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Based on record review and interview, the facility failed to ensure two (Patient #7 and #35) of 12 patients received informed consent and failed to ensure their internal therapeutic status (order for level of resuscitation and life support) policy was followed for two (Patient #7 and #6) of 12 patients. The facility census was 92.

Findings included:

1. Review of the facility's policy titled, "Informed Consent" reviewed 01/09, gave direction, in part, to include the following:
"These forms are to be completely filled out and signed by the appropriate persons before treatment or procedures commence."
"A signed special consent form should be procured prior to every medical and surgical treatment. This includes but is not limited to:
1. Major or minor surgery, which involves an entry into the body, either through an incision or through one of the natural body openings;
2. Procedures in which anesthesia is used; regardless of whether an entry into the body is involved'
3. Non-surgical procedures involving more than a slight risk of harm to the patient, or that involve the risk of a change in the patient's body structure. These procedures shall include but are not limited to diagnostic procedures ..."
"The law in Missouri, as well as in every other state, holds that no medical or surgical treatment or procedure may be rendered to any patient without first obtaining his/her INFORMED CONSENT. The physician performing the procedure or treatment must explain to the patient in layman's language the nature of the proposed procedure, its risks and possible consequences."
"The patient signifies consent by signing an accurately completed CONSENT FORM, also to be signed by the physician."
"It is the legal responsibility of the physician performing the procedure to make certain the CONSENT FORM is accurately and completely filled out and signed."
"Members of the Department of Anesthesia are responsible for explaining the risks, benefits, and alternative for anesthesia at any time a member of this department is assigned care of a patient."
"Guidelines for authorization of anesthesia are like those for authorization of surgery."

Review of the facility's policy titled, Patients Rights and Responsibilities", reviewed 04/10, gave direction, in part, to include the following:
"Every patient and/or designated representative has the right to:"
"information necessary to give informed consent before any procedure or treatment."

Review of the facility's policy titled, "Therapeutic Support Level (TSL)", reviewed 05/08, gave direction, in part, to include the following:
"One of the following therapeutic support levels will be clearly specified in the attending/admitting physician's orders."
"It is the responsibility of the attending physician to inform, educate, communicate and assist the patient and family in making such decisions."
"The patient's TSL will be determined at the time of admission."
"The attending physician after consultation with the patient, family, and/or surrogate will complete the Therapeutic Support Level Order Sheet."
"The RN (Registered Nurse) may assist the patient, family, and/or surrogate during the decision-making process and document accordingly in the nurse's notes. When this occurs, the RN (and a witness) may communicate the preference to the physician and obtain orders for the appropriate TSL. These orders will be documented on the TSL and Order Sheet and signed by the attending physician within 24 hours."
"The physician shall date and time his/her signature."


2. Review of current Patient #7's medical record on 04/20/10 at 9:45 a.m. showed the following:
- A document titled, "Consent for Esophagogastroduodenscopy (procedure to look at the upper part of the digestive system)", was not signed by the physician under the section that stated, "Physician Declaration: I have best explained the contents of this document to the patient/responsible party and have answered all the patient's/responsible party's questions. To the best of my knowledge, I feel the patient has been adequately informed and has consented to the proposed procedure." Documentation showed that the patient had the procedure on 04/09/10.
- A document titled, "Consent for Colonscopy (procedure to look at the lower part of the digestive system)", was not signed by the physician under the section that stated, "Physician Declaration: I have best explained the contents of this document to the patient/responsible party and have answered all the patient's/responsible party's questions. To the best of my knowledge, I feel the patient has been adequately informed and has consented to the proposed procedure." Documentation showed that the patient had the procedure on 04/09/10.
- A document titled, "Procedure Consent" for a "Left colon resection possible open possible liver biopsy (surgery to remove part of the digestive system and possible removal of a piece of the liver for biopsy)", was not signed by the physician under the section that stated, "Physician Declaration: I have best explained the contents of this document to the patient/responsible party and have answered all the patient's/responsible party's questions. To the best of my knowledge, I feel the patient has been adequately informed and has consented to the proposed procedure." This document was also not signed by the anesthesia provider under the section that stated, "Anesthesia Declaration: I have best explained the administration of anesthesia to the patient/responsible party and have answered all the patient's/responsible party's questions. To the best of my knowledge, I feel the patient has been adequately informed and has consented to the administration of anesthesia." Documentation showed that the patient had this surgical procedure on 04/15/10.

