HospitalInspections.org

Based on observation, document review and interview the facility failed to:


A. provide registered nurse (RN) assessment and reassessment of 2 (#3, #4) of 10 patients reviewed. The RNs did not supervise the LVNs (licensed vocational nurse) resulting in inconsistent wound care, injury from a fall and a failure to manage the patient's pain. The patient's antibiotic treatments and intravenous fluid treatments were delayed due to a lack of assessment, reassessment and communication among the healthcare providers.
Refer to Tag A0386

B. provide an adequate number of nursing staff to safely meet the care needs of the patients on 34 of 50 shifts reviewed.
Refer to Tag A0392

C. provide an adequate number of registered nurse staffing to safely meet the care needs of the patients on 5 of 50 shifts reviewed.
Refer to Tag A0395

D. enforce the established policy for assessment/reassessment of patients. The RN assigned the care of 1 of 10 patients to the LVN and the RN failed to assess/reassess the patient every 24 hours.
Refer to Tag A0397


E. identify medication errors and enforce the Medication Error policy for 1 (#3)
of 10 patients reviewed.
Refer to Tag A0406

F. follow the established, Patient and Customer Complaint/Grievance policy.
Refer to Tag A0119

G. investigate a patient complaint/grievance but provided a letter stating a investigation had been conducted.
Refer to Tag A0123


It was determined that these deficient practices created an Immediate Jeopardy situation that resulted in harm and a likelihood of resulting in further harm, serious injury, and subsequent death to patients.

Based on document review and interviews the facility failed to:

A. provide registered nurse (RN) assessment and reassessment of the 2 (#3,#4)
of 10 patients reviewed. The RNs did not supervise the LVNs (licensed
vocational nurse) resulting in inconsistent wound care, injury from a fall and
a failure to manage the patient's pain. The patient's antibiotic treatments and
intravenous fluid treatments were delayed due to a lack of assessment,
reassessment and communication among the healthcare providers.
Refer to Tag A0386

B. provide an adequate number of nursing staff to safely meet the care needs of the patients on 34 of 50 shifts reviewed.
Refer to tag A0392

C. provide an adequate number of registered nursing staff to safely meet the care needs of the patients on 5 of 50 shifts reviewed.
Refer to tag A0395

D. enforce the established policy for nursing assessment and reassessment. The RN assigned the care of 1 of 10 patient reviewed to the LVN and the RN failed to assess/reassess the patient every 24 hours.
Refer to tag A0397

E. identify medication errors and enforce the Medication Error policy for 1 (#3) of 10 patients reviewed.
Refer to tag A0406



It was determined that these deficient practices created an Immediate Jeopardy situation, that resulted in harm and a likelihood of resulting in further harm, serious injury, and subsequent death to patients.

The facility failed to provide a sanitary environment in the dietary department (food storage and preparation areas). Potential for cross-contamination due to unsanitary food handling, unsanitary cooking implement storage, unsanitary food service item (pots, pans, bowls and plates) storage, and poor general sanitation practices was found throughout the dietary department.
A tour was conducted on 1-28-2014, with staff #2, #18, and #20. Findings were as follows:
-Carbon build up was found on four frying pans, a large deep roasting pan, multiple baking sheets, muffin pans, cake pans, bundt pans, and multiple large pots. These items are unable to be cleaned properly to prevent contamination.
- An inspection of the stacked metal pans revealed the first pan had water condensation on the inside. The second pan in the stack had water condensation on the outside and inside of the pan. All of the pans in the stack revealed the same results. Approximately five pans stored in the stack had water pooling on the outside of the bowl and water condensation on the inside of the bowl. The pooling of water and water condensation on the metal pans provided a medium for bacterial growth.
-The microwave is used to heat and prepare foods. The microwave was soiled with food particles and grease on the inside. The outside door and handle were soiled with a greasy substance. The top of the cart that held the microwave had food particles and a greasy substance on it. When the microwave is not properly cleansed, food borne illnesses and contamination can occur.
-A plastic water container, labeled, " ICE, " was on the top shelf of a three-tier plastic cart. Staff #2 reported the cart was used to take ice from the back of the kitchen to the outer serving line. The cart was soiled with dust and food particles. The wheels on the cart were soiled with dirt, hair, and food particles.
- A wire rack with multiple shelves was found holding bundt pans, shallow baking pans, cake pans, and bowls. Staff #2 reported these were clean pans and bowls. The pans were soiled with a greasy substance, dried crusty yellow substance, dust, and dried food particles. The pans and bowls were removed to reveal an impermeable barrier soiled with food and grease particles. When the baking pans and surfaces are not cleaned properly food contamination and food borne illnesses can occur.
- In the center of the kitchen next to the food preparation area, a stainless steel food tray container was present. The trays were stacked in the container for patient use. The top of the container was soiled with a greasy substance and dried food particles.
-In the refrigerator, multiple vegetables, cake squares, and pieces of pie were found covered in plastic wrap with no dates. Out dated food could be re-served which could cause food borne illnesses.
- Below the sink was an open stainless steel shelf. The shelf contained a plastic container holding two spray bottles. The bottles were confirmed to be cleaning products by staff #2. Approximately 12-15 inches to the left of the cleaning bottles was a large open container of onions and a container of potatoes sitting under the sink area on the shelf. The shelf was soiled with greasy and dried liquid substances. The outer base of the sink was soiled with greasy build up and dried liquid substances. Spillage from the sink and chemicals stored next to the food can cause food contamination.
-An open stainless steel shelf under the sink contained a plastic container holding two spray bottles. The bottles were confirmed to be cleaning products by staff #2. Approximately 18-20 inches to the right of the spray bottles was a plastic tub holding Styrofoam bowls, condiment cups, and lids. Multiple bowls and cups were found to be uncovered. Staff #2 confirmed these items were used to serve the patients. When serving containers are not properly cleaned food borne illnesses and food contamination can occur.
- A wire shelf cart was moved to expose the floor next to the refrigerator. The floor was covered with dust, food particles, and pieces of unidentifiable trash. A candy sucker stick was observed lying on the floor against the wall. A thick black build up was observed on the floor. The thick black buildup became darker as it neared the wall and baseboard. The floor covered with dust, food particles, and pieces of unidentifiable trash along with the thick black build up provided a medium for bacterial growth and posed a fall hazard.
- The floor behind the sink was soiled with grease, dust, dried food particles, black gooey substances, and dried liquid substances. The floor under the ice machine had a buildup of grease, dust, dried food particles, and a dried heavy white substance. Soiled floors and surfaces can cause a medium for bacteria and food contamination.
- On a stainless steel counter, a meat slicer was found covered with plastic. Staff #2 reported the meat slicer was cleaned and covered with plastic. Staff #2 reported that the slicer is rarely used. Upon removing the plastic cover, the meat slicer was found with what appeared to be meat lodged in the blade. The top and bottom of the slicer had a greasy feel with dried yellow/ dark brown substances on the top. The on and off switch was caked in a greasy substance and dried food particles. The food and grease build up provided a medium for bacterial growth and food contamination.
- On a stainless steel counter, a toaster was found sitting on a plastic red tray. The toaster and the red tray were found to have a greasy substance, dried food particles, dust, a pencil, and a bread tag.
- The refrigerator contained an open bacon strips and sausage patties on a pan covered with wax paper. No dates were on the paper. Out-dated food could be reserved which could cause food borne illnesses.
- The wire storage units in the refrigerator and freezer had no impermeable barriers on the bottom shelves. Meat was found thawing in the refrigerator on the bottom shelf. With no impermeable barrier, these food items stored on the bottom shelves were not being protected from contamination by floor debris becoming airborne.
-The freezer door was not closed properly due to a thick sheet of ice all around the door. Staff #18 reported condensation builds up around the door and freezes causing it to not close properly. When the freezer door is unable to make a tight seal, the temperature cannot be properly maintained. Food borne illnesses and food contamination can occur.
- Shipping boxes were found in the refrigerator. Cardboard shipping boxes may contain bacteria, rodents, or insects.
- An industrial fryer was found to have dark grease in the vat. There were food particles floating on the grease and on the side of the fryer wall and basket. The inside of the mechanical workings of the fryer had grease build up and what appeared to be food particles.
- The convection oven glass doors, hinges, and wire racks were soiled with grease, dried food particles, and a heavy carbon build up.
-A steam serving table was sitting next to the kitchen preparation area. Staff #2 reported the steam table was taken out of the kitchen area, down the patient hallways, and into two different dining rooms at meal times. Staff #2 reported the table was wiped down each time it was brought back into the kitchen but there was no log of the cleaning process. No guidelines were offered on how to cleanse the steam table. The steam table has a stainless steel shelf. When not in use the shelf is turned upside down. Under the shelf, dried food particles and a greasy build up was found. A thick hard dried substance mixed with hair, food, and dirt was found on the wheels of the steamer, allowing for contaminated materials to reenter the clean kitchen preparation area.
During the tour, Staff #2, #18, and #20 confirmed the above findings.

