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Based on review of policies/procedures, hospital documents, medical records, and interviews, it was determined that the hospital failed to protect and promote each patient's rights as evidenced by:

(A118) failing to establish a process for prompt resolution of patient grievances;

(A145) failing to assure that a patient has the right to be free from all forms of abuse or harassment for 1 of 1 patient where a family complained of mistreatment of the patient (Pt #1);

(A168) failing to require that the use of restraints is in accordance with the order of a physician or other licensed independent practitioner (LIP);

(A174) failing to require that restraints be discontinued at the earliest possible time, regardless of the length of time identified in the order;

(A175) failing to require that a patient who is restrained is monitored by trained staff at an interval determined by hospital policy; and

(A214) failing to have a policy which meets the requirements of the CMS Conditions of Participation for the reporting of patient deaths within 24 hours after a patient has been removed from restraints and failing to report the deaths of two patients who died within 24 hours after being removed from restraints.

The cumulative effect of these systemic problems resulted in the hospital's failure to be in compliance with the Condition of Participation for Patient Rights to protect and promote each patient's rights.

Based on review of policies/procedures, hospital documents, medical records, and interviews, it was determined that the hospital failed to provide an organized nursing service 24-hours per day with an adequate number of registered nurses and competent nursing staff to assess patients' care needs and supervise and evaluate the care provided to each patient as evidenced by:

(A395) failing to require that a registered nurse supervise and evaluate the nursing care of each patient;

(A398) failing to require that non-employee licensed nurses who are working in the hospital adhere to the policies and procedures of the hospital and are adequately supervised and evaluated; and

(A404) failing to require that nursing staff administer medications according to physicians' orders.

The cumulative effect of these systemic problems resulted in the hospital's failure to be in compliance with the Condition of Participation for Nursing Services by providing an adequate, organized service.

Based on review of policy/procedure, hospital documents and interview, it was determined that the hospital failed to establish a process for prompt resolution of patient grievances.

Findings include:

Review of the hospital policy/procedure titled Complaint/Grievance Process revealed: "...To provide a mechanism for patients/families or the patient's representative to make complaints/grievances regarding patient treatment and care and by which prompt resolution of problems can be accomplished...The CEO (Chief Executive Officer) has assigned the responsibility of investigating complaints and grievances to the Department Heads and/or Clinical Directors...A. Complaint: A concern voiced by a patient or the patient's representative regarding the patient's medical treatment plan or care which can be resolved within a reasonable time of the complaint, typically within twenty fours (sic) of the complaint...B. Grievance: The CMS Interpretative guidelines define a patient grievance as 'a written or verbal complaint by a patient, or the patient's representative, regarding the patient's care (when the complaint is not resolved at the time of the complaint by staff present), abuse or neglect...'Should a staff member overhear or be the recipient of a complaint voiced by a patient...the staff member is responsible for resolving the complaint promptly...If the complaint is resolved immediately the Clinical Director or designee will initiate entry on the Complaint/Grievance Log Book along with documented resolution or outcome for tracking purposes. An Event Report Form is not required at this time if patient, family or patient's representative is satisfied with the resolution...If the complaint cannot be resolved in a reasonable period of time or patient, family or patient's representative is not satisfied with the outcome then it is to be logged on the Complaint/Grievance Log Book and an Event Report Form and an Event Follow-Up Form are to be initiated...Grievance Report form should be made available: If resolution to complaint was not achieved by the actions taken by staff or Nurse Executive, if the patient/family requests...Staff members will inform the patient or person acting on the patient's behalf that he or she may file a grievance with the CEO...."

Review of hospital documents revealed that no Grievances were filed in 2010; 56 complaints were recorded in the Complaint Grievance Log. Review of the Complaint/Grievance Log for January & February 2011, revealed that a staff member recorded 7 complaints from Pt. #1's family.

On 1/4/11, the issue/concern recorded was "...pressure sore R (right) heel...Date Resolved: 1/4...Resolution: wound care saw pt...Follow-Up; wound care following pt care...."

On 1/10/11, the issue/concern recorded was "...pressure sore R buttock...Date Resolved: 1/10...Resolution: wound care saw pt...Follow-Up: wound care following pt care...."

On 1/14/11, the issue/concern recorded was "...bruising of pts R arm...Date Resolved: 1/14...Resolution: Charge spoke with Family regarding Coumadin side effects...Follow-up: N/A (not applicable)."

On 1/16/11, the issue/concern recorded was: "...contamination with care s (sic)...Date Resolved: 1/17...Resolution: Issue addressed with Charge by DON (Director of Nursing)...Follow-Up: Staff Education...."

On 1/19/11, the issue/concern recorded was: "...Unhappy with Nursing Care...Date Resolved: 1/19...Resolution: Charge Nurse/ recovery...Follow-Up: Change of Staff & Education...."

On 1/21/11, the issue/concern recorded was: "...Phone call complaint regarding wounds...Date Resolved: 1/24...Resolution: Charge Nurse Notified Mon- Wound Team...Follow-up: Wound Care...."

On 2/6/11, the issue/concern recorded was: "...Arm band up higher on arm and snug...Date Resolved: 2/6/11...Resolution: Moved armband down on arm...Follow-up: blank...."

On 2/10/11, the issue/concern recorded was: "...pt nutrition...Date Resolved: 2/10/11...Resolution: Charge RN discussed TF (Tube Feeding) with family...."

The Complaint/Grievance Log did not contain documentation for any complaints logged whether the resolution recorded was satisfactory to the patient/family. The complaints listed above focused on various ongoing patient care issues, but the facility had no documentation that a Grievance Report form was made available to the family or documentation that the actions documented under resolutions may not have resolved the family's complaints.

The Chief Nursing Officer (CNO) confirmed during interview on 2/18/11, that none of the complaints were considered grievances since the personnel determined that the complaint was resolved.

Based on review of facility policy/protocol, facility documents, and interviews, it was determined that the hospital failed to assure that a patient has the right to be free from all forms of abuse or harassment for 1 of 1 patient where a family complained of mistreatment of the patient (Pt #1).

Findings include:

Patient #1 was admitted to the Long Term Acute Care Hospital (LTAC) on 12/18/10. The patient had been transferred from an Acute Inpatient Hospital. During that hospital stay, she was intubated and placed on a ventilator. She suffered a cardiorespiratory arrest, resulting in a severe diffuse, anoxic/ischemic encephalopathy. She also suffered a Cerebral Vascular Accident (CVA). On December 15, 2010, the patient was responsive only to painful stimuli. The patient underwent a tracheostomy due to severe respiratory failure and also underwent a gastrostomy feeding tube placement. The patient was ventilator dependent at the time of admission to this LTAC hospital. She also had possible pneumonia at the time of admission. While at the current LTAC hospital, the patient has been weaned from the ventilator, but has an aerosol trach cuff in place. She is able to track activity with her eyes, but is unable to speak or make voluntary movements. She has an appointed guardian who is a family member. S/he is frequently referred to as a "POA" (Power of Attorney) in the medical record.

Review of the hospital's Policy Statement titled Investigating Allegations of Physical Abuse revealed: "...All reported incidents of physical abuse are promptly and thoroughly investigated...Policy Interpretation and Implementation...Physical abuse is defined as hitting, slapping, pinching, kicking, etc...When conducting an investigation of physical abuse, implement the following protocol:...a. Conduct a full body exam paying particular attention to areas of patient complaint... b. Check range of motion...Consult with the patient's attending physician and/or the facility's medical director as to the need for further diagnostic examination or X' rays...Monitor the patient's condition closely for the next 24 hours...Procedures governing the investigation of abuse are outlined in a separate policy of this chapter entitled (sic) 'Abuse Investigation Protocol'...."

Review of the hospital's Policy Statement titled Investigating Allegations of Neglect revealed: "...All reported incidents of neglect are promptly and thoroughly investigated...Policy Interpretation and Implementation...1. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, mental illness or deterioration of a patient's physical or mental condition. Neglect also means the failure to protect the patient from abuse, neglect, or exploitation. Neglect is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury...2. When conducting an investigation of neglect, implement the following protocol: a. Determine what goods or services were not provided to the patient...b. Determine if physical harm, mental anguish...or deterioration in the patient's physical or mental condition resulted...Conduct the investigation in accordance with established policy. (See policy entitled 'Abuse Investigation Protocol'...."

Review of the hospital's Policy Statement titled Reporting Abuse to Facility Management revealed: "...Policy Interpretation and Implementation...2. All reports of abuse...are promptly investigated...4. When an alleged or suspected case of mistreatment, neglect, injuries of an unknown source, or abuse is reported, the facility administrator, or his/her designee, will notify the following persons or agencies of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State ombudsman; c. The patient's representative...d. Adult protective services; e. Law enforcement officials; f. The patient's attending physician; and g. The facility medical director. 5. Notices to the above agencies/individuals shall be made within the first business day after the occurrence of the incident or when the facility learns of the abuse...."