During an interview on 04/20/10 at 10:50 a.m., Director of Surgical Services, staff J, confirmed the lack of physician signatures and stated that when they look at the consent form prior to surgery, they only are looking to see if the procedure matches what they have scheduled.

3. Review of discharge Patient #35's medical record showed that he/she was admitted on 02/22/10 and discharged on 02/27/10. A document titled, Procedure Consent" for a "Left ankle open reduction internal fixation", and a section that stated, "Anesthesia Declaration: I have best explained the administration of anesthesia to the patient/responsible party and have answered all the patient's/responsible party's questions. To the best of my knowledge, I feel the patient has been adequately informed and has consented to the administration of anesthesia." This was not signed by an anesthesia provider until 03/03/10. Documentation showed that the patient had this surgical procedure on 02/24/10.

4. Review of current Patient #7's medical record on 04/20/10 showed he/she was admitted on 04/07/10. The document titled, "Therapeutic Support Level Physician Orders" was not signed by the physician above the "Physician's Signature" line. The level of support checked was "Level I - All therapy procedures possible to reduce morbidity and mortality".

5. Review of current Patient #6's medical record on 04/21/10 showed he/she was admitted on 04/19/10. The document titled, "Therapeutic Support Level Physician Orders" was not signed by the physician above the "Physician's Signature" line. The patient signed the consent on 04/21/10. The level of support checked was "Level II - Individualized therapy. Certain diagnostic and/or therapeutic measures may not be consistent with the patient's wishes or appropriate for the medical condition of the patient. Procedures and/or treatments will be individualized according to these conditions. All medically appropriate diagnostic and/or therapeutic measures will be done unless otherwise specified. All procedures and/or treatments to be discontinued or omitted (including CPR) must be specifically noted:"
- The following were preceded with a checkmark:
"No pacemaker (device that stimulates the electrical activity of the heart)"
"No cardioversion (shocking the heart with electricity)"
"No intubation (inserting a tube into the airway to assist with breathing)"
"CPR (cardiopulmonary resuscitation) - NO"

Based on observation and interview, the facility failed to ensure privacy to one patient (Patient #5) of 24 patients observed and failed to protect patient's rights to privacy by placing patient identifiers in public view on five patient care floors. The facility census was 92.

Findings included:

1. Review of the facility policy titled, "Patient's Rights and Responsibilities", reviewed 04/10, gave direction, in part, to include the following:
"Purpose of Policy
To assure patients and their families' appropriate respect and dignity during their treatment, to provide assistance in resolving concerns raised by patients and family members, and to comply with Medicare Conditions of Participation and HFAP (Healthcare Facilities Accreditation Program) standards."
"Every patient and/or designated representative has the right to:"
"be cared for in a safe, clean and private environment free from abuse, harassment or indiscretion."
"confidentiality of all clinical records and communication to the extent permitted or required by law."

2. Observation on 04/19/10 at 3:00 p.m. showed Patient Care Technician, staff F, provide foley catheter (tube inserted into bladder to drain urine) care (clean the genital area, insertion site and tubing) to Patient #5. Patient #5 was unable to move or communicate and the bed covers were pulled down to expose the patient's genitals. The patient did not have a sheet or any other cover to prevent exposure. Nurse Manager, staff E, stood at the foot end of the bed with the curtain separated approximately one foot, enough separation for him/her to stand. Behind staff E was the public hallway. During the foley care, staff E moved from the area and left the curtain open, exposing the patient to the public hallway. The foley care was continued without any staff member noticing or addressing the open curtain.

During an interview on 04/21/10 at 11:00 a.m., Nurse Manager, staff E, stated that he/she didn't know what to say about leaving the curtain open and that he/she must have been distracted.

During an interview on 04/21/10 at 12:00 noon, Director of Clinical Quality, staff A, agreed that leaving the curtain open exposing the patient was inappropriate.