The facility failed to provide a sanitary environment in the dietary department (food storage and preparation areas). Potential for cross-contamination due to unsanitary food handling, unsanitary cooking implement storage, unsanitary food service item (pots, pans, bowls and plates) storage, and poor general sanitation practices was found throughout the dietary department.
A tour was conducted on 1-28-2014 with staff #2, #18, and #20. Findings were as follows:
-Carbon build up was found on four frying pans, a large deep roasting pan, multiple baking sheets, muffin pans, cake pans, bundt pans, and multiple large pots. These items are unable to be cleaned properly to prevent contamination.
- An inspection of the stacked metal pans revealed the first pan had water condensation on the inside. The second pan in the stack had water condensation on the outside and inside of the pan. All of the pans in the stack revealed the same results. Approximately five pans stored in the stack had water pooling on the outside of the bowl and water condensation on the inside of the bowl. The pooling of water and water condensation on the metal pans provided a medium for bacterial growth.
-The microwave is used to heat and prepare foods. The microwave was soiled with food particles and grease on the inside. The outside door and handle were soiled with a greasy substance. The top of the cart that held the microwave had food particles and a greasy substance on it. When the microwave is not properly cleansed, food borne illnesses and contamination can occur.
-A plastic water container, labeled, " ICE, " was on the top shelf of a three-tier plastic cart. Staff #2 reported the cart was used to take ice from the back of the kitchen to the outer serving line. The cart was soiled with dust and food particles. The wheels on the cart were soiled with dirt, hair, and food particles.
- A wire rack with multiple shelves was found holding bundt pans, shallow baking pans, cake pans, and bowls. Staff #2 reported these were clean pans and bowls. The pans were soiled with a greasy substance, dried crusty yellow substance, dust, and dried food particles. The pans and bowls were removed to reveal an impermeable barrier soiled with food and grease particles. When the baking pans and surfaces are not cleaned properly food contamination and food borne illnesses can occur.
- In the center of the kitchen next to the food preparation area, a stainless steel food tray container was present. The trays were stacked in the container for patient use. The top of the container was soiled with a greasy substance and dried food particles.
-In the refrigerator, multiple vegetables, cake squares, and pieces of pie were found covered in plastic wrap with no dates. Out dated food could be re-served which could cause food borne illnesses.
- Below the sink was an open stainless steel shelf. The shelf contained a plastic container holding two spray bottles. The bottles were confirmed to be cleaning products by staff #2. Approximately 12-15 inches to the left of the cleaning bottles was a large open container of onions and a container of potatoes sitting under the sink area on the shelf. The shelf was soiled with greasy and dried liquid substances. The outer base of the sink was soiled with greasy build up and dried liquid substances. Spillage from the sink and chemicals stored next to the food can cause food contamination.
-An open stainless steel shelf under the sink contained a plastic container holding two spray bottles. The bottles were confirmed to be cleaning products by staff #2. Approximately 18-20 inches to the right of the spray bottles was a plastic tub holding Styrofoam bowls, condiment cups, and lids. Multiple bowls and cups were found to be uncovered. Staff #2 confirmed these items were used to serve the patients. When serving containers are not properly cleaned food borne illnesses and food contamination can occur.
- A wire shelf cart was moved to expose the floor next to the refrigerator. The floor was covered with dust, food particles, and pieces of unidentifiable trash. A candy sucker stick was observed lying on the floor against the wall. A thick black build up was observed on the floor. The thick black buildup became darker as it neared the wall and baseboard. The floor covered with dust, food particles, and pieces of unidentifiable trash along with the thick black build up provided a medium for bacterial growth and posed a fall hazard.
- The floor behind the sink was soiled with grease, dust, dried food particles, black gooey substances, and dried liquid substances. The floor under the ice machine had a buildup of grease, dust, dried food particles, and a dried heavy white substance. Soiled floors and surfaces can cause a medium for bacteria and food contamination.
- On a stainless steel counter, a meat slicer was found covered with plastic. Staff #2 reported the meat slicer was cleaned and covered with plastic. Staff #2 reported that the slicer is rarely used. Upon removing the plastic cover, the meat slicer was found with what appeared to be meat lodged in the blade. The top and bottom of the slicer had a greasy feel with dried yellow/ dark brown substances on the top. The on and off switch was caked in a greasy substance and dried food particles. The food and grease build up provided a medium for bacterial growth and food contamination.
- On a stainless steel counter, a toaster was found sitting on a plastic red tray. The toaster and the red tray were found to have a greasy substance, dried food particles, dust, a pencil, and a bread tag.
- The refrigerator contained an open bacon strips and sausage patties on a pan covered with wax paper. No dates were on the paper. Out-dated food could be reserved which could cause food borne illnesses.
- The wire storage units in the refrigerator and freezer had no impermeable barriers on the bottom shelves. Meat was found thawing in the refrigerator on the bottom shelf. With no impermeable barrier, these food items stored on the bottom shelves were not being protected from contamination by floor debris becoming airborne.
-The freezer door was not closed properly due to a thick sheet of ice all around the door. Staff #18 reported condensation builds up around the door and freezes causing it to not close properly. When the freezer door is unable to make a tight seal, the temperature cannot be properly maintained. Food borne illnesses and food contamination can occur.
- Shipping boxes were found in the refrigerator. Cardboard shipping boxes may contain bacteria, rodents, or insects.
- An industrial fryer was found to have dark grease in the vat. There were food particles floating on the grease and on the side of the fryer wall and basket. The inside of the mechanical workings of the fryer had grease build up and what appeared to be food particles.
- The convection oven glass doors, hinges, and wire racks were soiled with grease, dried food particles, and a heavy carbon build up.
-A steam serving table was sitting next to the kitchen preparation area. Staff #2 reported the steam table was taken out of the kitchen area, down the patient hallways, and into two different dining rooms at meal times. Staff #2 reported the table was wiped down each time it was brought back into the kitchen but there was no log of the cleaning process. No guidelines were offered on how to cleanse the steam table. The steam table has a stainless steel shelf. When not in use the shelf is turned upside down. Under the shelf, dried food particles and a greasy build up was found. A thick hard dried substance mixed with hair, food, and dirt was found on the wheels of the steamer, allowing for contaminated materials to reenter the clean kitchen preparation area.
Staff #2, #18, and #20 confirmed the above findings.
Review of policy and procedures " Safety " for food services states the following:
" Purpose: To analyze present and potential hazards within the department to protect employees, visitors, and patients. Procedure: The quality, safety and sanitation of the department of Food Services is monitored for appropriateness through criteria set forth in the Performance Improvement Manual, Safety Manual, and Infection Control Manual. "
AND
" D. the Infection Control Nurse and safety officer directs department activities to ensure compliance. Walking tours and reviews of monitoring systems are performed monthly by these individuals. Written recommendations are sent to department as needed. Recommendations are reviewed at department meetings and action is taken as needed. "
Review of the Infection Control Log on 1/16/14 revealed no reports, monthly reviews, or recommendations for the Dietary Department.
An interview with staff #10 on 1/16/2014 revealed staff #10 was unaware of the present kitchen condition. Staff #10 reported to have been in the dietary department in the last month. Staff #10 reported walking rounds do occur. Staff #10 did not produce any paperwork on the safety rounds for the last three months upon request.

Based on documents review and interviews, the facility failed to follow the established, Patient and Customer Complaint/Grievance policy for 1 of 3 (#3) patient complaints reviewed.

A review of the document titled, Patient and Customer Complaint/Grievance policy, revealed; A complaint/grievance is defined as an issue that meets any of the following criteria: ... ...2. Complaint/Grievance is of a significant nature such patient care and treatment issue ....