Review of the hospital's Policy Statement titled Abuse Investigation Protocol revealed: "...Policy Interpretation and Implementation...3. The individual conducting the investigation will, as a minimum:...c. Review the completed 'Patient Abuse Report Form'... i. Interview staff members (on all shifts) who have had contact with the patient during the 48-hour period prior to the time of the incident...Interview other employees to determine if they have ever witnessed other incidents of mistreatment involving the accused employee...o. Review all events preceding the alleged incident...5. Witness reports will be reduced to writing. Witnesses will be required to sign and date such reports. (Note: A copy of such reports must be attached to the 'Patient Abuse Report Form'...9. Employees of this facility who have been accused of patient abuse will be reassigned to non-patient care duties or suspended from duty until the administrator has reviewed the results of the investigation...11. The administrator will inform the patient and his/her representative...of the progress of the investigation...15. The Administrator shall report ALL allegations of abuse to: the local police department, the ombudsman, the state licensing agency and others as may be required by state or local saws within five days of the results of the completion of the investigation...."

The timeline required for reporting to agencies in the Protocol differs from the timeline required in the Policy titled Reporting Abuse to Facility Management.

Review of unsigned Case Management/Discharge Planning notes dated 2/8/11 at 1415, provided by Employee #19, a Case Manager, revealed: "...QA (Quality Assurance) Director and CM (Case Manager) met w/ (family member) for chart review...stated nurse brushed hair roughly hair on pillow then roughly moved her around felt that is why (pt) has bruises then did mouth care again roughly poking toothette in mouth asked...to leave...alone and no longer touch her nurse stomped out of room threw toothette in trash...QA left to S/W (Speak With) nursing...."

Review of document dated 2/8/11, provided by DQM revealed: "...I was advised by...charge nurse that...requested that...RN no longer take care of (pt). This has not been an uncommon occurrence...has requested that approximately 4-5 staff members have no further contact with...At 1420...stated...never wanted...to take care of (pt) again...Stated that she witnessed...being very rough when giving oral care to...and that...had a witness...the CNA (Certified Nursing Assistant)...stated that...now knows why (pt) has burses (sic) all over her body...1430 interview was conducted with...RN...and...CNA...assessed her head to toe. Pt's oral cavity showed no signs or symptoms of trauma, no active bleeding, skin tears etc. Pt. has discolored areas all over her body however; pt has been on anticoagulation medications. I have been personally assessing her since the 01/19/2011 and her condition has remained unchanged...informed...that ...would no longer be taking care of...."

DQM stated during interview conducted on 2/11/11, that a police officer had arrived at the facility on 2/10/11, after the patient's family reported possible assault. S/he stated that the patient has bruising on her body due to anticoagulant therapy and that DQM has been completing head to toe assessments of the patient daily due to family complaints. S/he did not provide documentation of the specific findings of his/her ongoing assessments and the patient's medical record did not contain documentation. S/he stated that the RN was assigned to other patients but did not provide care to Pt #1 for remainder of the shift or subsequent shifts.

The DQM provided an Event Report dated 2/8/11 at 1330, initiated by the RN who was assigned to the patient on 2/8/11. S/he documented that the family member had complained of the RN being rough with the pt and that the RN left the room and the family member then asked to speak with the Charge Nurse. The Event Report contained documentation in the Follow-Up Section dated 2/10/11, that the DQM had assessed the patient and interviewed the RN and CNA. "...No further actions required at this time...Family meeting held same day as complaint...When pt was assessed she was found to have (no) oral injuries or S/S (Signs/Symptoms) of injury...." The Report was signed by the CNO on 2/8/11, and the DQM on 2/10/11.

The DQM provided a copy of the Abuse Investigation Checklist for review. This document revealed: "...Date Investigation Initiated 2/10/11...Notify Agencies: "...State Licensing in building 2/11/11...Patient Representative 2/10/11...APS (Adult Protective Services) 2/11/11...MPD (Mesa Police Department) 2/10/11...Patient's Physician 2/11/11...Medical Director 2/11/11...."

The Abuse Investigation Checklist contained documentation that the RN and CNA who were providing care to the patient at the time of the allegation were interviewed on 2/8/11, and that RN #12 who works as a Charge Nurse on the dayshift was interviewed on 2/11/11.

DQM confirmed on 2/11/11, that the facility had not self reported the allegation to agencies because the family's complaints had been constant. The police officer was the first to use the term assault. The family's complaints have focused on neglect.

The CNO confirmed on 2/11/11, that the facility's policy/procedure regarding abuse prevention was not followed because the family member making the allegation was always positive to the nurses but calls other family members with complaints. S/he stated that she had considered the family member's statement/allegation to be another complaint and didn't believe it was serious at the time. The family member had been disruptive in the patient's room.

Review of the hospital's Complaint/Grievance Log for January & February, 2011 revealed that a staff member recorded 7 complaints from Pt. #1's family. The log contained complaints dated 2/6/11 & 2/10/11, however neither complaint contained the allegation reported by the family member on 2/8/11.

Based on review of policies/procedures, medical records, and interviews, it was determined that the hospital failed to require that the use of restraints is in accordance with the order of a physician or other licensed independent practitioner for 7 of 7 patients that were restrained (Pts #4, #5, #6, #11, #13, #21, & #23).

Findings include:

Review of the hospital policy/procedure titled Restraints and Seclusion revealed: "...Physicians and Independent Allied Health Practitioners (LIP) are granted the authority for giving/writing restraint orders...A new order must be obtained prior to reinitiating the use of restraint...Types of Restraints...Leg restraints...Wrist restraints...Mitts when tied down...Side rails when used to restrict the patients' freedom to exit the bed...Medical Management...MD order required...A new order is required in the event restraints are reapplied after discontinuation...."

Pt #4's medical record contained a form titled Medical Restraint Record and Plan of Care. The form contained documentation that the patient was in bilateral soft cloth wrist restraints on 12/18/10 from 0700 through 1900. The medical record did not contain a physician's order for restraints on 12/18/10.

Pt #4's medical record contained a Medical Restraint Record and Plan of Care form which contained documentation that restraints were removed at 2100 on 1/1/11. The word "removed" was written across the form for the hours of 2100 on 1/1/11 through 0500 on 1/2/11. However, on 1/2/11 at 0000 (midnight), a nurse documented in the progress notes: "...wrist restraints released q 2h (every two hours)...." The record did not contain a physician's order for restraints after 2100 on 1/1/11 or on 1/2/11.

Employee #18 confirmed during interview on 2/15/11 at 1125, that Pt #4 was in restraints on 1/1/11 at 1900 when s/he came on duty and remained in restraints through midnight on 1/2/11. S/he confirmed that the record did not contain a physician's order for restraints after 2100 on 1/1/11 or on 1/2/11. S/he was unaware as to why the word "removed" was written across the form.

On 1/3/11, a nurse documented: "...remains restrained for pt. safety as per MD orders...." The record did not contain a physician's order for restraints on 1/3/11.

Employee #16 confirmed during interview on 2/16/11 at 1330, that Pt #4 was in restraints on 1/3/11, and that the record did not contain a physician's order for restraints on 1/3/11.

Pt #5 was admitted on 1/31/11. His/her medical record contained an unsigned/untimed Restraint Order/Assessment Sheet dated 2/10/11. The Medical Restraint Record and Plan of Care form dated 2/10/11, contained documentation that the patient was in bilateral soft cloth wrist restraints from 0700 through 2/11/11 at 0500.

Pt #6 was admitted on 1/24/11. His/her medical record contained an unsigned/untimed Restraint Order/Assessment Sheet dated 2/3/11. A nurse noted on 2/3/11 at 0100: "...remains restrained per protocol and order...." At 0800, a nurse noted: "...pt restrained per protocol for attempts of pulling at lines and tubes...." The Medical Restraint Record and Plan of Care contained documentation that the patient was in restraints on 2/3/11 from 0700 through 2/4/11 at 0500.

Pt #6's medical record contained an unsigned/untimed Restraint Order/Assessment Sheet dated 2/4/11. A nurse noted on 2/4/11 at 0800: "....agitated and restless, restraints per protocol for attempts of pulling at lines and tubes...." The Medical Restraint Record and Plan of Care contained documentation that Pt #6 was in restraints on 2/4/11 from 0700 through 2/5/11 at 0500.

Pt #6's medical record contained an unsigned/untimed Restraint Order/Assessment Sheet dated 2/5/11. A nurse noted on 2/5/11: "...remains in restraints per protocol...0930...4 point restraints in place...." The Medical Restraint Record and Plan of Care contained documentation that the patient was in bilateral soft cloth wrist and ankle restraints and bilateral mitts with ties on 2/5/11 from 0700 through 2/6/11 at 0500.

The Chief Nursing Officer (CNO) confirmed during interview on 2/11/11, that the medical records of Pts #5 and #6 contained documentation that these patients were in restraints without the required physician orders.

