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Based on record review and interview, the facility failed to develop and/or update care plans to ensure patient's care needs and response to interventions are addressed for eight patients (#12, #13, #15, #1, #2, #4, #22, and #24) of nine care plans reviewed. The facility census was 24.

Findings included:

1. Review of the facility policy titled, "Transdisciplinary Team: Care Planning" reviewed March 2010 showed that patient care needs are identified and prioritized and a plan of care, which appropriately addresses priority needs, is initiated within 24 hours of admission by the Registered Nurse (RN).

2. Review of Patient #12's medical record showed admission to the facility on 10/05/11. Observation of the patient's room on 10/18/11 at 2:32 PM showed an orange Contact Isolation (contact isolation is a name for safety procedures that prevent specific germs from spreading in the hospital) sign posted on the outside of the room under the room number. The sign showed that all who entered the room must don gloves and gown.

Review of Patient #12's care plan showed no care plan related to the patient being on Contact Isolation for Vancomycin-resistant Enterococcus(VRE), (bacteria that are resistant to the antibiotic vancomycin).

3. Review of Patient #13's medical record showed admission to the facility on 10/05/11.

Observation of the patient's room on 10/18/11 at 10:15 AM showed an orange Contact Isolation sign posted on the outside of the room under the room number. The sign showed that all who entered the room must don gloves and gown.

Review of Patient #13's care plan showed no care plan related to the patient being on Contact Isolation for Methicillin Resistant Staph Aureus (MRSA) (is any strain bacteria that has developed resistance to antibiotics). Resistance does make MRSA infection more difficult to treat with standard types of antibiotics and thus more dangerous) and VRE of the abdominal wound or for the colostomy (a surgical opening from the colon through the abdominal wall to the outside of the body for the purpose of emptying waste products (stool) from the body.

Further review showed staff failed to develop a care plan for the colostomy.

4. Review of current Patient #15's medical record showed admission to the facility on 09/0/11.

Observation of the patients' room on 10/18/11 at 9:15 AM showed an orange Contact Isolation sign posted on the outside of the room under the room number.

Review of Patient #15's care plan showed staff failed to develop a care plan related to the patient being on Contact Isolation for VRE or MRSA of the abdominal wound.

During an interview on 10/20/11 at 9:30 AM Staff A, Chief Clinical Officer, stated that care plans should include Contact Isolation precautions and colostomy care.


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5. During an interview on 10/18/11 at 10:05 AM Staff D, RN, Discharge Planner, stated that he/she is in and out all of the patient rooms so he/she is able to keep up with each patient's care. Patient #2 was admitted due to an infected left hip prosthesis and Patient #4 had a flap (skin from another part of the body) surgery to the left neck and thigh wounds on left and right legs. The reason for Contact Isolation was the following:
Patient #2
-There was VRE in his/her nares (openings of the nose) which was not checked again at the current facility.
-There was a left hip wound after a surgical procedure which had MRSA and VRE in the wound.
Patient #4
-There was a MRSA in a neck wound from flap surgery on the left side of the patient's neck.
- A positive rectal swab for VRE.
-There was sputum positive for Haemophilus influenzae (A bacteria in the respiratory tract that can cause disease processes.)

6. Observation on 10/20/11 at 8:30 AM of rooms for Patient #1, #2, #4, #22, and #24 showed an orange Contact Isolation sign posted on the outside of the room under the room number. The sign showed that all who entered the room must don gloves and gown.

7. During an interview on 10/20/11 at 8:55 AM Staff D, stated that: the following patients were on contact precautions:
-Patient #1 was on Contact Isolation for a urinary tract infection (UTI) with Providencia (A bacteria associated with urinary tract infections) and Enterococcus (E. coli) (A bacteria that is found in the intestines and frequently causes UTI's).
-Patient #22 was on Contact Isolation for a positive culture of Enterococcus from a Peripherally Inserted Central Catheter (PICC) (This is a slender, small, flexible tube that is inserted into a vein in a patient's arm and advanced until it reaches a large vein in the chest near the heart.) line, which was discontinued.
-Patient #24 was on Contact Isolation for a right heel osteomyelitis (infection in the bone).

8. Record review of Patient #24's History and Physical showed the right heel osteomyelitis was due to E. coli and proteus mirabilis (A bacteria found in water, soil, and feces. It is commonly the reason for UTI's and wound infections).

9. Record review of Patient's #1, #2, #4, #22, and #24's Transdisciplinary Care Plan showed staff failed to develope a plan of care for Contact Isolation so the patient's nursing care needs were identified and appropriate interventions were put in place.

Based on observation, interview, review of facility policy and medication administration record (MAR) review, the facility failed to ensure safe medication administration when facility staff failed to accurately document the time medications were given to three (#7, #8, and #1) of five patients observed and when staff failed to check the arm bands and ask the patient their name before adminstering medications for two (#12,#15) of two patients during medication administration observations during the survey. The facility census was 24.

Findings included:

1. Record review of the facility's policy titled, "Drugs Administration: General" approved 06/09, showed that unless the prescriber orders otherwise, drugs should be administered at standard times (assigned by pharmacy). Doses are considered "on time" if administered within one-half hour before or one-half hour after scheduled time. The drug administration procedure instructed staff before administering any drug, mentally review the five rights: (1) Right patient, (2) Right drug, (3) Right dose, (4) Right route and (5) Right time.

