28028 Based on policy and medical record reviews and staff interviews it was determined the facility failed to ensure medications were administered in accordance with physician orders for one (#4) of 10 patient records reviewed. Findings included: Review of the facility policy titled Medication Reconciliation Policy # MM.039 with a review date of 11/15 showed reconciliation of medication may be defined as all medication appropriately and consciously continued, discontinued, or modified .upon any transfer to a different level of care the transferring physician will need to continue, discontinue or edit orders .Pharmacy will verify the orders .transfer to a different level of care will be defined as the following .from surgery to a medical/surgical, progressive care or ICU (Intensive Care Unit) bed. On 01/19/17 at approximately 10:55 a.m. review of patient #4's history and physical (H&P) dated 01/16/17 at 6:51 a.m. revealed the patient was taken to surgery later that day for abdominal surgery. Review of the post anesthesia care unit (PACU) documentation revealed the patient left PACU and returned to the nursing unit at 9:33 p.m. Review of physician orders for the antibiotic Flagyl 500 milligrams (mg) IV (Intravenous) every 8 hours revealed the initial order was placed before surgery. It was dated 01/16/17 at 1:30 p.m. There were no further physician orders for the Flagyl found in the medical record. Review of the medication administration record (MAR) revealed Patient #4 received the Flagyl 500 mg IV every 8 hours from 01/16/17 at 1:30 p.m. through the post operatively period on 01/19/17 without a physician order to continue the medication as required by facility policy. An interview on 1/19/17 at 4:12 p.m. with the Pharmacist confirmed the Flagyl should have been discontinued. It should have been reordered post operatively if the physician wanted it to be continued. The Pharmacist confirmed there was not a new order for Flagyl post operatively. The Pharmacist confirmed if the physician did not discontinue an orders post operatively the patient will continue to receive pre operatively ordered medications. On 01/19/17 at approximately 10:45 a.m. an interview conducted with the Director of Advanced Clinicals confirmed there was no physician's order for Flagyl post operatively in Patient #4's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28028 Based on review of medical records and staff interview it was determined the registered nurse failed to supervised and evaluated the care related to assessments an implementation of physician orders for three (#1, #2, #5) of ten patient sampled. Findings included: 1. Review of the nursing documentation for patient #1 dated 4/01/2016 at 4:43 a.m. revealed the RN (Registered Nurse) documented the patient had labored breathing, shortness of breath, productive cough with brown white, thick sputum and coarse breath sounds. Review of the record revealed the respiratory therapist noted the patient's oxygen saturation was 89% on oxygen at 2 liters via nasal cannula with coarse lung sounds and a small amount of thick tan sputum. Review of the record revealed no evidence of nursing intervention or physician notification of the patient's change in condition noted on 4/01/2016 at 4:43 a.m. Review of the medical record and interview with the CNO (Chief Nursing Officer) on 1/19/2017 at approximately 12:30 p.m. confirmed the findings. 2. Review of patient #2's medical record revealed a physician order for neurological checks every 2 hours were ordered upon admission on 3/09/2016. Review of the nursing documentation revealed no evidence the neurological checks were completed every 2 hours as ordered. Interview with the CNO on 1/19/2017 at approximately 2:30 pm confirmed the findings. 3. On 01/19/17 at approximately 11:35 a.m. review of Patient #5's history and physical (H&P) revealed the patient was admitted on [DATE] at approximately 11:30 a.m. to the Medical Unit for safe alcohol withdrawal. The patient was noted to have a long history of alcohol abuse. On admission the patient was noted to have tremors, palpitations and an anxious mood. Review of physician orders dated 01/18/17 at 12:10 p.m. revealed orders for Clinical Institute of Withdrawal Assessment (CIWA-each item on the scale is scored independently and the summation of the scores yields an aggregate value that correlates to the severity of alcohol withdrawal with ranges of scores designed to prompt specific management decisions). The RN assessments were ordered to occur every 4 hours and included the following components: Nausea and vomiting Tremor Paroxysmal sweats Anxiety Agitation Tactile disturbances Auditory disturbances Headache/Fullness in head Orientation/clouding on sensorium Review of the same orders revealed neurological assessments should be performed every 6 hours by the RN. Review of the CIWA revealed a scale that each of the above components must be assigned every 4 hours. 0 None 1 Mild 4 Intermittent/Dry Heaves 7 Constant Review of nursing assessments for CIWA every 4 hours and neurological assessments every 6 hours revealed the following: 01/18/17 at 4:10 p.m.-no CIWA assessment performed. 01/18/17 at 6:10 p.m.-no Neurological assessment performed. 01/18/17 at 8:10 p.m.-no CIWA assessment performed. 01/18/17 at 10:00 p.m.-CIWA assessment performed. 01/19/17 at 12:10 a.m.- no CIWA and no Neurological assessment performed. 01/19/17 at 3:57 a.m.-CIWA assessment performed. 01/19/17 at 4:10 a.m.-no CIWA assessment no performed. 01/19/17 at 6:10 a.m.-no Neurological assessment performed. 01/19/17 at 8:10 a.m.-no CIWA assessment performed. 01/19/17 at 12:10 a.m.-no CIWA and no Neurological assessment performed. A total of 6 CIWA assessments should have occurred in the above timeframe. There were only 2 CIWA assessments found in the medical record. A total of 4 Neurological assessments should have occurred in the above timeframe. There were no neurological assessments documented in the medical record. On 01/19/17 at 12:25 p.m. an interview with the RN caring for Patient #5 confirmed the above findings. On 01/19/17 at 12:30 p.m. an interview with the unit Charge RN confirmed the CIWA assessments were ordered to occur every 4 hours and the Neurological assessments were to occur every 6 hours. The Charge RN confirmed the nursing assessments had not been performed as ordered on 01/18/17 and 01/19/17 by the RNs. On 01/19/17 at 12:40 p.m. an interview performed with the Director of Advanced Clinical and the CNO confirmed the findings. They stated they could not find any further documentation of CIWA or Neurological assessments being performed by nursing on the date of admission, 01/18/17 or the following day, 01/19/17.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31166 Based on record review, document review, policy review, observations and staff interview, the facility failed to ensure the effective implementation of and compliance with infection control measures for two (#5, #6) of ten sampled patients and failed to maintain a sanitary environment for two patient rooms. Findings include: 1. Patient #5 was admitted on [DATE] with a foot ulcer. Patient #5 was administered Vancomycin 1 gram intravenously on 7/27/15 at 3:33 p.m. as ordered by the Emergency Department (ED) physician. Patient #5 was seen in consultation by an Infectious Disease physician who ordered a culture of the foot ulcer on 7/28/15 at 11:43 a.m. The culture sample was collected on 7/28/15 at 4:00 p.m. The final results of the culture were dated 7/31/15 at 12:05 p.m. The results were reported as two infectious organisms (pseudomonas and methcillin sensitive staph aureus-MSSA) that were not sensitive to treatment with Vancomycin. The Daily Antibiotic Stewardship report dated 8/6/15 included documentation of the laboratory culture results dated 7/31/15 at 12:05 p.m. The documentation indicated the pharmacist reviewed the culture report on 8/3/15 and called the attending physician with recommendations to add an antibiotic that would be effective in treating the identified organisms. The physician order to begin administering an additional antibiotic was signed by the attending physician on 8/4/15. On 8/5/15 the Infectious Disease physician wrote an order to discontinue the antibiotic ordered by the attending physician and begin administering the antibiotic recommended by the pharmacist to treat the identified infectious organisms in the foot wound. The Antimicrobial Stewardship Program, policy #MM 0.011, last review date 5/15, was reviewed on 8/6/15. Page 2, C. indicated a report on patients on Antimicrobial treatment is generated daily. Page 2, D. indicated the Antimicrobial report will be reviewed daily by a pharmacist and acted upon as described in pharmacy policies. Page 3, 5 indicated the policies included determining the appropriate Antimicrobial based on the culture results. An interview and record review was conducted with the [NAME] President of Quality and the Pharmacy Clinical Coordinator on 8/6/15 at approximately 3:30 p.m. They confirmed the finding Patient #5 did not receive appropriate Antimicrobial therapy for the infection until 5 days following the final results of the culture and sensitivity report and 8 days following his admission. They confirmed the finding the 3 day interval between the results of the wound culture being reported and the pharmacist's recommendation to the attending physician was not in compliance with the facility policy. 