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Based on the review of policies and procedures, the review of documentation, staff interviews and the review of 31 of 31 patient records (Patient #s 1-21, 25, 26, 28, 29, 30, 31, 39, 40, 41 and 42), it was determined that the hospital failed to inform each patient (or support person where appropriate) of his or her visitation rights, including any clinical restriction or limitation on such rights, when he or she is informed of his or her other rights; the hospital also failed to formulate a clear policy and procedure for all patients that included any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reason for the clinical restriction or limitations.

Findings include:

The hospital admit packet was received on 08/23/11 at 0730. The packet contained a folded document titled "Your Rights and Responsibilities as a Patient," dated revised 07/21/03. None of the information contained within the packet included patient visitation rights, including any clinical restrictions or limitations that the hospital may need to place on such rights.

The policy and procedure titled "Rights and Responsibilities of Patients," dated last revised 03/2008 was received and reviewed. The policy and procedure reflected "Holy Rosary Medical Center patients have the right of access to people outside the hospital by means of visitors, and by verbal and written communication." Review of the policy reflected "Patients are to be informed of their rights and responsibilities prior to the provision of care and/or cessation of care/treatment," however the policy and procedure lacked documentation that included a process for informing patients of visitation rights and any clinical restrictions or limitations on such rights when he or she is informed of his or her other rights.

The policy and procedure titled "Individual Rights: Inquiries and Complaints, Patient Grievances," dated last revised 03/2011 reflected "1...In advance of providing care for inpatient or outpatient treatment, (or if in the Emergency Department, at the first available opportunity), upon registration, Saint Alphonsus Medical Center--Ontario will provide a Patient or his/her personal representative (referred to collectively or in the alternative as the "Patient") with: a written notice of the Patient's rights (See Appendix A)." Review of page seven of the policy and procedure, titled "APPENDIX A NOTICE OF YOUR RIGHTS AS AN INDIVIDUAL," determined there was no information that included informing each patient (or support person, where appropriate) of his or her visitation rights, including any clinical restriction or limitation on such rights as required.

During an interview with the Risk Manager on 08/23/11 at 1100, he/she said there are times when visitors need to be restricted such as when a patient is receiving a procedure, when there is a "court order" that restricts a visitor, and/or when a visitor becomes disruptive to others. He/she further said that when patient visitors call the hospital to inquire regarding visitation hours, he/she informs them of that same information. During the interview the patient rights policies and procedures, including Appendix A, and the admit packet with the patient rights document was reviewed. He/she acknowledged that the admission packet information was the process in which patients receive their patient rights. He/she acknowledged that there was no information contained within those documents that included a process for informing each patient (or support person where appropriate) of his or her visitation rights, including any clinical restriction or limitation on such rights.

This information was reported during an interview that included the Chief Nursing Officer and the Risk Manager on 08/24/11 at approximately 1630. On 08/25/11 at 1300, a visitation rights policy and procedure "corporate policy," was received by the Risk Manager. The policy was scheduled to be approved by the "Senior Team" on 08/31/11; also an admission packet which included patient visitation rights, dated 08/25/11 was received, however those documents were not available for review prior to that time.

Based on the review of the hospital's policy and procedure, the review of documentation, a staff interview, and the review of 8 of 8 patient/patient representative (Patient #s 23, 32, 33, 34, 35, 36, 37 and 38) grievances from the hospital grievance log, it was determined that the hospital failed to establish a policy and procedure that included that the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for all grievances submitted by a patient or patient representative.


Findings include:


Review of the hospital's policy titled "Individual Rights: Inquiries and Complaints, Patient Grievance Process" dated last revised 03/2011 reflected "The Designated Representative will, as soon as reasonably possible, but ideally within seven (7) business days of the communication of a Patient Grievance, begin an investigation by contacting the Patient either in writing or orally acknowledging receipt of the Patient Grievance, describing the Patient Grievance Process steps and estimating time to Saint Alphonsus Medical Center-Ontario's conclusion of the Patient Grievance Process (see Appendix D) (If resolution has been reached within that time, then final written notice is sent to Patient.)...The Designated Representative shall complete investigation of the Patient Grievance, either by resolving the Patient Grievance by agreement with the Patient and providing written notice to the Patient, or by making recommendations to the Patient Grievance Committee in the absence of agreement on the Patient Grievance...In cases in which a Patient Grievance remains unresolved, the Patient Grievance Committee shall...draft a written response to the Patient within thirty (30) days from the Patient Grievance Committee's receipt of the Investigation File. (The patient must have already received some written notice of the investigation within seven (7) days of receipt of grievance)...The Patient Grievance Committee response will outline the steps taken to investigate the Patient Grievance...the results of the grievance process, and the date of completion.