Customer Complaint/Grievance- Action to be taken: 2. The individual (staff) identifying the complaint/grievance is to complete a hospital incident report. 3. Administrator or designee must initiate investigation, in conjunction with Facility Risk Management. 5. The investigation into the complaint and the appropriate follow up actions will continue until corrective action has been taken to satisfaction of patient/family. 7. Facility Risk Management will follow up with departmental supervisor for action taken regarding employee issues if indicated. 8. In its resolution of the grievance, the Hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance process, and the date of the completion.

Customer Complaint/Grievance- Documentation Requirements: 1. The Hospital should make sure that it is responding to the substance of each complaint/grievance while identifying, investigating and resolving and deeper, systemic problems indicated by the grievance.

Responsibility: 3. The Quality Committee and Governing Body will be responsible for identifying areas and initiatives that require quality improvement as a result of the complaint/grievance process information gathered and reported. These two entities will also be responsible for implementing appropriate corrective action as needed on identified trends.


Review of the document titled Incident Report revealed that patient #3 had an unwitnessed fall and was found by staff lying on the floor. Patient denied any complaint of pain at the time of the incident. M.D. #22 was notified of the patient's fall 8/24/13 at 2:30PM. Incident Report was completed by LVN staff #6 and dated 8/24/13 at 11:30AM. The document contained the signature of the Director of Quality/Risk Management staff #17 with a date of 8/26/13 at 8:15AM.

A review was conducted of the written statements provided by patient #3's wife, CNA (certified nurse aide) staff #12, LVN staff #44, RN staff #41, Rehab Nursing Tech staff #46, staff #47, Nurse Tech staff #48, Nurse Tech staff #49 and staff #50. The written statements revealed that patient #3 was transferred from his bed using a mechanical lift and placed in his wheelchair sitting on a pillow. The patient was transferred to the dining room. The patient's wife stated the patient slid out of his chair. The written statements by the staff revealed the patient was found on the floor. The written statements by the staff revealed the mechanical lift would not lower to the floor and was not used to lift the patient. The written statements revealed patient #3 complained of back and butt pain once he was placed back into the wheelchair.

A review was conducted of the undated and un-timed, written statements by RN staff 11. The document revealed patient #3's wife verbalized a complaint. RN staff #1 did not submit the required incident report. The written statement revealed the wife was told the patient would have 25 days to stay in the facility but was being discharged on the 9th day. ... Someone put a pillow in the pt's wheelchair. O2 was not always on the pt. when going to Physical Therapy. Wife feels staff is rude today, 8/24/13. The staff was not checking the pt. for incontinence of bowels. Wife stated, "I was here for 3 hours and no one checked on him".

A review was conducted of the undated and un-timed, written statements by QAPI/Risk Manager staff #17. The document revealed "added items to her (patient #3's wife) complaint from the weekend. (see 8/24/13 Incident Report)". The document also revealed the patient had bedsores on his bottom that developed since he was admitted to the facility. Patient #3's wife asked about a wound care nurse and staff told her the night shift did that. Patient #3's wife complained several times when the patient's c-pap (Continuous positive airway pressure - CPAP - is the use of continuous positive pressure to maintain a continuous level of positive airway pressure) did not have the required water in it. "Today there was not a connection to the O2 (oxygen)." Patient #3's wife complained that the patient was found in his wheelchair without oxygen. Patient #3's wife complained that she was told the nurses would make hourly rounds and that had not happened while she was present with the patient. Patient #3's wife complained she read from the facility's brochure that family member and patients meet regularly with physician and rehab teams. Patient #3's wife stated "this whole thing has been misleading".

An interview on 8/27/13, at approximately 2:30 PM, with QAPI/Risk Manager staff #17 revealed the only action on incident report dated 8/24/13, filled out as a result of patient #3's fall. The findings provided by the staff's written statements were not addressed. (The written statements revealed patient#3 was transferred from his bed using a mechanical lift and placed in his wheelchair sitting on a pillow. The patient was transferred to the dining room. The patient's wife stated the patient slid out of his chair. The written statements by the staff revealed the patient was found on the floor. The written statements by the staff revealed the mechanical lift would not lower to the floor and was not used to lift the patient. The written statements revealed patient #3 complained of back and butt pain one placed back into the wheelchair. The incident revealed the M.D. was not notified to the patient's fall until three hours after the fall.) QAPI/Risk Manager staff #17 revealed, the staff did not know how to use the mechanical lift and that is why staff could not use it to pick the patient up off the floor. No action was taken to educate the staff of the proper use of the mechanical lift. The QAPI/Risk Manager staff #17 provided no evidence of follow up on patient #3's wife's complaint, documented by staff #11.

An interview with CNO staff #7 on 8/27/13, at approximately 2:30 PM, revealed there had been no follow up or education as a result of incident report dated 8/24/13, documenting patient #3's fall. CNO staff #7 confirmed there had not been a review of patient #3's medical record.

Based on document review and interview, the facility failed to investigate a complaint/grievance for 1 of 3 (#3) patients complaints reviewed. The CEO provided patient #3's wife a letter of a detailed investigation conducted on behalf of her husband. The CEO was unable to provide evidence of the investigation.

Customer Complaint/Grievance- Action to be taken: 2. The individual (staff) identifying the complaint/grievance is to complete a hospital incident report. 3. Administrator or designee must initiate investigation, in conjunction with Facility Risk Management. 5. The investigation into the complaint and the appropriate follow-up actions will continue until corrective action has been taken to satisfaction of patient/family. 7. Facility Risk Management will follow up with departmental supervisor for action taken regarding employee issues if indicated. 8. In it's resolution of the grievance, the Hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance process, and the date of the completion.

Customer Complaint/Grievance- Documentation Requirements: 1. The Hospital should make sure that it is responding to the substance of each complaint/grievance while identifying, investigating and resolving and deeper, systemic problems indicated by the grievance.

A review of a letter dated 8/23/13, addressed to patient #3's wife and signed by CEO staff #20 revealed "You reported that you felt patient #3 had additional bed sores on his bottom that developed since he had come to the facility. Your concern prompted us to review our protocols and visit with our consulting enterostomal therapy (wound care) nurse in an attempt to improve our outcomes for future patients. You mentioned concerns related to management of patient #3's C-Pap and O2. Your concerns were shared with our CNO and we have reviewed our services. None of the examples you gave fit the expectations we have of our staff. I assure you that these issues have been addressed."

An interview on 8/27/13, at approximately 2:30 PM, with QAPI/Risk Manager staff #17 revealed the only action on incident report dated 8/24/13, was filled out as a result of patient #3's fall. The findings provided by the staff's written statements were not addressed. (The written statements revealed patient #3 was transferred from his bed using a mechanical lift and placed in his wheelchair sitting on a pillow. The patient was transferred to the dining room. The patient's wife stated the patient slid out of his chair. The written statements by the staff revealed the patient was found on the floor. The written statements by the staff revealed the mechanical lift would not lower to the floor and was not used to lift the patient. The written statements revealed patient #3 complained of back and butt pain one placed back into the wheelchair after the fall. The incident revealed the M.D. was not notified of the patient's fall until four hours after the fall.) QAPI/Risk Manager staff #17 revealed, the staff did not know how to use the mechanical lift and that is why staff could not use it to pick the patient up off the floor. No action was taken to educate the staff of the proper use of the mechanical lift. The QAPI/Risk Manager staff #17 provided no evidence of follow-up on patient #3's wife's complaint.

An interview with CNO staff #7 on 8/27/13, at approximately 2:30 PM, revealed there had been no follow up or education as a result of incident report dated 8/24/13, documenting patient #3's fall. CNO staff #7 confirmed there had not been a review of patient #3's medical record.

An interview with CEO staff #20 on 8/27/13, at approximately 2:30 PM, was unable to provide evidence of follow up that was documented in his above mentioned letter he sent to patient #3's wife.

Based on document review and interview the facility failed to:

A. provide registered nurse (RN) assessment and re-assessment of 2 (#3, #4) of 10 patient. The RNs did not supervise the LVNs (licensed vocational nurse) resulting in inconsistent wound care, injury from a fall and a failure to manage the patient's pain. The patient's antibiotic treatments and intravenous fluid treatments were delayed due to a lack of assessment, reassessment and communication among the healthcare providers.
Refer to tag A0386

B. provide an adequate number of nursing staff to safely meet the care needs of the patients on 34 of 50 shifts reviewed
Refer to tag A0392

C. provide an adequate number of registered nursing staff to safely meet the care needs of the patients on 5 of 50 shifts reviewed.
Refer to tag A0395

D. enforce the established policy. The RN assigned the care of the patient to the LVN and the RN failed to assess/ reassess the patient every 24 hours.
Refer to tag A0397

E. identify medication errors and enforce the Medication Error policy.
Refer to tag A0406

Based on documentation review and interview, the facility failed to provide registered nurse (RN) assessment and re-assessment of 2 of 10 (#3, #4,) patients reviewed. The RNs did not supervise the LVNs (licensed vocational nurse resulting in inconsistent wound care, injury from a fall and a failure to manage the patient's pain. Patient's antibiotic treatments and intravenous fluid treatments were delayed due to a lack of assessment, reassessment and communication among the healthcare providers.