2. Observations were conducted of patient room [ROOM NUMBER] and 209 on the 2 Progressive Care Unit (PCU) at the time of the tour on 8/6/15 at approximately 1:15 p.m. Both rooms were observed to have 35 gallon waste containers overflowing with discarded personal protective equipment (PPE) to the point the covers of the containers remained open 4-6 inches and the used PPE was hanging over the outside walls of the containers. The [NAME] President of Quality and the Director of the unit were present at the time of the observations and confirmed the finding. 3. Patient #6 was admitted on [DATE] at 8:32 a.m. to room [ROOM NUMBER] with a diagnosis of herpes zoster (shingles). The History and Physical dated 8/5/15 at 4:52 p.m. and signed by the attending physician indicated the treatment plan included contact isolation precautions. The Nursing Admission assessment dated [DATE] at 7:29 p.m. and signed by the Registered Nurse (RN) included documentation Patient #6 was on droplet isolation precautions. The shift assessment dated [DATE] at 12:30 p.m. and signed by the RN included documentation Patient #6 was on contact and droplet precaution isolation. The document Negative Pressure Room Monitoring was reviewed on 8/7/15. The review of the document failed to reveal documentation of the monitoring of room [ROOM NUMBER] on 8/5/15 or 8/6/15. room [ROOM NUMBER] was documented to have negative pressure on 7/27/15 and 8/7/15. Observations conducted at the time of the tour on 8/6/15 at approximately 1:15 p.m. included an 8 1/2 x 11 post card attached to the door frame of room [ROOM NUMBER] indicating Patient #6 was in airborne precaution isolation. Isolation Precautions, Policy #6.2, revised 10/14 was reviewed on 8/7/15. Page 4., 8.2. Airborne Precautions, c. Measles and Varicella indicated a private negative airflow room was required. TB Control Plan, Policy #8, revised 8/14 was reviewed on 8/7/15. Page 6. 1. included room [ROOM NUMBER] was one of several negative pressure rooms in the facility that conform to Centers for Disease Control (CDC) guidelines. Page 6. 2. indicated negative pressure rooms were to be monitored daily by the nursing supervisor when the room was in use, and documented in a logbook. An interview and record review was conducted on 8/7/15 at approximately 11:00 a.m. with the Director of Quality Management. In response to questions, he indicated the implementation of isolation precautions was part of the nursing plan of care and did not require a physician's order. He confirmed the finding Patient #6 was not placed in appropriate isolation precautions for the diagnosis until more than 24 hours following admission to the facility. An interview and document review was conducted on 8/7/15 at approximately 11:15 a.m. with the Nursing Supervisor. The Nursing Supervisor confirmed his signature appeared on the log indicating the negative pressure in room [ROOM NUMBER] was documented on 7/27/15 and 8/7/15. He confirmed the finding room [ROOM NUMBER] was in use and was not monitored in compliance with facility policy on 8/5/15 and 8/6/15.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 28028 Based on medical record review, staff interview and review of policy and procedure it was determined the registered nurse failed to ensure nursing assessed, intervened, and evaluated the care of patients for one (#2) of ten patients sampled related to diabetic care. Findings include: Patient #2 was admitted on [DATE]. Review of the H&P (History & Physical) dated 2/17/2014 revealed the patient had a history of Diabetes Mellitus and was on Insulin at home. Physician orders revealed the Insulin would be continued and the patient's blood glucose was to be monitored before meals and at bedtime. Review of nursing documentation revealed on 2/19/2014 at 6:12 a.m. the patient's blood glucose was 120 mg/dL. Review of the MAR (Medication Administration Record) revealed the patient received Novolog Mix 70/30, 40 units, at 7:00 a.m. as prescribed. Novolog Mix 70/30 results in insulin activity that is 30% short-acting and 70% long-acting. Review of the record revealed no documentation of the patient's breakfast intake on 2/19/2014. Review of nursing documentation revealed at 12:41 p.m. the blood glucose was 54 mg/dL. The blood glucose target range for diabetics, according to the American Diabetes Association, should be 90-130 (mg/dL) before meals and less than 180 mg/dL after meals. Review of nursing documentation revealed no nursing note or assessment of the patient at the time of the blood glucose reading of 54 mg/dL noted at 12:41 p.m. Review of the facility policy, Hypoglycemia Treatment, #GEN062, last reviewed 11/2013, stated (1) Mild Hypoglycemia: blood glucose 50-69 mg/dL without early symptoms: diaphoretic, shaky, anxious, tachycardia, lip numbness, drowsy, weak, blurred vision (a) call physician STAT if pre-printed insulin order sets not previously ordered. If patient is awake and able to take PO (by mouth), give treatment while notifying physician. Treatment if awake and able to take PO is 15 g (grams) of fast acting carb in liquid form: (one of the following): 4 oz (ounces) juice, 4-6 oz of regular soda, or 8 oz of low fat or skim milk. Then repeat the blood glucose in 15 minutes, repeat treatment if blood glucose remains <70 mg/dL or symptoms persist, and repeat blood glucose every 15 minutes until blood glucose >70 mg/dL and patient is asymptomatic. Review of the medical record revealed on 2/19/2014 at 12:55 p.m. the physician was notified by the nurse of recent lab results, transfer plans, and an update on the patient. The nurse documented no new orders were received. There was no evidence the nurse administered glucose intravenously or provided fast acting carb in liquid form as stated in facility policy and procedure for hypoglycemia treatment. There was no evidence the nurse communicated to the physician the patient was administered Insulin at 7:00 a.m., did not eat breakfast, and was made NPO (nothing by mouth) at approximately 11:30 a.m. for nuclear medicine testing therefore received no lunch. Review of the medical record revealed at 12:50 p.m. the patient was transported to the nuclear medicine department for testing. Documentation revealed the patient arrived back to the nursing unit at approximately 2:30 p.m. Nursing documentation revealed the patient was assessed and noted to be unresponsive. The patient's blood glucose was tested and revealed a result of 30 mg/dL. Documentation revealed immediate intervention was provided and the physician notified. Review of the record revealed the patient was transferred to the ICU (Intensive Care Unit). Review of the record revealed the nurse failed to assess, intervene and evaluate/re-evaluate according to facility policy. Interview with Quality Coordinator and review of the medical record on 4/8/2014 at approximately 10:00 a.m. confirmed the above findings.

19139 Based on record review, policy review and staff interview it was determined the facility failed to ensure the restraints were used as ordered by the physician for 1 (#3) of 32 sampled patients. This practice does not ensure patients are free from unnecessary restraints. Findings include: The facility's policy Restraint and Seclusion #PC 027, last revised 3/12, required that orders for application of physical restraint must be for a specific duration, not to exceed twenty-four hours. Review of the medical record for patient #3 revealed an order for the application of bilateral wrist restraints on 8/18/12 at 10:00 a.m. The ordered time limit was twenty-four hours. The next order for restraints was dated 8/19/12 at 1:45 p.m. Review of the medical record revealed the patient remained in restraints the entire time between the first and second order. The patient was in restraints three hours and forty-five minutes beyond the time limit of the restraint order. The Chief Nursing Officer was present during the record review on 8/21/12 at approximately 10:30 a.m. an confirmed the staff did not obtain the renewal order within the required time frame.

19139 Based on staff interview it was determined the facility failed to ensure the Emergency Department policies and procedures are reviewed and approved by the medical staff. This practice does not ensure the medical staff is aware of the care provided in the Emergency Department. Findings include: The Chief Nursing Officer was interviewed on 8/22/12 at approximately 10:00 a.m. She indicated she could provide no evidence that the Emergency Department policies and procedures were reviewed, revised as needed and approved by the medical staff.

