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Based on medical record review, policy review and interview, the facility failed to ensure nursing assessments were completed every shift and failed to ensure assessments were being completed by registered nurses in accordance with the facility's policy (A0392). The facility failed to ensure staff cleaned and disinfected equipment after each patient use (A0392). The facility failed to ensure physician orders for reporting abnormal vital sign assessments were followed (A0395). The facility failed to ensure vital signs were assessed and documented every eight (8) hours as per facility specified practice. (A0395) The facility failed to ensure the nursing care plan for each patient addressed all needs and deficits identified by assessment and included interventions for helping the patient(s) to achieve their goals (A0396).The cumulative effect of these systemic practices resulted in the facility's inability to ensure the patients' nursing needs would be identified and met.

Based on medical record review, observation, policy review and interview, the facility failed to ensure nursing assessments were completed every shift and failed to ensure assessments were being completed by registered nurses in accordance with the facility's policy for nine (Patient #1, #3, #4, #5, #6, #7, #8, #9 and #10) of ten medical records reviewed. The facility failed to ensure staff cleaned and disinfected equipment after each patient use in use for one (Patient #11) of one glucometer observation conducted. This had the potential to affect all of the facility's 29 active patients.

Findings include:

1) The medical record review for Patient #9 revealed a nurse did not complete an assessment of Patient #9 on the following shifts:
- 12/31/14, 7:00 PM to 1/1/15, 7:00 AM shift.
- 01/01/15, 7:00 AM to 7:00 PM shift
The medical record review for Patient #9 revealed a licensed practical nurse completed the Nursing Shift Assessments for Patient #9 on the following shifts:
- 01/04/15 7:00 AM to 7:00 PM
- 01/03/15, 11:00 PM to 01/04/15, 7:00 AM
- 01/03/15, 7:00 AM to 7:00 PM
-01/02/15, 11:00 PM to 01/03/15 7:00 AM
- 01/02/15, 7:00 AM to 6:00 PM
- 01/01/15, 7:00 PM to 01/02/15, 7:00 AM
- 12/30/14, 7:00 AM to 7:00 PM

2) The medical record review for Patient #10 revealed a nurse did not complete an assessment of Patient #10 on the following shift:
01/16/15, 7:00 PM to 01/17/15, 7:00 AM

The medical record review revealed a licensed practical nurse completed the Nursing Shift Assessments for Patient #10 on the following shifts:
01/15/15, 11:00 PM to 01/16/15, 7:00 AM
01/16/15, 7:00 AM to 7:00 PM

3) Patient #1 was admitted to the facility with diagnosis of Subarachnoid Hemorrhage. The Nursing Shift Assessments for Patient #1 were reviewed for the period of time 07/17/15-07/28/15 and revealed the following:

On 07/18/15 for the shift 7:00 AM - 7:00 PM only one RN (registered nurse) assessment was completed and read "call device in reach, bed height, ID band on, Bed brakes on, q2h per policy" and "no sx of acute distress. No complaints/concerns voiced. Call light within reach, safety maintained." There was no evidence of a physical assessment or assessment every shift.

On 07/21/15 for the shift 7:00 AM - 7:00 PM the assessment was completed by a LPN (licensed practical nurse), and for the shift 7:30 PM - 11:30 PM the RN completed the assessment and noted "patient is alert and oriented times 2. Denies pain at this time. siderails up times 3 bed in low position call light pad in place due to bilateral UE amputations. Patient was able to take meds whole with water w/o difficulty." There was no evidence of a physical assessment.

On 07/23/15 for the shift 7:00 PM - 7:00 AM the assessment was completed by a LPN. On 07/25/15 for the shift 7:00 AM - 7:00 PM the RN assessment was incomplete and unsigned by the RN as of 07/29/15 , and for the shift 7:00 PM - 7:00 AM the assessment was completed by a LPN.

On 07/26/15 for the shift 7:00 AM - 7:00 PM the RN assessment was incomplete and unsigned by the RN as of 07/29/15, and for the shift 7:00 PM - 7:00 AM the assessment was completed by a LPN.

4) Patient #3 was admitted to the facility with diagnosis of Occluded Carotid Artery with Infarct. The Nursing Shift Assessments for Patient #3 were reviewed for the period of time 07/14/15-07/28/15 and revealed the following:

On 07/15/15 for the shift 7:00 PM - 7:00 AM the assessment was completed by a LPN, and on 07/16/15 for the shift 7:30 PM - 7:00 AM the assessment was completed by a LPN. On 07/18/15 both the 7:00 AM - 7:00 PM and 7:00 PM - 7:00 AM assessments were completed by a LPN. At 7:37 AM the RN made a note that read "patient resting quietly at this time. Call light is within reach bed is on lowest position." There was no documented physical assessment.