A review of The Texas Nursing Practice Act (NPA) defines the legal scope of practice for professional registered nurses (RN).

15.28 The Registered Nurse Scope of Practice

The professional registered nurse is an advocate for the patient and the patient's family, and promotes safety by practicing within the NPA and the BON Rules and Regulations. The RN provides nursing services that require substantial specialized judgment and skill. The planning and delivery of professional nursing care is based on knowledge and application of the principles of biological, physical and social science as acquired by a completed course of study in an approved school of professional nursing. Unless licensed as an advanced practice registered nurse, the RN scope of practice does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures.2 RNs utilize the nursing process to establish the plan of care in which nursing services are delivered to patients. The level and impact of the nursing process differs between the RN and LVN as well as between the different levels of RN education.


The comprehensive assessment is the first step, and lays the foundation for the nursing process. The comprehensive assessment is the initial and ongoing, extensive collection, analysis and interpretation of data. Nursing judgment is based on the assessment process. The RN uses clinical reasoning and knowledge, evidence-based outcomes, and research as the basis for decision-making and comprehensive care. Based upon the comprehensive assessment the RN determines the physical and mental health status, needs, and preferences of culturally, ethnically, and socially diverse patients and their families using evidence-based health data and a synthesis of knowledge. Surveillance is an essential step in the comprehensive assessment process. The RN must anticipate and recognize changes in patient conditions and determines when reassessments are needed.


A critical and fourth step in the nursing process is evaluation. The RN evaluates and reports patient outcomes and responses to therapeutic interventions in comparison to benchmarks from evidence-based practice and research findings, and plans any follow-up care and referrals to appropriate resources that may be needed. The evaluation phase is one of the times when the RN reassesses patient conditions and determines if interventions were effective and if any modifications to the plan of care are necessary.


A review of The Texas Nursing Practice Act (NPA) defines the legal scope of practice for the Licensed Vocational Nurse (LVN).

15.27 The Licensed Vocational Nurse Scope of Practice

The LVN is an advocate for the patient and the patient's family and promotes safety by practicing within the NPA and the BON Rules and Regulations. LVN scope of practice does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures. The practice of vocational nursing must be performed under the supervision of a RN, APRN, physician, physician assistant, podiatrist or dentist. Supervision is defined as the active process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The LVN is precluded from practicing in a completely independent manner; however, direct and on-site supervision may not be required in all settings or patient care situations. Determining the proximity of an appropriate clinical supervisor, whether available by phone or physical presence, should be made by the LVN and the LVN's clinical supervisor by evaluating the specific situation, taking into consideration patient conditions and the level of skill, training and competence of the LVN. An appropriate clinical supervisor may need to be physically available to assist the LVN should emergent situations arise.

The LVN assists in determining the physical and mental health status, needs, and preferences of culturally, ethnically, and socially diverse patients and their families based on interpretation of health-related data. The LVN collects data and information, recognizes changes in conditions and reports this to the RN supervisor or another appropriate clinical supervisor to assist in the identification of problems and formulation of goals, outcomes and patient-centered plans of care that are developed in collaboration with patients, their families, and the interdisciplinary health care team. The LVN participates in the nursing process by appraising the individual patient's status or situation at hand. Also known as a focused assessment, this appraisal may be considered a component of a more comprehensive assessment performed by a RN or another appropriate clinical supervisor. For example, a RN may utilize the data and information collected and reported by the LVN in the formation of the nursing process; however, the RN's comprehensive assessment lays the foundation for the nursing process. The LVN reports the data and information collected either verbally or in writing. Written documentation must be accurate and complete, and according to policies, procedures and guidelines for the employment setting.

A critical and fourth step in the nursing process is evaluation. The LVN participates in the evaluation process identifying and reporting any alterations in patient responses to therapeutic interventions in comparison to expected outcomes. The LVN may contribute to the evaluation phase by suggesting any modifications to the plan of care that may be necessary and making appropriate referrals to facilitate continuity of care.

Communication is a fundamental component in the nursing process. The LVN must communicate verbally, in writing, or electronically with members of the healthcare team, patients and their families on all aspects of the nursing care provided to patients. Communications must be appropriately documented in the patient record or nursing care plan. Because LVNs are members of the healthcare team, provide nursing care, and contribute to the nursing process, collaboration is a quality that is crucial to the communication process. When patient conditions or situations have changed or exceeded the LVN's level of competency and scope of practice, the LVN must be prepared to seek out his or her clinical supervisor and actively cooperate to develop solutions that ensure patient safety.

A review of the hospital policy titled, "Care of Patient/ Documentation, Subject: Interdisciplinary Daily Documentation, Procedure: 5. Daily Nursing Assessment:" revealed: a. All patients will have an RN assessment conducted every 24 hours, at a minimum. If any reassessment findings are abnormal, an assessment will be conducted by an RN and a narrative note will be written describing the problem area, abnormality, the intervention, and the follow-up, signing under the "Additional problem specific system review completed with significant finding within the narrative". The time of this assessment will be noted next to the nurse's signature.


A review of the hospital's "2012 Wound Assessment Policy", revealed: "2. Description Methodology, b. Classification of Pressure Ulcers, II. Category/Stage II: Partial thickness skin loss ...., 7. Policy Adherence and Reporting, I. If a patient is admitted without a documented pressure ulcer, but develops a pressure ulcer, Stage II or greater, then a Hospital Incident Report (HIR) form must be completed, The risk manager will initiate an investigation as needed." No evidence of an incident report was provided by the facility.

A. Wound: The LVNs failed to communicate the changes in patient's wounds and follow the wound care orders.

Review of the document titled, "Interdisciplinary Daily Documentation "(IDD), completed by RN staff #21 on 8/15/13 upon the admission of patient #3 revealed "Skin Breakdown, Description: Scabs to bilateral knees, redness to bottom".


A review of the photos taken on 8/15/13, of patient #3's butt on admit to the facility, revealed a red butt with no skin breakdown.


During the review of patient #3's medical record, the document dated 8/15/13, at 5:30PM, and titled "Physician's Orders Sheet," revealed: "wound care nurse staff #9 consult for wound care. Lantiseptic Cream to buttocks BID (twice a day) and PRN (as needed). Desenex powder to ABD (abdominal) fold and groin BID and PRN. Clean wounds to bilateral knees with NS (normal saline). Apply bactroban oint (ointment) and leave open to air."

Review of patient #3's medical record, the document dated 8/15/13, at 8:30PM, and titled, "Physician's Orders Sheet," revealed a change in the wound care orders for the bilateral knees. The changed order was "Apply Adaptic (oil emulsion) dressing to R (right) and L (left) knees. Cover with 4X4s. Wrap with kerlix. Change daily."

A review of the photos taken on 8/18/13, by LVN staff #23, of patient #3's butt revealed a new wound on the patient's butt. LVN staff #23 documented on the photo, "skin breakdown" and the area was circled. There was no evidence the LVN reported the new findings to the RN, MD, or Wound Care Nurse.

Review of the document dated 8/19/13, and titled "Interdisciplinary Daily Documentation (IDD)," revealed LVN staff #4 documented new findings in patient #3's chart, "Skin Breakdown, Description: Pink Buttocks/red groin." There was no evidence of an RN assessment.

Review of the document dated 8/20/13, and titled, "Interdisciplinary Daily Documentation (IDD)", revealed LVN staff #14 and LVN staff #17 did not assess patient #3's wounds. The "Integument: Skin breakdown:" area located on the document was left blank.

Review of the document dated 8/20/13, and titled, "Daily Progress/Narrative" (Narrative Nurses Notes), revealed at 8:00PM "Pt. very lethargic. Will arouse ... Has temp of 100.6 ...." There was no documentation that patient #3's elevated temperature was reported to the RN or MD. No RN assessment was done.