31098 Based on record and facility documents review and staff interview it was determined that the facility failed to conduct a thorough review following the death of 1 (#5) of 10 sampled patients within 15 hours of admission to the the facility. This practice does not ensure identification of problems related to patient care and implementation of corrective action. Findings include: Patient #5 was admitted to the New Vision program for medical stabilization for alcohol detoxification on 5/14/12 at 4:31 p.m. The patient was found on 5/15/12 at 7:40 a.m. in the patient's room on the floor unresponsive. Resuscitation efforts were not successful a.m. Review of facility documentation revealed the New Vision program was initiated in 11/11 and had not been integrated in the facility's Quality Assurance Performance Improvement plan. An Interview was conducted with the Risk manager on 6/14/12 at approximately 3:00 p.m. The interview confirmed the adverse patient event had not been investigated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31098 Based on interview, clinical record and facility document review, the facility failed to develop and maintain an effective, on-going, data-driven quality assessment and performance improvement program related to the New Vision program for medical stabilization services for alcohol and drug detoxification. The facility: Failed to implement and monitor indicators related to an adverse event following the death of a patient (#5) who expired within approximately fifteen hours of admission to the New Vision program. The patient had an abnormal electrocardiogram with shortness of breath on admission and the Registered Nurse failed to report the information to the physician. Interview with the Risk Manager on [DATE] revealed no investigation had been conducted. There was no rationale as to why an investigation was not performed. (Refer to A0257) Failed to implement and monitor indicators related to patient safety concerns to ensure physician orders for assessments were implemented as ordered. Interview with the Chief Nursing Officer on [DATE] revealed the electronic system was not showing the complete physician orders for the New Vision program for assessment of the Withdrawal symptoms resulting in nursing not being aware of the assessment needed to be conducted every four hours for twenty four hours for five of five New Vision patients. (Refer to A0267) Failed to ensure the admitting physician, who did not know the new patient, was aware of the patient's medical history, status on admission and home medications that included Lisinopril, Coreg, Aspirin, Ventolin, Phenergan and Amox-clav for patient #5. (Refer to A0267) Review of Quality Assessment and Performance Improvement Plan dated and meeting minutes from initiation of the program in ,d+[DATE] to ,d+[DATE] and interview with the [NAME] President of Quality on [DATE] revealed the New Vision Program for Medical Stabilization for alcohol and drug detoxification was not uded in the plan. (Refer to A0286) The cumulative effect of the facility's failure to analyze and implement a plan of action following an adverse patient event and failure to include a new specialized program in the Quality Assessment Performance Improvement program resulted in the determination that the Condition of Participation for Quality Assessment Performance Improvement is not in compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31098 Based on record and facility document review and staff interview it was determined the facility failed to initiate tracking of indicators following an adverse incident (#5) and for patients (#6, #7, #8, #9) in the New Vision Program, which was a new program for medical stabilization for alcohol and drug detoxification. This resulted in continued lack of nursing assessment of the Withdrawal Severity Nursing Assessment per physician orders for five of five patients and failure to inform the physician of abnormal test result and changes in condition for one (#5) of five patients in the New Vision Program. This practice places patients at risk of a delay in treatment and prevention of injury related to withdrawal symptoms in the New Vision patients. Findings include: 1. Patient #5 was admitted on [DATE] at 3:52 p.m. with an admitting diagnosis of acute alcohol withdrawal. Review of nursing documentation dated [DATE] at 4:31 p.m. revealed the patient's vital signs were within normal limits except for a blood pressure of ,d+[DATE] and an oxygen saturation level of 93%. Review of the Admission Assessment completed by the registered nurse (RN) on [DATE] at 5:36 p.m. revealed the following assessments were not Within Defined Parameters (WDP): Neurological, ears, eyes, nose and throat (EENT), cardiovascular and gastrointestinal(GI)/nutrition. The patient currently had no pain. The neurological evaluation revealed the patient was alert, awake and oriented. His speech was soft. His left and right hand grips were weak. He had distant and recent past memory impairment. The behavior was anxious and cooperative. There were no tremors noted. The EENT evaluation revealed bilateral vision impairment and was hard of hearing in the left ear. The patient stated that he needs glasses and hearing aide. The cardiovascular evaluation revealed the bilateral post tibia pulses were weak and he denied chest pain. The respiratory evaluation revealed the respirations were shallow. The breath sounds evaluation revealed the left lower and posterior lungs were diminished with a comment of history of left lung tumor removal. The GI/nutrition evaluation revealed the abdomen was obese. Review of the New Vision Standing Admission Orders, dated [DATE] at 5:40 p.m., revealed the orders were received as telephone orders from the physician to the RN. The orders included to admit to inpatient status, vital signs every 4 hours for twenty four hours, then every 4 hours while awake, call the physician if the blood pressure was less than ,d+[DATE] or greater than ,d+[DATE], and to complete the withdrawal severity nursing assessment every 4 hours for 24 hours then every 4 hours while awake. The standing orders instructed for an electrocardiogram (EKG) on admission if age 50 or older and if history of hypertension or cardiac disease, or as needed for symptoms of chest pain, shortness of breath or palpitations and call the physician. An EKG was performed on [DATE] since the patient was older than [AGE] years. The computerized documented time of the EKG was 4:36 p.m. The EKG machine generated an unconfirmed interpretation of possible anterior infarct (heart attack), age undetermined, Abnormal ECG. There was no documentation revealing the physician was notified of the abnormal EKG. Review of the Admission History dated [DATE] at 6:09 p.m. completed by the RN revealed the admission diagnosis was Acute Alcohol Withdrawal. The documentation noted the patient was currently complaining of shortness of breath. The cardiovascular history revealed hypertension and anticoagulant therapy. The respiratory history noted the patient had asthma and shortness of breath. The home medication inventory receipt dated [DATE] (no time) was completed by the same RN. The form revealed the patient's current home medications were: Lisinopril, Coreg, amox-clav, aspirin, ventolin inhaler and Phenergan syrup. There was no evidence of what the medications were used for, the dosage, frequency, or when the last does was taken. The patient's vital signs at 8:45 p.m. were within normal limits except for the blood pressure of ,d+[DATE]. The RN note at 8:06 p.m. revealed the patient was alert and oriented to person, place and time. There were no tremors noted. The physician was notified and received new order. There was no evidence of new orders from the physician being obtained or written. A Withdrawal Severity Nursing Assessment was completed by the Licensed Practical Nurse (LPN) on [DATE] and documented at 11:21 p.m. The assessment revealed hypertension at ,d+[DATE]. A shift evaluation completed by the LPN at 11:26 p.m. revealed all systems were WDP except respiratory. An entry from respiratory therapy at 9:41 p.m. revealed the patient was receiving oxygen therapy at 3 liters per nasal cannula with a pulse oximetry reading at 97%. Review of the nursing documentation revealed no evidence the admitting physician was notified of the abnormal EKG, the high blood pressure,or abnormal findings on the initial assessment. There was no physician order for oxygen in the clinical record. At 11:00 p.m. the patient received Trazodone 50 mg by mouth for insomnia and Seroquel 50 mg by mouth for anxiety. LPN documentation dated [DATE] at 1:00 a.m., for the New Visions Withdrawal Severity, revealed the patient's heart rate was increased at ,d+[DATE], blood pressure 150 and below, mild sweating, and the patient was oriented to person, place and time. The vital signs at 1:07 a.m. were pulse 111 and blood pressure ,d+[DATE]. Review of the MAR revealed the patient did not receive the scheduled Ativan 1 mg by mouth on [DATE] at 1:57 a.m. because he was lethargic. There was no documentation of notifying the physician of the lethargy as ordered by the physician. Nursing documentation at 3:55 a.m. noted the patient had removed his intravenous line. The vital signs at 5:35 a.m. were pulse 112, respirations 20 and blood pressure ,d+[DATE]. Nursing documentation at 8:21 a.m., by the day shift RN, revealed at approximately 7:10 a.m., went to the patient's room for bedside report with night shift nurse and patient was sleeping in bed naked. Prior to report, night shift nurse informed me that she just put the patient back in bed due to patient being found sleeping in the floor naked and was very confused. According to report patient has been doing this, in various occasions during the night. After finishing report for my other patients, at approximately 7:35 a.m. went back to patient's room and patient was out of the bed and appeared to be sleep walking, snoring with eyes closed. Tried to reorient patient and patient seemed to be still asleep. Put patient back in bed. Comfort measures provided .When I came back to the room to move the patient at approximately 7:40 a.m. the patient was found on the floor unresponsive. Assessed the patient and patient was not breathing and had no pulse. Code blue was called and started cardiopulmonary resuscitation (CPR) immediately. Unable