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Based on clinical record review, policy and procedure review, manufacturer's guidelines, and interview, it was determined the facility failed to ensure patients received care in a safe setting in that there was no protocols or other identifying measures that informed nursing staff what procedures they were allowed to initiate without physician's orders. Failure to ensure mechanisms were in place identifying procedures nurses could initiate and implement without physician's orders did not ensure facility nurses were operating within the scope of practice established by the facility. The failed practice affected Patient #1, #4, #6 and #15. Findings follow:

A. Review of the clinical records of Patients #1, #4, #6 and #15 showed all were admitted to the facility with a Fecal Management System (FMS) in place.

B. Review of Patient #1's clinical record showed the Fecal Management System was removed on 05/16/17 and reinserted on 05/25/17. Review of Patient #1's clinical record showed no physician's order to re-establish the Fecal Management System. Review of Patient #1's clinical record showed a physician's progress note dated 05/16/17 that an irrigation and debridement of the roof of a perirectal abscess was performed at the bedside by the physician on 05/16/17.

C. Review of the Lippincott Procedures for Fecal Containment Device Insertion, Internal, received from the Director of Quality at 12:30 PM on 04/24/18 did not show a physician's order was required to initiate the device.

D. Review of the Guidelines for Management of Fecal Incontinence with Flexi-Seal FMS showed under Directions for Use: 1. Obtain physician order per facility policy.

E. The Chief Nursing Officer (CNO) was asked during an interview at 2:35 PM on 04/24/18 if a physician's order was needed for a nurse to initiate a FMS, especially for a patient who had an irrigation and debridement of a perirectal abscess. The CNO stated no order was needed. The CNO was asked if an order was required to initiate a Foley catheter and she stated yes.

F. The Charge Nurse was asked during an interview at 10:20 AM on 04/25/18 if an order was required for a FMS and an external female catheter. The Charge Nurse stated she thought staff was getting orders for the FMS but no physician's order was required for the external female catheter.

G. The CNO was asked during an interview at 9:10 on 04/25/18 if there was a list of procedures or protocols nurses can perform without a physician's orders and the CNO stated no there was not.

Based on policy review, clinical record review, and interview, it was determined the facility failed to ensure restraint monitoring was conducted every two hours as per policy for two (#5 and #7) of five (#4, #5, and #7-#9) restrained patients. The failed practice did not ensure the patient's needs were assessed periodically, and created the likelihood the patient would remain in restraints longer than necessary and had the potential to affect any restrained patient. Findings follow.

A. Review of the policy titled "Restraint Reduction Plan" stated "Patients placed in restraint for safety, non-violent, and non-destructive behavior should be monitored at least every two hours."
B. Review of the clinical record of Patient #5 showed the following:
1) An order for restraints on 04/07/18 beginning at 7:00 AM, there was no evidence of restraint monitoring from 7:00 AM until 4:00 PM.
2) An order for restraints on 04/08/18 beginning at 7:00 AM, there was no evidence of restraint monitoring from 7:00 AM until 7:00 PM.
3) An order for restraints on 04/09/18 beginning at 7:00 AM, there was no evidence of restraint monitoring from 7:00 AM until 7:00 AM the following day.
4) An order for restraints on 4/22/18 beginning at 7:00 AM, there was no evidence of restraint monitoring for the entire day.
C. Review of the clinical record for Patient #7 showed an order for restraints on 04/24/18 beginning at 1:15 PM, there was no evidence of restraint monitoring from 7:00 PM until 11:00 PM, and from 1:00 AM until 5:00 AM on 04/25/18.
D. The lack of restraint monitoring was confirmed during an interview with the CNO on 04/25/18 at 9:50 AM.

