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Based on record reviews and interviews, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient as evidenced by:
1. failing to document wound care for 1 (#2) of 2 (#2, #5) patients reviewed for documentation of wound care from a total patient sample of 5.
2. failing to document repositioning every 2 hours of patients at risk for skin breakdown for 1 (#2) of 2 (#2, #5) patients sampled for skin breakdown risk/wounds from a total patient sample of 5.
3. failing to document daily shift nursing assessments for 1 (#2) of 5 (#1, #2, #3, #4, #5) patients reviewed.

Findings:
1. Failing to document ordered daily wound care .

Review of Patient #2's medical record revealed a treatment administration record dated April 2022 indicating a physician's order as follows: Sacrum: Cleanse with wound cleanser. Apply wet to moist with 0.125% Dakins solution soaked gauze, ABD pads, and secure with tape daily.

Further review of Patient #2's treatment administration record revealed the nursing staff did not document performing wound care daily as ordered on 04/02/2022, 04/03/2022, 04/09/2022 and 04/10/2022.

In an interview on 06/22/2022 at 2:30 p.m. S2DON verified documentation of performing wound care daily as ordered was not completed on the above stated dates for Patient #2.

2. Failing to document repositioning every 2 hours of patients at risk for skin breakdown/wounds.

Review of Patient #2's medical record revealed an initial nursing assessment with an admission date of 03/21/2022 and an admitting LTAC diagnosis of wound care. Further review revealed Patient #2 had a sacral wound.

Review of the daily nursing assessments revealed no documentation of repositioning of Patient #2 every 2 hours on the following shifts:
A.M. shift: 03/23/2022; 03/29/2022; 04/01/2022; 04/03/2022; and 04/09/2022
P.M. shift: 03/23/2022; 03/25/2022; 03/28/2022; 04/02/2022; 04/03/2022; and 04/05/2022

In an interview on 06/22/2022 at 2:55 p.m. S2DON verified there was no documentation of repositioning of Patient #2 every 2 hours for the above stated shifts. S2DON stated if the documentation is left blank by the nursing staff then the task was not conducted.

3. Failing to document daily shift nursing assessments.

Review of Patient #2's medical record revealed no documented evidence of a completed daily nursing assessment for the following shifts:
A.M. shift: 03/29/2022 and 04/09/2022
P.M. shift: 03/24/2022; 04/02/2022; and 04/08/2022

In an interview on 06/22/2022 at 2:55 p.m. S2DON verified there was no documented evidence of a completed daily nursing assessment for the above stated shifts. S2DON stated if the documentation is left blank by the nursing staff then the task was not conducted.

Based on observation, record review, and interview, the hospital failed to ensure non-employee licensed nurses working in the hospital were oriented and evaluated for competency for 1 (S3RN) of 1 sampled contracted staff , observed working at the time of the onsite survey, whose personnel record was reviewed.

Findings:

On 06/22/2022 at 10:20 a.m. S3RN was observed working with patients during the onsite survey at the hospital.

Review of sampled Patient #5's MAR revealed S3RN had administered the patient's IV push Lasix on 06/22/2022 at 10:36 a.m. when the first of 3 daily doses of Lasix had been ordered to be given NOW on 06/22/2022 at 6:30 a.m. Patient #5 had been symptomatic with complaints of SOB and was on oxygen via nasal cannula.

On 06/22/2022 at 10:40 a.m., S3RN's personnel file was requested, from S1ADM, for review. S1ADM reported S3RN was an agency nurse and she would get her personnel file from the hospital's main campus.

Review of S3RN's personnel documentation, provided by S1ADM, revealed there was no documentation that S3RN had received a hospital orientation. Further review revealed a self-attested skills competency evaluation, performed by S3RN, evaluating her own skills competency, from the staffing agency. Additional review revealed no documented evidence that S3RN's skills competencies had been evaluated by staff at the staffing agency. There was also no documentation that S3RN's skills competencies had been assessed by staff at Sage Specialty Hospital.

In an interview on 06/22/2022 at 3:00 p.m. with S2DON, she indicated the hospital used the skills competency evaluations provided through the agency for agency nurses (non-employee licensed nurses). She reported skills competency evaluations of agency staff were not performed through this hospital. S2DON further confirmed S3RN also had not had a hospital orientation.

Based on record review, observation, and interview, the hospital failed to ensure drugs, biologicals, and ordered oral nutritional supplements were administered in accordance with accepted standards of practice, the orders of the practitioner responsible for the patient's care, and hospital policy. This deficient practice was evidenced by:
1. failure to administer medications as ordered by the practitioner for 1(#5) of 5 (#1, #2,#3,#4, #5) sampled patient medical records reviewed.; and
2. failure to document medication and nutritional supplement administration or reason for not administering medications/nutritional supplements, for all ordered medications/nutritional supplements, on the patients' MARs for
1 (#5) of 5 (#1, #2,#3,#4, #5) sampled patient medical records reviewed.