Page 10 of the policy and procedure, titled "APPENDIX D ACKNOWLEDGEMENT OF PATIENT GRIEVANCE," was reviewed and reflected" As a result of your initiating the Patient Grievance Process, I will conduct an investigation and make a report and recommendations to a Patient Grievance Committee...The Patient Grievance Committee will review your Patient Grievance and will communicate directly with you concerning that grievance...the Patient Grievance Committee will send a reply to you within thirty (30) days of the date of this letter." Although the acknowledgement letter reflected that the patient grievance committee would send a reply letter in response to the grievance, not all grievances were forwarded to the grievance committee, and therefore not all patient grievances received a written response which included all of the required elements. This was discussed with the Risk Manager during an interview on 08/23/11 at 1100. He/she acknowledged that the policy and procedure did not include a clear process for providing a written response that included all of the required elements to all patients including patients whose grievances were not forwarded to the grievance committee.

During an interview with the Risk Manager on 08/23/11 at 1300, the hospital grievance log was received and reviewed. He/she was asked to provide a written response for eight of the grievances contained within the grievance log. He/she said written responses, with all of the required elements had not been provided to those eight patients/patient representatives. This information was reported to the Chief Executive Officer and Chief Nursing Officer on 08/24/11 at approximately 1630. On 08/25/11 at 0745, the Risk Manager provided written responses for three of the eight requested grievances. The documentation contained within those written responses failed to include all of the elements as required by this regulation. For example, review of the written response for patient #38 contained the name of the hospital contact person, but lacked documentation of the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. No further documentation that included all of the required elements was received for the duration of the survey.

Based on documentation review, an interview with facility staff, and review of clinical records it was determined that in 8 of 31 clinical records (Record #s 7, 11, 12, 13, 15, 16, 21, and 31) the facility failed to document whether or not the patient had executed an advance directive, as required by this regulation.

Findings include:

The hospital had a policy ADM 117, titled Advanced Directives that was last Revised/Reviewed on 07/11, which stated: "Procedure:....2. The RN performing the initial assessment will ask all inpatients and outpatients about the status of their advance directive decision during pre-admission interviews.

An interview with the Clinical Data Analyst on 08/24/2011 at approximately 0800, determined that for surgical patients, the documentation of the discussion of the Advanced Directive would be found on the second page of the Pre-Operative Assessment under #13 entry. When reviewing 12 clinical records of surgical patients, Record #s 6, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20 and 21, the #13 entry was reviewed as well as throughout the entire initial assessments of all patients. Note that patients # 11, 12, 13, 15, 16, and 21 were surgical patients with no entry under #13 entry or elsewhere in the medical record.

Patient #7: Review of the record revealed the patient was admitted on 07/12/11. The admission and patient health history form reflected "1. Social...l. Do you have an Advance Directive:" The following choices were listed and each had a preceding checkbox: "No existing documentation," "Written information given," and "Written information refused." None of the boxes were marked. There was also a "Yes" and "No" column to indicate whether or not the patient had an advance directive. None of the areas were marked in order to determine whether or not the patient had executed an advanced directive, and whether or not the patient had been provided information to allow the patients to formulate an advance directive.

Patient #31: Review of the record revealed the patient was admitted on 07/23/11. The obstetric admitting labor record had an advanced directive section that included the following listed choices "Patient's Rights Given," "Inquiry complete," "Copy on chart," "Document exists-will bring in by___________," "*Verbal Advance Directive (document in narrative notes)," "Written information provided," and "Written information refused." Each choice had a preceding checkbox. The box next to "Patient Rights Given" was marked with an "X," however none of the remaining listed choices were marked in order to determine whether or not the patient had executed an advance directive, and whether or not the patient had been provided information to allow the patients to formulate an advance directive.

Based on observations made in the C.T. Scan area of the hospital at 11:30 on 08/23/2011, staff interviews at that time, and hospital documentation, it was determined that the hospital failed to maintain the supplies within the resuscitation cart that would ensure the delivery of emergency services in accordance with medical staff directives and according to acceptable standards of care in a safe setting.
Findings are:

On the above stated time and date, the plastic lock on the code cart located in the C.T. room was removed and the contents of the cart examined. The code cart contained the following expired items, that if used, would have compromised the safety of the patient.