Pt #11 was admitted on 1/26/11. On 2/7/11 at 2300, a nurse noted: "...Reminded to not attempt to get out of bed. Pt verbally aggressive...Siderails X4...." The medical record did not contain an order for restraints.

Employee #45, a Charge Nurse, confirmed during interview on 2/16/11, that 4 siderails are considered a restraint and that Pt #11's medical record contained no order for siderail restraint.

Pt #13 was admitted on 1/13/11. Review of the medical record revealed:

On 1/16/11, the Medical Restraint Record and Plan of Care contained documentation that the patient was in bilateral soft cloth wrist restraints from 0700 through 1/17/11 at 0500. The record did not contain a physician's order for restraints during this time period.

The Chief Nursing Officer (CNO) confirmed during interview on 1/17/11, that the record contained documentation that the patient was in restraints without a physician's order.

Pt. #21 was admitted on 1/19/11. Review of the medical record revealed:

A nurse recorded a physician's telephone order on 1/19/11 at 1930 for left wrist restraint. On 1/20/11 at 0300, a nurse documented: "...still in wrist restraints bilateral...." The Medical Restraint Record and Plan of Care form contained documentation: "...Restraints Off..." on 1/20/11 from 0700 through 1/21/11 at 0500. On 1/20/11 at 1300, a nurse documented: "...pt. w/wrist restraints to prevent pulling out tube. Restraint released. Shower given...." The medical record did not contain a physician's order for reapplication of restraints after 1/20/11 at 0700.

On 1/26/11 at 0100, a nurse documented: "...restraints intact. Will continue to monitor...." The Medical Restraint Record and Plan of Care form contained documentation that the patient was not in restraints from 1/26/11 0700 through 1700, and was in restraints from 1900 through 1/27/11 at 0500. The medical record did not contain a physician's order for reapplication of restraints on 1/26/11 at 1900.

Pt #23 was admitted on 2/23/10. Review of the medical record revealed:

The patient was in bilateral soft wrist restraints and 4 side rails on 3/10/10 from 1300 through 1900. The medical record did not contain a physician's order for restraints.

The CNO confirmed during interview on 1/18/11 at 1100, that the patient records contained documentation that the patients were in restraints without the required physician's orders.

Based on review of policy/procedure, medical records, and interview, it was determined that the hospital failed to require that restraints be discontinued at the earliest possible time, regardless of the length of time identified in the order for 2 of 7 patients who were placed in restraints (Pts #4 & #6).

Findings include:

Review of the hospital policy/procedure titled Restraints and Seclusion revealed: "...A restraint will be used only in emergency situations when less restrictive interventions have been considered or attempted, found to be ineffective to protect the patient or others from harm, and/or it is needed to improve or protect the patient's well being. Any use of restraints will be ended at the earliest possible time...Procedure...Medical Management: Ensure physical safety of nonviolent patient...Discontinued at the earliest possible time...."

Review of Pt #4's medical record revealed a nurse's note on 12/26/10 at 1000: "...patient resting quietly...no s/s (signs/symptoms) of distress vented and trached...restraints intact...."

Pt #6's medical record contained a nurse's note on 2/9/10 at 0100: "...Pt resting with eyes closed, resps (respirations) even and unlabored. Restraints on per hospital protocol...."

The CNO confirmed during interview on 2/15/11, that these patients' medical records contained documentation which indicated that restraints were not discontinued at the earliest possible time.

Based on review of hospital documents, policies/procedures, & medical records, it was determined that the hospital failed to require that a patient who is restrained is monitored by trained staff at an interval determined by hospital policy for 2 of 7 patients who were in restraints (Pts #4 & #5).

Findings include:

Review of the hospital form titled Restraint Order/Assessment Sheet revealed a section "Daily Comprehensive Assessment completed by RN" which included a list of items to be included in a patient assessment: "...Orientation unchanged from patient's baseline...Oriented to ___person___place___time...Temperature within patient baseline or being treated...BP (Blood Pressure), P (Pulse), R (Respirations)...Na (Sodium), BUN (Blood Urea Nitrogen) creatinine within patient baseline or being treated (if available)...Hg (Hemoglobin) within patient baseline or being treated (if available)...Blood sugar within patient baseline or being treated...Adequate nutrition (oral, enteral, or TPN (Total Parenteral Nutrition)...Pain assessed: if present, being treated...Pulse oximeter reading, if present, within patient's baseline or being treated. (Obtain ABG's (Arterial Blood Gases) if abnormal)...Medications reviewed: e.g. diuretics, analgesics, sedatives, reglan, steroids...Narrative note complete...."

The RN marks the box to the left of the item assessed and signs in the space provided for RN signature to indicate that s/he completed the assessment.

Review of hospital policy/procedure titled Restraints and Seclusion revealed: "...Procedure...Medical Management: ensure physical safety of nonviolent patient...Monitoring every 2 hours to include: behavioral response...5 minutes release of restraint for circulation check...vital signs...nutrition...toileting...personal care...patient safety...."

Review of the hospital form titled Restraint Record and Plan of Care revealed a section: "Continuing Observations/Interventions for Restrained Pt.: Document q (every) 2 hours and prn (as needed):...1. Re-Assess Need & Or Alternatives...2. Provide Comfort Measures...3. Reposition...Exercise...OOB (Out of Bed)...Back to Bed...4. Assess Skin Integrity...5. Offer Food/Fluids...6. Offer Urinal/Bedpan...Reorient PRN...Pt Family Education PRN...Person At Bedside PRN...Line of View PRN...Removed Restraints for 10 minutes...Direct Observation...."

A staff member marks a check mark in a designated space to indicate that the observation/intervention was completed every 2 hours or prn while the patient was in restraints.

Pt #4's medical record contained a Restraint Order/Assessment Sheet, dated 12/11/10, and signed by a physician, indicating that the patient required bilateral wrist restraints. The "Daily Comprehensive Assessment completed by RN" section was blank.

Pt #5's medical record contained documentation that s/he was in restraints on 2/1/11 from 0700 through 2/2/11 at 0500. The section of the Restraint Record and Plan of Care for documentation of Assessment of Skin Integrity was blank on 2/1/11 from 0700 through 1700.

Pt #5's medical record contained documentation that the patient was in restraints on 2/5/11 from 0700 through 2/6/11 at 0500. The section of the Restraint Record and Plan of Care for documentation of Assessment of Skin Integrity was blank on 2/5/11 from 0700 through 2/6/11 at 0500.

Pt #5's medical record contained a Restraint Order/Assessment Sheet, dated 2/6/11, and signed by a physician. The type of restraint is blank and the "Daily Comprehensive Assessment completed by RN" section was blank.

Pt #5's medical record contained documentation that s/he was in restraints on 2/6/11 from 0700 through 2/7/11 at 0500. Several sections of the Medical Restraint Record and Plan of Care were blank on 2/6/11 from 0700 through 2/7/11 at 0500.

Pt #5's medical record contained documentation that s/he was in restraints on 2/7/11 from 0700 through 2/8/11 at 0500. The section of the Restraint Record and Plan of Care for documentation of Assessment of Skin Integrity was blank on 2/7/11 from 0700 through 1800.

The CNO confirmed during interview on 2/15/11, that the Restraint Order/Assessment Sheet in Pt #4's medical record and the Restraint Record and Plan of Care documentation forms in Pt #5's medical record were incomplete.

Based on review of hospital policy/procedure, medical records, and interview, it was determined that the hospital's policy/procedure failed to accurately reflect the CMS requirements, and the hospital failed to report the deaths of two patients who died within 24 hours after being removed from restraints (Pts #4 & #23).

Findings include:

Review of the hospital policy/procedure titled Restraint and Seclusion revealed: "...The hospital must report to CMS any death that occurs while a patient is in restraints for behavioral management reasons or when it is reasonable to assume that the patient's death is a result of restraint use for behavioral management reasons. The hospital should report these deaths to their CMS regional office by the next business day follow (sic) the patient's death...Behavioral Management-An occasion when unanticipated, severely aggressive or destructive behavior places the patient or others in imminent danger...."

Pt. #4's medical record contained documentation that s/he was in bilateral soft cloth wrist restraints on 1/3/11 at 0001. A nurse noted: "...pt remains restrained for pt safety as per MD's orders...." On 1/3/11 at 1315, a nurse noted: "...pt noted to have absence of heart tones, respirations, pulse, and pupils fixed and dilated...Respiratory therapist turned ventilator off...trach tube removed...."

RN #16 confirmed during interview on 2/16/11, that the patient was in restraints at midnight on 1/3/11 and died within 24 hours.

Pt #23's medical record contained documentation that s/he was in bilateral soft cloth wrist restraints on 3/10/10 from 1300 to 1500 and from 1600 to 2100. The last nurse's note was dated 3/10/10 at 2200. The patient's medical record contained documentation that s/he expired on 3/11/10.

