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Based on review of documentation and interview with staff, it was determined the nursing staff failed to supervise and evaluate the care of patient #1. The nursing staff failed to transfer the complete physician order to the Medication Administration Record (MAR). An incident report was not completed after a medication error occurred. The day shift nurse failed to document for 7 hours and patient #1 complained to the night shift nurse of diarrhea. The nursing staff failed to report to the food service department when patient #1 did not eat meals.

Findings included:

A review of facility policy# PS170 entitled, "Medication Variances" which was approved by the Medical Executive Committee and the Governing Body with an effective date of 9/06, stated "To clarify the mechanism for reporting medication variances and follow-up by pharmacy in conjunction with the nursing staff and physicians." Further review revealed, "II. Policy, B. Medication variance reporting and follow-up serves to improve the quality of future patient care ... G. Every medication variance is reported, via the facility incident reporting process, to the risk manager and the pharmacy director or pharmacist designee." Further review revealed, "Definitions of Variances ... Improper dose variance: Administration to the patient of a dose that is greater than or less than the amount ordered ..." The procedure stated, "A. 3. The clinician documents the variance, its impact, and what steps were taken by making a notation in the patient's medical record. 4. A facility incident report is to be completed and communicated to the risk manager."

A review of facility policy# PC090 entitled, "Reassessment" which was approved by the Medical Executive Committee and the Governing Body with an effective date of 9/06, stated "Subsequent reassessment of a patient's physical status may be performed by either a registered nurse or licensed practical nurse (LVN). " Further review revealed,"B. Patients will also have reassesments occur when: 1. Changes occur in condition and/or diagnosis."

A review of facility policy# FN 020 entitled, "Meals and Food Service" stated, "The nursing department will document the patient intake of meals to assist in the dietary department in assuring proper patient nutrition." Further review revealed, "D. 2. The food service department will be told when the patient is not eating or is not accepting a diet."

1. A review of the medical record of patient #2 revealed the nursing staff failed to transfer the complete physician order to the MAR. A review of the physician order dated 11/5/11 stated, "Give 0.5 mg Dilaudid every 4 hrs scheduled (unless patient is heavily sedated) IVP." The nurse transferred the order to the MAR as "Dilaudid 0.5 mg q4 (every 4 hours)." The next day the same nurse wrote the physician order on the MAR as "Dilaudid 0.5 mg q4 (every 4 hours) scheduled." The nurse failed to write the complete physician order.

2. A review of the medical record of patient #1 revealed a medication error on 11/22/11 that was not reported. Patient #1's physician on 11/17/11 ordered Dilaudid 2.5 mg IV push from 6:00am-6:00pm and 3mg IV push from 6:00pm to 6:00am. On 11/22/11, according to the Medication Administration Record (MAR), patient #1 received Dilaudid 3mg at 9:55am. A review of the nurses progress notes dated 11/22/11 at 10:00am, the nurse noted "the patient requested pain medication and Dilaudid was given 2mg IVP." It was confirmed in multiple interviews on 4/4/12 and 4/5/12 with staff member #1 and staff member #2 a medication error occurred and was not reported.

3. The nursing staff failed to supervise and evaluate patient #1's condition as there was no documentation for 7 hours. A review of the medical record of patient #1 revealed the day shift nurse last documented at 12:00pm on 11/19/11. The night shift nurse on 11/19/11 documented at 7:30pm "Pt denies any c/o (complaints of) pain but c/o stomach discomfort and diarrhea... Pt c/o hospital food... will pass information to day shift nurse." The patient care tech (PCT) documented the patient had medium loose stool at 11:00am, 3:00pm, and 5:00pm. There was no documentation found or provided to the surveyor at the time of the survey the nurse addressed the patient's concerns.

4. A review of the 11/18/11 "Daily Flowsheet Treatment Record" revealed on the document stated patient #1 ate 0% for breakfast and 50% for both lunch and dinner. On 11/19/11, the flowsheet revealed patient #1 ate 50% of breakfast and the lunch and dinner sections were blank. On 11/21/11, the staff noted patient #1 had 0% for breakfast and lunch, and 25% for dinner. There was no documentation found for 11/22/11. The nursing staff failed to report to the food service department that patient #1 was not eating meals as per facility policy.

In multiple interviews on 4/4/12 and 4/5/12 with staff member #1 it was confirmed the nurse failed to transfer to the MAR the complete physician order. The physician order stated "unless patient is heavily sedated" was not transferred over to the MAR. It was also confirmed that it was the responsibility of the nursing staff to report medication errors and there was no incident report filed for the medication error on 11/22/11. Staff member #1 also confirmed the day shift nurse last documented at 12:00pm. In an interview with staff member #15 the afternoon of 4/4/12, it was confirmed the nurses failed to notify the food fervice department that patient #1 was not eating meals.

Based on review of documentation and interview with staff, it was determined the facility failed to train personnel in administering Intravenous medications.