One Fiva intubating introducer without cannula expired 05/2010;
One Cook Airway exchange catheter with RAPI fit expired 03/2010;
Ten syringes containing 10 ml of 0.9% Sodium Chloride Inj. USP expired 01/1/2010;
One bottle of Povidone Iodine topical solution expired 01/2009;
Five packages of Povidone Iodine containing a single swab expired 09/09/2005;
One Arrogator Blu plus multilumen CVC kit expired 03/2008;
Six 16 Ga X 1.77' Insyte autogaurd expired 01/2009;
Four 20 Ga X 1.16" Insyte autogaurd expired 01/2010;
Two 18 Ga X 1.16" Insyte autogaurd expired 04/2009;
One LSL sterile IV start kit expired 11/2008;
Two 24 Ga X 0.75" Insyte autogaurd expired 01/2009;
Four 20 Ga X 1.16" Insyte autogaurd expired 01/2010;
Three 14 Ga X 1.75" Insyte autogaurd expired 12/2007;
One 30 ml bottle of Bacteriostatic 0.9% Sodium chloride solution expired 02/01/2010;
Five filter needles expired 06/2007;
Five Povidone Iodine USP preparation pads, medium expired on 01/2009;
Five packages of ECG electrodes, 5 electrodes per package, 2 packages expired on 11/2008 and 3 expired on 01/2009; and
Approximately 28 additional supply items all expired from 09/2005 to 04/2011.

Taped to the top of the code cart and under a number of reference books, supplies , and equipment was an inventory list titled "Crash Cart - Supply Expiration (sic) Checklist." This list had 7 columns titled from left to right as "Stock #," Description," "Exp. Date,"(Blank), "Stock #," Description," and "Exp. Date." Rows were identified as "Drawer 2," "Drawer 3,"and "Drawer 4" on the left 3 columns and "Drawer 5," and "Drawer 6" on the right 3 columns. Under the drawer number was listed supplies found in the drawer and the expiration date for those supplies. The expiration dates ranged from 12/2007 to 08/2011. According to this list, the only supplies that had not expired were monitoring electrodes that were listed as expiring on 08/2011.

The hospital policy and procedure, "Crash Cart: Maintenance, Exchange and Defibrillator Check" revised last on 03/2011, stated:
"Important Considerations:
....3. Maintenance of supplies on crash cart and defibrillator will be assigned on each unit....
Procedure:
...2. Each month a staff member will be assigned on each unit to open the crash cart and check for presence of contents according to crash cart inventory list.
a. Inventory list will be kept on the crash cart.
b. Any outdated supplies will be removed and replaced immediately.
c. The inventory checklist will be signed indication completion of this task......
...3. Replacing the Crash Cart lock:
c. The Respiratory Therapy or Pharmacy Technician opens the crash cart to check their equipment expiration dates and intact packaging. They are not responsible to check the entire cart, and only need to replace the numbered lock(s)....
...5. Department of Respiratory Therapy will check the respiratory supplies in Drawer 3 every month and sign the checklist found in the drawer."

An interview of the Director of the Imaging Department, while reviewing the contents of the code cart, revealed that the Imaging Department Director thought Pharmacy was responsible for checking medications on the code cart and Respiratory Services staff were responsible for checking the cart's supplies.

Based on the review of the hospital's policy and procedure, the review of 3 of 3 patient records of patients who were physically restrained with soft wrist restraints (Patient record #s 2, 3 and 6), and a staff interview, it was determined that the hospital failed to ensure that the use of the physical restraints were in accordance with a written modification to the patient's plan of care as directed by the hospital policy and procedure.

Review of the hospital's policy and procedure titled "RESTRAINTS-ORDER, REORDER AND APPLICATION" dated last revised/reviewed 01/2011 reflected "...uses of restraints are defined as: 1. Acute Medical/Post-Surgical Care Restraint is used to restrict freedom of movement that puts the patient or others at risk for injury or interference with medical treatment necessary to promote medical healing. Use of restraints to protect a patient from pulling out lines, tubes or drains whose termination would impede medical healing is an example of acute medical/post-surgical care type restraint." The policy directed the following documentation requirements...Nursing documentation per restraint documentation form/nursing progress notes and care plan updated to reflect changes in patient condition within 8 hours of restraint initiation and discontinuation...The Nursing Plan of Care will be developed and/or updated by the care team... at initiation of restraints and evaluated and updated as patient's condition changes."

Review of patient record #s 2, 3 and 6 revealed that all three patients had wrist restraints applied for a period exceeding eight hours. Review of each of those patient records determined that although each of the records included a patient restraint documentation form, none of the records contained a care plan that was updated to reflect changes in the patient condition within eight hours of restraint initiation; and none of the records contained a nursing plan of care by the care team at the initiation of the restraints as directed by the hospital policy and procedure.