The CNO confirmed during interview on 2/18/11 that Pt #23 died within 24 hours of being removed from restraints. In addition the CNO confirmed that the facility did not report either patient's death to CMS.

Based on review of Medical Staff Bylaws, hospital policies/procedures, medical records and interview, it was determined that the hospital failed to require that the medical staff be accountable to the governing body for meeting the requirements of hospital policies related to physicians' orders as evidenced by:

1. failing to require that physicians' medication orders comply with the requirements of the hospital policy/procedure for 2 of 3 patients who received titrated vasoactive medications (Pts #5 & 25); and

2. failing to require that physicians' orders comply with the hospital requirements for completeness for 6 of 30 medical records (patients #3, 4, 5, 6, 13, and 21).

Findings include:

Review of Medical Staff Bylaws revealed: "...Responsibilities...The following responsibilities shall be applicable to every Medical Staff applicant and appointee for staff appointment or reappointment as a condition of consideration of such application and as a condition of continued Medical Staff appointment if granted:...(3) An agreement to abide by all policies of the Hospital, including all Bylaws, Rules and Regulations of the Medical Staff as shall be in force during the time the individual is appointed to the Medical Staff...."

1. Review of the hospital policy/procedure titled Drug Prescribing/Ordering Orders: Drugs revealed: "...3. Required Elements of Drug Orders: Each drug order will include:...Drug name, strength (and dosage form, if necessary)...Directions for use (including route and rate of administration)...."

Pt #4's medical record contained a physician's telephone order, recorded by an RN on 2/8/11 at 1200: "...Neosinephrine (sic) gtt (drip). Titrate to maintain SBP>90 (systolic blood pressure greater than 90). Wean off as tolerated...."

Pt #25's medical record contained a physician's telephone order, recorded by an RN on 2/7/11 at 0930: "...Use Neosenephrine (sic) to keep SBP > 90...."

RN #45, a Charge Nurse, confirmed on 2/16/11, that the order on Pt #25's medical record was incomplete. RN #45 confirmed on 2/17/11, that the order on Pt #4's medical record was incomplete. S/he confirmed that neither order contained the route, dosage, or rate of administration.

2. Cross reference Tag (A0450)

Based on review of the Medical Staff Bylaws, hospital documents related to Medical Staff Credentialing, Governing Board Committee Meeting Minutes, and interview it was determined that the hospital Governing Board failed to act on a medical staff member's expired appointment to the medical staff.

Findings include:

Review of Bylaws of the Medical Staff revealed: "...Each current appointee who is eligible to be re-appointed to the Medical Staff shall be responsible for completing the reappointment application form approved by the Board. The reappointment application shall be submitted to the hospital CEO or designee at least four months prior to the expiration of the appointee's current appointment period...Reappointment, if granted by the board, shall be for a period of not more than two (2) years. If an application for reappointment is filed and the Governing Authority has not acted on it prior to the expiration of the appointee's current term of appointment, that appointment shall continue in effect until such time as the Governing Authority acts on the reappointment application...Factors to be Considered...Compliance with the Hospital Bylaws and policies and with the medical Staff Bylaws and Rules and Regulations...."

Review of Physician #4's credential file on 2/16/11, revealed that his/her privileges expired 5/12/10. The hospital provided documents which contained lists of physicians with their privilege status which was reported to the Medical Executive Committee on a monthly basis. The documents dated 2/24/10, 3/31/10, 4/28/10, 10/27/10, 12/8/10, & 1/26/11, all contained Physician #4's name in the section titled Re-Appointments in Process.

Review of governing board Committee Meeting Minutes dated 9/28/10 revealed: "...Credentialing...Reviewed 24 physicians for Full Privileges, 13 Re-Appointments and 3 Temporary privileges and 20 termed physicians. No issues identified, all in good standing...Approved by GB (governing board). Physician #4's name is included in the list of 13 physicians for re-appointment. The title Re-Appointments in Process is the heading at the top of the list. The hospital was unable to provide documentation regarding the length of time that Physician #4's reappointment would be allowed to be in process after his/her privileges had expired.

Employee # 9 confirmed during interview on 2/18/11, that Physician #4's reappointment has been in process since February, 2010 and that s/he has brought it to the Governing Board and the Medical Executive Committee.

Cross reference Tag A0450 regarding Physician #4 and documentation in medical records.

Based on review of policy/procedure, medical records, hospital reference text, and interview, it was determined that the hospital failed to assure that a registered nurse supervise and evaluate the nursing care for each patient as evidenced by:

1. failing to document RN patient assessment, as required by policy, for 3 of 3 patients who were assigned to a Licensed Practical Nurse (LPN) for 6 of 6 shifts (Pts # 1, 11, & 20);

2. failing to document RN patient assessment and supervision of the care provided by an LPN, as required by policy, for 1 of 2 patients who received intravenous (IV) titration of a vasoactive medication (Pt #5);

3. failing to document telemetry monitoring for 1 of 1 patient per hospital policy (Pt #4); and

4. failing to document turning of patient every 2 hours per hospital policy/procedure for 1 of 1 patient (Patient #3).

Findings include:

Review of the hospital's policy/procedure titled Assessment-Reassessment revealed: "...Nursing will re-assess each patient every shift or as warranted by the patient's medical condition and documented on the Nursing Care Records...Definitions: Assessment: The systematic collection and analysis of patient-related data necessary to determine patient care and treatment needs...Data: Uninterpreted sets of values that can assist in decision-making...Nursing...B. Reassessment...Time-Frame: Routinely once every 12 hours (each shift) and more frequently as indicated. More frequent observations and assessments may be recorded (up to every 15 minutes for continuous 1:1 observations) depending on the status of the patient. This need will be determined by the judgment of the RN assigned to the patient's care...Licensed-Practical Nurse: A Registered Nurse will have direct supervision of the technical tasks assigned the LPN. The practice of the licensed practical nurse is defined as performing tasks and responsibilities under the direction of a registered nurse or licensed and legally authorized physician orders. These tasks include but are limited (sic) to: participate in data collection for assessment, planning of care and discharge planning, performance of therapeutic interventions as identified by their scope of practice as defined in policy, such as medication administration, IV therapy, treatments, and patient and family education...."

Review of the policy/procedure titled Acuity and Staffing Plan-East Valley revealed: "...Each patient is assessed by an RN and assigned a level of care...Using the nursing process, patients' needs will be assessed every shift by the registered nurse...."

Review of the hospital policy/procedure titled Physician Orders revealed the following: "...In hospital settings, transcription of orders written, verbal, electronic, fax, and telephone orders can be performed by clerical personnel, but must be reviewed and signed by a RN...Nursing Team Assignments According to Scope of Practice...Assessment...RN Yes...LPN No...."

Review of the form titled Nursing Daily Record revealed that it contained sections for a nurse to document findings regarding the patient's Neurological Status, Respiratory Status, Cardiovascular Status, Genitourinary Status, Musculoskeletal Status, Psychosocial/Emotional Behavioral, Safety Assessment, Integumentary Status, Decubiti/Wounds/Drains-Treatment/Appearance/Size, Intravenous Therapy, Mobility/Activity, Intake/Output, Pain Management, Miscellaneous (Bath, Foley/Peri Care, Oral Care, Antiembolitic device, Isolation Precautions Maintained) and Progress Notes. The form also contained vertical columns for a nurse to record findings during specific time frames: 0001-0359, 0400-0759, 0800-1159, 1200-1559 1600-1959, & 2000-2400. The nursing staff work 12 hour shifts: 0700-1900 (Day Shift) and 1900-0700 (Night Shift).

1. On 2/15/11, the Nursing Assignments/Daily Data Form for the Day Shift indicated that Pt #1 was assigned to LPN #46 with RN #45 supervising the LPN.

Review of nursing documentation on 2/15/11 in Pt #1's medical record revealed that LPN #46 completed all of the sections of the Nursing Daily Record at 0830, 1215, & 1630 and wrote a progress note at 0830: "...assess. Pt (without) indications of pain...." At 1700, LPN #46 wrote: "...Bleeding noted to PICC (Peripherally Inserted Central Catheter) line...Charge Nurse notified and applied new sterile drsg (dressing) and pressure to site for 5 min. Kurlex wrapped around PICC line lightly...." RN #45 signed the bottom of each page of the Nursing Daily Record, however, the medical record did not contain documentation that an RN assessed the patient during the Day Shift as required by policy.

On 2/14/11, the Nursing Assignments/Daily Data Form for the Day Shift indicated that Pt #11 was assigned to LPN #39 with RN #12 supervising the LPN. RN #45, the Charge Nurse, stated on 2/16/11, that s/he had shared the responsibility for supervising LPN #39, although the Nursing Assignment/Daily Data Form did not contain this information.

