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The facility failed to administered drugs according to the physician's orders and hospital policies; a registered nurse must evaluate the nursing care for each patient (A 395); the facility failed to administered drugs according to the physicians order (A-404)

Based on interview and record review the facility failed to evaluate and deliver the nursing care determined for the needs of the patient, for 3 of 10 patients (patients #2, #4 and # 9).

On 02/08/11 at approximately 0900, patient # 2 was observed sitting in his bed. The patient asked for his ordered medication. When queried patient #2 stated that he "never" gets his medication "on time" or, "sometimes I don't get it at all." Registered Nurse #1 was present at the bed side during the interview. When Registered Nurse #1 was queried she stated that the patient was going to hemodialysis. Patient #2's "Medication Administration Record (MAR)" was reviewed. No medications were given; The "MAR" showed the time that the medication was to be administered. Registered Nurse circled all the ordered medications that were due at 0900 and 1200 and put her initials next to the time. "When the time is circled it means it was held" according to Registered Nurse #1. The following 0900 medications were held according to Registered Nurse #1 "because the patient is going to hemodialysis" .
1. Anti fungal nail paint topical to all toenails every 12 hours
2. Bacitracin. topical to the perineum three times a day
3. Cincalcet, one tablet by mouth every day.
4. Clonidine, one tablet by mouth every eight hours.
5. Docusate, one tablet by mouth twice a day.
6. Folic Acid, one tablet by mouth twice a day.
7. Gabapentin, on tablet by mouth every day.
8. Lactulose, one by mouth twice a day.
9. Methylpred, IVP (IV push) every eight hours.
10. Miconazole Nitrate, topical to the scrotum every day.
11. Nystatin, topical to both feet and toes every twelve hours.
12. Omeprazole, one tablet by mouth every day.
13. Propafenone, one tablet by mouth every eight hours.
14. Saline flush, (saline lock) one time every day.
15. Verapamil, one tablet by mouth, give with breakfast once a day.

The following 1200 ordered medications were marked held at 0900 according to Registered Nurse #1 "because the patient is going to hemodialysis":
1. Sevelamer, one by mouth three times a day, give with meals.
2. Sucralfate, one by mouth every six hours.


On 02/08/11 at approximately 1300 review of the policy titled "Hemodialysis Services" under "#14 titled Scheduled Medications, 14.1 All scheduled medications should be given, regardless of hemodialysis unless ordered held by the physician" .

On 02/08/11 at 1530 Registered Nurse #1 and the Chief Clinical Nurse confirmed these findings.

Patient #4 was admitted on 01/18/2011 . The patient's weight was documented as 176.1 upon admission on 01/18/2011. The physician ordered on 01/20/2011 for the patient to receive "one can of Ensure at B, L, D and a pm snack ". There was no documentation to show that the patient was receiving Ensure at B,L,and D per doctor's ordered. There was no documentation to show that the patient was receiving a pm snack per doctor's ordered. As of 02/7/2011 the documented weight was 154.8. The patient has lost 21.3 pounds since admission.

On 02/08/11 at 1030 during record review for patient # 9 it was determined that according to the document titled "Medication Administration Record" dated 11/11/10, it was determined that the patient did not receive his medication per physician's order. Patient # 9 did not receive the artificial tears that were ordered every six hours, Hydromophone was not given for pain, and this patient had an open abdominal wound. Reglan was not given to settle the stomach.

"Vital Sign Record" document revealed patient #9's temperature at 1600 was measured at 104.6. The temperature did not leave 104 degrees until a documented temperature at 1955 of 102.7 degrees. The patient remained with a temperature while physician orders for Tylenol were not carried out.

Based on record review and interview the facility failed to provide dietary services in accordance with the orders of the practitioner responsible for the care of the patient in 2 of 2 clinical charts reviewed (patient #2 and #4) Findings include:

On 02/08/21 at 1500 during clinical record review it was determined that the nutritional diet orders for patient #2 was not met. Patient #2 was admitted on 02/03/11 . The patient's weight was documented as 187 lbs. on that date. The physician order on 02/05/11 read "Add one can of Ensure @ B, L, D ". There was no documentation to support that the patient was receiving Ensure at breakfast, lunch and dinner. On 02/06/11 the documented weight was 168.2 lbs. The nursing documentation supported that the patient had lost 18.8 lbs pounds since admission.