3. Observation on 04/19/10 at 10:55 a.m. on 3A, orthopedic (musculoskeletal [muscles and bones]) floor, showed a dry erase board with patients' first initial and first three letters of their last name written and visible from the public hallway. This affected 23 patients on 3A.

4. Observation on 04/19/10 at 1:30 p.m. on 2C, general surgery, bariatrics (obesity), and orthopedic overflow, showed a dry erase board with patients' first initial and first three letters of their last name written and visible from the public hallway. This affected two patients on 2C.

5. Observation on 04/19/10 at 2:10 p.m. on the ACE (Acute Care of the Elderly) unit showed a dry erase board with patients' first initial and first three letters of their last name written and visible from the public hallway. This affected 18 patients on the ACE unit.

6. Observation on 04/20/10 at approximately 9:30 a.m. showed Registered Nurse, staff I, move a workstation on wheels (WOW [computer on a mobile cart]) through the public hallway. The computer monitor showed current Patient #7's name and additional information. The patient's name was visible to anyone passing in the hallway.

7. Observation on 04/20/10 at 2:35 p.m. on 2C showed two patient charts lying on the nurses' desk and visible to the public hallway. The chart binders were labeled with patients' first initial and first three letters of their last name.

8. Observation on 04/20/10 at 3:10 p.m. on the ACE unit showed several patient charts lying on the nurses' desk and visible to the public hallway. The chart binders were labeled with patients' first initial and first three letters of their last name.

9. During an interview on 04/19/10 at 2:00 p.m., Director of Clinical Quality, staff A, and Director of Orthopedics, staff D, stated that they thought they could use the patient's first initial and first three letters of their last name as patient identifiers.



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10. Observation on 04/19/10 at 2:00 p.m. on 4A (Intensive Care Unit/Critical Care Unit), showed a dry erase board with patients' first initial and first three letters of their last name written and visible from the public hallway. This affected 20 patients on this unit.

Observation at that time also showed the medical records with the patients' first initial and first three letters of their last name written, stored in the chart rack and visible from the public hallway. This affected 20 patients on this unit.

11. Observation on 04/19/10 at 11:00 a.m. on 4C (Cardiac Telemetry Unit) showed the medical records with the patients' first initial and first three letters of their last name written, stored in the chart rack and visible from the public hallway. This affected 13 patients on this unit.

Based on observation, record review, and interview, the facility failed to provide storage of confidential patient medical information in a manner to prevent unauthorized access for 92 patients. The facility census was 92.

Findings included:

1. Review of the facility policy titled, "Patients Rights and Responsibilities", reviewed 04/10, gave direction, in part, to include the following:
"Every patient and/or representative has the right to:"
"Confidentiality of all clinical records and communication to the extent permitted or required by law."

2. Observation on 04/19/10 at 11:10 a.m. in Patient #1's room showed a binder held in an unlocked, clear, wall-mounted holder. Patient Care Technician, staff C, removed the binder from the holder to document the patient's blood sugar results and then returned the binder to the holder. The binder was not secured and was available to anyone who entered the room. During Patient #1's medical record review, this binder was retrieved by staff members for surveyor use and was found to have patient records including nursing notes, fall risk score, skin breakdown/risk score, vital signs, plan of care and blood sugar record. Each document had the patient's name, date of birth, admission date, and details regarding that patient's care.

3. Observation and record review on 04/19/10 at 2:20 p.m. in Patient #3's room showed a binder held in an unlocked, clear, wall-mounted holder. The binder was not secured and was available to anyone who entered the room. Director of Clinical Quality, staff A, stated that he/she would retrieve that chart from the patient's room for the surveyor's review. The binder contents included a six-page document titled, "Telemetry Patient Care Notes", patient labels with the full name, date of birth, and admission date, a form titled, "Glucose (Blood Sugar)/Coagulation (Blood Clotting) Flowsheet, a form titled, "Patient/Family Teaching Record, an eight-page Plan of Care document, a two-page document titled, "Skin/Wound Assessment", two wound pictures, and a two-page document titled, ACE (Acute Care of the Elderly) Unit Interdisciplinary Discharge Rounds".