Findings included:

A review of facility policy# PS090 entitled, "Medication Administration" which was approved by the Medical Executive Committee and the Governing Body with a revision date of 4/11, stated "To provide safe pharmaceutical care to all patients." The policy revealed, "Drugs will be administered by, or under the supervision of, appropriately licensed personnel ... Clinical competency in the area must be validated prior to administration of any medication. No medication may be administered when outside the scope of practice of the clinician. The following clinicians may administer medications: Licensed Practical Nurse (also known as Licensed Vocational Nurse), all medications except IV push and IV medications (unless competent with additional education), all routes except intravenous (unless competent/trained)." Further review revealed, "3. Verbal orders for medications are permissible within the scope of practice of each health care provider listed above." Further review revealed, "G. medication errors/near miss, 1. Any variance in medication administration must be documented in a hospital incident report."

A review of facility policy# PS170 entitled, "Medication Variances" which was approved by the Medical Executive Committee and the Governing Body with an effective date of 9/06, stated "To clarify the mechanism for reporting medication variances and follow-up by pharmacy in conjunction with the nursing staff and physicians." Further review revealed, "II. Policy, B. Medication variance reporting and follow-up serves to improve the quality of future patient care ... G. Every medication variance is reported, via the facility incident reporting process, to the risk manager and the pharmacy director or pharmacist designee." Further review revealed, "Definitions of Variances ... Improper dose variance: Administration to the patient of a dose that is greater than or less than the amount ordered ..." The procedure stated, "A. 3. The clinician documents the variance, its impact, and what steps were taken by making a notation in the patient's medical record. 4. A facility incident report is to be completed and communicated to the risk manager."


1. A review of the medical record of patient #1 revealed that on 11/16/11, 11/17/11, 11/18/11, 11/19/11, 11/20/11, 11/21/11, and 11/22/11 IV and IVP medications were administered by facility nursing staff (LVN's).

2. A review of the medical record of patient #2 revealed that on 11/05/11 IV and IVP medications were administered by facility nursing staff (LVN's).

3. A review of the medical record of patient #1 revealed the physician order was for Dilaudid 2.5 mg IVP every 2 hours as needed for pain from 6:00am-6:00pm and 3 mg IVP every 2 hours as needed for pain from 6:00pm-6:00am. A review of the medical record revealed a medication error on 11/22/11. The MAR revealed the patient received Dilaudid 3mg IVP at 9:55am. The patient should have received Dilaudid 2.5 mg. The nurse documented "the patient requested pain medication and Dilaudid was given 2mg IVP."

4. A review of facility personnel files for 7 of the 9 LVN's (staff members #4, #6, #9, #10, #11, #12, and #13) who work at the facility revealed that there was no documentation found to indicate that these 7 LVN's had had any competency training in the administration of IV or IVP medications. Further review of the personnel files revealed that these 7 LVN's did not have any documentation that the proper training needed for the administration of IV medications had been conducted and evaluated for competency. Found in each of the 7 personnel files was a copy of the facility "Mesquite Specialty Hospital Skills Competency RN/LVN" form. This form stated in the section "IV drug concentration, Medication errors, Medication administration (six rights)" that the type was "high risk," the age of the patients served was (adolescents, adults, older adults/geriatrics), the competency level, the method of assessment, and the assessor. This competency class was taught by the pharmacist.

In an interview with staff member #1 and staff member #14 the afternoon of 4/4/12, it was confirmed that there was no documentation found by or provided to the surveyor to indicate that the 7 LVN's whose personnel files were reviewed had the proper training to administer IV medications. Additionally in other interviews on 4/4/12 and 4/5/12 with staff member #1, it was confirmed that the competency class was taught by the pharmacist and not a Registered Nurse (RN). Staff member #1 also stated a RN must check off the LVN prior to administering IV medications. Staff member #1 stated that effective immediately the LVN's will no longer be able to administer IV medications until further training.

Based on review of documentation and interview with staff, it was determined the facility failed to train personnel in administering Intravenous medications.

Findings included:

A review of facility policy# PS090 entitled, "Medication Administration" which was approved by the Medical Executive Committee and the Governing Body with a revision date of 4/11, stated "To provide safe pharmaceutical care to all patients." The policy revealed, "Drugs will be administered by, or under the supervision of, appropriately licensed personnel ... Clinical competency in the area must be validated prior to administration of any medication. No medication may be administered when outside the scope of practice of the clinician. The following clinicians may administer medications: Licensed Practical Nurse (also known as Licensed Vocational Nurse), all medications except IV push and IV medications (unless competent with additional education), all routes except intravenous (unless competent/trained)." Further review revealed, "3. Verbal orders for medications are permissible within the scope of practice of each health care provider listed above." Further review revealed, "G. medication errors/near miss, 1. Any variance in medication administration must be documented in a hospital incident report."

1. A review of the medical record of patient #1 revealed that on 11/16/11, 11/17/11, 11/18/11, 11/19/11, 11/20/11, 11/21/11, and 11/22/11 IV and IVP medications were administered by facility nursing staff (LVN's).

