked off as being unstageable, >50% necrotic tissue or slough present and a left great toe wound also unstageable. Further review of the assessment revealed no documented evidence the sacral wound had been measured or assessed for odor.

Review of the wound assessment by RN S9 Certified Wound Care Nurse dated/timed 06/29/11 0900 (9:00am) performed approximately 15 hours after admit of Patient #10 revealed ..... left ischial - 2 X 0.75 (type of measurement used not documented); left buttock - 2.5 X 6 (type of measurement used not documented); left upper buttock 5 X 6 (type of measurement used not documented); sacrum 5 X 8 X 3 (type of measurement used not documented); with tunneling at 9? - 9cm, 11? - 6cm, 12? - 2cm, 3? - 0.5, 6? - 0.5; right buttock - 5 X 6 cm; and left hip 1 X 1 X 0.5 (type of measurement used not documented).

2) Ensure a Registered Nurse assessed a significant variation in patients' weights to determine if the weight fluctuation was obtained in error or if the patient's physician needed to be notified:
Patient #4
Review of the medical record for Patient #4 revealed a 68 year old male admitted to the hospital on 07/11/11 for a pleural effusion, respiratory distress and strengthening. Patient #4 had a history of CAD (Coronary Artery Disease), CHF (Congestive Heart Failure), Hyperlipidemia, and Diabetes Mellitus.

Review of the "Graphic Record" used to record vital signs and weights, dated 07/11/11 through 08/26/11 for Patient #4 maintained an average weight of 65kg. On 07/27/11 Patient #4 was assessed as weighing 65.6kg; however three days later on 07/30/11 #4 was documented as weighing 59.8kg, a weight loss of 5.6kg or 12.6 pounds. Patient #4's entire medical record revealed no documented evidence of re-weighing Patient #4 or notifying the patient's physician of a substantial weight loss.

Patient #5
Review of the medical record for Patient #5 revealed a 60 year old female admitted to the hospital on 02/16/11 for respiratory failure, CVA (Cerebral Vascular Accident) and a Pontine hemorrhage. Further review revealed Patient #4 had a long history with hypertension non-compliance.

Review of the "Graphic Record" used to record the vital signs and weights for Patient #5 dated 02/16/11 through 06/01/11 revealed the following: 03/08/11 - 61.4kg weight loss of 6.5kg or 14.3 pounds in three days; 03/09/11 - 62.0kg; 03/10/11 - 58.7kg weight loss of 4.3kg or 9.1 pounds in one day; 03/31/11 - 57.0kg; 04/01/11 - 61.1kg weight loss of 4.1kg or 9.0 pounds in one day; 04/04/11 - 60.0kg; 04/05/11 - 67.4kg weight loss of 7.4kg or 16.2 pounds in one day. Review of Patient #5's entire medical record revealed no documented evidence of re-weighing Patient #5 or notifying the patient's physician of a substantial weight loss.

Patient #6:
Patient #6 was admitted to the hospital on 8/17/2011 with diagnoses that included Repair of Perforated Esophagus.

Review of Patient #6's Nursing Documentation dated 8/26/2011 (no documented time) revealed in part, "Previous (8/23/2011) Weight 116.7 (kilograms). Today's (8/26/2011)weight 102.3 (kilograms)/(loss of 14.4 kilograms or 31.7 pounds in 3 days). Review of Patient #6's entire medical record revealed no documented evidence of re-weighing Patient #6 or notifying the patient's physician of a substantial weight loss.

Patient #10
Review of the medical record for Patient #10 revealed a 67 year old female admitted to the hosptial on 06/28/11 for treatment of an infected stage IV wound with a history of Diabetes Mellitus, Hypertension and DJD (degenerative joint disease).

Review of the "Graphic Record" dated 06/28/11 through 08/10/11 revealed Patient #10 weighed 103.3kg on 06/28/11 at the time of admit and 120.0kg on 07/09/11 the next documented weight which represented a weight gain of 16.7kg (36.7 pounds) in 10 days. Patient #10 was re-weighed on 07/10/11 with the results of 119.3kg. Review of the Graphic Record revealed no documentation of a weight for Patient #10 until 07/23/11 at which time she weighed 102.3kg, a weight loss of 17kg (37.4 pounds) in 13 days). On 07/25/11 Patient #10 weighed 102.2kg, 07/26/11 109.8kg (a weight gain of 16.7 pounds in one day) and 07/28/11 101.8 (weight loss of 19.3 pounds in two days). Review of Patient #10's entire medical record revealed no documented evidence of re-weighing Patient #10 or notifying the patient's physician of a substantial weight loss or gain.


Review of the entire medical record for Patient #10 revealed no documented evidence the weights were rechecked for accuracy or the physician notified of the change in the patient's condition.

These finding were confirmed by Director of Quality S9 on 9/01/2011 at 8:40 a.m. who further indicated variations in weights could be a result of inconsistent weighing methods by staff in the hospital such as variations in the equipment that remained in the bed with the patient when the patient was weighed.