Review of nursing documentation on 2/14/11, in Pt #11's medical record, revealed that LPN #39 completed all of the sections of the Nursing Daily Record at 0800, 1200, & 1600 and wrote a progress note at 1120: "...Assessment as charted...Denies pain...O2 sats (Oxygen saturation) maintained greater than 92%...LS (Lung Sounds) clear...." An RN signed the bottom of each page of the Nursing Daily Record, however, the medical record did not contain documentation that an RN assessed the patient during the Day Shift as required by policy.

On 2/14/11, the Nursing Assignments/Daily Data Form for the Night Shift (2/14/11 at 1900 until 2/15/11 at 0700) indicated that Pt #11 was assigned to LPN #44 with RN #41 supervising the LPN.

Review of nursing documentation on 2/14/11 from 2000 through 2/15/11 at 0430, in Pt #11's medical record, revealed that LPN #44 completed all of the sections of the Nursing Daily Record at 2400 (midnight) & 0430 and a progress note at 2400: "...(no changes) in assessment. repositioned. bath given. afebrile. vs wnl (vital signs within normal limits) WCTM (will continue to monitor)...." At 0430, LPN #44 wrote: "...pt repositioned. R (right) knee hurting. mild pain. afebrile. vs wnl. Cont (continue) on RA (Room Air). (no) s/s (signs/symptoms) of distress noted @ this time. WCTM. RN #41 signed the bottom of each page of the Nursing Daily Record, however, the medical record did not contain documentation that an RN assessed the patient from 2000 on 2/14/11 through 2/15/11 at 0759.

On 2/15/11, the Nursing Assignments/Daily Data Form for the Day Shift indicated that Pt #11 was assigned to LPN #39 with RN #45 supervising the LPN.

Review of nursing documentation on 2/15/11 in Pt #11's medical record revealed that LPN #39 completed all of the sections of the Nursing Daily Record at 0800, 1200, & 1600 and wrote a progress note at 0915: "...Assessment as charted. RA 96% appetite good. Denies pain. S/P (Status Post) trach (tracheotomy) site healing well. Drsg CDI (Clean Dry Intact)...." At 1100, LPN #39 wrote: "...Removed peg & Foley catheter scant bleeding from peg. (no) other discomfort noted...." RN #45 did not sign the Nursing Daily Record on 2/15/11, and the medical record did not contain documentation that an RN assessed the patient during the Day Shift as required by policy.

On 2/15/11, Nursing Assignments/Daily Data Form for the Night Shift (2/15/11 from 1900 until 2/16/11 at 0700) indicated that Pt #11 was assigned to LPN #44 with RN #41 supervising the LPN.

LPN #44 completed the Nursing Daily Record on 2/15/11 at 2000, and on 2/16/11 at 2400 and 0430. LPN #44 wrote a progress note on 2/15/11 at 2000: "...Assessment completed...." LPN #44 wrote a progress note on 2/16/11 at 2400: "...(no change) in assessment...." LPN #44 also wrote a progress note on 2/16/11 at 0400. Pt #11's medical record did not contain documentation that an RN assessed the patient during the Night Shift from 2/15/11 at 1900 until 2/16/11 at 0700.

Pt #11's medical record did not contain documentation that an RN assessed the patient from 2/14/11 at 0800 through noon on 2/16/11.

Pt #20's medical record contained telephone orders for admission recorded by LPN #46 on 2/15/11 at 1800. The admission orders do not contain an RN signature.

On 2/15/11, the Nursing Assignments/Daily Data Form for the Night Shift (2/15/11 at 1900 until 2/16/11 0700) indicated that Pt #20 was assigned to LPN #1 (a registry LPN) with RN #41 supervising the LPN.

Review of nursing documentation on 2/15/11 in Pt #20's medical record revealed that LPN
#46 completed the Nursing Daily Record at 1840. The column designated for 2/15/11 from 2000-2400 was partially completed at 2100 and contained no staff initials. On 2/15/11 at 2100, a staff member wrote an unsigned progress note: "...TF (tube feeding) pump started...Placement checked. (no) residual. Husband @ bedside...."

RN #41 signed the bottom of each page of the Nursing Daily Record. Pt #20's medical record contained no documentation of an RN assessment on 2/15/11 from 1840 through midnight 2/16/11.

2. Cross reference Tag A404, findings #2 for information regarding Pt #5.

Review of Pt #5's medical record revealed that LPN #33 initialed all of the entries contained in the Nursing Daily Record under the section IV Drips for documentation of titration of Neosynephrine on 2/8/11, from 1200 (first entry) through 1900 and on 2/9/11, from 0700 through 1900. In addition, LPN #33 completed all of the other sections of the Nursing Daily Record on 2/8/11 at 0800, 1200, and 1600, and on 2/9/1, at 0800, 1200, and 1630. RN #45 was assigned to supervise LPN #33 on 2/8/11 and did not sign the Nursing Daily Record on 2/8/11. RN #12 signed the Nursing Daily Record on 2/9/11.

On 2/8/11, LPN #33 recorded progress notes: "...1000 BP (Blood Pressure) 108/70 vss resting quietly...1130 patients blood pressure 53/49 retaken 67/43...fluids started BP 91/46, will continue to monitor...1200 neosynephrine started at 1200 to reg (regulate) BP...will cont (continue) to monitor every 15 minutes...1400 BP 98/52..1720 new PICC line placed left brachial vein 44 centimeters. awaiting X-ray to verify placement...1830 Blood pressure 86/50 neosynephrine (increased) to 35mcg. will continue to monitor BP...."

On 2/9/11, LPN #33 recorded progress notes: "...0900 trach (tracheostomy) insertion not done...new order for FFP (Fresh Frozen Plasma) transfuse X 2 Units restart heparin drip and hold heparin drip at 4 AM...1100 patient conts on heparin drip neosynephrin drip conts at 30 mcg per minute...conts on tele monitor sinus tachy (tachycardia)...1500 FFP arrived started at 1445...1600 second bag FFP started infusing...new orders for new picc line to be placed consents signed...1630 Stat CBC (Complete Blood Count) drawn...picc line being placed...1730 picc line placed in luA (left upper arm) awaiting xray to verify placement...1900 unable to obtain INR (international normalized ratio) (for anticoagulant monitoring) after FFP given attempts X5 charge nurse made aware of unable to obtain, attempted with both machines, both INR machines reading error. report given to oncoming nurse to try and obtain INR...heparin drip conts...."

Pt #5's medical record did not contain documentation that an RN assessed the patient or supervised the patient care on 2/8/11 from 0800 through 1900 and on 2/9/11 from 0800 through 1900.

RN #45, a Charge Nurse confirmed on 2/16/11, that the patient records did not contain documentation of the RN supervision and evaluation of patient care other than a signature at the bottom of the Nursing Daily Record. S/he confirmed that the RN signature was missing from Pt #11's medical record for the Day Shift on 2/15/11. The RN signature was also missing from Pt #5's medical record for the Day Shift on 2/8/11.

3. Review of hospital policy/procedure for Department: Nursing, titled Telemetry Monitoring revealed: "...Routine rhythm strips shall be obtained once per shift, interpreted, labeled, and placed in the patient's chart...."

Review of Pt #4's medical record revealed a physician's order for Telemetry dated 12/8/10. The order was not discontinued. The patient remained in the hospital until he expired on 1/3/11. Review of the Telemetry Log Sheets dated 12/8/10 from 2000 through 1200 on 1/3/11 revealed that he was monitored via telemetry however, Pt #4's medical record contained one rhythm strip dated 12/18/10.

The CNO confirmed during interview on 2/17/11, that the nursing staff did not follow the procedure for documenting Pt #4's telemetry monitoring.

4. Review of the facility's policy and procedure titled "Lippincott Clinical Procedures" Policy #ADM 12 requires: "...The hospital...adopts...Lippincott...clinical procedures..clinical staff...."

Review of the Lippincott Manual of Nursing Practice, 8 th Edition 2006, page 187, revealed: "...Prevent pressure ulcer...Provide meticulous care and positioning...reposition every 2 hours...use alternating-pressure mattress or air-fluid bed...."

Review of the facility's policy and procedure titled "Turn Program Policy," Policy # CSM 138 revealed: "...Patients with low Braden Scores...limited ability to reposition...placed on Turning Program...."

Review of the patient's post flap orders (Patient #3) dated 07/13/10 at 1030 hours revealed: "...Turn left to right or back to opposite side every 2-4 hours...."

The Daily Nursing Record has a total of 8 pages. Page 4 , line 12 contains the word "Turns" containing a key as follows: R-right, L-left, B-back, and I-independent. Included in the line is a total of 24 small columns indicating the hours in the day 00, 01, 02, through 23. Staff is to document (R, L, B, or I) position of the patient in the time column corresponding with the time the patient is turned.

Review of the patient's Daily Nursing Record dated 07/13/10 through 07/16/10, page 4, revealed documentation across all hours "Clinitron Bed refuses turning." The Nurses Progress Notes at 2000 hours revealed the patient was refusing to be turned, and would like to wait to be turned, "...requested for R (right) shoulder Lidocaine & Bacitracin to JP (Jackson-Pratt) sites to wait until wound care comes tomorrow so...only has to move once...."