2. Observation on 10/18/11 at 10:15 AM showed Staff U, Registered Nurse (RN) gave the following medications to Patient #8:
-Hydrochlorothiazide (medication to prevent high pressure and heart attacks) 12.5 milligrams (mg) one tablet by mouth (PO) daily;
-Lisinopril (medication to prevent high pressure and heart attacks) 20 mg PO daily;
-Protonix (medication to decrease stomach acid) 40 mg PO daily;
-Senokot (stool softener) 17.2 mg PO daily; and
-Digoxin (heart medication) 0.25 mg PO daily.

Review of Patient #8's MAR showed Staff U RN initialed (documented) these medications were given at 9:00 AM (the standard time the medications should have been given as determined by pharmacy), even though they were observed as given at 10:15 AM., one hour and fifteen minutes later.

3. Observation on 10/18/11 at 10:25 AM showed Staff T, RN gave the following medications to Patient #7:
-Vasotec (medication for high blood pressure) 10 milligrams (mg) one tablet by mouth (PO) daily;
-Levothroid (medication used to treat an underactive thyroid) 50 micrograms PO daily;
-Lopressor (medication to prevent high pressure and heart attack) 75 mg PO daily;
-Pancrease (digestive medication, to be given with each meal) 2 capsules PO daily; (Note: breakfast was from approximately 7:30 AM to 9:00 AM and there was no food tray observed during medication administration); and
-Protonix (medication to decrease stomach acids) 40 mg PO daily.

Review of Patient #7's MAR showed Staff T RN initialed (documented) these medications were given at 9:00 AM (the standard time the medications should have been given as determined by pharmacy), even though they were observed as given at 10:25 AM., one hour and twenty-five minutes later.

4. During an interview on 10/20/11 at 10:30 AM, Staff L RN charge nurse stated that she/he was not aware that the above medications were given late. Staff L confirmed that medications would be considered late if not given within thirty minutes before or after the scheduled times. Staff L stated that staff should have circled the 9:00 AM pre-printed time listed on the MAR and documented the actual time the medications were given prior to initialing, "especially if more than an hour late".

5. During an interview on 10/20/11 at 10:40 AM, Staff B, RN Educator stated that staff should have circled 9:00 AM on the MAR and documented the time the medications were actually given. Staff B stated, "There should be a nurses' note written on why the medications were late or held and if a couple of hours late, or so, would be cause for concern and an incident report should be written". Staff B stated that she/he was not sure the facility had a policy and procedure regarding this procedure.

6. During an interview on 10/20/11 at 2:15 PM, Staff A, Chief Clinical Officer stated that the facility did not have a policy and procedure specifically addressing documentation of late medications. Staff A stated that if medications were not given within the hour window, she would expect nurses to circle and document the actual time of medication administration. Staff A stated that she was not aware of this problem and confirmed this was not included in their quality program and therefore, was not being captured during their internal medical record chart reviews.


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7. Observation on 10/18/11 at 10:00 AM showed Staff E, RN gave Patient #1 Novolog Insulin (medication to decrease blood sugar) 2 units sub-cutaneous (give an injection just below the skin).

Observation on 10/18/11 at 10:05 AM showed Staff E, RN gave the following medications to Patient #1:
-Aspirin Chewable (medication given to thin the blood) 81 milligrams (mg) one tab by mouth (PO), daily;
-Atenolol (medication to decrease blood pressure) 25 mg, ? tab, PO, daily;
-Digoxin 0.25 mg PO, daily;
-Dilitiazem HCL (medication to treat chest pain, irregular heartbeat, high blood pressure, and migraine headaches) 240 mg, 2 tabs of 120 mg, PO, daily;
-Furosemide (medication to remove excess water from the body) 40 mg PO, daily;
-Guaifensin LA (medication to loosen congestion in the chest and throat) 600 mg PO, twice a day (BID);
-Methlephenidate HCL (medication treatment for Attention Deficit Hyperactivity Disorder, Narcolepsy, Depression in the ill and elderly, and to enhance analgesia and sedation in patients receiving opioids [medications for pain]) 7.5 mg PO, daily;
-Pantoprazole (medication to treat acid reflux from the stomach) 40 mg PO, every 8:00 AM;
-Tamsulosin (medication to treat and enlargement of the prostate, which is [ a gland surrounding the bladder neck and urethra in a male] ) 0.4mg PO, daily; and
-Thiamine (vitamin B) 200 mg PO, daily.

Record review of Patient #1's MAR showed Staff E; RN initialed these medications given at 9:00 AM, even though they were observed as given at 10:05 AM, an hour and five minutes later, with the exception of the following:
-Staff E initialed Pantoprazole given at 8:00 AM, even though observed as given at 10:05 AM, two hours and five minutes later.
-Staff E initialed Novolog Insulin given at 11:00 AM, which was the pre-printed time on the medication record, even though observed as given at 10:00 AM, an hour before.

8. During an interview on 10/18/11 at 11:15 AM Staff E, RN stated that if he/she gave medication past the ordered time he/she wrote in the nurses notes why medication was late. Staff E also stated staff may give medication up to one hour before or one hour after the ordered time.


















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9. Observation on 10/18/11 at 8:30 AM showed Staff R, RN, administered medications to Patient #12. The RN did not check the arm band or ask the patient's name; therefore the staff did not observe the five rights of patient's before medication administration and the risk of giving the wrong medication to the wrong patient was increased.

10. Observation on 10/18/11 at 8:45 AM showed Staff R administered medications to Patient #15. The RN did not check the patients arm band or ask the patient's name; therefore the staff did not observe the five rights of patient's before medication administration and the risk of giving the wrong medication to the wrong patient was increased.