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Based on the record review and interviews, the hospital failed to have an organized nursing service that was furnished or supervised by a registered nurse, in that,

1. LVN's were staffed in the ICU (Intensive Care Unit) without the immediate availability of a registered nurse.

The 6/2/2014 "Floor Assignments for 7P-7A" reflected the RN (Personnel #13) was scheduled as the nurse supervisor for 33 patients and the RN for 6 ICU (Intensive Care Unit) patients who were under the LVN's primary care. Personnel #13 was also scheduled as the Team Leader and Medication Nurse for the Rapid Response and Code Blue teams.

The 6/3/2014 "Floor Assignments for 7P-7A" reflected the RN (Personnel #13) was scheduled as the RN Supervisor for 35 patients, the RN for 7 ICU patients who were under the LVN's primary care, and the primary nurse for 2 patients on the 2nd floor medical-surgical unit. Personnel #13 was also scheduled as the Team Leader and Medication Nurse for Rapid Response and Code Blue Teams.


(Cross Reference to Tag A392), and


2. LVN's were providing assessment and care of patients without the supervision or evaluation of a registered nurse.

The facility failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient, in that, 3 of 10 patients (Patient #2, #3, and #4) did not receive an assessment by an RN (Registered Nurse) within a 24 hour period. Note: This is out of the scope of practice for an LVN (Liccensed Vocational Nurse) according to the Texas Board of Nursing, Scope for Practice of an LVN.


(Cross Rerence to Tag A395).

Based on record review and interviews, the hospital failed to have a QAPI (Quality Assurance Performance Improvement) program which identified opportunities for improvement, in that, for 2 of 2 months (May and June 2014), there were 52 medication errors that were reported through QA (Quality Assurance) identified on the Medication Error Log. Twelve of the 52 medication errors were for controlled substances. There was no follow-up, disciplinary action or Performance Improvement Plan identified as a result of this identification of medication error data included in the hospital's Quality Assurance plan.

Findings included:

The Medication Error log for May and June 2014 indicated that out of the 52 total medication errors listed, 12 of these errors involved the dispensing of a controlled substance that was not documented as given.

The QA minutes from May and June 2014 did not include a documented follow-up, staff education or disciplinary measures taken as a result of the medication error findings identified in May and June, 2014.

During an interview on 6/11/2014 at 10:45 AM in the Board Room, the Pharmacist (Staff #31) stated that incident reports are filled out "on unaccounted for" controlled substances with no feedback.

During an interview on 6/11/2014 at 2:00 PM in the Board Room, the Chief Clinical Officer (Staff #2) agreed that the incidents regarding the missing medication including the missing controlled substances were not handled correctly or according to policy and that this was not included as part of the hospital's QA plan.

Based on record review and interviews, the facility failed to have adequate numbers of registered nurses immediately available for bedside care of patients, in that, on 6/2/2014, 6/3/2014, and 6/4/2014, LVN's were assigned to patient care without an RN immediately available for the bedside care of each of the hospitalized patients as needed. The same RN was assigned to function in different roles on 06/02/14, 06/03/14 and 06/04/14.

Findings Included:

On 6/10/2014 in the Board Room, review of staffing sheets revealed:

The 6/2/2014 "Floor Assignments for 7P-7A" reflected the RN (Personnel #13) was scheduled as the nurse supervisor for 33 patients and the RN for 6 ICU (Intensive Care Unit) patients who were under the LVN's primary care. Personnel #13 was also scheduled as the Team Leader and Medication Nurse for the Rapid Response and Code Blue teams.

The 6/3/2014 "Floor Assignments for 7P-7A" reflected the RN (Personnel #13) was scheduled as the RN Supervisor for 35 patients, the RN for 7 ICU patients who were under the LVN's primary care, and the primary nurse for 2 patients on the 2nd floor medical-surgical unit. Personnel #13 was also scheduled as the Team Leader and Medication Nurse for Rapid Response and Code Blue Teams.

The 6/4/2014 "Floor Assignments for 7P-7A" reflected the RN (Personnel #13) was scheduled as the nurse supervisor for 35 patients and the RN for 7 ICU patients who were under the LVN's primary care. Personnel #13 was also scheduled as the Team Leader and Medication Nurse for the Rapid Response and Code Blue teams. This assignment sheet indicated 3 RNs were cancelled for the shift.

During an interview on 6/10/2014 at 3:00 PM, Personnel #4 was informed of the above findings, and Personnel #4 confirmed the findings. Personnel #4 was asked if the nurse coverage reflected appropriate staffing for the facility. Personnel #4 said "There should have been an RN in ICU and the nurse supervisor should not have had a patient load." Personnel #4 was asked about the Rapid Response and Code Blue Team assignments for Team Leader and Medication Nurse. Personnel #4 said, "It should not be scheduled as the same person for both duties."