Review of the document dated 8/22/13, and titled, "Interdisciplinary Daily Documentation (IDD)", revealed RN staff #1 assessed patient #3's wound and charted "Integument: Skin breakdown: Redness to buttocks, Stage II."

A review was done of an untitled document provided by the facility. The document provided wound care protocols (treatments) for a "Stage II healing ..... Consult Wound Nurse." No documentation was provided a wound care nurse was consulted.

A review/observation of the photos taken on 8/22/13, by RN staff #1, of patient #3's butt revealed a large open wound. The wound had a red bloody area in the center of the wound. Just to the left of the bloody area the top portion of the skin appears to be missing leaving what appeared to be a moist area. The documented size of the wound was "length 7cm (2.75 inches), width 6cm (2.36 inches)."

Review of the document dated 8/22/13, at 5:30PM, and titled "Physician's Orders Sheet", revealed "... Change wound care to Xenaderm BID and PRN until healed to buttocks."

Review of the document dated 8/23/13, and titled "Daily Progress/Narrative" (Narrative Nurses Notes), revealed at 2:00 AM LVN staff #24 documented, ".... Dressing removed, scant amt. serous/sanguinous drainage to knees area. Applied Opti foam to open area." No new wound care orders were noted, changing the treatment. The last wound care orders for the treatment of the bilateral knee wounds was dated 8//15/13, at 8:30PM, "Apply Adaptic (oil emulsion) dressing to R (right) and L (left) knees. Cover with 4X4s. Wrap with kerlix. Change daily." There was no evidence of an RN assessment or notification of the change in the wound care treatment.


Review of the document dated 8/24/13, titled "Daily Progress/Narrative" (Narrative Nurses Notes), revealed LVN staff #24 documented at 5:00 AM ".... Lantiseptic oint. applied to buttocks ...." At 8:40 AM, LVN staff #6 documented Stage II to buttocks, Lantiseptic applied." The Physician's Orders Sheet, dated 8/22/13, at 5:30PM, revealed "... Change wound care to Xenaderm BID and PRN until healed to buttocks." The evidence supported the LVNs were not following the wound care orders. There was no evidence of an RN assessment.
A review/observation was done of the photo taken on 8/24/13, by LVN staff #25 at 9:00 PM, of patient #3's butt. The photo was dark and of poor quality. Though the photo was of poor quality, it was obvious there was a large open wound. The wound had a red bloody area around the edges. The center of the wound appeared dark in color. LVN staff #25 failed to fill out these areas on the document: Staging (Pressure Ulcers), Size:, Exudate:, Wound Base Tissue:, Wound Edges:, Surrounding Skin Color:, Edema:, Signs of Infection:, and Pain Associated with Wound:. No RN assessment of the wound was documented.

Review of the document dated 8/25/13, titled "Interdisciplinary Daily Documentation" (IDD), revealed LVN staff #6 documented "Bilat. Knees- Allevyn dsg. C/D/I (dressing clean, dry and intact)." The Physician's Orders Sheet, dated 8/15/13, at 8:30PM, revealed "Apply Adaptic (oil emulsion) dressing to R (right) and L (left) knees. Cover with 4X4s. Wrap with kerlix. Change daily." There was no evidence of an order for an Allevyn Wound Dressing. The evidence supported the LVN was not following the wound care orders. No evidence of an RN assessment.

Review of the document dated 8/26/13, titled "Interdisciplinary Daily Documentation" (IDD), revealed RN staff #3 described patient #3's wound on his butt, "Stage II/ excoriation. Pink with bright red, scant, bleeding and foul odor." No evidence was provided the RN staff #3 reported the change in the wound odor to the M.D. or the Wound Care Nurse.

Review of the document dated 8/27/13, titled "Interdisciplinary Daily Documentation" (IDD), Description, revealed LVN staff #27 described patient #3's wound on his butt, "Buttocks broke down/Lantiseptic applied". The Physician's Orders Sheet, dated 8/22/13, at 5:30PM, revealed ".... Change wound care to Xenaderm BID and PRN until healed to buttocks." The evidence supported the LVN was not following the wound care orders. There was no evidence of an RN assessment.

Review of the document dated 8/27/13, titled "Interdisciplinary Daily Documentation" (IDD), Description, revealed LVN staff #27 described patient #3's wound on his butt, "Buttocks with open wound. Baseball size with pink granulation, with some exudate. Without oder with Xenaderm." There was no evidence the LVN reported the wound size to the M.D, RN or the Wound Care Nurse.

Review of the document dated 8/29/13, titled "Interdisciplinary Daily Documentation" (IDD), revealed RN staff #13 described patient #3's wound, "Location: Buttocks, Description: excoriated, un-stageable with necrotic (death of cells or tissues) area." There was no evidence the RN reported the wound to the MD or the Wound Care Nurse.

A review of the photos taken on 9/01/13, by LVN staff #31 of patient #3's butt revealed Wound Location: Buttock, Onset Date: Prior to admit, Wound Type: pressure, Current Treatment: Roho cushion, limit up time to therapy and feeding, Xenaderm. Has the patient's skin condition improved: NO. The LVN staff #31 was re-assessing patient #3's wound. Only the fore mentioned areas of the document was filled out. The patient did not have the stage II wound prior to admit. The LVN failed to fill out these areas on the document, Staging (Pressure Ulcers), Size:, Exudate:, Wound Base Tissue:, Wound Edges:, Surrounding Skin Color:, Edema:, Signs of Infection:, and Pain Associated with Wound:. No RN assessment of the wound was documented.
Review of the document dated 9/4/13, titled "Interdisciplinary Daily Documentation" (IDD), revealed LVN staff #23 documented patient #3's wound as, Description: Breakdown to coccyx, Xenaderm and Lantiseptic to buttocks.
Review of the document dated 9/4/13,, timed 5:00PM, titled "Daily Progress/Narrative" (Narrative Nurses Notes), revealed LVN staff #23 documented, "pt. wife reported nausea and wondering when husband was eating. Reported to Dr., Ordered Zofran PO given." No evidence of an RN assessment. No evidence LVN #23 addressed patient #3's wife's concern of when the patient was eating.
A review/observation was done of the photo taken on 9/7/13, by LVN staff #6 at 1:45 PM, of patient #3's butt. The photo was dark and of poor quality. Though the photo was of poor quality, it was obvious there was a large open wound. The wound had a red bloody area around the edges. The center of the wound appeared dark in color. LVN staff #6 failed to fill out these areas on the document, Signs of Infection:, and Pain Associated with Wound:. No RN assessment of the wound was documented.

A review/observation was done of the photo taken on 9/9/13, by RN staff #39 at 3:00 PM, of patient #3's butt. The photo revealed a large wound that covered approximately 50% of the patient's butt. The description of the wound starting at the intermediate intergluteal cleft or "crack" re it is white (blanched) with no skin tone color. This white area covered approximately 25% of the total wound. From the crack the wound moves over the buttocks. The tissue that joins the white area was black and has the appearance of leather. This black area twins itself on both buttocks. This black area covers approximately 25% of the total wound. Next to the black, leathery skin the wound became bright red circling the black area and covering both buttocks. This bright red area covers approximately 45% of the total wound. Next to the red area the skin became black and leathery on the outside edges of the wound. This black area covers the remaining 5 % of the wound.



B. Patient Fall: The LVNs failed to communicate the changes in patient's condition after a fall and report the patient's uncontrolled pain to the RN.

Review of patient #3's medical record, revealed the document titled, "Fall Risk Assessment, Nursing Physical Assessment: Unwitnessed- Pt's wife present at time of incident. No visible injuries. Pt being sent for X-ray of Lumbosacral spine per Dr. Thomas orders. Document completed by LVN staff #6 on 8/24/13, at 1430 (2:30pm)."
Review of patient #3's medical record, revealed the document dated 8/24/13, titled Daily Progress/Narrative (Narrative Nurses Notes), revealed no evidence of patient #3 falling or being found on the floor by staff. The document revealed no evidence patient #3 was assessed by an RN after the patient was found sitting on the floor. Document revealed no evidence the M.D. (Medical Doctor) was notified of the patient's fall.
Nursing entry at 1405 (2:05PM) LVN staff #8 documented "Pt c/o (complained of) pain at 10/10 on pain scale (pain scale is a number system for measuring a patient's perception of pain. A scale of 0-10, 0 is no pain and 10 being the worst pain imaginable) to lower back. HCD 10/325mg (pain medication) one po (by mouth) given. Will continue to monitor."
1430 (2:30PM) LVN staff #8 documented "Dr. #22 informed of pt. back pain. Advised to X-ray of lumbosacral spine. RN staff #11 notified."
1505 (3:05PM) LVN staff #8 documented "Pt still c/o pain a 10/10 on pain scale. Repositioned pt. and informed him not time for more HCD/APAP. Pt. verbalized understanding. Will continue to monitor. Call light in reach." There was no evidence of a RN assessment of the patient's unrelieved pain.
1620 (4:20PM) LVN staff #8 documented, "Lifenet (ambulance service) here to transfer pt. for lumbosacral spine x-ray." There was no evidence an RN assessed patient #3 prior to leaving the facility or was there evidence an RN assessed the patient upon returning to the facility.