Review of the patient's Daily Nursing Record dated 07/14/10 at 0000 hours page 4, revealed documentation across all hours "Clinitron Bed refuses turning." The Nurses Progress Notes at 2015 hours revealed: "...Clinitron bed, refuses to turn to do assessment...I am not moving more than once so they will just have to do it in the morning...."

Review of the patient's Daily Nursing Record dated 07/15/10 at 0000 hours page 4, revealed documentation across all hours "Clinitron Bed refuses turning." The Nurses Progress Notes at 0015 hours revealed: "...Pt (patient) on Clinitron bed, refuses repositioning...."

Review of the patient's Daily Nursing Record dated 07/16/10 at 0000 hours page 4, revealed documentation across all hours "Clinitron Bed refuses turning." The Nurses Progress Notes at 2200 hours revealed: "...Pt refused to be turned, stated they did my wound and turned me. Explained to pt that I needed to see his buttocks and back, pt stated not now...."

Review of the patient's Daily Nursing Record dated 07/17/10 through 09/02/10 page 4, revealed documentation the patient is now being turned at least every 2 hours (equal to 12 per 24 hours), except for the following dates:
07/26/10, it was documented the patient was turned 9 times.
07/27/10, it was documented the patient was turned 10 times, patient transported to another facility for thoracentesis procedure.
07/28/10, it was documented the patient was turned 11 times, patient transported to another facility for thoracentesis procedure.
08/06/10, it was documented the patient was turned 11 times.
08/10/10, it was documented the patient was turned 11 times.
08/12/10, it was documented the patient was turned 8 times, there was no documented turning from 0000 hours to 0700.
08/19/10, it was documented the patient was turned 10 times, patient transported to another facility for "CT" (computed tomography) of head.
08/21/10, it was documented the patient was turned 11 times, there was documentation "see turn sheet."
08/27/10, it was documented the patient was turned 9 times, patient to wound clinic.

Patient #3's Daily Nursing Records dated 07/12/10 through 09/03/10 revealed the patient's repositioning was not documented every two hours in 10 of the 52 days of hospitalization as required per policy.

RN #35 confirmed the following during an interview conducted on 02/17/11, that she remembered patient #3 had a lot of back pain and did not like to be turned. The patient was heavy and required 2-3 people to help turn.

RN #5 also confirmed the patient #3's spouse was concerned about the patient getting turned and a piece of paper was hung on the patient's wall to remind staff to frequently turn the patient. The RN remembers that the "turn schedule" on the wall had a key similar to the Daily Nursing Record with L, R, and B. The RN confirmed the nursing staff no longer uses the "turn schedule."

LPN #33 confirmed the following during an interview conducted on 02/17/11, patient #3 did not like to be turned, however, the patient did better with turning when the patient's spouse was at the bedside. The LPN "vaguely" remembers the "turn schedule" and was "unsure what it looked like."

The Wound Care Nurse #22 confirmed during an interview conducted on 02/17/11, remembers patient #3 refusing to be turned but does not recall a specific "turn schedule." Nurse #22 also confirmed the facility has added the "three P's" (pain, potty, position) to the Intake & Output sheet placed in the patient rooms to remind staff about positioning.

The Director of Nursing (DON) confirmed during an interview conducted on 02/18/11, that s/he had created the additional "turn sheet" (after talking with the patient's spouse) to remind staff to encourage and turn the patient. The DON also confirmed the "turn sheet" was not a part of the patient's record and the facility was no longer using the sheet.

The DON also confirmed during the interview the documentation regarding turning was inconsistent.

Based on review of contracted staff records and medical records, it was determined that the hospital failed to require that non-employee licensed nurses who are working in the hospital adhere to the policies and procedures of the hospital and failed to provide adequate supervision and evaluation of the clinical activities of non-employee nursing personnel for 4 of 4 contracted licensed nurses (RN's #2 & 32, and LPN's #1 & 29).

Findings include:

Review of RN #2's contract staff record revealed that RN #2 is a Registry RN. His/her records did not contain documentation of his/her orientation to the facility's policies/procedures or documentation of supervision and evaluation of his/her clinical activities.

Review of Pt #11's medical record revealed that RN #2 was responsible for this patient's care on 2/9/11 from 1900 through 2/10/11 at 0700. Pt #11's medical record contained physician orders for blood glucose checks every 6 hours. Blood glucose checks were not recorded at midnight or 0600 on 2/10/11 as required.

Review of RN #32's contract staff record revealed that RN #32 is a Traveling RN. His/her records did not contain documentation of his/her orientation to the facility/s policies/procedure regarding seclusion and restraint or documentation of supervision and evaluation of his/her clinical activities.

Review of Pt #13's medical record revealed that RN #32 was responsible for completing the Daily Comprehensive Assessment on the Restraint Order/Assessment Sheet on 1/18/11, 1/19/11, 1/20/11, and 1/21/11.

Review of LPN #1's contract staff record revealed that LPN #1 is a Registry LPN. His/her records did not contain documentation of his/her orientation to the facility's policies/procedures or documentation of supervision and evaluation of his/her clinical activities.

Review of Pt #11's medical record revealed that LPN #1 provided care to the patient during the Night Shift on 2/7/11 from 1900 until 2/8/11 at 0700. Pt #11's medical record contained physician's orders for blood glucose checks every 6 hours with "moderate scale, regular insulin sliding scale." On 2/8/11, LPN #1 recorded the patient's blood glucose level at midnight as 173 (3 Units insulin required).The medical record did not contain documentation of administration of insulin.

LPN #1 wrote a progress note in P #11's medical record on 2/7/11 at 2300: "...Pt trying to get out of bed...Pt verbaly (sic) aggressive...Siderails X4. Call light in reach...."

Review of hospital policy/procedure titled Restraints and Seclusion revealed: "...Types of Restraints...Side rails when used to restrict the patients' freedom to exit the bed...Medical Management...MD order required...."

Pt #11's medical record did not contain an order for restraints on 2/7/11.

Review of LPN #29's contract staff record revealed that LPN #29 is a Registry LPN. His/her records did not contain documentation of his/her orientation to the facility/s policies/procedures or documentation of supervision and evaluation of his/her clinical activities.

Review of Pt #9's medical record revealed that LPN #29 provided care to the patient during the Night Shift on 2/13/11 from 1900 until 2/14/11 at 0700. Pt #9's medical record contained physician's orders for blood glucose checks every 6 hours with moderate scale, regular insulin sliding scale. On 2/14/11, LPN #29 recorded the patient's blood glucose level at midnight as 159 (3 Units insulin required). The medical record did not contain documentation of administration of insulin or the required blood glucose level check at 0600.

The hospital was unable to provide additional documentation of the orientation, supervision, and evaluation of RN's #2 & 32, and LPN's #1 & 29.

Based on review of the facility's policies and procedures, medical records, and interview with staff, it was determined the hospital failed to maintain medical records that were legible, complete, dated, timed, and authenticated in 6 of 30 medical records (patients #3, 4, 5, 6, 13, and 21).

Findings include:

The hospital policy and procedure titled Physician Orders, Policy #CSM142 requires: "...Orders must be written clearly, legibly and completely...All orders...must be dated, timed, and authenticated by the ...practitioner...authorized to write orders...."

Patient #3 was admitted to the hospital on 07/12/10 and transferred to another facility on 09/03/10. Review of the closed medical record revealed the following:
Physician orders dated 07/20/10, 07/26/10, 08/05/10, 08/11/10, 08/15/11, 08/18/11, 08/20/10, and 08/27/10, were not timed by Medical Staff #4.
Physician orders dated 08/07/10, were not timed by Medical Staff #9.
Telephone orders noted by nursing staff on 08/23/10, were not timed.
Telephone orders noted by RN #19 on 09/02/10, were not timed.

Patient #4 was admitted to the hospital on 12//08/10 and expired on 1/03/11. Review of the closed medical record revealed the following:
Physician admission orders dated 12/08/10, were not timed and the physician's signature was illegible.
The Restraint Order/Assessment Sheets dated 12/14/10, 12/23/10, and 01/01/11, were not timed and the physician's signature was illegible.
The Restraint Order/Assessment Sheet dated 12/31/10, the physician's signature was illegible.

Patient #5 was admitted to the hospital on 01/31/11. Review of the current medical record revealed the following:
The Restraint Order/Assessment Sheet dated 02/06/11, was dated in the "time" space area of the sheet, the order was not timed, and the physician's signature was illegible.
The Restraint Order/Assessment Sheet dated 02/08/11, the physician's signature was illegible.
The Restraint Order/Assessment Sheet dated 02/10/11, was not timed and the order contained no physician's signature.
The Restraint Order/Assessment Sheet dated 02/11/11, was not timed and the physician's signature was illegible.