3) Ensure vital signs were assessed prior to the administration of medications (Metoprolol) per physician's orders for parameters governing the administration of the medication:

Patient #8: Patient #8 was admitted to the hospital on 8/19/2011 with diagnoses that included Acute Pulmonary Syndrome, Cerebral Vascular Accident, Malnutrition, and Dementia.

Review of Patient #8's Physician's orders dated 8/20/2011 at 9 (a.m./p.m. not specified) revealed in part, "Lopressor (Metoprolol) 25 mg (milligrams) 1 tab (tablet) via tube bid (two times per day), hold for SBP (systolic blood pressure) < (less than) 90 or HR (heart rate) < 50."

Review of Patient #8's Medical Record revealed no documented evidence of an assessment of vital signs prior to the administration of Metoprolol as follows:
8/20/2011: no documented evidence of monitoring B/P (Blood Pressure) and HR (Heart Rate) prior to the 10:00 a.m. dose
8/21/2011: no documented evidence of monitoring B/P and HR prior to the 10:00 a.m. dose
8/22/2011: no documented evidence of monitoring B/P and HR prior to the 10:00 p.m. dose
8/23/2011: no documented evidence of monitoring B/P and HR prior to the 10:00 p.m. dose
8/24/2011: no documented evidence of monitoring B/P and HR prior to the 10:00 a.m. and 10:00 p.m. dose
8/25/2011: no documented evidence of monitoring B/P and HR prior to the 10:00 a.m. dose
8/27/2011: no documented evidence of monitoring B/P and HR prior to the 10:00 p.m. dose
8/29/2011: no documented evidence of monitoring B/P and HR prior to the 10:00 a.m. and 10:00 p.m. dose
8/30/2011: no documented evidence of monitoring B/P and HR prior to the 10:00 a.m. dose

Review of 2011 Drug Reference Literature regarding the medication Metoprolol, provided by the hospital as current, revealed in part, "(page 748) Apical/Radial pulse before administration; notify prescriber of any significant changes or pulse < (less than) 50 bpm (beats per minute)".

During a face to face interview on 9/01/2011 at 10:10 a.m. Director of Quality S9 confirmed there had been no monitoring of patient #8's vital signs immediately prior to administering Metoprolol for the dates/times listed above. S9 indicated vital sign parameters as ordered by the physician should be monitored and documented to verify that administration of the medication is appropriate.

Patient #9
Review of the medical record for Patient #9 revealed a 62 year old female admitted to the hospital on 08/15/11 with the diagnoses of Left AKA (Above Knee Amputation), sacral decubitus and a history of DM (Diabetes Mellitus), ESRD (End Stage Renal Disease), Anemia, Lupus, Hypertension, Atrial Fibrillation and CHF (Congestive Heart Failure).

Review of the MAR (Medication Administration Record) for Patient #9 dated 08/17/11 at 2200 (9:00pm) revealed a circle around the time with the nurse's initial and the explanation of
"refused" next to the following medications: Clonidine HCL 0.1mg (Catapres) used to treat high blood pressure, Metoprolol Tartate 100mg (Lopressor) used to treat high blood pressure and abnormal rhythms of the heart, and Heparin 5000 units subcutaneously an blood anticoagulant.

Review of the Nursing Notes dated 08/17/11 at 2230 (10:30pm) revealed..... Patient (#9) and family refused Catapres 0.1mg dose & Lopressor 100mg po (by mouth) dose & Heparin 5000 units SQ (subcutaneously).

Review of the "Graphic Record" for Patient #9 dated/timed 08/18/11 at 0400 (4:00am) revealed a blood pressure of 153/93 and a pulse of 117. Further review of the "Graphic Record" for Patient #9 since her admit on 08/15/11 revealed no documented evidence #9's pulse or blood pressure were documented as being higher than pulse of 100 (on 08/15/11 at 8:00pm) and blood pressure of 148/76 (on 08/16/11 at 8:00am).

Review of the Nursing Notes for Patient #9 dated 08/17/11 ay 2230 (10:30pm) through 08/18/11 0605 (6:05am) revealed no documented evidence the RN or the physician had been notified of the patient and family's refusal of the medication, the elevated blood pressure and pulse even though the patient was scheduled for a cath lab procedure on 08/18/11.

In a face-to-face interview on 09/02/11 at 2:30pm, Chief Clinical Officer S14 offered no explanation for the RN not performing assessments with a change in condition.

4) Ensure a Registered Nurse assessed a patient with a drop in blood pressure and notified the physician when indicated:

Review of Patient #3's medical record revealed she was admitted on 06/23/11 with diagnoses of Pneumonia, MRSA (methicillin-resistant staph aureus), rule out Sepsis, and endocarditis. Further review revealed Patient #3 had a history of HIV (human immunodeficiency virus), Anemia, Malnutrition, Dementia, Diabetes Mellitus, and multiple Stage II wounds.