On 07/19/15 for the shift 7:00 AM - 7:00 PM the assessment was completed by a LPN On 07/20/15 assessments for the shifts 7:00 AM - 3:00 PM, 3:00 PM - 7:00 PM and 7:00 PM - 7:00 AM were all completed by a LPN.

On 07/21/15 for the shifts 7:00 AM - 7:00 PM and 7:00 PM - 7:00 AM both assessments were completed by a LPN. ON 07/22/15 the LPN completed the assessment for the 7:00 AM - 7:00 PM shift. The RN completed the assessment for the 7:00 PM - 7:00 AM shift, simply noting "patient resting in bed. call light in reach. no needs at this time. will continue to monitor with q2 hour rounding throughout shift." There was no documented physical assessment.

On 07/23/15 for the shifts 3:00 PM - 7:00 PM and 7:00 PM - 7:00 AM both assessments were completed by a LPN. On 07/25/15 for the sifts 7:00 AM - 7:00 PM and 11:00 PM - 7:00 AM both assessments were completed by a LPN. Both assessments, 7:00 AM - 7:00 PM and 7:00 PM - 7:00 AM, on 07/26/15 were completed by a LPN. And on 07/27/15 for the shift 7:00 PM - 7:00 AM the assessment was completed by a LPN.

5) Patient #4 was admitted to the facility with diagnosis of Ruptured Abdominal Aortic Aneurysm. The Nursing Shift Assessments for Patient #4 were reviewed for the period of time 07/21/15-07/28/15 and revealed the following:

On 07/22/15 for the shift 7:00 AM - 3:00 PM the RN completed the assessment and noted "patient participated in all scheduled therapy. All safety precautions in place. Patient does have some loose stool, patient is refusing stool softeners." There was no documented physical assessment.

For the shift 7:00 PM - 7:00 AM the LPN completed the assessment and noted "patient resting in bed. call light in reach. no needs at this time. will continue to monitor with q2 hour rounding throughout the shift." There was no documented physical assessment.

On 07/24/15 for the shifts 7:00 AM - 7:00 PM and 7:00 PM - 7:00 AM the assessments were completed by a LPN. For the 7:00 PM -7:00 AM assessment the LPN noted the patient was "alert and oriented able to make needs known. Pt slept peacefully throughout the night. Surgical incision to abd left OTA with steristrip. Scrotum continues to have edema. Pt denies pain or discomfort, pillow placed under scrotum for comfort and elevation. Will continue to monitor and provide safety." There was no documented physical assessment.

On 07/25/15 for the shift 7:00 AM - 7:00 PM the assessment was completed by a LPN. On 07/26/15 for the shifts 7:00 AM - 3:00 PM and 3:00 PM - 7:00 PM the assessments were completed by a LPN. And on 07/27/15 for the shift 7:00 AM - 7:00 PM the assessment was completed by a LPN.

6) Patient #5 was admitted to the facility with diagnosis of Closed Skull Fracture. The Nursing Shift Assessments for Patient #5 were reviewed for the period of time 07/22/15-07/28/15 and revealed the following:

On 07/23/15 for the shift 7:00 AM - 7:00 PM and on 07/24/15 for the shift 7:00 PM - 11:00 PM assessments were completed by the LPN. On 07/25/15 and 07/26/15 all of the assessments were completed by a LPN.

7) Patient #6 was admitted to the facility with diagnosis of Intracerebral Hemorrhage. The Nursing Shift Assessments for Patient #6 were reviewed for the period of time 07/20/15-07/28/15 and revealed the following:

On 07/20/15 for the shift 7:00 AM - 7:00 PM the assessment was completed by a LPN, and on 07/21/15 for the shift 7:00 PM - 7:00 AM the assessment was completed by a LPN. On 07/22/15 for the shift 7:00 PM - 7:00 AM the assessment was completed by a LPN, and on 07/23/15 for the shift 11:47 AM - 7:00 PM the assessment was completed by a LPN.

On 07/24/15 for the shift 7:00 PM - 7:00 AM the assessment was completed by the LPN. On 07/25/15 for the shifts 7:00 AM - 3:00 PM and 3:00 PM - 7:00 PM the assessments were completed by a LPN. And on 07/26/15 for the shift 7:00 PM - 7:00 AM the assessment was completed by a LPN.

8) Patient #7 was admitted to the facility on 07/27/15 with diagnosis of Right Sided Subdural Hematoma. The Nursing Shift Assessments for Patient #7 were reviewed for 07/27/15 and 07/28/15 and revealed the following:

On 07/27/15 for the shift 7:00 AM - 7:30 PM the assessment was completed by a LPN, and on 07/28/15 for the shift 7:00 AM - 7:00 PM the assessment was completed by a LPN.