Based on policy and procedure review, interview and clinical record reviews, it was determined a Registered Nurse failed to supervise and evaluate patient care in that eight (#1, #9, #11, #14-18) of twenty (#1-20) patients did not receive a bath or had no notation that one had been offered and refused; four (#1, #11, #14 and #16) of twenty (#1-20) patients did not have weights performed and documented as ordered; four (#1, #11, #14 and #16) of twenty (#1-20) patients did not have dressing changes performed and documented as ordered to the PICC (Peripherally inserted central catheters)/central line insertion sites; one (#1) of twenty (#1-20) patients did not have meal intake percentages documented and one (#18) of two (#1 and #18) patients did not have sacral dressings performed as ordered by the physician. Failure to ensure patients received or were offered a bath did not ensure the patients were clean and comfortable; failure to obtain and document patient weights in the clinical record did not ensure information was available to staff and physicians to make care decisions; failure to change the dressing to the PICC central line catheter insertion sites weekly did not allow staff to assess for redness, drainage and signs of infections; failure to document meal percentages did not allow the physician, dietitian and nursing staff to be knowledgeable of patient's intake and avoid malnutrition; and failure to document a dressing change did not ensure the wound was assessed and cared for as ordered. The failed practice affected Patients #1, #9, #11, and #14-18. Findings follow:

A. Review of the policy and procedure titled "Personal Hygiene" received from the Director of Quality at 9:55 AM on 04/25/18 showed all patients were to be offered a bath and linen change on a daily basis. If a bath or linen change was declined documentation will be placed in the medical record. The Chief Nursing Officer (CNO) stated during an interview at 2:35 PM on 04/24/18 that each patient was to be offered a bath every day.

B. Review of the policy and procedure titled "Changing a PICC Dressing/Midline" received from the Director of Quality at 9:15 AM on 04/25/18 showed nursing personnel were to change PICC/ML/Central dressings 24 hours post insertion and on Sundays and PRN (as needed). The CNO stated during an interview at 2:35 PM on 04/24/18 that all central lines and PICCs were to have a dressing change every Sunday.

C. The CNO stated during an interview at 2:35 PM on 04/24/18 that each patient was to be weighed every Sunday unless there was a specific order issued by a physician.

D. Review of Patient #1's clinical record showed the following: no documentation a bath was given or refused on 14 (05/17/17, 05/19/17, 05/20/17, 05/24/17, 05/26/17-05/29/17, 06/01/17-06/03/17, and 06/06/17-06/08/17) of 44 (05/10/17-06/22/17) days; no documentation weights were performed and documented for two (05/14/17 and 05/28/17) of the six (05/14/17, 05/21/17, 05/28/17, 06/04/17, 06/11/17 and 06/18/17) Sundays the patient should have been weighed; and no documentation the PICC dressing change was performed on 3 (06/04/17, 06/11/17 and 06/18/17) of six (05/14/17, 05/21/17, 05/28/17, 06/04/17, 06/11/17, and 06/18/17) Sundays the PICC dressing should have been changed. During an interview with the CNO at 1:50 PM on 04/25/18 the above findings were verified. Review of the clinical record showed no documentation meal percentages for each day were recorded for 12 (05/10/17,05/12/17, 05/15/17, 05/16/17, 05/19/17, 05/20/17, 05/24/17, 05/28/17, 05/29/17, 06/04/17, and 06/06/17) of 28 days (05/10/17-06/06/17). During an interview with the Director of Quality at 1:15 PM on 04/27/18 the above findings were verified.

E. Review of Patient #9's clinical record showed no documentation baths were given or refused for two (04/22/18 and 04/23/18) of three (04/21/18-04/23/18) days. During an interview with the CNO at 12:57 PM on 04/25/18 the above findings were verified.

F. Review of Patient #11's clinical record showed no documentation baths were given or refused for three (04/19/18, 04/23/18 and 04/24/18) of six (04/19/18-04/24/18) days and no documentation weights were performed and documented for one (04/22/18) day the patient should have been weighed. During an interview with the CNO at 2:03 PM on 04/25/18 the above findings were verified. Review of the clinical record showed no documentation the PICC dressing change was performed on one of one (04/22/18) day it should have been performed on. Observation of Patient #11's PICC line at 1:30 PM on 04/25/18 showed a dressing date of 04/16/18. During an interview with the Director of Quality at 1:30 PM on 04/25/18 the above findings were verified.