Review of Patient #3's "Graphic Record" for 06/25/11 revealed her blood pressure at 12:00pm was 86/62. Review of the "Daily Nursing Flow Sheet" for 06/25/11 revealed no documented evidence LPN (licensed practical nurse) S6 notified the RN of the blood pressure reading of 86/62. There was no documented evidence that an assessment of Patient #3 had performed by the RN to determine if she (the patient) was symptomatic or if the physician needed to be notified.

Review of Patient #3's "Graphic Record" for 07/10/11 revealed her blood pressure at 4:00pm was 83/54. Review of the "Daily Nursing Flow Sheet" for 07/10/11 revealed no documented evidence that RN S4 had assessed Patient #3 to determine if she was symptomatic or if the physician needed to be notified.

Review of Patient #3's "Daily Nursing Flow Sheet" for 07/15/11 revealed LPN S5 documented a blood pressure reading at 4:00pm of 81/53. Further review revealed no documented evidence LPN S5 reported the blood pressure to the RN for assessment of the patient or that the physician was notified.

Review of Patient #3's "Daily Nursing Flow Sheet" for 07/16/11 revealed LPN S5 documented a blood pressure reading at 4:00pm of 87/63. Further review revealed no documented evidence LPN S5 reported the blood pressure to the RN for assessment of the patient or that the physician was notified.

Review of Patient #3's "Daily Nursing Flow Sheet" for 07/18/11 revealed RN S7 documented a blood pressure reading at 4:00pm of 85/49. Further review revealed no documented evidence of an assessment of Patient #3 at 4:00pm by RN S7 to determine if she was symptomatic or that the physician needed to be notified.

Review of Patient #3's "Daily Nursing Flow Sheet" for 07/31/11 revealed RN S4 documented a blood pressure reading at 4:00pm of 86/47. Further review revealed no documented evidence of an assessment of Patient #3 at 4:00pm by RN S4 to determine if she was symptomatic or that the physician needed to be notified.

In a face-to-face interview on 09/02/11 at 2:30pm, Chief Clinical Officer S14 offered no explanation for the RN not performing assessments with a change in condition, specifically a drop in blood pressure.

Review of the hospital policy titled "Vital Signs, Taking of", policy number 155 effective 08/08 and submitted by QAPI (quality assessment and performance improvement) Director S2 as their current policy for vital signs, revealed in part, "...F. Vital signs taken by ancillary staff are reviewed by a nurse. Abnormal results are reported to patient's primary care nurse. ...Charting ... S. Notify physician and document in Nurses Notes any significant changes in vital signs and/or action taken. (all nursing units)...".

Review of the policy titled "Assessment/Documentation" effective date August 2000 and submitted as the one currently in use by the hospital revealed......." Procedure: E. Re-assessments are completed and documented at least every shift or as the patient's status deems necessary. F. The physician should be notified of any significant changes in assessment".

5) Ensure an accurate wound assessment was performed weekly as required by policy:
Review of Patient #3's medical record revealed she was admitted on 06/23/11 with diagnoses of Pneumonia, MRSA (methicillin-resistant staph aureus), rule out Sepsis, and endocarditis. Further review revealed Patient #3 had a history of HIV (human immunodeficiency virus), Anemia, Malnutrition, Dementia, Diabetes Mellitus, and multiple Stage II wounds.

Review of Patient #3's "Wound Care Initial Skin Assessment & (and) Weekly Update" revealed the initial assessment was performed by Wound Care RN S9 on 06/24/11. Further review revealed wounds were identified to the right ischium, sacrum, left ischial hip, and the right hip. Review of the narrative written by S9 on the "Interdisciplinary Progress Notes" on 06/24/11 (no time documented) revealed wounds identified were to the right ischial, sacrum, left ischial, and a scab to the right wrist and fingers on the right hand. Further review revealed the heels were floated. Review of the pictures taken by RN S9 on 06/24/11 revealed pictures of the right ischial, left ischial, right heel, right wrist, left heel, and sacrum.

Review of the weekly wound assessment performed by RN S9 on 07/01/11 revealed the same wounds identified on 06/24/11, the right ischium, sacrum, left ischial hip, and the right hip. Review of the pictures taken on 07/01/11 by RN S9 revealed pictures of the right hip, right ischial, right wrist, bilateral heels (no evidence of breakdown noted), right hand, sacrum, and left hip.

Review of Patient #3's "Wound Care Initial Skin Assessment & Weekly Update" revealed the assessment on 07/07/11 included the same wounds initially identified on 06/24/11, the right ischium, sacrum, left ischial hip, and the right hip. Review of the narrative written on 07/07/11 at 7:00am on the "Interdisciplinary Progress Notes" by RN S9 included wounds to the right hand, left hip, sacrum, right hip, right lower achilles, and right ischial. Wound pictures taken on 07/07/11 by RN S9 were to the left hip, right hand, sacrum, right wrist, and left heel. There was no documented evidence of a picture of the wound to the right lower achilles or an entry of this wound on the "Wound Care Initial Skin Assessment & Weekly Update". Review of the physician orders revealed no documented evidence wound care orders were obtained to treat the wound to the right lower achilles.