4. Observation on 04/21/10 at 10:25 a.m. on the ACE (Acute Care of the Elderly) unit showed two patient charts lying on the nurses' desk. The nurses' desk height was low and was open to the public hallway. There was no one attending the patient charts.

5. Record review on 04/21/10 at 10:40 a.m. of current Patient #6's medical record showed some of the documents not in the main chart. Staff A stated that he/she would get the patient's bedside chart (from the patient's room). At 10:45 a.m., staff A stated that he/she was still looking for the bedside chart as it was not in the patient's room and that the students may have it. At 10:47 a.m., the bedside chart was found to be with the students in another location.



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6. Observation on 04/19/10 at 11:15 a.m. in Patient #16's room on 4C (Cardiac Telemetry Unit) showed a binder held in an unlocked, clear, wall-mounted holder. The binder was not secured and was available to anyone who entered the room. During Patient #16's medical record review, this binder was retrieved by staff members for surveyor use and was found to have patient records including nursing notes, fall risk score, skin breakdown/risk score, vital signs, and plan of care. Each document had the patient's name, date of birth, admission date, and details regarding that patient's care.

Staff N, Registered Nurse (RN) Director of 4C (Cardiac Telemetry Unit) said during an interview on 04/19/10 at 11:30 a.m. that all the patient rooms in their unit contained a binder with nursing notes, fall risk score, skin breakdown/risk score, vital signs, and plan of care. The unit had thirteen patients at the time of the survey.

7. Observation on 04/19/10 at 2:00 p.m. in Patient #11's room on 4A (Intensive Care Unit/Critical Care Unit) showed a binder held in an unlocked, clear, wall-mounted holder. The binder was not secured and was available to anyone who entered the room. During Patient #11's medical record review, this binder was retrieved by staff members for surveyor use and was found to have patient records including nursing notes, fall risk score, skin breakdown/risk score, vital signs, wound flow sheet, and plan of care. Each document had the patient's name, date of birth, admission date, and details regarding that patient's care.

8. Observation on 04/20/10 at 9:00 a.m. in Patient #9's room on 4A (Intensive Care Unit/Critical Care Unit) showed a binder held in an unlocked, clear, wall-mounted holder. The binder was not secured and was available to anyone who entered the room. During Patient #9's medical record review, this binder was retrieved by staff members for surveyor use and was found to have patient records including nursing notes, fall risk score, skin breakdown/risk score, vital signs, wound flow sheet, and plan of care. Each document had the patient's name, date of birth, admission date, and details regarding that patient's care.

9. Observation on 04/20/10 at 11:30 a.m. in Patient #8's room on 4A (Intensive Care Unit/Critical Care Unit) showed a binder held in an unlocked, clear, wall-mounted holder. The binder was not secured and was available to anyone who entered the room. During Patient #8's medical record review, this binder was retrieved by staff members for surveyor use and was found to have patient records including nursing notes, fall risk score, skin breakdown/risk score, vital signs, wound flow sheet, and plan of care. Each document had the patient's name, date of birth, admission date, and details regarding that patient's care.

Based on observation, medical record review, facility policy review and interview, the facility failed to follow the facility policy with regard to wound documentation for two patients (Patient #8 and #5) out of four patients records reviewed with pressure sores. The facility census was 92.

Findings included:

1. Facility policy titled "Wound Care and Pressure Ulcer Protocol", last reviewed on 01/09 states on page 1, "All patients will be assessed upon admission and each shift for impaired skin integrity resulting in pressure ulcer development.
A Skin Report Form will be initiated on any patient with a pressure ulcer on admission or acquired during the hospital stay. This form will serve as the main documentation tool for assessment, treatment and progress. Documentation is required every shift. Remeasuring of wounds are done every Monday and recorded on the Skin Report Form".

2. Observation of wound care on 04/20/10 to current Patient #8 showed the patient had wounds on the right foot, right heel and left heel.
Medical record review conducted on 04/21/10 on Patient #8 showed the patient had presented to the Emergency Department and admitted to the facility on 04/10/10. Pictures were taken of the wounds on 04/10/10 and measurements of the wounds documented on the Skin/Wound Assessment and Treatment sheet on 04/10/10.
There were no further measurements found in the medical record.