9) Patient #8 was admitted to the facility on 07/24/15 with diagnosis of Pain in Thoracic Spine. The Nursing Shift Assessments for Patient #8 were reviewed for the period of time 07/24/15-07/28/15 and revealed the following:

On 07/25/15 for the shift 7:00 AM - 7:30 PM the assessment was completed by a LPN. And on 07/26/15 for the shifts 7:00 AM - 3:00 PM and 3:00 PM - 7:00 PM the assessments were completed by a LPN.

10) Staff A was made aware of and confirmed the above findings on 07/29/15 at 10:50 AM.

11) The facility's Assessment and Reassessment - Nursing policy was reviewed. The policy stated a registered nurse completes an assessment of each patient admitted and reassesses the patient as needed in order to determine appropriate care, treatment and services to meet the needs of the patient. Each patient is re-assessed by a Registered Nurse each shift, or more often as needed. The results and recommendations from ongoing evaluations and/or re-assessments are entered into the medical record. Reassessment is documented in the medical record.

12) Staff D was observed checking Patient #11's blood glucose level on 07/29/15 at 11:35 AM. Staff D was observed performing the blood glucose check and returning the glucometer to a clean area at the nursing station. Staff B did not clean or disinfect the glucometer after performing the test on Patient #11.

The facility's Cleaning Frequency of Unit Based Equipment policy was reviewed. The policy stated all reusable patient care equipment that is placed in the immediate vicinity of the patient or that has contact with the patient should be cleaned and disinfected between patients. This equipment may include but is not limited to blood glucose machines.

On 07/29/15 at 11:40 AM, the findings were shared with Staff D and confirmed.











31597

Based on medical record reviews and staff interviews, the facility failed to ensure vital signs were assessed and documented every eight (8) hours as per facility specified practice. This affected six (Patients' #1, #2, #3, #4, #5 and #6) of six patients whose medical records were reviewed for vital signs. The facility failed to ensure physician notification for out of range vital signs was completed in accordance with physician orders for one (Patient #10) of 10 medical records reviewed. The census at the time of the survey was 29.

Findings include:

1) Staff A was interviewed on 07/28/15 at 2:44 PM and was asked how often vital signs (VS) are to be assessed and recorded. Staff A stated VS were to be taken every eight (8) hours on every patient. All VS were obtained and recorded by a STNA (state tested nurse aide). All VS were to be entered into the electronic medical record on the same day they were obtained.

2) Per admission orders for Patient #1 dated 07/17/15, the physician was to be notified for systolic BP >160 or <90 and diastolic BP >90 or <50. Documented VS for Patient #1 were reviewed electronically for the period of time 07/17/15-07/28/15 and revealed the following:

On 07/21/15 VS were recorded at 7:24 AM and not again until 11:00 PM, approximately 15 1/2 hours later. At 7:24 AM Patient #1's BP (blood pressure) was 128/47, and there was no documented evidence the RN or physician were notified. At 11:00 PM Patient #1's BP was 121/97, and there was no documented evidence the RN or physician were notified

On 07/22/15 at 7:24 AM Patient #1's BP was 111/41, and there was no documented evidence the RN or physician were notified. On 07/24/15 at 7:46 AM his BP was 128/30, and on 07/25/15 at 10:28 PM his BP was 48/17. There was no documented evidence the RN or physician were notified. After that Patient #1's VS were not recorded again until 07/26/15 at 11:16 PM, approximately 23 hours later, at which time his BP was 139/95. There was no documented evidence the RN or physician were notified.

On 07/27/15 at 5:22 PM Patient #1's BP was 140/32, and on 07/28/15 at 10:42 PM Patient #1's BP was 121/40. There was no documented evidence the RN or physician were notified.

3) Documented VS for Patient #2 were reviewed electronically for the period of time 07/27/15-07/28/15 and revealed the following:

On 07/28/15 VS were recorded at 3:34 PM and then not again until 7:00 AM on 07/29/15, approximately 15 1/2 hours later.

4) Documented VS for Patient #3 were reviewed and revealed the following:

On 07/18/15 VS were recorded at 3:00 PM and again at 3:09 PM. There were no documented first or third shift VS. On 07/21/15 VS were recorded at 9:32 AM and again at 5:10 PM. VS were not recorded again until 07/22/15 at 9:25 PM, approximately 28 hours later. On 7/23/15 VS were recorded twice, once at 8:40 AM and again at 4:00 PM. There were no documented third shift VS.