Review of Patient #3's "Wound Care Initial Skin Assessment & Weekly Update" revealed the assessment on 07/14/11 included the same wounds initially identified on 06/24/11, the right ischium, sacrum, left ischial hip, and the right hip. Review of the narrative written on 07/14/11 by RN S9 revealed no documented evidence of an assessment of the wound to the right lower achilles that was identified on 07/07/11. Review of the pictures taken by RN S9 on 07/14/11 revealed pictures of the right hip, right posterior ankle (picture revealed skin breakdown), sacrum, and left hip.

Review of Patient #3's "Interdisciplinary Progress Notes" revealed no documented evidence wound care was performed to the right lower achilles wound that was identified on 07/07/11 from 07/07/11 through 07/21/11. Review of the physician's orders revealed the first documented order for wound care to the right posterior ankle was received by telephone order to RN S9 on 07/22/11 at 9:00am.

Review of Patient #3's "Wound Care Initial Skin Assessment & Weekly Update" revealed the assessment on 07/21/11 included the same wounds initially identified on 06/24/11, the right ischium, sacrum, left ischial hip, and the right hip. Review of the narrative written on 07/21/11 by RN S9 revealed wound measurements of the right ischial, left hip, right heel, and right hip. Review of the pictures taken by RN S9 on 07/21/11 revealed pictures of the left hip, right ankle, right hip/sacrum, and right hand.

Review of Patient #3's "Wound Care Initial Skin Assessment & Weekly Update" revealed the assessment on 07/28/11 and 08/03/11 by RN S9 included the addition of the wound to the right heel.

In a face-to-face interview on 09/02/11 at 2:30pm, when informed by the surveyor that the chart review of Patient #3 revealed the right heel wound was not documented on the weekly wound assessment form from 07/07/11 (when first identified) until 07/28/11 and wound care had not been documented as performed from 07/07/11 through 07/21/11, RN S9 could offer no explanation. S9's only response was to ask of which patient the surveyor was speaking.

Review of the policy titled "Assessment/Documentation" effective date 08/2000 and submitted as the one currently in use revealed.... "Procedure: Skin Abnormalities - Mechanism for Documentation - Skin abnormality diagram, Nursing Process Record or other approved form; Frequency of Documentation - Any time a skin abnormality is identified or a change in a skin abnormality is noted".



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Based on record review and interviews, the hospital failed to: 1) ensure a nursing care plan was developed, kept current, and updated with changes in condition for 2 of 10 sampled patient (#3, #5) and 2) ensure the physician'sorders were implemented as evidenced by failure to obtain vital signs, weights, accuchecks, and perform wound care as ordered for 6 of 10 sampled patients (#3, #4, #5, #6, #7, #10). Findings:

1) Ensure a nursing care plan was developed, kept current, and updated with changes in condition:
Patient #3
Review of Patient #3's medical record revealed she was admitted on 06/23/11 with diagnoses of Pneumonia, MRSA (methicillin-resistant staph aureus), rule out Sepsis, and endocarditis. Further review revealed Patient #3 had a history of HIV (human immunodeficiency virus), Anemia, Malnutrition, Dementia, Diabetes Mellitus, and multiple Stage II wounds.

Review of Patient #3's medical record revealed she developed wounds during her stay, had episodes of drops in blood pressure and increased heart rate, had antibiotics administered due to positive blood cultures, and was on accuchecks every 6 hours with orders for sliding scale insulin. Review of the entire medical record revealed no documented evidence that a plan of care was developed for Patient #3 upon admission or during her course of treatment.

Patient #5
Review of the medical record for Patient #5 revealed a 60 year old female admitted to the hospital on 02/16/11 for respiratory failure, CVA (Cerebral Vascular Accident) and a Pontine hemorrhage. Further review revealed Patient #4 had a long history with hypertension non-compliance.

Review of Patient #5's medical record revealed she developed a stage IV pressure ulcer with undermining, required antibiotic therapy, was re-intubated due to respiratory decline, and required tube feedings. In addition, Patient #5 sustained an eye and facial injury when her head was caught in the siderail of the bed when receiving care. Review of the entire medical record revealed no documented evidence that the plan of care was updated for Patient #5 during her course of treatment.

In a face-to-face interview on 09/02/11 at 2:30pm, QAPI (quality assessment and performance improvement) Director S2 indicated she could not find evidence that a care plan had been developed or updated with changes for Patient #3 or Patient #5.

