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Based on record review and interview, the facility failed to ensure the medical record contained properly authenticated physician's orders for three (#s 1,10 and 17) of 22 sampled patients.
Findings include:

1. Patient #1 was born on 1/5/15 via emergency c-section. Review of the nurses' notes reflected staff member E, RN, gave 0.3 mg of epinephrine 1:10,000 IM at 6:35 a.m., 6:38 a.m. and 7:00 a.m. per staff member O's (MD) verbal order.

During an interview on 4/20/15 at 4:35 p.m. staff member B, DON, stated it was an emergency situation, the nurse got the epi and there was an override in Pyxis. There was a place in Meditech to write verbal orders. She said unfortunately, the nurse did not write a verbal order and the doctor did not write or sign the order.

2. Patient #17 was admitted on 4/15/15 with a diagnosis of Stevens Johnson Syndrome. A review of the medical record reflected the patient was given six medications, by verbal orders, without an authentication from a practitioner and were not dated or timed. These medications were:
-Klonopin 0.5 mg P.O. Q p.m., ordered 4/15/15;
-Klonopine 0.5 mg P.O., tid, ordered on 4/15/15;
-Solu-Cortef 75mg IV Q 6 hours ordered on 4/15/15;
-Zyprexa 2.5 mg P.O. at bedtime, ordered on 1/15/15;
-Pepcid 20 mg IV Q 12 hours, ordered on 4/15/15;
-Benadryl 25 mg IV Q 6 hours, ordered on 4/15/15.

3. Patient #10 was admitted on 3/13/15 for a D&C for an incomplete abortion and thrombocytopenia. Review of patient #10's medical record reflected the patient was given medication on four occasions by verbal orders, without an authentication from a practitioner and were not dated or timed. These medications were:
-Fentanyl 200 mg, one time ordered on 3/23/15;
-Zemuron 10 mg one time ordered on 3/23/15;
-Anectine/Quelicon 200 mg one time ordered on 3/23/15;
-Tylenol 650 mg ordered on 3/23/15.

During an interview on 4/21/15 at 4:30 p.m., staff member C, executive assistant, stated medical records ran reports to see if there were outstanding orders that needed to be signed by the provider. Medical records would notify the doctor to sign off on the order within 48 hours. She stated if the verbal order was entered as a "written order," it would not show up in the medical records' report. Staff member B, DON, stated the epi was given to patient #1 and the order was not written. The documentation was in the nurse's notes.

During an interview on 4/22/15 at 10:45 a.m., staff member K, medical records manager, stated that most unsigned orders were those of the traveling doctors. Their new policy dictates that the unsigned records over 30 days would go to the chief of staff for signatures.

Review of the facility's medical records policy showed the chief of staff would complete incomplete charts when a provider left the facility prior to completing documentation, and after a failure of three documented attempts to resolve the deficiency.

Based on record review and interview the facility failed to maintain a record that included a dated signature of the doctor for three (#s 1, 10 and 17) of 22 sampled patients. Findings include:

1. Patient #1 was born on 1/5/15 via emergency c-section. A review of the medical record reflected the baby was in respiratory distress and had bradycardia. Review of the nurse notes showed staff member E, RN, gave 0.3 mg of epinephrine 1:10,000 IM. The medication was obtained from the OR and given as ordered at 6:35 a.m., 6:38 a.m. and 7:00 a.m. per the MD's verbal order.

During an interview on 4/20/15 at 4:35 p.m. staff member B, DON, stated it was an emergency situation, the nurse got the epi there was an override in Pyxis. There was a place in Meditech to write verbal orders. She said unfortunately, the nurse did not write a verbal order and the doctor did not write or sign the order. It was a verbal order in an emergent situation. This had happened before. They had since revised the verbal order policy and would be providing training to the nurses.

During an interview on 4/21/15 at 4:40 p.m., staff member B, DON, stated the epi was given to patient #1, and the order was not written. The documentation was in the nurse's notes.

2. Patient #17 was admitted on 4/15/15 with a diagnosis of Stevens Johnson Syndrome. A review of the medical record reflected the patient was given six medications by verbal orders, without an authentication from a practitioner and were not dated or timed. These medications were:
-Klonopin 0.5 mg P.O. Q p.m., ordered 4/15/15;
-Klonopine 0.5 mg P.O., tid, ordered on 4/15/15;
-Solu-Cortef 75mg IV Q 6 hours ordered on 4/15/15;
-Zyprexa 2.5 mg P.O. at bedtime, ordered on 1/15/15;
-Pepcid 20 mg IV Q 12 hours, ordered on 4/15/15;
-Benadryl 25 mg IV Q 6 hours, ordered on 4/15/15.

3. Patient #10 was admitted on 3/13/15 for a D&C for an incomplete abortion and thrombocytopenia. Review of patient #10's medical record reflected the patient was given medication on four occasions by verbal orders, without an authentication from a practitioner and were not dated and timed. These medications were:
-Fentanyl 200 mg, one time ordered on 3/23/15;
-Zemuron 10 mg one time ordered on 3/23/15;
-Anectine/Quelicon 200 mg one time ordered on 3/23/15;
-Tylenol 650 mg ordered on 3/23/15.

During an interview on 4/21/15 at 4:30 p.m., staff member C, executive assistant, stated medical records ran reports to see if there were outstanding orders that needed to be signed by the provider. Medical records would notify the doctor to sign off on the order within 48 hours. She stated if the verbal order was entered as a "written" order, it would not show up in the medical records' report.