Based on record review and interview, the facility failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient, in that, 3 of 10 patients (Patient #2, #3, and #4) did not receive an assessment by an RN (Registered Nurse) within a 24 hour period. Note: This is out of the scope of practice for an LVN (Liccensed Vocational Nurse) according to the Texas Board of Nursing, Scope for Practice of an LVN.

Findings included:

On 6/10/2014 in the Board Room of the facility, the nursing assessments of the electronic medical records were reviewed with the navigation of the document provided by Staff #1, #4 and #6.

Patient #2 an Intensive Care Unit (ICU) patient, received primary care from an LVN on:

6/4/2014 for the 7AM - 7PM shift and the 7PM - 7AM shift;

6/3/2014 for the 7AM-7PM shift and the 7PM - 7AM shift; and

6/2/2014 for the 7AM-7PM shift and the 7PM-7AM shift.

The medical record for 06/02/2014 through 06/04/2014 did not include an assessment by an RN.

Patient #3 received primary care provided by an LVN on:

6/8/2014 for the 7PM - 7AM shift;

6/9/2014 for the 7AM-7PM; and the 7PM-7AM shift; and

6/10/2014 for the 7AM-7PM shift.

The medical record for 06/08/2014 through 06/10/2014 did not include an assessment by an RN.

Patient #4 received primary care provided by an LVN on:

6/4/2014 for the 7AM-7PM shift and the 7PM-7AM shift; and

6/9/2014 for the 7AM-7PM shift and the 7PM-7AM shift.

The medical record for 06/04/2014 and 06/09/2014 did not include an assessment by an RN.

During an interview with Staff #1, #4, and #6 on 6/10/2014 in the Board Room, the staff members were asked if they could show in the medical record for Patient #2, #3, and #4 where an RN had assessed these patients for these dates. All three staff reviewed the medical records and stated, "No."

Note: Texas Board of Nursing 15.27 The Licensed Vocational Nurse Scope of Practice states..."The LVN scope of practice is a directed scope of practice and requires appropriate supervision. The LVN, with a focus on patient safety, is required to function within the parameters of the legal scope of practice and in accordance with the federal, state, and local laws, rules, regulations, and policies, procedures and guidelines of the employing health care institution or practice setting. The LVN is responsible for providing safe, compassionate and focused nursing care to assigned patients with predictable health care needs." "...The Board believes that for a nurse to successfully make a transition from one level of nursing practice to the next requires the completion of a formal program of education."

Based on record review and interviews, the hospital failed to have a pharmaceutical service provided in accordance with nationally accepted standards of practice, in that, the pharmacist failed to report the loss of 12 of 12 controlled substances from 5/01/2014 through 06/10/2014, in accordance with applicable Federal and State laws, and to the hospital's chief executive officer.

(Cross reference A509).

Based on record review and interview, the pharmacist (Personnel #31) failed to report 12 of 12 missing controlled substances identified on the Medication Error log for the period of 5/01/2014 to 6/10/2014, to the appropriate State and Federal agencies and to the Hospital's Chief Executive Officer.

Findings included:

Review of the Medication Error log on 6/10/2014 in the Board room included the following:
For the month of May 2014 there were 5 controlled substances documented as "waste not documented, not charted as given."

For 06/01/2014 to 06/10/2014, 7 controlled substances were documented as "waste not documented, not charted as given."

During an interview in the Board Room on 6/11/2014, the Pharmacist (Personnel #31) was asked if the missing controlled substances were being reported through QA, the Pharmacy and Therapeutics Comittee, all the way up to Medical Executive Committee. She answered, "No."

The Pharmacist (Personnel #31) stated that she has never reported any loss of controlled substances to the Pharmacy Board or DEA (Drug Enforcement Agency). When asked if the loss of the controlled substances was reported to her supervisor, the Chief Executive Officer, the Pharmacist (Staff #31) stated, "No."

The "Controlled Drugs: Storage and Distribution and Accountability (General)" PCS-09-0, reviewed by the surveyor on 6/11/2014, stated: "The Director of Pharmacy is responsible for determining that all records for controlled drugs are accurate and correct and that an account of all controlled drugs is maintained and recorded. The Director of Pharmacy is also responsible for tracking the movement of Controlled Drugs from receipt from wholesaler to administration to the patient, destruction or return to wholesaler...The pharmacist should retain this documentation in a file that is readily retrievable to an inspector."