to resuscitate patient after CPR. Physician progress note for [DATE] at 8:00 a.m. code blue note revealed arrived to find patient intubated with CPR in progress. According to nursing staff patient has been confused, lying in floor, curled up in corner, sleeping. Staff had talked to patient within 3 minutes prior to finding him unresponsive. Advanced cardiac life support (ACLS) protocol undertaken by resident staff, patient remained asystole and unresponsive to all interventions. Review of the discharge summery dictated by the admitting physician on [DATE] at 12:41 p.m. revealed the patient had a history of chronic alcoholism who presents with acute alcohol withdrawals. He was admitted and started on the usual withdrawal protocol. The patient was remarkably confused on admit suggestive of acute delirium tremors. He was placed in a quiet room, found to be walking with his eyes closed and had to be redirected. He was found not to be breathing, had no pulse, code blue was called and CPR was started. The patient expired. The documentation noted the patient had underlying heavy alcohol use suggestive of likely sudden death episode likely hypertensive. An interview conducted with the Chief Nursing Officer (CNO) on [DATE] at approximately 4:50 p.m. confirmed the above findings. An interview with patient #5's physician was conducted on [DATE] at approximately 10:30 a.m. The physician stated he did recall the patient. He stated he did not recall being notified of the results of the EKG that indicated a possible Anterior Infarct. He stated he did not recall being notified at any time of the patient's elevated blood pressure readings. Review of nursing documentation did not reveal evidence of the nurse assessing the patient every four hours as ordered. The was no evidence of the admitting physician being notified of an abnormal EKG, Increased blood pressure, shortness of breath, the admitting history, use of oxygen via nasal cannula or home medications. The home medications included medications that may be used for high blood pressure, cardiac problem, nausea, anticoagulation therapy, and an antibiotic. There was no documentation by nursing that the patient had become confused or had a change in behavior, other than the lethargy, during the night. The patient may have experienced harm by the nurse not assessing, evaluating, implementing physician orders and notifying the physician of a patient's changes in condition and needs. 2. Patient #6 was admitted to the Medical Stabilization Unit at 5:06 p.m. on [DATE] for medical stabilization of acute withdrawal from drugs. Review of the Withdrawal Severity Nursing Assessments revealed the assessment was not performed every 4 hours for 24 hours and then every 4 hours while awake as ordered by the physician. The Withdrawal Severity Nursing Assessment was documented on [DATE] at 8:00 p.m., on [DATE] at 12:31 a.m., 8:00 a.m., 4:00 p.m. and 8:00 p.m. The assessment was not done every four hours as ordered by the physician. The assessment was performed on [DATE] at 12:00 p.m. and 8:00 p.m. There was no evidence of the assessment being performed every four hours while awake or note if the patient was asleep. Patient #6's New Vision Standing Orders showed the physician signed the admission orders on the day of the patient's admission, [DATE] at 5:40 p.m. There was a progress note dated on [DATE] (no time noted). Review of the record failed to reveal documentation that the nursing staff had notified the chain of command that the patient had not been seen by her physician since arriving at the hospital for a period of over 24 hours. An interview was conducted on [DATE] at 11:15 a.m. with the New Vision patient. On entrance to the patient's room, the patient was observed to be sitting on her bed working on a laptop computer. She stated that she had just seen her physician for the first time this morning [DATE], on her 4th hospital day. An interview with the CNO and [NAME] President of Quality/Risk Management conducted on [DATE] at approximately 11:40 a.m. confirmed the above findings. 3. Patient #7 was admitted to the Medical Stabilization Unit on [DATE] at 2:50 p.m. for medical stabilization for acute alcohol withdrawal. Review of physician orders dated [DATE] at 4:40 p.m. indicated the patient was to be assessed every four hour for twenty four hours then every four hours while awake. The Withdrawal Severity Nursing Assessment was not performed every 4 hours for 24 hours as ordered by the physician. The Withdrawal Severity Nursing Assessment was documented on [DATE] at 4:00 p.m. and 8:01 p.m. On [DATE] at 8:00 a.m.,12:00 p.m. and 4:00 p.m. 4. Patient #8 was admitted to the Medical Stabilization Unit on [DATE] at 1:01 p.m. for medical stabilization for acute alcohol withdrawal. The Withdrawal Severity Nursing Assessment was not performed every 4 hours for 24 hours and then every 4 hours while awake as ordered by the physician on [DATE] at 2:15 p.m. The Withdrawal Severity Nursing Assessment was documented on [DATE] at 2:00 p.m. and 6:00 p.m. and on [DATE] at 8:00 a.m. The assessment was not performed every four hours for twenty four hours. On [DATE] at 8:00 a.m., 12:00 p.m. and 4:00 p.m. On [DATE] at 8:00 a.m., 12:00 p.m., 4:00 p.m. and 9:00 p.m. On [DATE] at 8:15 a.m., 11:04 a.m. and 8:00 p.m. There was no evidence of the patient being assessed every four hours while awake or if the patient was asleep. 5. Patient #9 was admitted to the Medical Stabilization Unit of the facility on [DATE] at 7:28 p.m. for medical stabilization of acute opiate (narcotic) withdrawal. The Withdrawal Severity Nursing Assessment was not performed every 4 hours for 24 hours and then every 4 hours while awake as ordered by the physician on [DATE] at 9:10 p.m. The Withdrawal Severity Nursing Assessment was documented on [DATE] at 8:53 p.m. On [DATE] at 12:00 a.m., 6:00 a.m., 8:59 a.m., 1:00 p.m., 5:00 p.m. and 8:00 p.m. The assessment was not performed every four hours. on [DATE] at 8:00 a.m., 4:00 p.m. 8:00 p.m. The assessment was not performed every four hours while awake or noted if the patient was asleep. 6. An interview with the Chief Nursing Officer (CNO) was conducted on [DATE] at approximately 4:50 p.m. while reviewing the electronic medical record for Patient #5. The CNO confirmed the computer screen the nurses used to view the physician's order for the Withdrawal Severity Nursing Assessment only permitted part of the order to appear. Instead of seeing the actual order to perform the assessment every 4 hours for 24 hours, the computer screen shows every 4 hours x 2. The CNO confirmed this would affect the nursing implementation of physician orders for the Withdrawal Severity Nursing Assessment for every patient admitted to the Medical Stabilization Unit since the inception of the program in [DATE]. The CNO stated the facility admitted an average of ,d+[DATE] patients per month to the Medical Stabilization Unit. An interview with the Nurse Manager of the Medical Stabilization Unit was conducted on [DATE] at approximately 4:40 p.m. The Nurse Manager was questioned during the interview regarding what had been done to correct the problem with the computer screen displaying only a portion of the physicians orders for the Withdrawal Severity Nursing Assessment. The Nurse Manager stated that she had emailed her contact that day in Health Information Technology and was awaiting a response. The lack of nursing assessments, providing care as ordered by the physician and notifying the physician of changes in the patient's condition places current and future patients in the New Vision program a risk for harm. A review of the facility's Quality Assurance Performance Improvement documentation from ,d+[DATE] to ,d+[DATE] failed to reveal any integration of the New Vision Medical Stabilization Services with the Quality Assurance performance Improvement Plan. An interview was conducted on ,d+[DATE] and [DATE] with the Chief Nursing Officer, Risk Manager and [NAME] President of the Quality Assurance. The participants were questioned concerning the Quality Assurance program for the New Vision Services. They responded the only they were tracking was based upon how many patients had been admitted since the program opened. There had not been any tracking or trending of the services to ascertain how the program was functioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31098 Based on record and facility document review and staff interview it was determined the facility failed to initiate tracking of indicators following an adverse incident (#5) and for patients (#6, #7, #8, #9) in the New Vision Program, which was a new program for medical stabilization for alcohol and drug detoxification. This resulted in continued lack of nursing assessment of the Withdrawal Severity Nursing Assessment per physician orders for five of five patients and failure to inform the physician of abnormal test result and changes in condition for one (#5) of five patients in the New Vision Program. This practice places patients at risk of a delay in treatment and prevention of injury related to withdrawal symptoms in the New Vision patients. Findings include: 1. Patient #5 was admitted on [DATE] at 3:52 p.m. with an admitting diagnosis of acute alcohol withdrawal. Review of nursing documentation dated [DATE] at 4:31 p.m. revealed the patient's vital signs were within normal limits except for a blood pressure of ,d+[DATE] and an oxygen saturation level of 93%. Review of the Admission Assessment completed by the registered nurse (RN) on [DATE] at 5:36 p.m. revealed the following assessments were not Within Defined Parameters (WDP): Neurological, ears, eyes, nose and throat (EENT), cardiovascular and gastrointestinal(GI)/nutrition. The patient currently had no pain. The neurological evaluation revealed the patient was alert, awake and oriented. His speech was soft. His left and right hand grips were weak. He had distant and recent past memory impairment. The behavior was anxious and cooperative. There were no tremors noted. The EENT evaluation revealed bilateral vision impairment and was hard of hearing in the left ear. The patient stated that he needs glasses and hearing aide. The cardiovascular evaluation revealed the bilateral post tibia pulses were weak and he denied chest pain. The respiratory evaluation revealed the respirations were shallow. The breath sounds