3. Staff O, Registered Nurse (RN), Wound Care Nurse said during an interview on 04/21/10 at 11:00 a.m. that pressure sores/wounds are to be measured every Monday by either the wound care nurse or by the nurse providing care to the patient that day. Staff O said that measurements should have been done on Patient #8's wounds.




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4. Observation of current Patient #5 on 04/19/10 showed he/she was admitted on 04/09/10 and had a healing wound to his/her buttocks and open wounds to both feet.

Review of Patient #5's medical record on 04/20/10 showed no measurements of these wounds documented for 04/19/10 (Monday). Pictures dated 04/13/10 were not identified to indicate body part (left foot vs. right foot).

During an interview on 04/21/10 at 4:00 p.m., staff O, RN, Wound Care Nurse, stated that the measurements would be logged under the "measurements" column of the facility's form titled, "Skin/Wound Assessment and Treatment" and confirmed that the measurements were not documented on 04/19/10.

Based on record review and interview, the facility failed to follow their internal policy to ensure the plan of care was reviewed for three (Patient #7, #5, and #6) of 12 patient records reviewed for plan of care. The facility census was 92.

Findings included:

1. Review of the facility policy titled, "Nursing/Clinical Documentation Assessment, Reassessment, Education and Care Planning", reviewed 12/07, gave direction, in part, to include the following:
"Plan of Care"
"A nurse reviews the plans of care each shift and upon transfer of the patient to another unit. Revisions and updates are made on an ongoing basis."
"Exceptions to the care plan are to be documented on the plan of care or in the nursing progress note. This update is completed as frequently as the patient's conditions dictate, but not less than once each shift."

2. Review of current Patient #7's medical record on 04/20/10 at 9:45 a.m. showed he/she was admitted on 04/07/10. The patient's plan of care was not reviewed on 04/12/10 night shift, 04/13/10 day shift, or 04/13/10 night shift.

3. Review of current Patient #5's medical record on 04/20/10 at 3:10 p.m. showed he/she was admitted on 04/09/10. The patient's plan of care was not reviewed on 04/15/10 day shift, 04/18/10 night shift, or 04/19/10 night shift.

4. Review of current Patient #6's medical record on 04/21/10 at 10:15 a.m. showed he/she was admitted on 04/19/10. The patient's plan of care was not reviewed on 04/20/10 night shift. During an interview, Nurse Manager, staff E, confirmed that the care plan was to updated each shift and was this patient's care plan was not updated as it should have been.

Based on observation and interview, the facility failed to ensure medications were administered safely for one (Patient #7) of eight patients observed during medication administration. The facility census was 92.

Findings included:

1. Review of the document titled, "Micromedex" dated 04/21/10 provided by the Director of Quality and Risk Management, staff L, gave direction to administer Dilaudid (a narcotic pain medication) IV (intravenous [catheter inserted into the vein for administering medications and fluid]) push "slowly over at least 2 to 3 minutes".

2. Observation on 04/20/10 at 9:25 a.m. showed Registered Nurse, staff I, administer Dilaudid 2 mg (milligrams) IV over a time-frame of three seconds to Patient #7.

3. During an interview on 04/22/10 at 9:55 a.m., Director of Orthopedics, staff D, stated that Dilaudid should probably be given over a couple of minutes but would have to look it up for sure. Staff D confirmed that three seconds was too fast for administration of Dilaudid.

Based on medical record review, the facility failed to ensure medications were administered within 30 minutes of the scheduled time for three (Patient #4, #7, and #6) of eight patients' medication administration records reviewed. The facility census was 92.

Findings included:

1. Review of the facility policy titled, "Medication Administration", reviewed 09/07, gave direction, in part, to include the following:
"Nursing will administer medications within a time frame of 1 hour before or 1 hour after the scheduled dose."

2. Review of current Patient #4's medical record showed that on 04/19/10, Ciprofloxacin (antibiotic used to treat infection) was scheduled to be administered at 8:00 a.m. and was given at 9:00 a.m.