Patient #6 was admitted to the hospital on 01/24/11. Review of the current medical record revealed the following:
The Restraint Order/Assessment Sheet dated 01/29/11, contained no physician's signature.
The Restraint Order/Assessment Sheet dated 01/30/11, was not timed.
The Restraint Order/Assessment Sheets dated 02/03/11, 02/04/11, and 02/05/11, were not timed and contained no physician's signature.

Patient #13 was admitted to the hospital on 01/13/11, and discharged to a skilled nursing facility on 01/27/11. Review of the closed medical record revealed the following:
The Restraint Order/Assessment Sheets dated 01/18/11, 01/19/11, 01/21/11, and 01/23/11, were not timed and the physician's signature was illegible.

Patient #21 was admitted to the hospital on 01/19/11, and discharged home on 02/07/11. Review of the closed medical record revealed the following:
The Restraint Order/Assessment Sheet dated 01/24/11, was not timed and the physician's signature was illegible.
The Restraint Order/Assessment Sheet dated 01/28/11, was not timed.

The Director of Nursing confirmed the medical records were not maintained according to hospital policy during an interview conducted on 02/17/11.

Based on review of hospital policy/procedure, and interview, it was determined that the hospital's policy/procedure failed to accurately reflect the CMS requirement that all orders must be authenticated promptly by the ordering practitioner or another practitioner who is responsible for the care of the patient.

Findings include:

Review of the hospital policy/procedure titled Physician Orders revealed: "...Telephone orders can be signed off with the same requirements for completion of medical records (within 30 days).

Review of the CMS requirement regarding authentication of orders revealed: "...All orders, including verbal orders, must be dated, timed, and authenticated promptly...."

The Director of Health Information Systems (HIMS) confirmed during interview on 2/18/11 that although the HIMS Department and hospital administration prefers that physicians authenticate their orders promptly, the physicians are required to authenticate their orders within 30 days.

Based on review of hospital policy/procedure, medical records and interview, it was determined that the hospital failed to require that medication orders and administration of medication be consistent with hospital policy/procedure for 2 of 3 patients who received titrated vasoactive medications (Pt's #4 & 24).

Findings include;

Review of the hospital policy/procedure titled Drug prescribing/Ordering Orders: Drugs revealed: "...Required Elements of Drug Orders: Each drug order will include:...Drug name, strength (and dosage form, if necessary)...Directions for use (including route and rate of administration)...."

Cross reference Tag (A347) for information regarding medication orders for Pts #4 & #25.

Director of Pharmacy Services confirmed during interview on 2/17/11, that the orders for Neosynephrine titration on the medical records of Pt #4 & #25 were incomplete (did not specify dose, route, or rate of administration).

Based on review of hospital documents, policy and procedure, medical records, and interview with staff, it was determined the hospital failed to transfer patient's with necessary medical information to an appropriate facility for proper patient care in 3 of 3 patients (patients #3, #7, and #8) reviewed.

Findings include:

Review of Medical Staff Rules and Regulations revealed: "...Current patients with...need exceeding capabilities...will be transferred...patients arriving at hospital unscheduled...admitted or ...transferred...to most accessible and appropriate...Hospital's procedures for patient transfers to other facilities will be followed...."

The hospital policy and procedure titled Transfer of a Patient-Planned, Policy # CSM132 requires: "...Obtain physician order...Arrange transportation...conduct...phone report with the accepting facility...The following forms are required to be completed when transferring the patient/resident: "...a. Consent to Transfer/Transport (Form #TS-MR-903D)
b. Memorandum of Transfer...(Form #TS-MR-903)
c. Continuation of Care Transfer Instructions...if transferring...General Acute Hospital...Acute Rehab...(Form #TS-MR-A)
d. Continuation of Care Transfer Orders...if transferring to a SNF (skilled nursing facility)...Assisted Living...Hospice...(Form #TS-MR-B)...."

Patient #3's Physician Orders dated 09/02/10, revealed: Transfer to a subacute/rehabilitation facility tomorrow 9/3/10 when bed available.

Review of patient #3's medical record revealed the following: the consent to transfer/transport was incomplete, the reason for the transfer and who the patient was to be accompanied by was not documented. No memorandum of transfer, and continuation of care transfer orders were located in the medical record.

Patient #7's Physician Orders dated 01/29/11, revealed: "...Transfer pt. to...ICU...."

Review of patient #7's medical record revealed no transfer/transport consent. The memorandum of transfer was incomplete, name of contact person at receiving hospital and transferring physician or hospital staff acting under physician's orders address and phone number were not documented. No continuation of care transfer instructions were located in the medical record.

Patient #8's Physician Orders dated 02/04/11, revealed an order to transfer the patient to another facility for Intensive Care Services. There was no transfer/transport consent. The memorandum of transfer was incomplete, the transferring physician or hospital staff acting under physician's orders address and phone number were not documented. No continuation of care transfer instructions were located in the medical record.

The Director of Nursing confirmed the incomplete transfer records during an interview conducted on 02/17/11.

Based on review of medical records and staff interviews, it was determined that the hospital failed to require that respiratory services were delivered in accordance with medical staff directives regarding administration of medications and documentation of respiratory treatments for 3 of 3 patients (patients #12, #24, # 27).

Findings include:

Review of the hospital form titled Medication Administration Record (MAR) Respiratory Med (medication) revealed: "...Comments...Circle and initial when MED NOT GIVEN, initial and time all administered MEDS...."

Patient #12's MAR for Respiratory Med contained a physician order for Tobramycin 300 mg (milligrams). Total Doses:18 Twice Daily (Respiratory only). Start 02/15 at 1900 hours. Stop 02/24 at 0701 hours.

Patient #12's MAR Administration period dated 02/16/11 at 0700 hours through 02/17/11 at 0659 hours, revealed at 0700 hours and 1900 hours there was no documentation of the tobramycin medication treatment.

Patient #24's MAR contained a physician order for "Levabuterol Hydrochloride 0.63 MG Every 6 hours while awake, via SVN (small volume nebulizer)...." START 1200 2/11/11.

Patient #24's MAR Administration period dated 02/16/11 at 0700 hours through 02/17/11 at 0659 hours, revealed at 1200 hours, 1800 hours and 0600 hours there was no documentation of the Levabuterol medication treatment.

Patient #27's MAR contained a physician order for "Albuterol 2.5-.5 SOL 1 DUONEB (duo-nebulizer) INH (inhaler) every 6 hours (Respiratory only)" start 1300 on 1/29/11.

Patient #27's MAR administration period dated 02/14/11 at 0700 hours through 02/15 /11 at 0659 hours, revealed at 0700 hours and 1300 hours there was no documentation of the Albuterol medication treatment.

Patient #27's MAR also contained a physician order "Budesonide 160/4.5 PWD (powder)
2 Puffs SYMBI (Symbicort) RT Twice a day..." start 1/31/11 at 2100.

Patient #27's MAR administration period dated 02/14/11 at 0700 hours through 02/15 /11 at 0659 hours, revealed at 0900 hours and 2100 hours there was no documentation of the Budesonide medication treatment.

The Respiratory Therapy Director confirmed during an interview conducted on 02/17/11, there was no documentation of the respiratory medication treatments.

Employees #4 and #5 confirmed that the MAR labeled "Respiratory Meds" is the location where respiratory therapists are to document the respiratory treatments given.

Based on review of policy and procedure, hospital documents, medical records, and interview, it was determined the hospital failed to require that drugs were administered in accordance with the orders of a practitioner and accepted standards of practice, as evidenced by:

1. failure of the nursing staff to document accucheck results and insulin dosages on the medication administration record (MAR) in 3 of 3 patients receiving moderate sliding scale insulin (patients #9, #10, and #11); and

2. failure of the RN to clarify an incomplete physician's order for intravenous titration of a vasoactive medication prior to administration of the medication for 2 of 2 (Pts #5 & 25).

Findings include:

1. The hospital policy titled Glucose Monitoring Policy #NSG158 requires: "...Nursing staff will follow the physician orders regarding glucose monitoring and sliding scale...Based upon...reading and...order...administer units...sliding scale...."

Per policy, the moderate sliding scale is based on average weight, moderate obese, and eating. If the blood glucose is below 65 and/or the patient is symptomatic give Glucagon 1 milligram (mg) /unit IV (intravenous), IM (intramuscular) or SQ (subcutaneous) & call MD (medical doctor).
Blood glucose 65-150, no coverage.
Blood glucose 151-200, 3 units.
Blood glucose 201-250, 5 units.
Blood glucose 251-300, 7 units.
Blood glucose 301-350, 10 units.
Blood glucose above 350, 12 units & call MD.

The hospital policy titled Medication Administration Policy # NDG132 requires: "...All medications administered will be recorded in the patients...MAR...date given, time given, and the initials...administering the medication...In some instances, medications/dosages may need to be verified by two nurses...All medications...administered...according to...Lippincot Procedure guidelines...."