Findings:

Review of the hospital policy titled, "Administration of Medication", Policy Number: K.11.31, effective date: 09/2017, revealed the following, in part:
Documentation: A. The individual administering the medication(s) must document all medications immediately after administration in the patient's MAR.
C. Following the dispensing of drugs from pharmacy, medications are to be administered by the practitioner who prepares them. D. Documentation of administration of medication on the MAR: There are 2 methods for documenting administered medications: The hospital may require the administrator to initial next to the time to indicate the medication has been administered or the hospital may use a single slash mark ( \ ) through the time of the administered dose. If a medication is not administered (held for example due to blood pressure parameters, patient refused, etc.), the appropriate documentation on the MAR, including the reason, must be recorded. The physician must also be notified. Further review of the policy revealed no guidance on time-frames for administration of medications ordered as "give NOW."

1. Failure to administer medications as ordered by the practitioner.

Patient #5
Review of Patient #5's medical record revealed an admission date of 06/09/2022 with an admission diagnosis of Stage IV Sacral Pressure Ulcer and biliary drainage management. Further review revealed the patient had the following Co-morbid conditions: Polycystic Liver Disease, s/p CABG, s/p DVT-RLE, s/p Renal Transplant (2005), CKD, CAD, AFIB, severe Sepsis, and Protein/Calorie Malnutrition.

On 06/22/2022 at 9:50 a.m. Patient #5 was observed in his room. He was supine in bed with the HOB elevated. Patient #5 was pale, thin/frail in appearance, and was receiving oxygen via nasal cannula. The patient was using accessory muscles to breath and had to pause when speaking to catch his breath. Further observation revealed the patient's feet were edematous. Patient #5 reported he thought he might be developing pneumonia.

Review of Patient #5's Medical Record revealed the following nursing notes entry starting on 06/21/2022 at 6:00 a.m. - 06/22/2022 at 05:30 a.m. (end of documentation):
06/22/2022 at 05:30 a.m.: Pt. reporting SOB after transferring out of bed and stepping on scale for weight. Crackles noted BIL lower lobes and pitting 4+ edema BIL legs and feet.

Further review of Patient #5's Medical Record revealed the patient had a CBC, CMP, and Blood Cultures x2 drawn on 06/21/22 at 5:30 p.m. due to the patient being febrile.

Additional review of Patient #5's Medical Record revealed the following physician's orders:
06/22/2022 at 6:35 a.m. - Lasix 40 mg IV daily x 3 doses, give first dose NOW. (Now was capitalized and underscored in the handwritten order).

Review of Patient #5's MAR on 06/22/2022 at 10:25 a.m. revealed no documented evidence that the dose of Lasix ordered as "give first dose now" had been administered at the time of the review.

On 06/22/2022 at 10:26 a.m., S3RN was asked if Patient #5 had received the ordered "NOW" dose of Lasix and she replied she had not administered the patient's Lasix yet she because she had been tied up with a discharge.

In an interview on 06/22/2022 at 1:53 p.m. with S2DON, she reported the hospital did not have a medication administration policy for medications ordered as "give NOW". She indicated, as a nurse, she would have given the medication ordered as "give first dose NOW", as soon as possible after receiving the order, especially if the patient was symptomatic like Patient #5. She indicated S3RN could have asked her or another nurse to administer Patient #5's Lasix if she was busy with another patient.

2. Failure to document medication and nutritional supplement administration or reason for not administering medications/nutritional supplements, for all ordered medications/nutritional supplements, on the patients' MARs.

Patient #5
Review of Patient #5's medical record revealed an admission date of 06/09/2022 with an admission diagnosis of Stage IV Sacral Pressure Ulcer and biliary drainage management. Further review revealed the patient had the following Co-morbid conditions: Polycystic Liver Disease, s/p CABG, s/p DVT-RLE, s/p Renal Transplant (2005), CKD, CAD, AFIB, severe Sepsis, and Protein/Calorie Malnutrition.

Review of Patient #5's medical record revealed the following medication and oral nutritional supplement orders:
Tamsulosin 0.4 mg capsule- take 1 capsule by mouth every day at 9:00 a.m.;
Senna-Plus 8.6 mg Sennosides /50 mg Ducosate Sodium tablet -- take 1 tablet by mouth every day at 9:00 a.m.;
Vitamin D 1000 IU (25 mcg) - 2.5 tablets (2500 IU) by mouth every day at 9:00 a.m.;
Eliquis 2.5 mg tablet- take 1 tablet by mouth twice a day at 9:00 a.m. and 9:00 p.m.;
Sodium Bicarbonate 650 mg tablet- take 2 tablets (1300 mg) by mouth twice a day at 9:00 a.m. and 9:00 p.m.;
Tacrolimus 0.5 mg capsule - take 1 capsule by mouth twice a day at 9:00 a.m. and 9:00 p.m.;
Megestrol (Megace) AC 40 mg tablet - take 1 tablet by mouth twice a day at 9:00 a.m. and 9:00 p.m.;
Pro-Stat Liquid (source of increased protein at low volume for wound healing) - 30 ml by mouth twice a day at 9:00 a.m. and 9:00 p.m.; and
Juven Fruit Punch Powder (nutritional powdered supplement for wound healing) - Mix contents of 1 packet with 8 ounces of water and drink by mouth twice a day at 9:00 a.m. and 9:00 p.m.