Review of the hospital policy titled "Care Planning", policy number 26 effective 07/14/06 and submitted by QAPI Director S2 as their current policy for care planning, revealed, in part, "...A. Within 24 hours of admission, all patients shall have a Plan of Care generated by the Registered Nurse or the Licensed Practical Nurse under the direct supervision of the Registered Nurse. B. The Plan of Care should be individualized, based on the diagnosis and patient assessment. ... D. The Plan of Care shall be updated daily, with revisions reflecting the reassessment of needs of the patient. This review, if no changes are required, will be documented in the daily nursing flow sheet. All staff using the Plan of care are responsible for establishment of goals and appropriate interventions, as well as ongoing evaluations and revisions...".

2) Ensure the physician's orders were implemented as evidenced by failure to obtain vital signs, weights, accuchecks, and perform wound care as ordered:
Patient #3
Review of Patient #3's medical record revealed she was admitted on 06/23/11 with diagnoses of Pneumonia, MRSA (methicillin-resistant staph aureus), rule out Sepsis, and endocarditis. Further review revealed Patient #3 had a history of HIV (human immunodeficiency virus), Anemia, Malnutrition, Dementia, Diabetes Mellitus, and multiple Stage II wounds.

Review of Patient #3's "Physician's Orders For Admission or Transfer" dated 06/23/11 at 2235 (10:35pm) revealed orders to weigh daily and to perform blood sugar accuchecks every 6 hours.

Review of Patient #3's "Physician's Orders" revealed orders on 06/24/11 at 1:00pm, 07/01/11 at 12:00pm, 07/04/11 at 9:20am, 07/07/11 at 7:00am, and 07/22/11 at 9:00am for wound care every day.

Review of Patient #3's "Graphic Record" and "Daily Nursing Flow Sheet" revealed no documented evidence Patient #3 was weighed daily as ordered on 06/27/11, 06/28/11, 06/29/11, 07/15/11, 07/20/11, 07/21/11, and 07/28/11.

Review of Patient #3's "Diabetes Flow Sheet", MARs, and "Daily Nursing Flow Sheet" revealed no documented evidence Patient #3's blood sugar accucheck was performed as ordered on 06/27/11 at 12:00am, 06/30/11 at 6:00pm, and 07/12/11 at 6:00pm.

Review of Patient #3's "Interdisciplinary Progress Notes", "Daily Nursing Flow Sheet", and the "Wound Care Initial Skin Assessment & (and) Weekly Update" revealed no documented evidence wound care was performed to the right ischial wound, the sacrum, the left hip wound, and the right hip wound as ordered on 06/26/11, 07/09/11, 07/10/11, 07/12/11, 07/16/11, 07/17/11, and 07/23/11.

In a face-to-face interview on 09/02/11 at 2:30pm, Medical Director S12 and Wound Team Physician S13 nodded their head affirmatively when told by the surveyor that wound care was not being performed on weekends when the wound care nurse was not present, as evidenced by chart review. S12 and S13 could offer no explanation for wound care not being performed by the staff nurse responsible for the care of the patient on weekends. When informed that weights and accuchecks were not being performed as ordered, Medical Director S12 could offer no explanation.

Patient #4
Review of the medical record for Patient #4 revealed a 68 year old male admitted to the hospital on 07/11/11 for a pleural effusion, respiratory distress and strengthening. Patient #4 had a history of CAD (Coronary Artery Disease), CHF (Congestive Heart Failure), Hyperlipidemia, and Diabetes Mellitus.

Review of the Physicians' Admit Orders dated 07/11/11 for Patient #4 revealed an order for daily weights.

Review of the "Graphic Record" used to record vital signs and weights, dated 07/11/11 through 08/26/11 for Patient #4 revealed no documented evidence weights were recorded on the following days: 07/12/11 through 07/18/11, 07/24/11, 07/28/11, 07/29/11, 08/04/11, 08/07/11, 08/10/11 through 08/14/11, 08/16/11 through 08/19/11and 08/23/11 through 08/25/11.

Patient #5
Review of the medical record for Patient #5 revealed a 60 year old female admitted to the hospital on 02/16/11 for respiratory failure, CVA (Cerebral Vascular Accident) and a Pontine hemorrhage. Further review revealed Patient #4 had a long history with hypertension non-compliance.

Review of the Physician's Admit Orders dated/timed 02/16/11 at 1600 (4:00pm) for Patient #5 revealed an order for daily weights.

Review of the "Graphic Record" used to record the vital signs and weights for Patient #5 dated 02/16/11 through 06/01/11 revealed no documented evidence weights were recorded for the following days: 02/18/11through 02/28/11, 03/05/11 through 03/07/11, 03/12/11, 03/19/11, 03/25/11, 03/29/11, 03/30/11, 04/02/11, 04/03/11, 04/08/11, 04/11/11 through 04/17/11, 04/19/11, 04/20/11, 04/26/11 through 04/30/11, 05/02/11 through 05/02/11, 05/17/11, 05/18/11, 05/21/11. 05/24/11, and 05/26/11 through 05/30/11.