Review of document provided by facility regarding subcutaneous insulin injections: "...To establish...consistent...insulin levels, rotate insulin injection sites within anatomical regions...Record...time and date...medication and dose...injection site...."

Patient #9's Physician Orders dated 02/02/11 at 1000 hours, revealed accuchecks every 6 hours with moderate sliding scale.

Patient #9's MAR dated 02/02/11 at 0700 hours through 02/03/11 at 0659 hours revealed: at 0000 hours and 0600 hours there was no documentation of blood sugar level, or insulin dosage, injection site, if applicable, or initials of nursing staff.

Patient #9's MAR dated 02/03/11 at 0700 hours through 02/04/11 at 0659 hours revealed: at 1200 hours blood sugar level was recorded 152. There was no documented evidence that the patient received any insulin coverage (3 units), the injection site, and no initials of nursing staff. At 0600 hours there was no documentation of blood sugar level, or insulin dosage, injection site, if applicable, or initials of nursing staff.

Patient #9's MAR dated 02/04/11 at 0700 hours through 02/05/11 at 0659 hours revealed: at 0600 hours there was no documentation of blood sugar level, or insulin dosage, injection site, if applicable, or initials of nursing staff.

Patient #9's MAR dated 02/05/11 at 0700 hours through 02/06/11 at 0659 hours revealed: at 1800 hours there was no documentation of blood sugar level, or insulin dosage, injection site, if applicable, or initials of nursing staff.

Patient #9's MAR dated 02/09/11 at 0700 hours through 02/10/11 at 0659 hours revealed: at 1200 hours the blood sugar level was recorded 154. There was no documented evidence that the patient received any insulin coverage (3 units), the injection site, or initials of nursing staff.

Patient #10's Physician Orders dated 01/27/11 at 1900 hours revealed accuchecks before meals and bedtime, moderate sliding scale.

Patient #10's MAR dated 01/28/11 at 0700 hours through 01/29/11 at 0659 hours revealed at 1100 hours there was no documentation of blood sugar level, or insulin dosage, injection site, if applicable, or initials of nursing staff. At 1600 hours the blood sugar level was recorded 210. There was no documented evidence that the patient received any insulin coverage (5 units), the injection site, or initials of nursing staff.

Patient #10's MAR dated 01/30/11 at 0700 hours through 01/31/11 at 0659 hours revealed at 1600 hours the blood sugar level was recorded 248. Documentation revealed the patient was covered with 7 units of insulin rather than the 5 units ordered. At 2100 hours the blood sugar level was recorded 155. There was no documented evidence that the patient received any insulin coverage (3 units), the injection site, or initials of nursing staff.

Patient #10's MAR dated 01/31/11 at 0700 hours through 02/01/11 at 0659 hours revealed at
1600 hours the blood sugar level was recorded 214. There was no documented evidence that the patient received any insulin coverage (5 units), the injection site, or initials of nursing staff.

The Quality Manager and RN #36 confirmed the insulin findings during an interview conducted on 02/14/11.

Review of Pt #11's medical record revealed:

An RN recorded a physician's telephone order on 2/1/11 at 1040: "...Continue Q6h BG (every 6 hour Blood Glucose) checks with moderate scale, reg insulin, sliding scale...."

The graphic sheet contained documentation of the patient's blood glucose at midnight on 2/3/11, as 175 (requiring 3 Units of insulin) and at 0600 as 155 (requiring 3 Units of insulin). The MAR did not contain documentation that insulin was administered at midnight or 0600.

The Pt's MAR dated 2/6/11 at 1800 hours, contained documentation that the pt's blood glucose was 318 and 7 Units of insulin was administered. The required dose of insulin was 10 Units.

The Pt's MAR dated 2/8/11 at 0000 (midnight), contained documentation that the patient's blood glucose was 173 (requiring 3 Units of insulin). The MAR did not contain documentation that insulin was administered.

The Pt's MAR dated 2/8/11 at 0700 through 2/9/11 at 0659, contained a hand written change for the blood glucose checks to be completed at "AC HS" (before meals and at bedtime) instead of every 6 hours. Blood glucose checks were recorded at 1200, 1800, 2000, and 0600. The medical record does not contain a physician's order to change the interval of blood glucose checks from Q6h to AC & HS.

The Pt's MAR dated 2/9/11 at 0700 through 2/10/11 at 0659, contained the order for blood glucose checks Q6h. No blood glucose checks were recorded for 2/10/11 at 0000 or 0600 as required.

Employee #45, a Charge Nurse, confirmed during interview on 2/16/11, that the blood sugar checks and insulin administration were incorrect for Pt #11.

2. Review of the hospital policy/procedure titled Drug prescribing/Ordering Orders: Drugs revealed: "...Required Elements of Drug Orders: Each drug order will include:...Drug name, strength (and dosage form, if necessary)...Directions for use (including route and rate of administration)...."

Review of the hospital policy/procedure titled Physician Orders revealed: "Orders must be written clearly, legibly and completely...When an order is unclear or the clinical staff questions the appropriateness, accuracy or completeness of the order, the order will not be implemented until it is verified for accuracy with the ordering practitioner...."

Pt #5's medical record contained a physician's telephone order, recorded by an RN on 2/8/11 at 1200: "...Neosinephrine (sic) gtt (drip). Titrate to maintain SBP>90 (systolic blood pressure greater than 90)...."

Pt #5's medical record contained documentation that a nurse started the Neosynephrine at 20 mcg/minute (micrograms per minute) on 2/8/11 at 1200, and continued the 20 mcg until 1500, when the dose was increased to 25mcg (SBP 98). The dose was increased to 30mcg at 1645 (SBP 83); increased to 35mcg at 1830 (SBP 86); increased to 50mcg at 1900 (SBP 93/52). Blood pressures were recorded every 15 minutes from 1200 through 1800 and every 30 minutes from 1800 through 2100. Blood pressures were recorded every hour from 2100 on 2/8/11 through 0800 on 2/9/11. The dosage continued at 50mcg through 2/9/11 at 0800, when it was decreased to 40mcg (SBP 129/69). At 0900, the dose was decreased to 30mcg (SBP 121) and continued at 30mcg until 1600, when it was decreased to 10mcg (SBP 118/60). Blood pressures were recorded every 30 minutes from 0800 through 1900 and every hour from 2000 through 0000 (midnight 2/10/11). The section of the Nursing Daily Record labeled IV Drips was blank on 2/9/11 from 2000 through 0000 2/10/11 . A nurse documented in the progress notes on 2/9/11 at 2000 that the patient continued on Phenylephrine (Neosynephrine) at 10mcg/min. At 2300, a nurse noted: "...Phenylephrine gtt rate remains the same...." On 2/10/11 at 0230, a nurse documented that the Phenylephrine was decreased to 6.67 mcg/minute (SBP 160) and was stopped at 0315 (SBP 121/62).

RN #45, a Charge Nurse, confirmed on 2/17/11, that the order on Pt #5's medical record was incomplete. The order contained no route, dosage, or rate of administration. Nursing did not clarify the order. Nursing started the IV and titrated it without complete physician's orders. In addition, nursing decreased the dosage and discontinued the medication without a physician's order.

Pt #25's medical record contained a physician's telephone order, recorded by an RN on 2/7/11 at 0930: "...Use Neosenephrine (sic) to keep SBP > 90. Wean off as tolerated...."

Pt #25's medical record contained documentation that a nurse started the Neosynephrine at 15 mcg/minute on 2/7/11 at 1000, and increased the dose to 25mcg/min at 1200 (SBP 91). The dose of 25mcg/min continued until 2100, when it was increased to 50mcg (SBP was 63). Blood pressure was recorded on 2/7/11 at 0800, 1000, 1200, 1300, 2000, 2100, 2200, and 2300. (The patient continued to receive 25mcg/min between 1300 and 2000, even though no blood pressure readings were recorded.) Blood pressures were recorded every hour from 0000 (midnight) on 2/8/11 through 2300. Dose of Neosynephrine continued at 50 mcg/min until 2/8/11 at 0800 when it was decreased to 40mcg (SBP 120). At 1100, the dose was decreased to 30mcg (SBP 114). At 1200, the dose was decreased to 20mcg (SBP 100). At 1300, it was decreased to 10mcg (SBP 95). The dose was continued at 10mcg/min on 2/8/11 from 1300 through 2/9/11 at 0700. Blood pressures were recorded every hour on 2/9/11 from midnight through 0700. It was then discontinued at 0800 (SBP 126).

RN #45, a Charge Nurse, confirmed on 2/16/11, that the order on Pt #25's medical record was incomplete. The order contained no route, dosage, or rate of administration. Nursing started the IV and titrated it without complete physician's orders. In addition, nursing decreased the dosage and discontinued the medication without a physician's order.

RN #13 confirmed during interview on 2/17/11, that s/he had initiated the IV for Pt #25 and determined the starting dose and titration rate based on his/her own judgment and experience. S/he confirmed that the physician's order did not specify the dosage or titration rate.