An interview was conducted with the Clinical Data Analyst on 08/25/11 at 0810. He/she reviewed patient #2's record and identified the patient restraint documentation form. He/she said that form was the restraint care plan, however review of the hospital's restraint policy and procedure directs that the restraint documentation form/nursing progress notes and care plan are to be updated. This was reported to the Performance Improvement Officer on 08/25/11 at 1130. No further documentation was received for those three patient records which included that a nursing plan of care had been developed and/or updated by the care team upon initiation of the restraints or within eight hours of restraint initiation as directed by the hospital's policy and procedure.

Based on the review of the hospital policies and procedures, the review of 2 of 3 patient records of patients who were physically restrained with soft wrist restraints (Patient record #s 2 and 3), and a staff interview, it was determined that the hospital failed to ensure that the use of physical restraints was in accordance with orders from a physician or other LIP (licensed independent practitioner) responsible for the care of the patient and authorized to order restraints in accordance with the hospital's policy and procedure.

Findings include:

Review of the hospital's policy and procedure titled "RESTRAINTS-ORDER, REORDER AND APPLICATION" dated last revised/reviewed 01/2011 reflected "If...alternatives are not effective or applicable, [the] RN will obtain a physician's order for the application of restraints. In the event of an emergent situation, restraints may be applied prior to LIP [licensed independent practitioner] order, the LIP will be notified immediately (within one hour of restraint initiation) of patient status change and need for restraint order."

Patient record #2: Review of the documentation reflected an admit date of 07/07/11 at 1850. The patient was admitted to the CCU (critical care unit) on 07/09/11. A form titled "Patient Restraint Documentation" was reviewed and revealed that the patient had soft wrist restraints to both extremities from 07/09/11 at 2315 through 07/10/11 at 0915. Review of the record determined there was no physician's order for the application of the restraints.

Patient record #3: Review of the documentation reflected an admit date of 07/08/11 at 1820. The patient was admitted to the CCU on 07/08/11 at 1905. A form titled "Patient Restraint Documentation" was reviewed and revealed that the patient had soft wrist restraints to both extremities from 07/08/11 at 2015 through 07/09/11 at 0800. Further review of the record revealed that the nurse discussed and/or received orders from the physician on 07/08/11 at 2015 and 07/09/11 at 0050, however the record lacked documentation of a physician order for the application of the restraints.

An interview was conducted with the Clinical Data Analyst on 08/25/11 at 0810. He/she reviewed patient #2's record and verified that the record lacked documentation of a physician order for the application of the restraints.

Based on the review of medical records, it was determined that in eight of twelve medical records of individuals who received surgical services, medical records # 2, 11, 12, 15, 16, 19, 20, and 21, the hospital failed to ensure that all drugs were administered in accordance with Federal and State laws and accepted standards of practice. Findings:

An interview of a staff member from the Oregon State Board of Nursing on 9/18/2006 determined that physician order sheets should be designed and implemented to avoid requiring a nurse to make a judgement as to which medication (or medications) to administer from a menu of medications. The orders should rank the medications as to which medication should be given first, second, etc. and the orders should specify a maximum dose for each medication before administering another medication. These decisions are beyond the scope of practice of the Registered Nurse, not in keeping with "prudent, safe, nursing practice standards," and border on prescriptive responsibilities.

The review of medical records revealed that the hospital utilized forms entitled "Post-OP Physician's Orders and Progress Notes," and "Physician's Orders Post Orthopedic Surgery."

Each of these forms list multiple medications to relieve post surgical pain, nausea, and/or itching. Each medication on these forms have a "checkbox" preceding them to indicate that the medication is ordered when a checkmark is placed through the checkbox or the checkbox is blackened out.

Medical records # 2, 11, 12, 15, 16, 19, 20, and 21 contained one or more of the listed forms with checkmarks identifying two or more medications in each category for pain, itching and/or nausea. The orders for medications were not written with clear direction for the administration of the medication: The orders were not ranked to identify which medication was to be given first, second, third, etc. and /or the orders did not specify a maximum dose for each medication before administering another medication. Findings include, but are not limited to, the following examples:

Patient Record #2 - This record contained a "Post-OP Physician's Orders and Progress Notes" form. On 07/08/2011 at 1300, the physician ordered medication for the relief of pain that included "Hydromorphone 0.1-0.4 mg IV (intravenous) every 30 minutes if needed for pain" and "Norco 5/325 1-2 p.o. (by mouth) every 4-6 hours prn (as needed) pain." Additionally, the orders for nausea included: "Zofran 4-8 mg IV every 8 hours prn nausea" and "Promethazine 6.25-12.5 mg slow IVP (intravenous push) every 4 hours prn nausea." The orders were not ranked to identify which medication to administer first or second

Patient Record # 11 - This record contained a "Post-OP Physician's Orders and Progress Notes" form dated 07/08/2011 but un-timed. The same medications as those ordered for Patient # 2 for pain and nausea were ordered for this patient.