C. Peripherally Inserted Central Catheter (PICC) line: The LVN failed to report a missing, newly placed Peripherally Inserted Central Catheter (PICC) to the RN.
Review of patient #3's medical record, revealed the document (physician's order) dated 8/23/13, titled Power PICC Placement (Peripherally Inserted Central Catheter) 1. Stat portable chest X-ray for PICC line placement.
There was no evidence found a stat portable chest X-ray for PICC line placement was ordered or the x-ray was performed.
Review of patient #3's medical record, revealed the document dated 8/24/13, and titled, Daily Progress/Narrative (Narrative Nurses Notes), revealed nursing entries at:
0840 (8:40AM) LVN staff #8 documented, ".... PICC RUE (right upper extremity) , site clear ...."
12:00PM LVN staff #8 documented, "Dr. #22 called concerning the start of fluids. Informed him PICC not to heart. Was told it was "Okay to go ahead and start fluids." Raven RN informed."
12:05 PM ) LVN staff #8 documented, "IV fluids not started d/t (due to) PICC placement not verified."
12:05 PM ) RN staff #1 documented, "IV fluids NS (normal saline) started to Right PICC per Dr. #22 order's, OK to use PICC line."
1620 (4:20PM) LVN staff #8 documented, "Lifenet (ambulance service) here to transfer pt. for lumbosacral spine x-ray." There was no evidence an RN assessed patient #3 prior to leaving the facility or was there evidence an RN assessed the patient upon returning to the facility.
Review of the document, dated 8/28/13, written at 3:45 PM,titled Physical Medicine and Rehabilitation Physician Progress Note, revealed FNP (Family Nurse Practitioner) staff #28 had just been made aware patient #3's PICC line was missing when the patient came back from having the lumbosacral spine x-ray on 8/23/13.
Review of the document dated 8/28/13, titled Daily Progress/Narrative (Narrative Nurses Notes), revealed RN staff #29 documented at 6:30PM, "Wound Care Nurse staff #9 here for PICC placement. Will have radiology to come in AM."
Review of the document dated 8/28/13, at 6:08PM, titled Physician's Orders Sheet, revealed RN staff #29 wrote an order, "X-ray for PICC line placement. OK to do 8/29/13 in AM early." Staff #29 signed the order, S.O. (standing order) Dr.#30/ RN staff #29. There was no evidence staff #29 communicated with the M.D. to change the standing order.
Review of patient #3's medical record, revealed the document (physician's standing order) dated 8/28/13 and titled, Power PICC Placement (Peripherally Inserted Central Catheter), 1. Stat (immediately, rush, urgent) portable chest X-ray for PICC line placement.
Review of the document dated 8/29/13, timed 1:00PM, titled Daily Progress/Narrative (Narrative Nurses Notes), revealed RN staff #13 documented, patient #3 was taken to radiology for chest x-ray - PICC line placement verification. There was no evidence staff #13 communicated with the M.D. to change the standing order or report a delay in the patient receiving the chest x-ray.
An interview by phone on 1/27/14, at approximately 7:00PM, was conducted. The interview with patient #3's wife revealed patient #3 had a PICC line placed on 8/23/13, by RN staff #9. Patient #3 had a PICC line on 8/24/13, when he was transferred by ambulance to a local hospital for a back x-ray. Upon the patient's return from the hospital, patient #3 did not have a PICC. Patient #3's wife revealed when the nursing staff was asked what happened to the PICC the staff replied they did not know. Patient #3's wife revealed no one seemed to be bothered the PICC line was missing nor did they try and find out what happened to it.
An interview on 1/28/14, at approximately 10:30AM, was conducted in the conference room with CEO staff #20. CEO staff #20 confirmed patient #33 had a PICC line on 8/24/13, when he was transferred by ambulance to a local hospital for a back x-ray. Upon the patient's return from the hospital, patient #3 did not have a PICC. CEO staff #20 thought he had seen in the chart where the missing PICC had been documented. CEO staff #20 reviewed Patient #3's medical record and confirmed the missing PICC had not documented.
An interview on 1/28/14, at approximately 10:30AM, was conducted in the conference room with CNO staff #7 reviewed patient #3's medical record and confirmed the missing PICC had not been documented. CNO staff #7 confirmed there was no evidence an RN assessed patient #3 prior to leaving the facility or was there evidence an RN assessed the upon returning to the facility. The CNO staff #7 was asked if the PICC may have been sheared off during the transfer and could it had been still in the patient, the CNO stated she would follow up with the hospital where patient #3 was transferred. No evidence was provided that follow up was made by the CNO. There also was no documentation or evidence supplied that the M.D. (Medical Doctor) was notified of the missing PICC.


Review of medical record for patient #4 revealed patient was admitted on 1/21/2014, for rehabilitation following a recent Left AKA (Above Knee Amputation). Review of patient #4's medical record revealed patient was experiencing a high level of pain. On 1/22/2014, a new order was received for pain medication - Norco 10/325 one tablet by mouth every 4 hours as needed for moderate pain and two tablets for severe pain. Nursing documentation revealed the following:
Staff #11 documented on 1/22/2014, at 7:30am, that patient#4 had a "0" on a pain assessment scale of 0-10. The patient's MAR (medication administration record) revealed patient was given a PRN pain medication at 7:45am. There was no documentation of patient complaining of pain or the reason the pain medication was given. Staff #11 documented on patient #4's MAR at 12:20pm that 2 tablets of Norco was given. There was no documentation that a pain assessment was done or that a reassessment was done of pain management effectiveness.
Staff #14 documented on 1/22/2014, at 4:30pm, that Norco 2 tablets was given. There was no documentation that a pain assessment was conducted and no evidence of a reassessment of the pain management effectiveness. Documentation at 8:55pm revealed patient had a pain level of 8 of 10. Two Norco were given for pain. There was no documentation of reassessment of pain management effectiveness.
Review of patient #4's MAR for 1/23/2014, revealed patient #4 received Norco, 2 tablets for pain at 9:30am and 1:45 pm. There was no documentation of pain assessment or reassessment of pain medication effectiveness. Review of nurses' notes at 6:30pm revealed Staff #36, a LVN (Licensed Vocational Nurse), documented patient #4 was in pain and Norco 2 tablets were given. At 9:00pm, Staff #36 documented, "Pt. awake, still c/o (complains of) AKA pain, med not due." There was no documentation the physician was notified or the Registered Nurse (RN) was informed of the patient's uncontrolled pain. At 10:40pm, patient was medicated by staff #36 with Norco 2 tablets for pain relief. There was no evidence of a reassessment of the pain medication ' s effectiveness.
Review of patient #4's MAR for 1/24/2014 revealed patient received Norco, 2 tablets at 12:05pm and 8:40pm. There was no evidence of a reassessment of the pain medication effectiveness.
Review of patient #4's MAR for 1/25/2014 revealed patient received Norco, 2 tablets at 8:50am and 4:15pm. There was no evidence of a reassessment of the pain medication effectiveness. Staff #41 documented at 6:30pm that patient had a pain assessment level of 5 out of 10. There was no evidence that Staff #41 intervened on behalf of patient #4. There was no documentation of pain management or nursing intervention. Staff #41 documented on the MAR at 8:00pm that Norco, 2 tablets were given. No pain assessment or reassessment was documented.
Review of patient#4 ' s MAR for 1/26/2014, revealed patient received Norco, 2 tablets at 7:40am. There was no evidence of a reassessment of the pain medication effectiveness. The MAR revealed patient received Norco, 2 tablets at 8:30 pm. Review of the nursing assessment form revealed a re-assessment was done and patient reported a pain level of 6 out of 10 at 9:25pm. There was no evidence of nursing interventions to address the patient ' s continued pain.
Review of patient #4's MAR for 1/27/2014, revealed patient received Norco, 2 tablets at 3:40am, 9:35am, 5:15pm, and 9:05pm. There was no nursing assessment documented of pain level or that pain medication was administered for the pain med administered at 3:40am, 9:35, and 5:15pm. There was no reassessment of the pain medication effectiveness of the 9:05pm dose.
Review of patient #4's MAR for 1/28/2014, revealed patient received Norco, 2 tablets at 8:25am. There was no nursing documentation of pain assessment or reassessment of pain medication effectiveness.