2. A review of the medical record of patient #2 revealed that on 11/05/11 IV and IVP medications were administered by facility nursing staff (LVN's).

3. The physician order was for Dilaudid 2.5 mg IVP every 2 hours as needed for pain from 6:00am - 6:00pm and 3 mg IVP every 2 hours as needed for pain from 6:00pm-6:00am. A review of the medical record revealed a medication error on 11/22/11. The MAR revealed the patient received Dilaudid 3mg IVP at 9:55am. The patient should have received Dilaudid 2.5 mg. The nurse documented " the patient requested pain medication and Dilaudid was given 2mg IVP."

4. A review of facility personnel files for 7 of the 9 LVN's (staff members #4, #6, #9, #10, #11, #12, and #13) who work at the facility revealed that there was no documentation found to indicate that these 7 LVN's had had any competency training in the administration of IV or IVP medications. Further review of the personnel files revealed that these 7 LVN's did not have any documentation that the proper training needed for the administration of IV medications had been conducted and evaluated for competency. Found in each of the 7 personnel files was a copy of the facility "Mesquite Specialty Hospital Skills Competency RN/LVN" form. This form stated in the section "IV drug concentration, Medication errors, Medication administration (six rights)" that the type was "high risk," the age of the patients served was (adolescents, adults, older adults/geriatrics), the competency level, the method of assessment, and the assessor. This competency class was taught by the pharmacist.

In an interview with staff member #1 and staff member #14 the afternoon of 4/4/12, it was confirmed that there was no documentation found by or provided to the surveyor to indicate that the 7 LVN's whose personnel files were reviewed had the proper training to administer IV medications. Additionally in other interviews on 4/4/12 and 4/5/12 with staff member #1, it was confirmed that the competency class was taught by the pharmacist and not a Registered Nurse (RN). Staff member #1 also stated a RN must check off the LVN prior to administering IV medications. Staff member #1 stated that effective immediately the LVN's will no longer be able to administer IV medications until further training.

Based on observation, review of documentation, and interview with staff, it was determined that the facility failed to maintain equipment used to transport food to the nursing units. The facility also failed to ensure the steam table in the serving line was clean. The facility failed to follow its own policies and procedures.

Findings included:

A review of facility policy# FN010 entitled, "Food Safety and Sanitation" stated, "To ensure infection control, food safety and sanitation practices are followed for the storage and distribution of food in order to minimize the risk of contamination and prevent food borne illness." Further review revealed, "H. 1. Food is transported in a manner that maintains safe food temperatures. 2. Food is transported to other areas in an enclosed cart. I.1. Equipment and work areas shall be clean and orderly."

During an abbreviated tour of the kitchen the morning of 4/4/12 with staff member #1 and staff member #5, the following was revealed:

1. The clip that secured the door to the food service cart was broken and therefore the cart was unable to maintain the proper temperature. The food service cart transports the patient's food from the kitchen to the nursing units.

2. During the abbreviated tour of the kitchen on 4/4/12, the surveyor followed the dietary staff delivering lunch trays to the 2nd floor and witnessed 2 covered lunch trays on top of the food service cart.

3. Examination of the steam table in the dietary serving line revealed an insect in the hot water beneath the food containers.

It was confirmed with staff #1 and staff #5 the morning of 4/4/12, the clip on the food service cart was broken and the facility was not aware of it until the same day of the kitchen tour. Staff member #5 stated the dietary staff members did not report the broken cart and was not sure how long it had been broken. It was also confirmed by staff members #1 and #5 that there was an insect in the steam table underneath a food container in the serving line. During the same interview with staff member #1, it was confirmed that the lunch trays were on top of the food service cart. It was also confirmed the facility failed to follow its own policies and procedures.

Based on review of documentation and interview with staff, it was determined the facility failed to perform rehabilitation services (physical therapy) on patient #1 as per physician orders dated 11/16/11.

Findings included:

A review of the medical record for patient #1 revealed that the physician had ordered physical therapy. The order which was dated 11/16/11 at 1:30pm stated, "PT eval (evaluation) and Mgt (management)" and signed by the physician.

1. During the medical record review of patient #1 no documentation was found by or provided to the surveyor indicating that patient #1 had received any physical therapy services or had even been evaluated for such services by the physical therapist.

2. A review of the "Interdisciplinary Physician Led Plan of Care" document initiated on 11/16/11, revealed that there was no evidence patient #1 was evaluated by the Physical Therapist. The signatures of the physician, case management, nursing, dietitian, occupational therapist, and pharmacist were found on the signature section of this document. There was no signature from a physical therapist.

In an interview on 4/4/12 at approximately 2:30pm with staff members #1, #8, and #16, it was confirmed that there was no documentation found in the medical record of patient #1 indicating that the patient had been evaluated or treated by the physical therapist. Additionally it was confirmed in the same interview that there was no signature from a physical therapist found on the facility "Interdisciplinary Physician Led Plan of Care. "