G. Review of Patient #14's clinical record showed no documentation baths were given or refused six (04/15/18-04/20/18, and 04/23/18) of ten (04/14/18-04/23/18) days. During an interview with the CNO at 12:55 PM on 04/25/18 the above findings were verified. Review of the clinical record showed no documentation the Internal Jugular (IJ) dressing change was performed on one (04/22/18) of two (04/15/18 and 04/22/18) days the dressing change should have been performed. Observation of Patient #14's IJ dressing at 1:40 PM on 04/25/18 showed a date of 04/15/18. During an interview with the Director of Quality at 1:40 PM on 04/25/18 the above findings were verified.

H. Review of Patient #15's clinical record showed no documentation baths were given or refused six (04/19/18 - 04/24/18) of 11 (04/14/18 - 04/24/18) days; and no documentation Patient #15 was weighed on one (04/22/18) of two (04/15/18 and 04/22/18) days the patient should have been weighed. During an interview with the CNO at 1:59 PM on 04/25/18 the above findings were verified.

I. Review of Patient #16's clinical record showed no documentation baths were given or refused on four (04/16/18, 04/19/18, 04/21/18 and 04/23/18) of 11 (04/14/18 - 04/24/18) days; and review of the clinical record showed no documentation Patient #16 was weighed on two of two (04/15/18 and 04/22/18) the patient should have been weighed. During an interview with the CNO at 1:03 PM on 04/25/18 the above findings were verified. Review of the clinical record showed no documentation the PICC dressing was changed on two of two (04/15/18 and 04/22/18) days the dressing change should have been performed on. Observation of Patient #16's PICC dressing at 1:35 PM on 04/25/18 showed no date visible on the dressing. During an interview with the Director of Quality at 1:35 PM on 04/25/18 the above findings were verified.

J. Review of Patient #17's clinical record showed no documentation baths were given or refused on three (04/21/18, 04/23/18 and 04/24/18) of twelve (04/13/18-04/24/18) days. During an interview with the Director of Quality at 1:24 PM on 04/25/18 the above findings were verified.

K. Review of Patient #18's clinical record showed no documentation baths were given or refused on seven (04/13/18, 04/17/18 - 04/21/18, and 04/24/18) of 13 (04/13/18 - 04/24/18) days; and review of the clinical record showed no documentation a sacral dressing change was performed one (04/24/18) of three (04/17/18, 04/20/18 and 04/24/18) days as ordered by the physician. During an interview with the CNO at 12:57 PM on 04/25/18 the above findings were verified.

Based on observation, clinical record review and interview, it was determined the Facility failed to develop care plans that were specific and updated to reflect the patient's current care and needs for 14 (#5-#13, #15, and #17-#20) of 17 (#4-#20) current patients. Failure to develop individualized, patient specific care plans which reflected the patient's current needs did not allow the Facility to ensure that the care rendered met the patient's needs. The failed practice affected Patients #2 and #3 on 11/14/16. Findings follow:

A. Review of the H&P (History and Physical) for Patient #5 showed he had acute kidney injury, was diabetic, and had an indwelling urinary catheter. Review of the Interdisciplinary Plan of Care showed no interventions or goals for fluid/electrolyte management (kidneys), hyperglycemia/hypoglycemia (diabetes), or elimination (catheter). Findings were confirmed by the Chief Nursing Officer (CNO) on 04/25/18 at 12:45 PM.
B. Review of Admission Orders for Patient #6 showed an admitting diagnosis of respiratory failure. Review of the Interdisciplinary Plan of Care showed no interventions or goals regarding pulmonary issues. Findings were confirmed by the CNO on 04/25/18 at 1:52 PM.
C. Review of Admission Orders for Patient #7 showed an admitting diagnosis of respiratory failure. Review of the Interdisciplinary Plan of Care showed no interventions or goals regarding pulmonary issues. Findings were confirmed by the CNO on 04/25/18 at 1:54 PM.
D. Review of the H&P for Patient #8 showed the patient had a PEG (Percutaneous Endoscopic Gastrostomy) tube. Review of the Interdisciplinary Plan of Care showed no interventions or goals regarding nutrition. Findings were confirmed by the CNO on 04/25/18 at 12:45 PM.
E. Review of the H&P for Patient #9 showed the Patient had had a stroke two weeks ago and was independent with activities of daily living prior to that, and that he was admitted to the facility on TPN (total parenteral nutrition). Review of the Interdisciplinary Plan of Care showed no interventions or goals related to nutrition (TPN) or loss of independence, fall risk, and musculoskeletal weakness (stroke). Findings were confirmed by the CNO on 04/25/18 at 12:45 PM.
F. Review of the H&P of Patient #10 showed the Patient had stage four chronic kidney disease, congestive heart failure (CHF), atrial fibrillation (a fib), and hypertension (HTN). Review of the Interdisciplinary Plan of Care showed no interventions or goals related to fluid/electrolyte management (kidney disease), or cardiovascular issues (CHF, a fib, HTN). Findings were confirmed by the CNO on 04/25/18 at 12:45 PM.
G. Review of the Admission Orders for Patient #11 showed an admitting diagnosis of pulmonary rehab (rehabilitation) and antibiotic treatment. Review of the Interdisciplinary Plan of Care showed no interventions or goals related to pulmonary issues (pulmonary rehab), or medication use (antibiotics). Findings were confirmed by the CNO on 04/25/18 at 2:03 PM.
H. Review of the H&P of Patient #12 showed the Patient had a PEG tube and a traumatic brain injury which affected his ability to speak. Review of the Interdisciplinary Plan of Care showed no interventions or goals related to speech/language or nutrition (PEG tube). Findings were confirmed by the CNO on 04/25/18 at 12:45 PM.
I. Review of the H&P of Patient #13 showed the Patient was homeless. Review of the Interdisciplinary Plan of Care showed no interventions or goals related to discharge planning. Findings were confirmed by the CNO on 04/25/18 at 12:45 PM.
J. Review of the Admission Orders of Patient #15 showed an admitting diagnosis of respiratory failure. Review of the Interdisciplinary Plan of Care showed no interventions or goals related to pulmonary issues. Findings were confirmed by the CNO on 04/25/18 at 1:59 PM.
K. Review of the H&P of Patient #17 showed the Patient had CHF, a fib, and respiratory failure. Review of the Interdisciplinary Plan of Care showed no interventions or goals related to cardiovascular issues (CHF, a fib), or respiratory issues. Findings were confirmed by the CNO on 04/25/18 at 12:45 PM.
L. Review of the H&P for Patient #18 showed the Patient was a paraplegic, had HTN, and was diabetic. Review of the Interdisciplinary Plan of Care showed no interventions or goals related to hyperglycemia/hypoglycemia (diabetes), cardiovascular issues (HTN), or rehabilitation issues (paraplegia). Findings were confirmed by the CNO on 04/25/18 at 12:45 PM.
M. Review of the H&P for Patient #19 showed the Patient was diabetic, had HTN and a fib. Review of the Interdisciplinary Plan of Care showed no interventions or goals related to hyperglycemia/hypoglycemia (diabetes), or cardiovascular issues (HTN, a fib). Findings were confirmed by the CNO on 04/25/18 at 12:45 PM.
N. Review of the H&P for Patient #20 showed the Patient had HTN, COPD (chronic obstructive pulmonary disease), and respiratory failure. Review of the Interdisciplinary Plan of Care showed no interventions or goals related to cardiovascular issues (HTN), or pulmonary issues (COPD, respiratory failure). Findings were confirmed by the CNO on 04/25/18 at 12:45 PM.