Review of Patient #5's MARs revealed the following medications/nutritional supplements were not documented as having been administered/circled as not administered and no documentation was present to indicate if they were held, refused, or unavailable for use:

06/12/2022 and 06/13/2022 the following medication entries on the patient's MARs were left blank for all ordered doses:

Tamsulosin 0.4 mg capsule once a day - 9:00 a.m. - blank.

Senna-Plus 8.6 mg Sennosides /50mg Ducosate Sodium - 1 tablet once a day - 9:00 a.m. -blank.

Vitamin D 1000 IU (25 mcg) - 2.5 tablets (2500 IU) once a day - 9:00 a.m. - blank.

Eliquis 2.5 mg tablet- 1 tablet by mouth twice a day at 9:00 a.m. and 9:00 p.m. - both doses blank.

Sodium Bicarbonate 650 mg tablet- 2 tablets (1300 mg) by mouth twice a day at 9:00 a.m. and 9:00 p.m. - both doses blank.

Tacrolimus 0.5 mg capsule - take 1 capsule by mouth twice a day at 9:00 a.m. and 9:00 p.m. - both doses blank.; and

Megestrol (Megace) AC 40 mg tablet - 1 tablet by mouth twice a day at 9:00 a.m. and 9:00 p.m. - both doses blank.

06/14/2022
Pro-Stat Liquid (source of increased protein at low volume for wound healing) - 30 ml by mouth twice a day at 9:00 a.m. and 9:00 p.m. - both doses - blank.

06/16/2022
Pro-Stat Liquid (source of increased protein at low volume for wound healing) - 30 ml by mouth twice a day at 9:00 a.m. and 9:00 p.m. - 9:00 a.m. dose - blank.

06/17/2022
Pro-Stat Liquid (source of increased protein at low volume for wound healing) - 30 ml by mouth twice a day at 9:00 a.m. and 9:00 p.m. - both doses - blank.

06/18/2022
Pro-Stat Liquid (source of increased protein at low volume for wound healing) - 30 ml by mouth twice a day at 9:00 a.m. and 9:00 p.m. - both doses - blank.

Juven Fruit Punch Powder (nutritional powdered supplement for wound healing) - Mix contents of 1 packet with 8 ounces of water and drink by mouth twice a day at 9:00 a.m. and 9:00 p.m. - both doses - blank.

06/20/2022
Eliquis 2.5 mg tablet- 1 tablet by mouth twice a day at 9:00 a.m. and 9:00 p.m. - 9:00 p.m. dose - blank.

Sodium Bicarbonate 650 mg tablet- 2 tablets (1300 mg) by mouth twice a day at 9:00 a.m. and 9:00 p.m. - 9:00 p.m. dose - blank.

Tacrolimus 0.5 mg capsule - take 1 capsule by mouth twice a day at 9:00 a.m. and 9:00 p.m. - 9:00 p.m. dose - blank.

Pro-Stat Liquid (source of increased protein at low volume for wound healing) - 30 ml by mouth twice a day at 9:00 a.m. and 9:00 p.m. - 9:00 a.m. dose - blank and 9:00 p.m. dose circled as not given with no reason documented.

Juven Fruit Punch Powder (nutritional powdered supplement for wound healing) - Mix contents of 1 packet with 8 ounces of water and drink by mouth twice a day at 9:00 a.m. and 9:00 p.m. - 9:00 a.m. dose - blank and 9:00 p.m. dose circled as not given with no reason documented.

06/21/2022
Pro-Stat Liquid (source of increased protein at low volume for wound healing) - 30 ml by mouth twice a day at 9:00 a.m. and 9:00 p.m. - both doses - blank.

Juven Fruit Punch Powder (nutritional powdered supplement for wound healing) - Mix contents of 1 packet with 8 ounces of water and drink by mouth twice a day at 9:00 a.m. and 9:00 p.m. - both doses - blank.

In an interview on 06/22/2022 at 3:00 p.m. with S2DON, she confirmed Patient #5's ordered medications/nutritional supplements referenced above, that were left blank, should have been documented as having been given if they were administered or should have been circled if they were not given. She reported a reason for not being administered such as being held, refused, or unavailable for use. S2DON reported Patient #5 was on Juven and Pro-Stat to promote healing of his pressure ulcer and if he was refusing the supplements that could affect his wound healing. She said the treatment team needed to be aware of this.

Based on record review, observation and interview, the hospital failed to ensure all drugs and biologicals were kept in a secure area. This deficient practice is evidenced by failing to lock the medication cart.

Findings:

Review of the hospital's policy titled "Administration of Medication" revealed in part, all medications must be properly stored / secured at all times prior to administration. Prepared medications must never be left unattended.

Observation on 06/22/2022 at 12:10 p.m. revealed the medication cart was in a hallway near the nurse's station and was unattended. Further observation revealed the medication cart was unlocked.

In an interview on 06/22/2022 at 12:11 p.m. S2DON verified the medication cart was unattended and unlocked. S2DON verified the medication cart should have been kept locked.