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Based on policy review, medical record review, and staff interview, the facility failed to ensure nurses evaluated the nursing care for each patient (A395). The facility failed to ensure all medications were administered as ordered by the physician (A405).

Based on policy review, medical record review, and staff interview, the facility failed to ensure nurses evaluated the nursing care for five of ten medical records reviewed (Patient #3, #5, #6, #7, and #9). The census was six at the offsite location.

Findings include:

Review of the policy titled, "Assessment; Admission Database," effective 7/95 and reviewed 8/20, revealed all admissions would receive an interdisciplinary assessment. Nursing would utilize the "Nursing Admission Assessment" form to collect and document the required information.

Review of the policy titled, "Guidelines and Protocols - Clinical," effective 9/12 and reviewed 4/17, revealed a head to toe assessment would be completed and documented on the "Daily Data Record" every 12 hours and with changes in condition. In addition, the Intake and Output would be documented and totaled every 12 hours.

1. Review of the medical record for Patient #3 revealed an admission date of 06/22/21. The "Nursing Admission Assessment" was blank except for the patient identification sticker. This was verified in an interview with Staff A on 06/29/21 at 2:45 PM.

2. Review of the medical record for Patient #5 revealed an admission date of 06/19/21. The "Nursing Admission Assessment" revealed the Continuing Care Needs section, the Discharge Planning section, and the signature of who completed the form were blank. The medical record contained orders on admission for Intake and Output and enteral (tube) feedings. The "Daily Data Record" for 06/24/21 lacked documentation of enteral feeding intake from 7:00 AM to 7:00 PM. The "Daily Data Record" for 06/28/21 lacked documentation of intake from 7:00 AM to 7:00 PM. This was verified in an interview with Staff A on 06/29/21 at 3:00 PM.

3. Review of the medical record for Patient #6 revealed an admission date of 05/21/21. The "Nursing Admission Assessment" pages three and four were blank. The medical record contained orders on admission for Intake and Output, and enteral feedings. The "Daily Data Records" for 06/05/21, 06/15/21, and 06/16/21 lacked documentation of enteral feeding intake from 7:00 AM to 7:00 PM. This was verified in an interview with Staff A on 06/29/21 at 4:15 PM.

4. Review of the medical record for Patient #7 revealed an admission date of 04/15/21. The medical record contained orders on admission for Intake and Output, and enteral feedings. The "Daily Data Records" for 04/19/21, 04/23/21, 05/08/21, 05/09/21, 05/14/21, and 05/18/21 lacked documentation of intake, including enteral feeding intake, and output from 7:00 PM to 7:00 AM. The "Daily Data Record" for 04/21/21 lacked documentation of enteral feeding intake from 12:00 PM to 6:00 PM. The "Daily Data Record" for 05/15/21 lacked documentation of an assessment of all systems, Intake, Central Line Associated Blood Stream Infection (CLABSI) Bundle, Ventilator Associated Pneumonia (VAP) Bundle, Infection Control, Catheter Associated Urinary Tract Infection (CAUTI) Bundle, and nursing narrative notes from 7:00 AM to 8:25 PM. This was verified in an interview with Staff A on 07/01/21 at 11:15 AM.

5. Review of the medical record for Patient #9 revealed an admission date of 04/28/21. The "Nursing Admission Assessment" was blank except for the admission date, allergies, height, weight, neurological assessment, and musculoskeletal assessment. This was verified in an interview with Staff A on 07/01/21 at 10:10 AM.

This substantiates substantial allegation OH00122560.

Based on medical record review and staff interview, the facility failed to ensure all medications were administered as ordered by the physician for two of ten medical records reviewed (Patient #7 and #9). The census was six at the offsite location.

Findings include:

1. Review of the medical record for Patient #7 revealed an admission date of 04/15/21. The Medication Administration Record (MAR) for 05/15/21 lacked documentation of any medications administered from 7:00 AM to 9:00 PM. The following medication was due at 8:00 AM: Centrum Liquid Multivitamin 15 milliliters (ml) daily. The following medications/treatments were due at 9:00 AM: Nystatin cream topically to abdominal folds twice a day, Famotadine 20 milligrams (mg) daily (for gastroesophageal refleux disease), Fluticasone nasal spray 50 micrograms each nostril daily (for allergies), Biotene Dry Mouth Mouthwash 15 ml three times a day, Protein/Amino Acids Supplement 45 ml three times a day, Liothyronine Sodium 10 mcg Daily (for hypothyroidism), Vancomycin oral solution 125 mg four times a day, Sodium Hypochlorite irrigation daily to sacrum, Aspirin 81 mg daily, and Vancomycin 500 mg/100 ml intravenous every 12 hours (antibiotic). The following medications/treatments were due at 12:00 PM: blood sugar check, sliding scale insulin, and 100 ml of water to flush the feeding tube every six hours. The following medication was due at 1:00 PM: Vancomycin oral solution 125 mg four times a day. The following medications were due at 2:00 PM: Sodium chloride 10 ml IV flush every eight hours and Meropenem 1000 mg/100 ml intravenous every eight hours (antibiotic). The following medications/treatments were due at 3:00 PM: Biotene Dry Mouth Mouthwash 15 ml three times a day and Protein/Amino Acids Supplement 45 ml three times a day. The following medication was due at 5:00 PM: Vancomycin oral solution 125 mg four times a day. The following medications/treatments were due at 6:00 PM: blood sugar check, sliding scale insulin, 100 ml of water to flush the feeding tube every six hours, and 100 ml of water to flush the feeding tube every six hours. In addition, Glucerna 65 ml per hour continuous enteral feeding was not documented. This was verified in an interview with Staff A on 07/01/21 at 11:15 AM.

2. Review of the medical record for Patient #9 revealed an admission date of 04/28/21. The medical record documented the patient arrived at 3:00 PM and the admission orders including medications were verified at 1:50 PM on 04/28/21. The MAR for 04/28/21 lacked documentation of any medications given. The following medications/treatments were due at 4:30 PM: blood sugar check and sliding scale insulin. The following medications/treatments were due at 6:00 PM: Nystatin suspension 5 ml every six hours (for yeast), Insulin Aspart (short acting) 12 units subcutaneously three times a day, and Guaifenesin DM 10 ml every six hours (cough suppressant and expectorant). The following medications/treatments were due at 9:00 PM: blood sugar check, sliding scale insulin, Insulin Glargine (long-acting) 28 units subcutaneously, Ranolazine 1000 mg twice a day (for chronic chest pain), Benzonatate 100 mg three times a day (cough medicine), Metoprolol 12.5 mg twice a day (for high blood pressure), Enoxaparin 40 mg subcutaneously every twelve hours (blood thinner), Atorvastatin 80 mg at bedtime (for high cholesterol), Lisinopril 20 mg twice a day (for high blood pressure and heart failure), and Famotidine 20 mg twice a day. This was verified in an interview with Staff A on 07/01/21 at 10:10 AM.

This substantiates substantial allegation OH00122560.