evaluation revealed the left lower and posterior lungs were diminished with a comment of history of left lung tumor removal. The GI/nutrition evaluation revealed the abdomen was obese. Review of the New Vision Standing Admission Orders, dated [DATE] at 5:40 p.m., revealed the orders were received as telephone orders from the physician to the RN. The orders included to admit to inpatient status, vital signs every 4 hours for twenty four hours, then every 4 hours while awake, call the physician if the blood pressure was less than ,d+[DATE] or greater than ,d+[DATE], and to complete the withdrawal severity nursing assessment every 4 hours for 24 hours then every 4 hours while awake. The standing orders instructed for an electrocardiogram (EKG) on admission if age 50 or older and if history of hypertension or cardiac disease, or as needed for symptoms of chest pain, shortness of breath or palpitations and call the physician. An EKG was performed on [DATE] since the patient was older than [AGE] years. The computerized documented time of the EKG was 4:36 p.m. The EKG machine generated an unconfirmed interpretation of possible anterior infarct (heart attack), age undetermined, Abnormal ECG. There was no documentation revealing the physician was notified of the abnormal EKG. Review of the Admission History dated [DATE] at 6:09 p.m. completed by the RN revealed the admission diagnosis was Acute Alcohol Withdrawal. The documentation noted the patient was currently complaining of shortness of breath. The cardiovascular history revealed hypertension and anticoagulant therapy. The respiratory history noted the patient had asthma and shortness of breath. The home medication inventory receipt dated [DATE] (no time) was completed by the same RN. The form revealed the patient's current home medications were: Lisinopril, Coreg, amox-clav, aspirin, ventolin inhaler and Phenergan syrup. There was no evidence of what the medications were used for, the dosage, frequency, or when the last does was taken. The patient's vital signs at 8:45 p.m. were within normal limits except for the blood pressure of ,d+[DATE]. The RN note at 8:06 p.m. revealed the patient was alert and oriented to person, place and time. There were no tremors noted. The physician was notified and received new order. There was no evidence of new orders from the physician being obtained or written. A Withdrawal Severity Nursing Assessment was completed by the Licensed Practical Nurse (LPN) on [DATE] and documented at 11:21 p.m. The assessment revealed hypertension at ,d+[DATE]. A shift evaluation completed by the LPN at 11:26 p.m. revealed all systems were WDP except respiratory. An entry from respiratory therapy at 9:41 p.m. revealed the patient was receiving oxygen therapy at 3 liters per nasal cannula with a pulse oximetry reading at 97%. Review of the nursing documentation revealed no evidence the admitting physician was notified of the abnormal EKG, the high blood pressure,or abnormal findings on the initial assessment. There was no physician order for oxygen in the clinical record. At 11:00 p.m. the patient received Trazodone 50 mg by mouth for insomnia and Seroquel 50 mg by mouth for anxiety. LPN documentation dated [DATE] at 1:00 a.m., for the New Visions Withdrawal Severity, revealed the patient's heart rate was increased at ,d+[DATE], blood pressure 150 and below, mild sweating, and the patient was oriented to person, place and time. The vital signs at 1:07 a.m. were pulse 111 and blood pressure ,d+[DATE]. Review of the MAR revealed the patient did not receive the scheduled Ativan 1 mg by mouth on [DATE] at 1:57 a.m. because he was lethargic. There was no documentation of notifying the physician of the lethargy as ordered by the physician. Nursing documentation at 3:55 a.m. noted the patient had removed his intravenous line. The vital signs at 5:35 a.m. were pulse 112, respirations 20 and blood pressure ,d+[DATE]. Nursing documentation at 8:21 a.m., by the day shift RN, revealed at approximately 7:10 a.m., went to the patient's room for bedside report with night shift nurse and patient was sleeping in bed naked. Prior to report, night shift nurse informed me that she just put the patient back in bed due to patient being found sleeping in the floor naked and was very confused. According to report patient has been doing this, in various occasions during the night. After finishing report for my other patients, at approximately 7:35 a.m. went back to patient's room and patient was out of the bed and appeared to be sleep walking, snoring with eyes closed. Tried to reorient patient and patient seemed to be still asleep. Put patient back in bed. Comfort measures provided .When I came back to the room to move the patient at approximately 7:40 a.m. the patient was found on the floor unresponsive. Assessed the patient and patient was not breathing and had no pulse. Code blue was called and started cardiopulmonary resuscitation (CPR) immediately. Unable to resuscitate patient after CPR. Physician progress note for [DATE] at 8:00 a.m. code blue note revealed arrived to find patient intubated with CPR in progress. According to nursing staff patient has been confused, lying in floor, curled up in corner, sleeping. Staff had talked to patient within 3 minutes prior to finding him unresponsive. Advanced cardiac life support (ACLS) protocol undertaken by resident staff, patient remained asystole and unresponsive to all interventions. Review of the discharge summery dictated by the admitting physician on [DATE] at 12:41 p.m. revealed the patient had a history of chronic alcoholism who presents with acute alcohol withdrawals. He was admitted and started on the usual withdrawal protocol. The patient was remarkably confused on admit suggestive of acute delirium tremors. He was placed in a quiet room, found to be walking with his eyes closed and had to be redirected. He was found not to be breathing, had no pulse, code blue was called and CPR was started. The patient expired. The documentation noted the patient had underlying heavy alcohol use suggestive of likely sudden death episode likely hypertensive. An interview conducted with the Chief Nursing Officer (CNO) on [DATE] at approximately 4:50 p.m. confirmed the above findings. An interview with patient #5's physician was conducted on [DATE] at approximately 10:30 a.m. The physician stated he did recall the patient. He stated he did not recall being notified of the results of the EKG that indicated a possible Anterior Infarct. He stated he did not recall being notified at any time of the patient's elevated blood pressure readings. Review of nursing documentation did not reveal evidence of the nurse assessing the patient every four hours as ordered. The was no evidence of the admitting physician being notified of an abnormal EKG, Increased blood pressure, shortness of breath, the admitting history, use of oxygen via nasal cannula or home medications. The home medications included medications that may be used for high blood pressure, cardiac problem, nausea, anticoagulation therapy, and an antibiotic. There was no documentation by nursing that the patient had become confused or had a change in behavior, other than the lethargy, during the night. The patient may have experienced harm by the nurse not assessing, evaluating, implementing physician orders and notifying the physician of a patient's changes in condition and needs. 2. Patient #6 was admitted to the Medical Stabilization Unit at 5:06 p.m. on [DATE] for medical stabilization of acute withdrawal from drugs. Review of the Withdrawal Severity Nursing Assessments revealed the assessment was not performed every 4 hours for 24 hours and then every 4 hours while awake as ordered by the physician. The Withdrawal Severity Nursing Assessment was documented on [DATE] at 8:00 p.m., on [DATE] at 12:31 a.m., 8:00 a.m., 4:00 p.m. and 8:00 p.m. The assessment was not done every four hours as ordered by the physician. The assessment was performed on [DATE] at 12:00 p.m. and 8:00 p.m. There was no evidence of the assessment being performed every four hours while awake or note if the patient was asleep. Patient #6's New Vision Standing Orders showed the physician signed the admission orders on the day of the patient's admission, [DATE] at 5:40 p.m. There was a progress note dated on [DATE] (no time noted). Review of the record failed to reveal documentation that the nursing staff had notified the chain of command that the patient had not been seen by her physician since arriving at the hospital for a period of over 24 hours. An interview was conducted on [DATE] at 11:15 a.m. with the New Vision patient. On entrance to the patient's room, the patient was observed to be sitting on her bed working on a laptop computer. She stated that she had just seen her physician for the first time this morning [DATE], on her 4th hospital day. An interview with the CNO and [NAME] President of Quality/Risk Management conducted on [DATE] at approximately 11:40 a.m. confirmed the above findings. 3. Patient #7 was admitted to the Medical Stabilization Unit on [DATE] at 2:50 p.m. for medical stabilization for acute alcohol withdrawal. Review of physician orders dated [DATE] at 4:40 p.m. indicated the patient was to be assessed every four hour for twenty four hours then every four hours while awake. The Withdrawal Severity Nursing Assessment was not performed every 4 hours for 24 hours as ordered by the physician. The Withdrawal Severity Nursing Assessment was documented on [DATE] at 4:00 p.m. and 8:01 p.m. On [DATE] at 8:00 a.m.,12:00 p.m. and 4:00 p.m. 4. Patient #8 was admitted to the Medical Stabilization Unit on [DATE] at 1:01 p.m. for medical stabilization for acute alcohol withdrawal. The Withdrawal Severity Nursing Assessment was not performed every 4 hours for 24 hours and then every 4 hours while awake as ordered by the physician on [DATE] at 2:15 p.m. The Withdrawal Severity Nursing Assessment was documented on [DATE] at 2:00 p.m. and 6:00 p.m. and on [DATE] at 8:00 a.m. The assessment was not performed every four hours for twenty four hours. On [DATE] at 8:00 a.m., 12:00 p.m. and 4:00 p.m. On [DATE] at 8:00 a.m., 12:00 p.m., 4:00 p.m. and 9:00 p.m. On [DATE] at 8:15 a.m., 11:04 a.m. and 8:00 p.m. There was no evidence of the patient being assessed every four hours while awake or if the patient was asleep. 