Patient Record # 12 - This record contained a "Post-OP Physician's Orders and Progress Notes" form. The form was undated and untimed. The physician ordered medication for the relief of pain that included "Morphine Sulfate 1-4 mg IV every 30 minutes prn pain" and "Hydrocodone/APAP 5/500 1-2 tabs po every 4 hours prn pain." The orders were not ranked to identify which medication to administer first or second.

Patient Record # 15 - This record contained a "Physician's Orders Post Orthopedic Surgery"
form dated 07/28/2011 at 1645. The physician ordered "Morphine Sulfate 1-2 mg IV every 1 hour prn pain" and "Hydrocodone/APAP 10 mg 1 or 2 tabs po every 4 hours prn pain - 6 h prn."

Patient Records # 16, 19, 20, and 21 reflected similar findings.

Based on the review of medical records, it was determined that in 12 of 20 medical records (medical records #s 1, 2, 3, 5, 7, 12, 13, 14, 15, 17, 20, and 31) the hospital failed to ensure that all verbal orders were authenticated within 48 hours.

Findings are:

Record # 20 - This patient was hospitalized from 06/09/2011 to 06/18/2011. This medical record contained 7 verbal ordersets; 06/12/2001 at 0730, 06/12/2011 at 1200, 06/12/11 at 1300, 06/12/2011 at 1620, 0613/2011 at 2330, 06/14/2011 at 11:00, and 06/14/2011 at 2130, that were countersigned but none of these ordersets were dated and timed to indicate when it was countersigned.

Record # 13 - This patient was hospitalized from 08/10/2011 through 08/13/2011. This medical record contained 11 ordersets, 3 of which were not timed. There was also a verbal order given on 08/10/2011 at 2015 that was not signed. There were also two "TORB (telephone order read back)" that were signed with no date or time to indicate when they were countersigned: 08/12/2011 at 0615 and 08/12/2011 at 0617.

Record # 17 - The patient was hospitalized from 06/06/2011 through 06/09/2011. This medical record contained 3 verbal ordersets; 06/06/2001 at 0700, 06/06/2011 at 1130, and 06/07/2011 at 1200, that were countersigned but none of these ordersets were dated and timed to indicate when it was countersigned.

Record # 15 - The patient was hospitalized from 7/28/2011 to 08/01/2011. This medical record a "TO (telephone order)" taken at 07/30/2011 0640 and one "TORB" taken at 08/01/2011 at 1550 that were countersigned but without a date or time to indicate when they were countersigned.

Similar findings were identified in patient record #s 1, 2, 3, 5, 7, 12, 14, and 31.

Based on the review of policies and procedures and the review of informed consent forms contained within 2 of 31 patient records (Patient #s 10 and 28), it was determined that the hospital failed to ensure that the consent forms were properly executed; the consent forms failed to include a date and time the consent form was signed by the patient or the patient's legal representative.

Findings include:

The policy and procedure entitled "INFORMED CONSENT," dated last revised 01/2005 was reviewed and reflected "...Informed consent shall be obtained for therapeutic and diagnostic procedures where disclosure of significant medical information including risks involved would assist a patient in making an intelligent decision whether to undergo the proposed procedures. Procedures presently performed at the HRMC [Holy Rosary Medical Center] that require informed consent include but are not limited to...All surgical or percutaneous procedures performed under general, regional or local anesthesia...circumcision of infants..."

Patient #10: Review of the record revealed that the patient arrived at the ED (emergency department) on 06/27/11 with acute left lower abdominal pain. The record contained a form titled "PATIENT INFORMED CONSENT." The general treatment or procedure to be undertaken was listed as four words that were illegible and "2. There may be other procedures or methods of treatment; and 3. There are risks to the procedure or treatment proposed." The consent form was signed by the patient, however there was no date and time the form was signed.

Patient #28: Review of the record revealed that the patient was born at the hospital on 06/27/11. The record contained a form titled "PATIENT INFORMED CONSENT" and "1. The general treatment or procedure to be undertaken: Circumcision; and 2. There may be other procedures or methods of treatment; and 3. There are risks to the procedure or treatment proposed." The consent form was signed by the newborn patient's father/mother, however there was no date and time the form was signed.