On 02/8/11 at 1615 during an interview with the Chief Clinical Nurse these findings were confirmed as documented.


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On 02/8/2011 at 14:20 during clinical record review it was determined that the nutritional diet orders of patient #4 was not met. Findings include:

Patient #4 was admitted on 01/18/2011 . The patient's weight was documented as 176.1 upon admission on 01/18/2011. The physician ordered on 01/20/2011 for the patient to receive " one can of Ensure at B, L, D and a pm snack ". There was no documentation to show that the patient was receiving Ensure at B,L,and D per doctor's ordered. There was no documentation to show that the patient was receiving a pm snack per doctor's ordered. As of 02/7/2011 the documented weight was 154.8. The patient has lost 21.3 pounds since admission.

During an interview on 02/8/2011at 1615 findings were confirmed by the chief clinical nurse.

Based on observation interview and record review, the hospital failed to ensure that equipment was maintained to ensure an acceptable level of quality for 2 0f 2 patient rooms observed (patients # 2, # 3) and 1 of 1 charts reviewed (patients # 9). Findings include:

On 02/08/11 at approximately 0930, patient # 2 was observed sitting in his bed. There were pieces of debris noted on the floor under the patient's bed ( a straw cover, torn pieces of paper,) The west wall of the patient's room had scattered dried white crusty spots on the lower half of the wall.

On 02/08/11 at approximately 0940, patient # 3 was observed sitting at the side of the bed. The patient's linens were stained with a large light brown substance approximately 3 inches x 5 inches in diameter. There were crumbs all over the bed. There were pieces of debris scattered all over the floor (straw covers, used alcohol pads, alcohol wrappers, and pieces of plastic wrap). The patient's bed side table had scattered dried white crusty spots on the surface area. There was a reddish crusty substance on the handle of the bedside table.

On 02/08/11 at approximately 1030, patient # 9's chart was reviewed. The patient was no longer in the facility but patient #9's son filed a formal "Complaint/Grievance Issue" on 10/20/10.

The Complaint/Grievance log was reviewed on 02/08/11 at approximately 1400. The issues documented was that the "son verbally complained to the clinical liaison that the room was not ready for his father when he was admitted so he waited on a stretcher for 45 minutes in the hallway then when he was admitted to the room it was not clean: stained ceiling tile, crude along baseboard and the room was dirty " .

On 02/08/11 at 0940 the Chief Clinical Nurse and the Manager of Housekeeping confirmed these findings.

Based on record review and interview the facility failed to administered drugs according to their policy for 1 of 1 patient (patient #2). Findings include:

On 02/08/11 at 0930 during record review for patient #2 it was determined that the patient was asking for his 0800 ordered medicine during interview. The nurse was asked why the patient did not receive his medication. Registered Nurse #1 stated the the patient was "going to dialysis" . According to the patients MAR (Medication Administration Record) and registered nurse #1, the patient did not receive ordered nystatin cream topical to both feet and legs at 0900 due to "hemodialysis" . The patient did not receive ordered miconazole nitrate topical to the scrotum due to "hemodialysis" . The patient did not receive ordered "antifungal nail paint" to every toe due to "hemodialysis" .

On 02/08/11 at 0940 during medication review for patient #2, it was revealed that ordered nystatin cream had not been applied to the legs and feet. Two (2) tubes of nystatin cream were in the patient's medication drawer. One tube of nystatin cream was dated as opened on 01/06/2011 and 01/07/2011. It was found that the tube had not been punctured in order to dispense medication. Both registered nurse #1 and the chief clinical nurse confirmed that the tube had not been punctured for use. One tube of nystatin cream was dated as being opened on 01/28/2011. Registered nurse #1 and the chief clinical nurse both confirmed that the tube contained more than expected for a medication order to apply nystatin cream three times daily to legs and feet.

On 02/08/2011 at 0943 during medication review for Patient #2 it was revealed that ordered anti-fungal paint had not been administered as ordered. Two bottles of anti-fungal paint 50 ml were measured in the presence of registered nurse #1 and the chief clinical nurse. Bottle number one of anti-fungal paint contained 49 ml of medication with an open date of 01/06/2011. Bottle number two contained 50 ml of medication with an open date of 01/29/2011. Registered nurse #1 and the chief clinical nurse both confirmed that both bottles contained more than expected for a medication order to apply anti-fungal paint twice daily to toenails.