5. Patient #9 was admitted to the Medical Stabilization Unit of the facility on [DATE] at 7:28 p.m. for medical stabilization of acute opiate (narcotic) withdrawal. The Withdrawal Severity Nursing Assessment was not performed every 4 hours for 24 hours and then every 4 hours while awake as ordered by the physician on [DATE] at 9:10 p.m. The Withdrawal Severity Nursing Assessment was documented on [DATE] at 8:53 p.m. On [DATE] at 12:00 a.m., 6:00 a.m., 8:59 a.m., 1:00 p.m., 5:00 p.m. and 8:00 p.m. The assessment was not performed every four hours. on [DATE] at 8:00 a.m., 4:00 p.m. 8:00 p.m. The assessment was not performed every four hours while awake or noted if the patient was asleep. 6. An interview with the Chief Nursing Officer (CNO) was conducted on [DATE] at approximately 4:50 p.m. while reviewing the electronic medical record for Patient #5. The CNO confirmed the computer screen the nurses used to view the physician's order for the Withdrawal Severity Nursing Assessment only permitted part of the order to appear. Instead of seeing the actual order to perform the assessment every 4 hours for 24 hours, the computer screen shows every 4 hours x 2. The CNO confirmed this would affect the nursing implementation of physician orders for the Withdrawal Severity Nursing Assessment for every patient admitted to the Medical Stabilization Unit since the inception of the program in [DATE]. The CNO stated the facility admitted an average of ,d+[DATE] patients per month to the Medical Stabilization Unit. An interview with the Nurse Manager of the Medical Stabilization Unit was conducted on [DATE] at approximately 4:40 p.m. The Nurse Manager was questioned during the interview regarding what had been done to correct the problem with the computer screen displaying only a portion of the physicians orders for the Withdrawal Severity Nursing Assessment. The Nurse Manager stated that she had emailed her contact that day in Health Information Technology and was awaiting a response. The lack of nursing assessments, providing care as ordered by the physician and notifying the physician of changes in the patient's condition places current and future patients in the New Vision program a risk for harm. A review of the facility's Quality Assurance Performance Improvement documentation from ,d+[DATE] to ,d+[DATE] failed to reveal any integration of the New Vision Medical Stabilization Services with the Quality Assurance performance Improvement Plan. An interview was conducted on ,d+[DATE] and [DATE] with the Chief Nursing Officer, Risk Manager and [NAME] President of the Quality Assurance. The participants were questioned concerning the Quality Assurance program for the New Vision Services. They responded the only they were tracking was based upon how many patients had been admitted since the program opened. There had not been any tracking or trending of the services to ascertain how the program was functioning.

29015 31098 Based on record review, policy review and staff interview, the nursing staff : failed to identify and notify the physician of an abnormal EKG obtained on patient (#5) on admission (possible Anterior Infarct age undetermined) and failed to notify to physician (of a patient who the physician did not know) of the medical history, high blood pressure, and home medications that included Lisinopril, Coreg, Aspirin, Phenergan, Ventolin and Amox-clav. the patient was admitted to the New Vision Program for acute alcohol detoxification. The patient was found on the floor without a heart rate or respirations and subsequently expired approximately fifteen hours after admission. (refer to A0395) failed to provide physician ordered patient assessment for patients in the New Vision Program for alcohol and drug detoxification for 5 (#5, #6, #7, #8, #9) of 5 sampled patients in the program. (Refer to A0395) failed to notify the physician of changes in a patient's (#5) condition that included neurological, respiratory, and vital signs that were not within defined parameters for patients in the New Vision Program for alcohol and drug detoxification. (Refer to A0395) failed to follow accepted standard of practice in the administration of medications for one (#2) patient of ten sampled patients with a known allergy over a six day period. (Refer to A0405) The cumulative effect of the failure of the nursing staff to assess, implement physician orders, notify the physician of changes in condition, failure to inform the physician of new admission needs and failure to ensure medications with known allergies are not administered to the patient has resulted in the determination that the Condition of Participation for Nursing Services is out of compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31098 Based on clinical record review, staff interview and policy review it was determined the Registered Nurse failed to supervise and evaluate care for five (#5, #6, #7, #8, #9) of five New Vision patients of ten sampled patients related to informing the physician of critical values, changes in the patient's condition, assess patient's per physician orders, and verify and inform the physician of the patient's home medications needs and prior medical history. This practice may have lead to the potential delay in treatment that may result in the death or injury to a patient seeking care in the New Vision program. Findings include: A review of the facility's policy, Care of the patient for Medical Stabilization in New Vision Service: Withdrawal Severity Nursing Assessment policy #Gen 065, dated ,d+[DATE], paragraph 1) indicated patients receiving medical stabilization with the New Vision Service will receive a nursing assessment every (4) hours for the initial twenty-four hours of admission and every (4) hours while awake thereafter, for signs and symptoms of impending or active withdrawal. Review of the Medical Staff Bylaws Page 5. 2. Frequency of Physician Visits indicated The patient shall be seen by a physician every day. 1. Patient #5's face sheet and registration form dated [DATE] at 3:52 p.m. noted the patient's admitting diagnosis was acute alcohol withdrawal. Review of nursing documentation dated [DATE] at 4:31 p.m. revealed the patient's vital signs were within normal limits except for a blood pressure of ,d+[DATE] and an oxygen saturation level of 93%. Review of the Admission Assessment completed by the registered nurse (RN) on [DATE] at 5:36 p.m. revealed the following assessments were not Within Defined Parameters (WDP): Neurological, ears, eyes, nose and throat (EENT), cardiovascular and gastrointestinal(GI)/nutrition. The patient currently had no pain. The neurological evaluation revealed the patient was alert, awake and oriented. His speech was soft. His left and right hand grips were weak. He had distant and recent past memory impairment. The behavior was anxious and cooperative. There were no tremors noted. The EENT evaluation revealed bilateral vision impairment and was hard of hearing in the left ear. The patient stated that he needs glasses and hearing aide. The cardiovascular evaluation revealed the bilateral post tibia pulses were weak and he denied chest pain. The respiratory evaluation revealed the respirations were shallow and unlabored. The breath sounds evaluation revealed the left lower and posterior lungs were diminished with a comment of history of left lung tumor removal. The GI/nutrition evaluation revealed the abdomen was obese. The patient stated that he always had a large abdomen. Review of the New Vision Standing Admission Orders, dated [DATE] at 5:40 p.m., revealed the orders were received as telephone orders from the physician to the RN. The orders included to admit to inpatient status, vital signs every 4 hours for twenty four hours, then every 4 hours while awake, call the physician if the blood pressure was less than ,d+[DATE] or greater than ,d+[DATE], and to complete the withdrawal severity nursing assessment every 4 hours for 24 hours then every 4 hours while awake. The standing orders instructed for an electrocardiogram (EKG) on admission if age 50 or older and if history of hypertension or cardiac disease, or as needed for symptoms of chest pain, shortness of breath or palpitations and call the physician. An EKG was performed on [DATE] since the patient was older than [AGE] years. The computerized documented time of the EKG was 4:36 p.m. The EKG machine generated unconfirmed interpretation was possible anterior infarct (heart attack), age undetermined, Abnormal ECG. There was no documentation revealing the physician was notified of the abnormal EKG. Review of the Admission History dated [DATE] at 6:09 p.m. completed by the RN revealed the patient arrived from home accompanied by family. The admission diagnosis was listed as Acute Alcohol Withdrawal. The documentation noted the patient was currently complaining of shortness of breath. The cardiovascular history revealed hypertension and anticoagulant therapy. The respiratory history noted the patient had asthma and shortness of breath. The home medication inventory receipt dated [DATE] (no time) was completed by the same RN who completed the Admission Assessment and history. The form revealed the patient's current home medications were: Lisinopril, Coreg, amox-clav, aspirin, ventolin inhaler and Phenergan syrup. There was no evidence of what the medications were used for, the dosage, frequency, or when the last does was taken. The patient's vital signs at 8:45 p.m. were within normal limits except for the blood pressure of ,d+[DATE]. The RN note at 8:06 p.m. revealed the patient was alert and oriented to person, place and time. There were no tremors noted. The physician was notified and received new order. There was no evidence of new orders from the physician being obtained or written. A Withdrawal Severity Nursing Assessment was completed by the Licensed Practical Nurse (LPN) on [DATE] and documented at 11:21 p.m. The assessment revealed hypertension at ,d+[DATE]. A shift evaluation completed by the LPN at 11:26 p.m. revealed all systems were WDP except respiratory. An entry from respiratory therapy at 9:41 p.m. revealed the patient was receiving oxygen therapy at 3 liters per nasal cannula with a pulse oximetry reading at 97%. Review of the nursing documentation revealed no evidence the admitting physician was notified of the abnormal EKG, the high blood pressure,or abnormal findings on the initial