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Based on record reviews, staff interviews and review of facility policy and procedure, the facility failed to ensure medications for 1 of 30 sampled patients (Patient 20) were administered per the physician order. The total sample size was 30. Facility census was 40.

Findings are:

A. Review of Patient 20's Physician Progress Notes dated 6/7/13 revealed the following diagnoses: endstage renal disease (kidney disease),coccyx ulcers (tailbone wounds), status post cardiac arrest with ventricular fibrillation (heart stopped), profound debility and osteoporosis (bone disease). Continue Enteral Tube-ET (tube feeding) as ordered.

Review of the MAR (Medication Administration Record) for 6/9/13 revealed the following 8:30 PM medications were not administered per physician order:
-Coreg (medication to treat heart failure and blood pressure), 6.25 mg (milligrams) 2 times daily per ET.
-Senokot S (a bowel medication), 8.61/50 mg 2 times daily per ET.
-Miralax (a bowel medication), 17 gm (grams) 2 times daily per ET.
-Renvela (medication used to decrease phosphorus levels in the blood for dialysis patients), 2.4 gm 3 times a day per ET.
-Humalog Insulin SubCutaneous (inject beneath the skin) per sliding scale 4 times a day, pre-meal and bedtime.

Interview and June 2013 MAR review with Director of LTACH (Long Term Acute Care Hospital) Nursing at 4:30 PM on 7/17/13 revealed that those meds (Coreg, Senokot S, Miralax, Renvela and Humalog Insulin) should have been administered by 9:30 PM on 6/9/13. "We have an hour on either side of the medication administration times to give the medication." "No, there were no incident reports completed on those medications."

Review of the 7/17/13 9:19 AM email from RN (Registered Nurse)-M, the co assigned nurse for Patient 20 on 6/9/13 PM shift, revealed, "The LPN (Licensed Practical Nurse)-S assigned to [Patient 20] did not update co-assigned RN on any concerns from day shift report. I checked in with [LPN S] approximately at 9:45 PM to see if I could assist with any tasks. [Gender] asked if I could pass medications on [Patient 20]. No update given at this point on patient status. Prepared medications and entered patient's room, approached patient and appeared to have expired. Started medical assist procedure and patient was a DNR [Do Not Resuscitate]."

Review of the undated Frequency Codes for Medication Administration revealed:
- Twice daily medication administration times are 0830 (8:30 AM) and 2030 (8:30 PM);
- 3 times a day medication administrations are 0830, 1400 (2:00 PM) and 2030.

Review of the Operational Definition (695) for Incident Reporting dated 10/25/07 identified under Medication Related Events:
- Wrong Time: "The failure to administer a medication to a patient within the appropriate interval (greater than one hour before or after) from its scheduled administration time."

Based on record reviews, staff interviews and review of facility policy and procedure, the facility failed to document an assessment on 1 of 30 sampled patients (Patient 20) on 6/9/13, evening shift. The total sample size was 30. Facility census was 40.

Findings are:

Review of Patient 20's Physician Progress Notes dated 6/7/13 revealed the following diagnoses: endstage renal disease (kidney disease),coccyx ulcers (tailbone wounds), status post cardiac arrest with ventricular fibrillation (heart stopped), profound debility and osteoporosis (bone disease). Continue tube feeding as ordered.

Review of Patient 20's Medical Record lacked any charting by the professional nurse (Registered Nurse or Licensed Practical Nurse) from 1900 (7:00 PM) - 2205 (10:05 PM) - Evening Ahift.

Review of the 6/9/13 0700 - 1900 Day Shift Adult Assessment and Intervention Documentation completed by LPN (Licensed Practical Nurse)-T showed the following 8:49 AM entries:
- Level of consciousness: "Lethargic/somnolent [drowsy, sluggish]; alert."
- Pain: "Unable to assess."
- Respiratory Rhythm/Pattern: "Agonal [abnormal pattern of breathing characterized by gasping, labored breathing, accompanied by strange vocalizations and myoclonus (twitching)]."
- Gastrointestinal: "PEG [Percutaneous Endoscopic Gastrostomy] tube for feeding, by pump."
- Skin: "pale, mottled [purplish blotchy appearance to skin.] Hot and clammy."

Review of the 6/9/13 LTACH (Long Term Acute Care Hospital) 2 East 7:00 PM - 11:00 PM Patient Assignment Sheet revealed that LPN-S was assigned as Primary Care for Patient 20 and RN (Registered Nurse)-M was co-assigned to to Patient 20.

Electronic record review with RN-N on 7/16/13 from 8:40 AM - 9:00 AM revealed the lack of nursing charting from 7:00 PM - 10:05 PM for Patient 20.

Interview with RN-N on 7/16/13 from 8:40 AM - 9:00 AM stated, "Yes I don't see any charting that evening [6/9/13] by a nurse until 10:05 PM when they found [gender] had died. A nurse aide did go do cares for [gender] at 9:02 PM that evening. We will have to look into that."

Review of the 7/17/13 9:19 AM email from RN-M (the co-assigned nurse for Patient 20 on 6/9/13 PM shift) revealed, "The LPN [LPN-S] assigned to [Patient 20] did not update co-assigned RN on any concerns from day shift report. I checked in with [LPN-S] approximately at 9:45 PM to see if I could assist with any tasks. [Gender] asked if I could pass medications on [Patient 20]. No update given at this point on patient status. Prepared medications and entered patient's room, approached patient and appeared to have expired. Started medical assist procedure and patient was a DNR [Do Not Resuscitate]."

Interview with the Director LTACH Nursing on 7/16/13 at 1:45 PM stated, "My expectation is that the professional nurses chart once per shift unless they feel the patient's condition had changed. [LPN S] should have collected data on the patient [Patient 20] and passed the medications on [gender] patients. [RN-M] should have done assessments and followed up with [LPN-S]." "That is one reason we changed the nursing models and do not have LPNs providing professional cares now. Not related to this incidence, just that we felt there were too many layers of staff providing cares." Reviewed 6/9/13 day shift charting with the Director LTACH Nursing and agreed that LPN-S should have checked on Patient 20's condition and reported to her co-assigned RN.

Review of the Operational Definition (1416) Documentation Policy & Procedure dated 4/17/08 revealed:
- Documentation will be completed as soon after an intervention/treatment as possible so that a sequentially ordered record is maintained and not left until the endo of shift/day.
- Daily Documentation will include: Any changes in medical, functional, physical, cognitive and/or emotional status.
- Patient care/services provided and patient response/input.