Based on document review and interview the facility failed to provide an adequate number of nursing staff to safely meet the care needs of the patients on 34 of 50 shifts reviewed
A review of the document titled, Staffing Matrix, revealed:
Dayshift Census HS Nurses Techs U/C
36 1 4 4 1
37 1 4.5 4 1
38 1 5 4 1
39 1 5 4 1
40 1 5 4 1
41 1 5 4 1
42 1 5 4.5 1
43 1 5 5 1
44 1 5 5 1
45 1 5 5 1
46 1 5.5 5 1
47 1 6 5 1
48 1 6 5 1
49 1 6 5 1
50 1 6 5 1
51 1 6 5 1
52 1 6 5.5 1

Night Shift
Census HS Nurses Techs
36 1 4 3.5
37 1 4 3.5
38 1 4 3.5
40 1 4 4
41 1 5 4
42 1 5 4
43 1 5 4
44 1 5 4.5
45 1 5 5
46 1 5 5
47 1 5 5
48 1 5.5 5
49 1 6 5
50 1 6 5
51 1 6 5
52 1 6 5

Census = Number of Patients, HS = House Supervisor, Techs = Nurses Aids, U/C = Unit Clerks
Staffing:
A review of the daily staffing sheets revealed:

8/16/13:

AM shift was short 1 House Supervisor and 1 Nurse Tech per staffing matrix. AM census 42.

PM staffing matrix requires 5 experienced nurse techs. The facility staffed 3 experienced nurse techs and 2 nurse techs being orientated. PM census 45

8/17/13:
PM shift was short 1 House Supervisor. PM census 43

8/19/13:
AM shift was short 1 Nurse per staffing matrix. AM staffing matrix requires 5 experienced nurse techs. Facility staffed 4 experienced nurse techs and 1 nurse techs being orientated. AM census 43

8/20/13:
AM shift was short 1 Nurse per staffing matrix. AM census 44

PM staffing matrix requires 4.5 experienced nurse techs. The facility staffed 2 experienced nurse techs and 2 nurse techs being orientated. PM census 44

8/21/13:
AM staffing matrix requires 5 experienced nurses. The facility staffed 4 experienced nurses and 1 nurse being orientated. AM staffing matrix requires 5 experienced nurse techs. The facility staffed 4 experienced nurse techs and 1 nurse tech being orientated. AM census 43

PM shift was short 1 House Supervisor. PM census 44

8/22/13:
The facility staffed one RN on the AM shift. The facility failed record the census for the AM shift on 8/22/13. At the PM shift change the census was 41 patients.
PM shift was short 1 House Supervisor. PM census 41

8/23/13:
AM staffing matrix requires 5 experienced nurses. The facility staffed 3 experienced nurses and 1 nurse being orientated. AM census 41

8/24/13:
AM staffing matrix requires 5 experienced nurses. The facility staffed 4 experienced nurses and 1 nurse being orientated. The AM staffing matrix requires 4.5 experienced nurse techs. The facility staffed 3 experienced nurse techs and 2 nurse tech being orientated. AM census 42

8/25/13:
The facility staffed one RN on the AM shift for a census of 42 patients.
AM staffing matrix requires 5 experienced nurses. The facility staffed 4 experienced nurses and 1 nurse being orientated. The AM staffing matrix requires 4.5 experienced nurse techs. The facility staffed 3 experienced nurse techs and 2 nurse tech being orientated.
8/26/13: AM staffing matrix requires 5 experienced nurses. The facility staffed 4 experienced nurses. The AM staffing matrix requires 5 experienced nurse techs. The facility staffed 4 experienced nurse techs. AM census 44

8/27/13:
AM staffing matrix requires 5 experienced nurses. The facility staffed 4 experienced nurses. AM census 38

PM staffing matrix requires 3.5 experienced nurse techs. The facility staffed 2 experienced nurse techs and 1 nurse techs being orientated. PM census 36

8/28/13:
The facility staffed one experienced RN on the AM shift for a census of 36 patients.
AM staffing matrix requires 4 experienced nurses. The facility staffed 3 experienced nurses and 2 nurses being orientated. The AM staffing matrix requires 4 experienced nurse techs. The facility staffed 3 experienced nurse techs.

8/29/13:
AM staffing matrix requires 5 experienced nurses. The facility staffed 4 experienced nurses and 1 nurse being orientated. AM census 38

8/30/13:
AM staffing matrix requires 4 experienced nurses. The facility staffed 2 experienced nurses and 1 nurse being orientated. AM census 36

8/31/13:
AM staffing matrix requires 4 experienced nurse techs. The facility staffed 3 experienced nurse techs and 2 nurse techs being orientated. AM census 41

9/1/13:
AM staffing matrix requires 4.5 experienced nurse techs. The facility staffed 3 experienced nurse techs and 2 nurse techs being orientated. AM census 42

PM shift was short 1 House Supervisor. The facility failed to record a PM census.

9/2/13:
AM staffing matrix requires 5 experienced nurses. The facility staffed 4 experienced nurses and 1 nurse being orientated. The AM staffing matrix requires 5 experienced nurse techs. The facility staffed 4 experienced nurse techs and 1 nurse tech being orientated. AM census 43

PM staffing matrix requires 5 experienced nurse techs. The facility staffed 4 experienced nurse techs and 1 nurse techs being orientated. PM census 45

9/3/13:
AM staffing matrix requires 5 experienced nurses. The facility staffed 3 experienced nurses and 2 nurses being orientated. The AM staffing matrix requires 5 experienced nurse techs. The facility staffed 4 experienced nurse techs. AM census 45

PM staffing matrix requires 5 experienced nurse techs. The facility staffed 3 experienced nurse techs and 1 nurse techs being orientated. PM census 45

9/4/13:
AM staffing matrix requires 5 experienced nurses. The facility staffed 3 experienced nurses and 2 nurses being orientated. AM census 45

PM staffing matrix requires 5 experienced nurse techs. The facility staffed 3 experienced nurse techs. PM census 46

9/5/13:
AM staffing matrix requires 5.5 experienced nurses. The facility staffed 4 experienced nurses. AM census 46

The facility staffed one RN on the PM shift with a census of 45 patients.
PM staffing matrix requires 5 experienced nurse techs. The facility staffed 4 experienced nurse techs.

9/6/13:
AM staffing matrix requires 5 experienced nurses. The facility staffed 4 experienced nurses and 1 nurse being orientated. The AM staffing matrix requires 5 experienced nurse techs. The facility staffed 4 experienced nurse techs and 1 nurse tech being orientated. AM census 45

9/7/13:
AM staffing matrix requires 5 experienced nurses. The facility staffed 4 experienced nurses and 2 nurses being orientated. The AM staffing matrix requires 5 experienced nurse techs. The facility staffed 4 experienced nurse techs. AM census 45

PM shift was short 1 House Supervisor. PM census 48

9/8/13:
PM shift was short 1 House Supervisor.
PM staffing matrix requires 6 experienced nurses. The facility staffed 5 experienced nurses. The PM staffing matrix requires 5 experienced nurse techs. The facility staffed 4 experienced nurse techs.

9/9/13:
AM staffing matrix requires 6 experienced nurses. The facility staffed 5 experienced nurses.The facility failed to record an AM census.

The facility staffed one experienced RN on the PM shift for a census of 51 patients.
PM staffing matrix requires 6 experienced nurses. The facility staffed 5 experienced nurses and 1 nurse being orientated. The PM staffing matrix requires 5 experienced nurse techs. The facility staffed 4 experienced nurse techs. PM census 51

Based on document review, the facility failed to provide an adequate number of registered nursing staff to safely meet the care needs of the patients on 5 of 50 shifts reviewed.