assessment. There was no physician order for oxygen in the clinical record. Review of the standing admission physician telephone orders for medications included catapress TTS 0.1 milligrams (mg) patch; apply to skin every 7 days, Ativan 1 mg intramuscularly (IM) now and at 9:30 p.m. Catapress 0.1 mg by mouth every 4 hours as needed (hold for blood pressure < ,d+[DATE]). Ativan Taper day 1-Ativan 1 mg by mouth every 4 hours, day 2-Ativan 1 mg by mouth every 6 hours x 4 doses, and day 3-Ativan 1 mg by mouth every 8 hours as needed for withdrawal symptoms. If the patient becomes drowsy notify the physician. Review of the Medication Administration Record (MAR) dated [DATE] at 7:51 p.m. revealed the patient received Ativan 1 mg IM and the other 1 mg IM at 9:30 p.m. The patient also received Ativan 1 mg by mouth at 7:14 p.m. and 10:59 p.m. At 11:00 p.m. the patient received Trazodone 50 mg by mouth for insomnia and Seroquel 50 mg by mouth for anxiety. LPN documentation dated [DATE] at 1:00 a.m., for the New Visions Withdrawal Severity, revealed the patient's heart rate was increased at ,d+[DATE], blood pressure 150 and below, mild sweating, and the patient was oriented to person, place and time. The vital signs at 1:07 a.m. were pulse 111 and blood pressure ,d+[DATE]. Review of the MAR revealed the patient did not receive the scheduled Ativan 1 mg by mouth on [DATE] at 1:57 a.m. because he was lethargic. There was no documentation of notifying the physician of the lethargy as ordered by the physician. Nursing documentation at 3:55 a.m. noted the patient had removed his intravenous line. The vital signs at 5:35 a.m. were pulse 112, respirations 20 and blood pressure ,d+[DATE]. Nursing documentation at 8:21 a.m., by the day shift RN, revealed at approximately 7:10 a.m., went to the patient's room for bedside report with night shift nurse and patient was sleeping in bed naked. Prior to report, night shift nurse informed me that she just put the patient back in bed due to patient being found sleeping in the floor naked and was very confused. According to report patient has been doing this, in various occasions during the night. After finishing report for my other patients, at approximately 7:35 a.m. went back to patient's room and patient was out of the bed and appeared to be sleep walking, snoring with eyes closed. Tried to reorient patient and patient seemed to be still asleep. Put patient back in bed. Comfort measures provided .When I came back to the room to move the patient at approximately 7:40 a.m. the patient was found on the floor unresponsive. Assessed the patient and patient was not breathing and had no pulse. Code blue was called and started cardiopulmonary resuscitation (CPR) immediately. Unable to resuscitate patient after CPR. Physician progress note for [DATE] at 8:00 a.m. code blue note revealed arrived to find patient intubated with CPR in progress. According to nursing staff patient has been confused, lying in floor, curled up in corner, sleeping. Staff had talked to patient within 3 minutes prior to finding him unresponsive. Advanced cardiac life support (ACLS) protocol undertaken by resident staff, patient remained asystole and unresponsive to all interventions. Review of the discharge summery dictated by the admitting physician on [DATE] at 12:41 p.m. revealed the patient had a history of chronic alcoholism who presents with acute alcohol withdrawals. He was admitted and started on the usual withdrawal protocol. The patient was remarkably confused on admit suggestive of acute delirium tremors. He was placed in a quiet room, found to be walking with his eyes closed and had to be redirected. He was found not to be breathing, had no pulse, code blue was called and CPR was started. The patient expired. The documentation noted the patient had underlying heavy alcohol use suggestive of likely sudden death episode likely hypertensive. An interview conducted with the Chief Nursing Officer (CNO) on [DATE] at approximately 4:50 p.m. confirmed the above findings. An interview with patient #5's physician was conducted on [DATE] at approximately 10:30 a.m. The physician stated he did recall the patient. He stated he did not recall being notified of the results of the EKG that indicated a possible Anterior Infarct. He stated he did not recall being notified at any time of the patient's elevated blood pressure readings. Review of nursing documentation did not reveal evidence of the nurse assessing the patient every four hours as ordered. There was no evidence of the admitting physician being notified of an abnormal EKG, Increased blood pressure, shortness of breath, the admitting history, use of oxygen via nasal cannula or home medications. The home medications included medications that may be used for high blood pressure, cardiac problem, nausea, anticoagulation therapy, and an antibiotic. There was no documentation by nursing that the patient had become confused or had a change in behavior, other than the lethargy, during the night. The patient may have experienced harm by the nurse not assessing, evaluating, implementing physician orders and notifying the physician of a change in a patient's condition or the patient's needs. 2. Patient #6 was admitted to the Medical Stabilization Unit at 5:06 p.m. on [DATE] for medical stabilization of acute withdrawal from drugs. Review of the Withdrawal Severity Nursing Assessments revealed the assessment was not performed every 4 hours for 24 hours and then every 4 hours while awake as ordered by the physician. The Withdrawal Severity Nursing Assessment was documented on [DATE] at 8:00 p.m., on [DATE] at 12:31 a.m., 8:00 a.m., 4:00 p.m. and 8:00 p.m. The assessment was not done every four hours as ordered by the physician. The assessment was performed on [DATE] at 12:00 p.m. and 8:00 p.m. There was no evidence of the assessment being performed every four hours while awake or if the patient was asleep. Patient #6's New Vision Standing Orders showed the physician signed the admission orders on the day of the patient's admission, [DATE] at 5:40 p.m. There was a progress note dated on [DATE] (no time noted). Review of the record failed to reveal documentation that the nursing staff had notified the chain of command that the patient had not been seen by her physician since arriving at the hospital for a period of over 24 hours. An interview was conducted on [DATE] at 11:15 a.m. with the New Vision patient. On entrance to the patient's room, the patient was observed to be sitting on her bed working on a laptop computer. She stated that she had just seen her physician for the first time this morning [DATE], on her 4th hospital day. An interview with the CNO and [NAME] President of Quality/Risk Management conducted on [DATE] at approximately 11:40 a.m. confirmed the above findings. 3. Patient #7 was admitted to the Medical Stabilization Unit on [DATE] at 2:50 p.m. for medical stabilization for acute alcohol withdrawal. Review of physician orders dated [DATE] at 4:40 p.m. indicated the patient was to be assessed every four hour for twenty four hours then every four hours while awake. The Withdrawal Severity Nursing Assessment was not performed every 4 hours for 24 hours as ordered by the physician. The Withdrawal Severity Nursing Assessment was documented on [DATE] at 4:00 p.m. and 8:01 p.m. and on [DATE] at 8:00 a.m.,12:00 p.m. and 4:00 p.m. 4. Patient #8 was admitted to the Medical Stabilization Unit on [DATE] at 1:01 p.m. for medical stabilization for acute alcohol withdrawal. The Withdrawal Severity Nursing Assessment was not performed every 4 hours for 24 hours and then every 4 hours while awake as ordered by the physician on [DATE] at 2:15 p.m. The Withdrawal Severity Nursing Assessment was documented on [DATE] at 2:00 p.m. and 6:00 p.m. On [DATE] at 8:00 a.m. The assessment was not performed every four hours for twenty four hours. The assessment was documented on [DATE] at 8:00 a.m., 12:00 p.m. and 4:00 p.m. On [DATE] at 8:00 a.m., 12:00 p.m., 4:00 p.m. and 9:00 p.m. and on [DATE] at 8:15 a.m., 11:04 a.m. and 8:00 p.m. There was no evidence of the patient being assessed every four hours while awake or if the patient was asleep. 5. Patient #9 was admitted to the Medical Stabilization Unit of the facility on [DATE] at 7:28 p.m. for medical stabilization of acute opiate (narcotic) withdrawal. The Withdrawal Severity Nursing Assessment was not performed every 4 hours for 24 hours and then every 4 hours while awake as ordered by the physician on [DATE] at 9:10 p.m. The Withdrawal Severity Nursing Assessment was documented on [DATE] at 8:53 p.m. and on [DATE] at 12:00 a.m., 6:00 a.m., 8:59 a.m., 1:00 p.m., 5:00 p.m. and 8:00 p.m. The assessment was not documented every four hours. on [DATE] at 8:00 a.m., 4:00 p.m. 8:00 p.m. The assessment was not performed every four hours while awake or noted if the patient was asleep. An interview with the Chief Nursing Officer (CNO) was conducted on [DATE] at approximately 4:50 p.m. while reviewing the electronic medical record for Patient #5. The CNO confirmed the computer screen the nurses used to view the physician's order for the Withdrawal Severity Nursing Assessment only permitted part of the order to appear. Instead of seeing the actual order to perform the assessment every 4 hours for 24 hours, the computer screen shows every 4 hours x 2. The CNO confirmed this would affect the nursing implementation of physician orders for the Withdrawal Severity Nursing Assessment for every patient admitted to the Medical Stabilization Unit since the inception of the program in [DATE]. The CNO stated the facility admitted an average of ,d+[DATE] patients per month to the Medical Stabilization Unit. An interview with the Nurse Manager of the Medical Stabilization Unit was conducted on [DATE] at approximately 4:40 p.m. The Nurse Manager was questioned during the interview regarding what had been done to correct the problem with the computer screen displaying only a portion of the physicians orders for the Withdrawal Severity Nursing Assessment. The Nurse Manager stated that she had emailed her contact that day in Health Information Technology and was awaiting a response. The lack of nursing assessments, providing care as ordered by the physician, and notifying the physician of changes in the patient's condition placed current and future patients in the New Vision program a risk for harm.