In a face to face interview on 09/01/11 at 10:00am RN S2 Director of Nursing indicated there were many places where the weights could be documented. Further S2 indicated sometimes the weights are done, but does not make it to the chart. S2 indicated the Charge Nurse was not assigned patients and was responsible for overseeing the care of all of the patients.

Patient #6:
Patient #6 was admitted to the hospital on 8/17/2011 with diagnoses that included Repair of Perforated Esophagus. Review of Patient #6's Physician's orders dated 8/18/2011 at 2300 (11:00 p.m.) revealed an order which included, "Measure finger stick blood glucose every 6 hours. Administer insulin according to the scale. Regular Insulin (Novolin) Medium dose Regimen> Glucose level 150 - 199 / 2 units, Glucose level 200 - 249/ 4 units, Glucose level 250 - 299/ 6 units, 300 - 349/ 8 units, 350 - 400 5 units. . .".
Review of Patient #6's medical record to include the Medication Administration Record and Diabetic graph revealed in part: 8/20/2011: no documented evidence of an accucheck (finger stick blood glucose) or insulin administration

This finding was confirmed in a face to face interview with Director of Quality S9 on 9/02/2011 at 1:30 p.m. who further indicated there should be documentation in the medical record that nursing staff were following physician's orders regarding accuchecks and sliding scale insulin.

Patient #7:
Patient #7 was admitted to the hospital on 8/19/2011 with diagnoses that included pyogenic brain abscess.

Review of Patient #7's Physician orders dated 28/19/2011 at 1345 (1:45 p.m.) revealed an order that included, "Measure finger stick blood glucose every 6 hours. Administer Insulin according to the scale: Low Dose Regimen. Glucose level 150-199/ 1 unit, Glucose level 200 - 249/ 2 units, Glucose level 250 - 299/ 3 units, Glucose level 300-349/4 units, Glucose level 350-400/ 5 units. Review of Patient #7's medical record to include the Medication Administration Record and Diabetic graph revealed in part: 8/26/2011: no documented evidence of an accucheck (finger stick blood glucose) or insulin administration

This finding was confirmed in a face to face interview with Director of Quality S9 on 9/02/2011 at 1:30 p.m. who further indicated there should be documentation in the medical record that nursing staff were following physician's orders regarding accuchecks and sliding scale insulin.

Patient #10
Review of the medical record for Patient #10 revealed a 67 year old female admitted to the hospital on 06/28/11 for treatment of an infected stage IV wound with a history of Diabetes Mellitus, Hypertension and DJD (degenerative joint disease).

Review of the Physician's Admit Orders dated 06/28/11 for Patient #10 revealed an order to weigh daily.

Review of the "Graphic Record" dated 06/28/11 through 08/10/11 for Patient #10 revealed weights were not recorded for the following days: 06/29/11, 06/30/11, 07/01/11, 07/02/11, 07/03/11, 07/04/11, 07/05/11, 07/06/11, 07/07/11, 07/08/11, 07/11/11, 07/12/11, 07/13/11, 07/14/11, 07/15/11, 07/16/11, 07/17/11, 07/18/11, 07/19/11, 07/20/11, 07/21/11, 07/22/11, 07/24/11, 07/27/11, 07/29/11, 07/30/11, 07/31/11, 08/01/11, 08/02/11, 08/03/11, 08/05/11, 08/07/11, 08/09/11 and 08/10/11.

Based on record review and interview, the hospital failed to ensure clarification orders for drugs and biologicals were received for all drug orders that did not include all elements of a drug order for 1 of 10 sampled patients (#3). Findings:

Review of Patient #3's medical record revealed she was admitted on 06/23/11 with diagnoses of Pneumonia, MRSA (methicillin-resistant staph aureus), rule out Sepsis, and endocarditis. Further review revealed Patient #3 had a history of HIV (human immunodeficiency virus), Anemia, Malnutrition, Dementia, Diabetes Mellitus, and multiple Stage II wounds.

Review of Patient #3's "Admission Medication Order Form" received by telephone order on 06/23/11 at 2300 (11:00pm) revealed the following medication orders:
Albuterol 0.5 ml (milliliters) by Neb (nebulizer) every 4 hours prn - there was no documented evidence of the indication for use;
Fosamax 70 mg/75 ml (milligrams per milliliters) - the column labeled "frequency" had a question mark "?" written and the column labeled "physician order continue on admission" had no documented evidence that "yes" or "no" had been checked;
Dextrose 20 gm (grams) IVP (intravenous push) prn (as needed) low BS (blood sugar) - there was no documented evidence of the frequency or the specific blood sugar result that would warrant the use of Dextrose 20 gm;
Dextrose 15 gm IVP prn low BS - there was no documented evidence of the frequency or the specific blood sugar result that would warrant the use of Dextrose 15 gm;
Glucagon 1 mg IM (intramuscular) prn low BS - there was no documented evidence of the frequency or the specific blood sugar result that would warrant the use of Glucagon;
Insulin R 2 - 12 units SQ (subcutaneous) prn blood glucose - there was no documented evidence of the frequency, specific amount of insulin to be given, or the specific blood sugar result that would warrant the use of Insulin;
Heparin Flush 50 units IVP prn - there was no documented evidence of the indication for use;
Dextrose injection 12.5 gm IVP prn for blood sugar (low) - there was no documented evidence of the frequency or the specific blood sugar result that would warrant the use of Dextrose 12.5 gm;
Dextrose injection 25 gm IVP prn blood sugar (low) - there was no documented evidence of the frequency or the specific blood sugar result that would warrant the use of Dextrose 25 gm.
Further review of the "Physician's Orders" revealed a telephone order received on 06/24/11 at 2100 (9:00pm) to discontinue Fosamax. This clarification order was received 22 hours after the original order was received. Further review revealed no documented evidence that clarification orders had been requested or received for the above-listed orders received at admit.