A review of the hospital policy titled Care of Patient/ Documentation, Subject: Interdisciplinary Daily Documentation, Procedure: 5. Daily Nursing Assessment: revealed a. All patients will have an RN assessment conducted every 24 hours, at a minimum. If any reassessment findings are abnormal, an assessment will be conducted by an RN and a narrative note will be written describing the problem area, abnormality, the intervention, and the follow-up, signing under the "Additional problem specific system review completed with significant finding within the narrative". The time of this assessment will be noted next to the nurse's signature.

A review of the daily staffing sheets revealed:

On 8/22/13 the facility staffed one RN on the AM shift. The facility failed to record the census for the AM shift on 8/22/13. At the PM shift change the census was 41 patients.

On 8/25/13 the facility staffed one RN on the AM shift for a census of 42 patients.

On 8/28/13 the facility staffed one experienced RN on the AM shift for a census of 36 patients.

On 9/5/13 the facility staffed one RN on the PM shift with a census of 45 patients.

On 9/9/13 the facility staffed one experienced RN on the PM shift for a census of 51 patients.

Based on document review and interview, the facility failed to enforce the established policy. The RN assigned the care of 1 (#3) of 10 patients reviewed to the LVN and the RN failed to assess/reassess the patient every 24 hours.

A review of the hospital policy titled Care of Patient/ Documentation, Subject: Interdisciplinary Daily Documentation, Procedure: 5. Daily Nursing Assessment: revealed a. All patients will have an RN assessment conducted every 24 hours, at a minimum.

A review of patient #3 medical record revealed:

On 8/22/13 patient #3 care was assigned to LVN staff #24 from 7:00 PM until 7:00 AM.

On 8/23/13 patient #3 care was assigned to LVN staff #35 from 7:00 AM until 7:00 PM. The care of the patient was transferred to LVN staff #36 from 7:00 PM until 7:00 AM.

On 8/24/13 patient #3 care was assigned to LVN staff #6 from 7:00 AM until 7:00 PM. The care of the patient was transferred to LVN staff #25 from 7:00 PM until 7:00 AM.

On 8/25/13 patient #3 care was assigned to LVN staff #6 from 7:00 AM until 7:00 PM. The care of the patient was transferred to LVN staff #36 from 7:00 PM until 7:00 AM.
The care of patient #3 was assigned to LVNs for 84 hours with no documented assessment by an RN.

On 8/30/13 patient #3 care was assigned to LVN staff #37 from 7:00 PM until 7:00 AM.

On 8/31/13 patient #3 care was assigned to LVN staff #35 from 7:00 AM until 7:00 PM. The care of the patient was transferred to LVN staff #31 from 7:00 PM until 7:00 AM.

On 9/1/13 patient #3 care was assigned to LVN staff #34 from 7:00 AM until 7:00 PM. The care of the patient was transferred to LVN staff #38 from 7:00 PM until 7:00 AM.

On 9/2/13 patient #3 care was assigned to LVN staff #34 from 7:00 AM until 7:00 PM. The care of the patient was transferred to LVN staff #38 from 7:00 PM until 7:00 AM.
The care of patient #3 was assigned to LVNs for 84 hours with no documented assessment by an RN.


An interview with CNO staff #7 revealed that the CNO had not reviewed patient #3's medical record. The CNO was aware a complaint had been submitted on behalf of patient #3 by his wife. The CNO was unaware the patient had not been regularly assessed by an RN. The CNO was asked, are you aware an LVN cannot do an assessment of a patient. The CNO stated an LVN can assess a patient. The CNO was asked if she was aware of the LVN's and RN's scope of practice. The CNO stated, I can't tell you them word for word. The CNO was provided with the information, It's the role of the RN to assess the patient and the role of the LVN to evaluate and report to the RN. The Corporate Quality Nurse was present at the time of the interview with the CNO and agreed by nodding her head yes upon proving the information to the CNO.

Based on document review and interview the facility failed to identify medication errors and enforce the Medication Error policy related to 1(#3) of 10 patients reviewed.

Review of the titled, Medication Error, revealed:

Purpose: When a medication error occurs, a specific procedure will be followed to ensure the safety of the patient and provide accurate documentation of the occurrence. The procedures for reporting a medication error and the mechanism for multi-disciplinary review to allow appropriate follow-up and implementation of change to prevent future medication errors are outlined.

Definition: a. A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, or patient. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use. b. Types of medication errors: ... 5. Omission of dose, one or some doses not given.

ROLES AND RESPONSIBILITY: It is the responsibility of the Chief Nursing Officer and the Pharmacy Director to disseminate the information regarding the medication error policy. Clinicians and medical staff are responsible for reporting errors found in the medication management process.

POLICIES: When a medication error occurs a specific procedure will be followed to ensure the safety of the patient and provide accurate documentation of the occurrence. An incident report will be completed for the medication error. A voluntary non-punitive reporting system is in place to monitor and report medication errors.


Review of the document for patient #3, dated 8/22/13, at 5:00PM and titled "Physician's Orders Sheet", revealed "IV (intravenous therapy) NS (normal saline) at 75 cc, every 8:00PM till every 8:00AM." This order was not initiated.

A review of patient #3's medical record, the Medication Administration Record (MAR) for patient #3 dated 8/22/13, at 0001, to 8/23/13, at 0000. The MAR revealed "NS at 75ml/hr X 12 hours. Start 8/23/13, after PICC line placement." Review of the Physician's Orders Sheet revealed no order to give NS at 75ml/hr X 12 hours, no order to "Start 8/23/13 after PICC line placement" and no order for a PICC placement.

A review of patient #3 ' s medical record, the Medication Administration Record (MAR) for patient #3 dated 8/23/13 at 0001 to 8/24/13 at 0000. The MAR revealed "NS at 75ml/hr X 12 hours. Start 8/23/13 after PICC line placement." LVN staff #24 documented giving the NS at 9:00 PM.
Review of the document (physician's order) for patient #3 dated 8/23/13, titled "Power PICC Placement (Peripherally Inserted Central Catheter) 1. Stat portable chest X-ray for PICC line placement. 2. Okay to use line when cleared by MD."
A review of the Medication Administration Record (MAR) for patient #3 dated 8/23/13, at 0001 to 8/24/13, at 0000. The MAR revealed "NS at 75ml/hr X 12 hours. Start 8/23/13, after PICC line placement." LVN staff #24 documented giving the NS at 9:00 PM. There was no evidence found a stat portable chest X-ray for PICC line placement was ordered or the x-ray was performed. No evidence the MD cleared the line to use.
Review of the Medication Administration Record (MAR) for patient #3 dated 8/23/13, at 0001 to 8/23/13, at 0000. The MAR revealed the medication Cogentin (reduces the effects of certain chemicals in the body that may become unbalanced as a result of disease (such as Parkinson's), drug therapy, or other causes.) 0.5mg by mouth twice a day was not given. A had written entry that read, "Wife wants medication held until talking with the doctor." There was no evidence the physician was notified of the patient's wife's wishes nor was there an order to hold the medication. The medication was held and not given again during the patient's stay in the facility. The patient was discharged on 9/5/13.

A review of the document for patient #3 dated 8/25/13, titled "Daily Progress/Narrative" (Narrative Nurses Notes), revealed LVN staff #26 documented at 1:00 AM: ".... No IV fluids at this time. No PICC to RUE or LUE." No evidence the M.D. or RN was notified.
Review of the Medication Administration Record (MAR) for patient #3 dated 8/29/13, at 0001 to 8/30/13, at 0000. The MAR revealed the IV Normal Saline the 8:00 AM and the 8:00 PM doses were not given because the PICC line had not been verified. The 3:00 AM, 11:00 AM, and 7:00 PM IV antibiotic, Zosyn, were not given because the PICC line had not been verified. There was no evidence the nurses called the MD or made an attempt to get the PICC line verified.
Review of the Medication Administration Record (MAR) for patient #3 dated 8/30/13, at 0001 to 8/31/13, at 0000. The MAR revealed 3:00 AM the IV antibiotic, Zosyn, was not given because the PICC line had not been verified. There was no evidence the nurses called the MD or made an attempt to get the PICC line verified.
Review of the Medication Administration Record (MAR) for patient #3 dated 8/30/13, at 0001 to 8/31/13, at 0000. The MAR revealed the IV Normal Saline the 8:00 AM and the 8:00 PM does were given. There was no evidence the PICC line was verified for placement. There was no M.D. order approving the use of the PICC line.