31098 Based on record review, interview and policy review it was determined the nursing staff failed to follow accepted standard of practice for administration of medication for 1 (#2) of 10 sampled patients by administering medication with known allergies. The practice may cause harm to patients and lead to a prolonged hospital stay. Findings include: Patient #2's admission physician orders dated 5/23/12 at 8:30 a.m. revealed allergies to Iodine, Codeine and Aspirin. A review of the History and Physical dictated on 5/23/12 at 10:40 a.m. revealed allergies to codeine, aspirin, and Iodine. It noted the medications would give the patient a rash. A review of the Nursing Admission Assessment, completed on 5/23/12 at 11:23 a.m. revealed the patient was allergic to Iodine-causes Hives, Codeine-causes Dyspnea and Aspirin-causes Nausea. Review of the Pulmonology/Critical care consultation dictated on 5/25/12 at 1:17 p.m. revealed the patient was allergic to codeine, aspirin and iodine. A review of the physician orders dated 5/31/12 at 10:15 p.m. revealed an order for aspirin 325 milligrams (mg) crushed now and then every 24 hours. A review of the Cardiology Consultation dictated 6/1/12 at 9:08 a.m. revealed allergies to codeine, aspirin and Iodine. They all cause a rash. Review of the Medication Administration Record (MAR), revealed the patient received Aspirin on 5/31/12, 6/1/12, 6/2/12, 6/4/12, and on 6/5/12. Review of nursing notes documentation dated 5/25/12 at 1:41 a.m. revealed urinary catheter was inserted using an aseptic technique. A review of the urinary insertion catheter kit used by the Intensive Care Unit (ICU) revealed the contents included povidone-Iodine solution. The patient was allergic to Iodine. A telephone interview was conducted with patient #2 on 6/13/12 at 4:45 p.m. The interview revealed she had a severe vaginal area rash. A review of the Nursing documentation from 5/31/12 to 6/5/12 did not reveal any communication with the physician concerning the patient being allergic to the aspirin or Iodine. An interview with the Chief Nursing Officer on 6/14/12 at approximately 4:30 p.m. revealed if a medication is profiled as an allergy, then nursing would not be able to give the medication. A review of the facility policy administration of medications, policy #MED 005, reviewed 9/11, revealed on page 1 of 2, paragraph 4,know the desired effects, toxic effects, side effects and contraindications of drug being administered .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 19139 Based on record review and staff interview the Registered Nurse failed to ensure appropriate nursing care for 6 (#1, #4, #5, #6, #8, #10) of 10 sampled patients related to wound care, intravenous therapy, and implementing physician orders. This practice does not ensure patient's goals are achieved. Findings include: 1. Patient #1 was admitted to the facility on [DATE]. Review of nursing documentation revealed the following inconsistencies related to the skin assessments. On 6/9/11 at 8:00 a.m. the wounds were documented on the sacrum, buttocks, right upper extremity and right heel. On 6/11/11 at 9:00 p.m. only the sacral wounds were assessed. On 6/12/11 only the sacral wounds were assessed. On 6/13/11, the wound appearance of the wound bed of an open wound was not documented. On 6/16/11 at 7:30 p.m. and 6/17/11 at 8:26 a.m. and 7:30 p.m. there was no assessment of the condition of the skin. On 6/18/11 at 8:00 a.m. there was no assessment of the wound on the heel. On 6/18/11 at 7:15 p.m. and on 6/19/11 at 8:10 p.m. there was no assessment of the skin. The wound care nurse was consulted on 6/15/11 and documented that the sacral wound was unstagable as it was covered with yellow slough. Until that time, the nursing staff had documented nursing interventions such as an alternating air mattress, turning every two hours and floating of the heels. The patient was transferred from the Intensive Care Unit to the Progressive Care Unit on 6/16/11. On 6/16/11 after the patient was transferred, there was no documentation of the pressure ulcer prevention interventions. There was also no documentation of the interventions on 6/17/11 and 6/18/11. The Chief Nursing Officer confirmed the above findings during interview on 7/1/11 at approximately 3:30 p.m. 2. Review of the medical record of patient #10 revealed the following inconsistencies regarding skin assessment. On 6/29/11 at 9:00 p.m. wounds were identified on the left forearm and left heel, but the appearance of the wound was not documented. On 7/1/11 at 6:27 a.m. and 8:00 a.m. the assessment of the wound on the left heel was not documented. The finding was confirmed by the nursing director on 7/1/11 at 3:20 p.m. The facility's policy Intravenous Therapy # IV 001, last revised 11/10, required that the assessment of the Intravenous (IV) site be done every 4 hours. 3. Review of the medical record of patient #4 revealed no intravenous (IV) site assessment on 6/29/11 at 8:00 p.m. and at midnight on 7/1/11. The nursing director confirmed the finding on 7/1/11 at 10:45 a.m. 4. Review of the medical record of patient #5 revealed a Peripherally Inserted Central Catheter (PICC) line was inserted on 6/29/11. Review of nursing documentation revealed no assessment of the site on 6/30/11 at noon or 4:00 p.m. and none on 7/1/11 at midnight. The nursing director confirmed the finding on 7/1/11 at 11:30 a.m. 5. Review of the medical record for patient #6 revealed lack of IV assessment on 6/30/11 at midnight , 4:00 a.m., noon, 6:00 p.m. On 7/1/11 at midnight, 4:00 a.m. and 8:00 a.m. The nursing director confirmed the findings on 7/1/11 at 12:20 p.m. 6. Review of the medical record for patient # 8 revealed no IV assessment on 6/30/11 at midnight and 4:00 p.m. On 7/1/11 at midnight and 4:00 a.m. The nursing director confirmed the findings on 7/1/11 at 1:55 p.m. 7. Review of the medical record of patient #4 revealed the physician had written an order for sequential compression devices (SCD) to the lower extremities on 6/29/11. Review of the nursing documentation on 6/29, 6/30 and 7/1/11 revealed no evidence the SCDs were in place. The nursing director confirmed the findings on 7/1/11 at 2:40 p.m. 8. Review of the medical record for patient #6 revealed the physician wrote an order for blood glucose monitoring every 4 hours on 6/29/11. Review of nursing documentation revealed documentation on 6/29/11 at 10:19 a.m., 5:51 p.m. and 10:24 a.m. There was no additional documentation of blood glucose monitoring on 6/30/11 or 7/1/11. There was no evidence the physician had discontinued the order. The nursing director confined the finding on 7/1/11 at 12:20 p.m.