Based on interview, the facility failed to comply with §485.641 by not completing a periodic evaluation of the total program of the CAH. See tags 331, 332, 333, 334, and 335.

Based on interview, the facility failed to complete a periodic evaluation of the total program for 2014.
Findings include:

During an interview on 4/22/15 at 2:00 p.m., staff member B, DON, stated each department reports to the quality assurance committee. Staff member B stated she was not aware of a yearly evaluation or report.

During an interview on 4/23/15 at 8:30 a.m., staff member D, QA director, stated there was not a yearly evaluation completed for the CAH. Staff member D stated a yearly evaluation had never been completed but monthly reports are completed by each department.

Based on interview, the facility failed to complete a yearly evaluation of its program to include the number of patients served and volume of services.
Findings include:

During an interview on 4/22/15 at 2:00 p.m., staff member B, DON, stated each department reports to the quality assurance committee. Staff member B stated she was not aware of a yearly evaluation or report.

During an interview on 4/23/15 at 8:30 a.m., staff member D, QA director, stated there was not a yearly evaluation completed for the CAH.

Based on interview, the facility failed to complete a yearly evaluation of its program to include the a sample of active and closed clinical records.
Findings include:

During an interview on 4/22/15 at 2:00 p.m., staff member B, DON, stated each department reports to the quality assurance committee. Staff member B stated she was not aware of a yearly evaluation or report.

During an interview on 4/23/15 at 8:30 a.m., staff member D, QA director, stated there was not a yearly report completed.

Based on interview, the facility failed to complete a yearly evaluation of its program to include a review of the CAH's health care policies.
Findings include:

During an interview on 4/22/15 at 2:00 p.m., staff member B, DON, stated each department reports to the quality assurance committee. Staff member B stated she was not aware of a yearly evaluation or report.

During an interview on 4/23/15 at 8:30 a.m., staff member D, QA director, stated there was not a yearly report completed.

Based on interview, the facility failed to complete a yearly evaluation of its program to include that the utilization of services was appropriate, and that policies were followed, updated or changed for the CAH services.
Findings include:

During an interview on 4/22/15 at 2:00 p.m., staff member B, DON, stated each department reports to the quality assurance committee. Staff member B stated she was not aware of a yearly evaluation or report.

During an interview on 4/23/15 at 8:30 a.m., staff member D, QA director, stated there was not a yearly report completed.

Based on record review and interview, the facility failed to ensure a discharge order, progress notes, and a discharge summary were obtained prior to an admission to a swing bed for one (#20) of two swing bed patients reviewed.
Findings include:

Review of patient #20's EHR reflected a discharge order, progress notes and discharge summary were not completed prior to the admission into a swing bed.

During an interview on 4/21/15 at 9:30 a.m., staff member B, DON, stated there was not a discharged order, progress note or discharge summary prior to admission to the swing bed status.

Review of the facility's Swing Bed policy reflected discharge orders from acute services, appropriate progress notes, discharge summary and subsequent admission orders to the swing bed status were required.

Based on record review and interview, the facility failed to ensure physical restraints were not used on one (#20) of two swing bed patients without an assessment, physician's order, and a medical symptom.
Findings include:


Patient #20 was admitted to swing bed status on 2/17/15 with diagnoses including CVA, decubitus ulcer and UTI with urinary retention.

Review of the EHR on 4/21/15 at 4:00 p.m., reflected patient #20 had four bed rails in the up position during her stay. The medical record did not contain a physician order, medical symptom, or assessment as to why the restraint was being used on patient #20.

During an interview on 4/22/15 at 7:45 a.m., staff member B, DON, stated she was not aware four side rails were being used. Staff member B stated an assessment, medical symptom, and physician's order were required prior to placing a patient in restraints.

Review of the facility's Restraint Policy reflected restraint use must have an assessment performed to determine the safety and protective needs of the patient prior to the application of restraints. The use of restraints will be limited to clinically appropriate and adequately justified situations, when other less restrictive measures have not been effective, and in accordance with a physician's order.

Review of the facility's Swing Bed Policy reflected the use of restraints should be based on each "resident's" [sic] capabilities, care plan, and the use of less restricted alternatives prior to the use of a restraint.

Based on record review and interview, the facility failed to design an ongoing activity program to meet the interest of two (#s 5 and 20) of two swing bed patients.
Findings include:

Review of patient #5's and patient #20's EHR reflected there was not an activity program based on the comprehensive assessment to meet the interests and provide on going activities.

During an interview on 4/22/15 at 7:45 a.m., staff member B, DON, stated activities are offered to swing bed patients by the long term care staff. The activities are not specialized for patients' interest.

Review of the facility's Swing Bed policy reflected an ongoing activity program should be provided to meet the interests, physical, mental, and psychosocial well-being of each "resident."

Based on record review and interview, the facility staff failed to complete a comprehensive assessment on two (#s 5 and 20) of two swing bed patients.
Findings include:

During an interview on 4/22/15 at 7:45 a.m., staff member B, DON, stated the swing bed comprehensive assessment was a one page form.

Review of the comprehensive assessment form reflected the minimum required areas to be assessed were missing for patient #5 and patient #20.
The areas not assessed were:
-customary routine;
-cognitive patterns;
-communication;-vision;
-mood and behavior patterns;
-psychosocial well-being;
-continence;
-dental and nutritional status;
-skin condition;
-activity pursuit;
-medications;
-special treatment and procedures;
-discharge potential; and
-documentation of summary information and if the patient participated in the assessment.

Review of the facility's Swing Bed policy reflected all the minimum required areas would be assessed for each swing bed patient.