5) Documented VS for Patient #4 were reviewed electronically for the period of time 07/14/15-07/28/15 and revealed the following:

On 07/22/15 VS were recorded only once at 9:45 PM. There were no documented first or second shift VS. On 07/23/15 VS were recorded only twice, once at 8:43 AM and again at 4:02 PM. There were no documented third shift VS. And on 07/25/15 there were no recorded VS at all.

6) Documented VS for Patient #5 were reviewed electronically for the period of time 07/22/15-07/28/15 and revealed the following:

On 07/23/15 VS were recorded at 4:36 PM and again at 11:12 PM. There were no documented first shift VS. On 07/25/15 VS were recorded at 10:16 AM and again at 3:50 PM. There were no documented third shift VS. On 07/27/15 VS were recorded at 6:00 AM and again at 10:30 PM, approximately 16 1/2 hours later. And on 07/28/15 VS were recorded at 6:05 AM and then again at 9:00 PM, approximately 15 hours later.

7) Documented VS for Patient #6 were reviewed electronically for the period of time 07/20/15-07/28/15 and revealed the following:

On 07/20/15 VS were recorded at 8:21 AM and 3:46 PM. There were no documented third shift VS. VS were not recorded again until 8:59 AM on 07/21/15, approximately 17 hours later. On 07/23/15 VS were recorded at 4:44 PM and 11:27 PM. There were no documented first shift VS. On 07/25/15 VS were recorded at 10:22 AM and 4:00 PM, but there were no documented third shift VS. On 07/27/15 VS were recorded just once, at 9:00 PM. And on 07/28/15 VS were recorded at 8:53 AM and 9:15 PM, approximately 12 hours later.

8) Staff A was made aware of and confirmed the above findings on 07/29/15 at 10:50 AM.

9) The medical record for Patient #10 contained physician orders from 01/14/15 at 9:30 PM. The orders stated to notify the physician for a diastolic blood pressure less than 50 mmHg. Review of Patient #10's vital signs showed Patient #10 had diastolic blood pressures of 45 on 01/14/15 at 10:50 PM, 49 on 01/14/15 at 11:00 PM, 46 on 01/16/15 at 9:49 AM and 42 on 01/16/15 at 11:00 PM. The medical record did not have documentation to verify a physician had been notified of the diastolic blood pressures.

Based on medical record reviews, staff interview and review of facility policy, the facility failed to ensure the nursing care plan for each patient addressed all needs and deficits identified by assessment and included interventions for helping the patient(s) to achieve their goals. This affected five of 10 patients whose nursing care plans were reviewed, Patients' #1, #2, #3, #5 and #6. The census at the time of the survey was 29.

Findings include:

1) Facility policy Plan of Care - Individualized and Interdisciplinary (PC 245) was reviewed. Per said policy, "The individualized plan of care, treatment and services is developed based on data from the initial assessment" and "the initial assessment findings of all disciplines problems, deficits and needs."

2) Patient #1 was admitted to the facility on 07/17/15 with diagnosis of Subarachnoid Hemorrhage, and the nursing admission assessment identified "left upper extremity function, left lower extremity function" deficits. These neurological deficits were not identified as focus/problem areas on the nursing plan of care, and there were no corresponding interventions.

Those areas identified on the nursing plan of care as focus/problem areas were circulatory/cardiovascular, pain management and pulmonary/respiratory, however, there were no corresponding interventions.

3) Patient #2 was admitted to the facility on 07/27/15 with diagnosis of Subdural Hemorrhage-Coma Not Otherwise Specified, and the nursing admission assessment identified "mild disability" using the Glasgow Coma Scale. Patient #2 was also noted to be blind her right eye. These neurological deficits were not identified as focus/problem areas on the nursing plan of care, and there were no corresponding interventions.

4) Patient #3 was admitted to the facility on 07/14/15 with diagnosis of Occluded Carotid Artery with Infarct. The nursing care plan identified diabetes: insulin-dependent, risk for hospital acquired infection and impaired safety awareness as focus/problem areas, but there were no corresponding interventions documented.

5) Patient #5 was admitted to the facility on 07/22/15 with diagnosis of Closed Skull Fracture, and the nursing admission assessment identified "right upper extremity function, left upper extremity function, right lower extremity function, left lower extremity function" deficits. Patient #5 was also noted to experience double vision and wear a patch on her left eye. These neurological deficits were not identified as focus/problem areas on the nursing plan of care, and there were no corresponding interventions.

6) Patient #6 was admitted to the facility on 07/02/15 with diagnosis of Intracerebral Hemorrhage, and the nursing admission assessment identified "mild disability" using the Glasgow Coma Scale. The assessment also identified deficits with "right upper extremity function." These neurological deficits were not identified as focus/problem areas on the nursing plan of care, and there were no corresponding interventions.

7) Staff A was made aware of and confirmed the above findings on 07/29/15 at 10:50 AM during an interview.