In a face-to-face interview on 09/02/11 at 2:30pm, Chief Clinical Officer S14 offered no explanation for the medication orders not being clarified when all elements of a medication order did not exist.

Review of the hospital policy titled "Medication Administration", policy number 83 revised 08/01/08 and submitted by QAPI (quality assessment and performance improvement) Director S2 as their current medication administration policy, revealed, in part, "...F. Questions regarding a medication order should be resolved by checking the original physician's order written on the Physician's Order Sheet and/or by contacting the ordering physician as appropriate. Any ambiguous or unclear medication orders are to be clarified by the ordering physician prior to medication administration. G. Ambiguous medication orders must be clarified with a subsequent "order clarification" order reflecting the accurate and intended medication order. ... Note: Remember the five (5) rights of medication administration:...2. Right dosage 3. Right route 4. Right time...".

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Based on record review and interview, the hospital failed to ensure medications were administered as ordered by the physician and according to hospital policy for 5 of 10 sampled patients (#3, #6, #7, #8, #10). Findings:


Patient #3:
Review of Patient #3's medical record revealed she was admitted on 06/23/11 with diagnoses of Pneumonia, MRSA (methicillin-resistant staph aureus), rule out Sepsis, and endocarditis. Further review revealed Patient #3 had a history of HIV (human immunodeficiency virus), Anemia, Malnutrition, Dementia, Diabetes Mellitus, and multiple Stage II wounds.

Review of Patient #3's "Physician's Orders" revealed the following orders"
06/28/11 at 6:55am - telephone order for Meripenem 1 gm (gram) IV (intravenous) every 8 hours and to give the first dose "now";
07/28/11 at 11:00pm - telephone order for Lopressor 5 mg (milligrams) IV every 6 hours as needed for heart rate greater than 120 beats per minute;
07/29/11 at 3:30pm - Rocephin 1 gm IV every 24 hours.

Review of Patient #3's MARs (medication administration records) revealed the following:
06/28/11 - first dose of Meripenem 1 gm IV was administered at 10:00am, rather than 30 minutes after ordered "now" at 6:55am per hospital policy; second dose of Meripenem was administered at 10:00pm, 12 hours after the first dose rather than 8 hours as ordered (no documented evidence of a physician order for the delay in administration of Meripenem;
06/30/11 - no documented evidence Meripenem 1 gm IV was administered at 6:00pm as ordered and scheduled;
07/01/11 - no documented evidence Meripenem 1 gm IV was administered at 6:00pm as ordered and scheduled;
07/30/11 - no documented evidence Rocephin 1 gm IV was administered as ordered every 24 hours;
07/31/11 - no documented evidence Rocephin 1 gm IV was administered as ordered every 24 hours.

Review of Patient #3's "Graphic Record", "Daily Nursing Flow Sheet", and MARs revealed the following (related to the administration of Lopressor for a heart rate greater than 120 beats per minute):
07/30/11 at 4:00am - heart rate was 125, and Lopressor was administered at 5:15am, 1 hour and 15 minutes after the heart rate was determined to require administration of Lopressor;
07/31/11 at 12:00am - heart rate was 125; no documented evidence Lopressor was administered as ordered;
08/01/11 - heart rate at 8:00am was 125 and at 12:00pm heart rate was 125; no documented evidence Lopressor was administered at 8:00am and 12:00pm as ordered;
08/02/11 - heart rate at 8:00am was 125, at 12:00pm was 129, at 4:00pm was 133, and at 8:00pm was 123; no documented evidence Lopressor was administered at 8:00pm, 12:00pm, 4:00pm, or 8:00pm as ordered;
08/03/11 - heart rate at 4:00pm was 131; no documented evidence Lopressor was administered as ordered;
08/04/11 at 12:00am - heart rate was 125; no documented evidence Lopressor was administered as ordered.

In a face-to-face interview on 09/02/11 at 2:30pm, Chief Clinical Officer S14 could offer no explanation for the medications not being administered as ordered. S14 indicated she was not surprised by the surveyor's findings.

Review of the hospital policy titled "Medication Administration", policy number 83 revised 08/01/08 and submitted by QAPI (quality assessment and performance improvement) Director S2 as their current medication administration policy, revealed, in part, "...N. STAT or NOW medications are to be given within 30 minutes from the time ordered. ... BB. Within the next hour of administration of a medication (PRN and/or single dose) the nurse will discuss with the patient the effects of the medication given to see if it has given the desired effect. ... HH. Documentation ... 5. The effects achieved from a PRN and/or single dose medication should be documented in the medical record...".

Patient #6:
Patient #6 was admitted to the hospital on 8/17/2011 with diagnoses that included Repair of Perforated Esophagus. Review of Patient #6's Physician's orders dated 8/18/2011 at 2300 (11:00 p.m.) revealed an order which included, "Measure finger stick blood glucose every 6 hours. Administer insulin according to the scale. Regular Insulin (Novolin) Medium dose Regimen> Glucose level 150 - 199 / 2 units, Glucose level 200 - 249/ 4 units, Glucose level 250 - 299/ 6 units, 300 - 349/ 8 units, 350 - 400 5 units. . ."
Review of Patient #6's medical record to include the Medication Administration Record and Diabetic graph revealed in part:
8/20/2011: no documented evidence of an accucheck (finger stick blood glucose) or insulin administration
8/21/2011: no documented evidence of administration of insulin for the 1800 (6:00 p.m.) accucheck of 158 which physician's orders indicated required administration of 2 units of Regular Insulin
8/24/2011: no documented evidence of administration of insulin for the 1800 accucheck of 171 which physician's orders indicated required administration of 2 units of Regular Insulin
8/25/2011: no documented evidence of administration of insulin for the 1800 accucheck of 187 which physician's orders indicated required administration of 2 units of Regular Insulin

This finding was confirmed in a face to face interview with Director of Quality S9 on 9/02/2011 at 1:30 p.m. who further indicated there should be documentation in the medical record that nursing staff were following physician's orders regarding sliding scale insulin.

Patient #7:
Patient #7 was admitted to the hospital on 8/19/2011 with diagnoses that included pyogenic brain abscess.

Review of Patient #7's Physician orders dated 28/19/2011 at 1345 (1:45 p.m.) revealed an order that included, "Measure finger stick blood glucose every 6 hours. Administer Insulin according to the scale: Low Dose Regimen. Glucose level 150-199/ 1 unit, Glucose level 200 - 249/ 2 units, Glucose level 250 - 299/ 3 units, Glucose level 300-349/4 units, Glucose level 350-400/ 5 units. Review of Patient #7's medical record to include the Medication Administration Record and Diabetic graph revealed in part:
8/21/2011:no documented evidence of administration of insulin for the 1800 (6:00 p.m.) accucheck of 224 which physician's orders indicated required administration of 2 units of Regular Insulin
8/26/2011: no documented evidence of an accucheck (finger stick blood glucose) or insulin administration

This finding was confirmed in a face to face interview with Director of Quality S9 on 9/02/2011 at 1:30 p.m. who further indicated there should be documentation in the medical record that nursing staff were following physician's orders regarding sliding scale insulin.

Patient #8:
Patient #8 was admitted to the hospital on 8/19/2011 with diagnoses that included Acute Airway Syndrome, Malnutrition, and Dementia.

Review of Patient #8's Physician orders dated 8/30/2011 at 1100 (11:00 a.m.) revealed an order for Ampicillin 500 milligrams Intravenously every 6 hours. Review of Patient #8's Medication Administration Record revealed the first dose of Ampicillin was administered on 8/31/2011 at 2400 (midnight)/ (13 hours after the medication had been ordered by the patient's physician).

This finding was confirmed in a face to face interview with Director of Quality S9 on 9/02/2011 at 1:30 p.m. S9 further indicated the hospital's pharmacy is located within the building and there would be no delay in receiving the medications. S9 indicated Patient #8 should have received her antibiotics at the next scheduled dose (6:00 p.m.).

Patient #10
Review of the medical record for Patient #10 revealed a 67 year old female admitted to the hospital on 06/28/11 for an infected stage IV sacral decubitus with a history of Diabetes Mellitus, Hypertension, and DJD (degenerated joint disease).

Review of the MAR (Medication Administration Record) revealed an order for Metoprolol Tartrate 50mg one po (by mouth) twice a day. Hold for a SBP (Systolic Blood Pressure) less than or equal to 110. Further review revealed the 10:00am dose on 08/02/11 was not given as evidenced by the dose being circled; however there was no documented evidence of the nurse ' s initials or the reason the medication was not given.

Review of the "Graphic Record" for Patient #10 dated 08/02/11 at 8:00am revealed the blood pressure documented as 122/48.

Review of the policy titled "Medication Administration" effective date 12/05/08 and submitted as the one currently in use, revealed no documented evidence the procedure to follow for medication being withheld had been included.