3. Review of current Patient #7's medical record showed that on 04/20/10, Prilosec (medication for heartburn) was scheduled to be administered at 6:30 a.m. and was given at 5:39 a.m.

4. Review of current Patient #6's medical record showed that on 04/21/10, the following medications were scheduled to be administered at 9:00 p.m. and were given at 9:39 p.m.:
- Niacin (type of B vitamin)
- Zocor (reduces cholesterol level in the blood).

Based on medical record review and facility policy review regarding verbal/telephone orders, the facility failed to follow their internal policy to ensure physicians authenticate verbal orders and telephone orders for three current patients (Patient #10, Patient #13, Patient #8) out of five current medical records selected for review of physician orders.
The facility census was 92.

Findings included:

1. Facility policy titled "Verbal/Telephone Orders, effective date November 2004, and last reviewed June 2009 stated on page two, "Verbal orders must be authenticated, signed, dated and timed, by the ordering physician within 48 hours".

2. Medical record review of current Patient #10 on 04/20/10 showed the following telephone orders that had not been authenticated by a physician:
- The Diabetes Care Admission Order Sheet for sliding scale insulin dated 04/16/10 at 1:30 p.m.

3. Medical record review of current Patient #13 on 04/20/10 showed the following telephone orders that had not been authenticated by a physician:
- The Stroke/TIA Orders dated 04/04/10 at 11:10 a.m.
- An order to change the accucheck (fingerstick) from every four hours to before meals and at bedtime written on 04/05/10 at 3:22 p.m.

4. Medical record review of current Patient #8 on 04/20/10 showed the following telephone orders that had not been authenticated by a physician:
- An order to change Zosyn (antibiotic) to 2.25 grams intravenous every six hours dated 04/11/10 at12:45 a.m.
- An order to reduce the intravenous rate to 75ccs an hour when present bag is completed dated 04/11/10 at 1:30 a.m.
- An order to change intravenous fluids to ? Normal Saline at 60cc an hour and included laboratory orders dated 04/13/10.
- An order to increase the intravenous flow rate to 75cc an hour, change insulin sliding scale to standard Novolin insulin dated 04/13/10 at 10:15 p.m.
- A Diabetes Care Admission Physician Order Sheet for Standard Sliding Scale insulin dated 04/13/10 at 10:25 p.m.
- An order for wound care to the patient's left heel dated 04/15/10 at 5:00 p.m.

Staff L, Director of Quality and Risk Management confirmed the lack of authentication on the above orders on 04/22/10 at 2:00 p.m.

Based on medical record review, Medical Staff Rules and Regulation review, and interview, the facility staff failed to follow the Medical Staff Rules and Regulations to ensure patient admission history and physicals were in the medical record and authenticated within twenty four hours of admission for two (Patients #15, and #18) of twenty-four (24) current medical records reviewed for completed admission history and physicals.
The facility census was 92.

Findings included:

1. Facility Medical Staff Rules and Regulations stated on page 21, "The attending physician shall be held responsible for the preparation of a complete medical record of each patient. No medical record shall be considered complete until so certified by the signature of the attending physician and no medical record may be filed until it is complete.
The medical record requires a history and physical examination be completed no more than 30 days before or 24 hours after admission for each patient by a physician. The medical history and physical must be placed in the medical record within 24 hours after admission".

2. Record review of current Patient #15 on 04/20/10 at 3:30 p.m. showed the patient was admitted to the facility on 04/16/10. The medical record did not contain the admission history and physical (H&P).

Staff N confirmed the medical record did not contain the H&P on 04/20/10 at 3:40 p.m.

3. Record review of current Patient #18 on 04/21/10 showed the patient was admitted to the facility on 04/13/10. The medical record contained the H&P, but it had not been authenticated by the physician.

Based upon record review, review of facility policy, and interview, the facility failed to have accurate documentation for the actual consumption of tube feedings for two patients (Patient #36 and Patient #37) of two patient records reviewed for tube feeding documentation.
The facility census was 92.

Findings included:

1. Policy review for "Operational Standard: TX-932A Tube Feedings" showed the policy to expect a weekly assessment by the Registered Dietitian at least weekly or more often and required the tubing and product to be changed at least every 24 hours. The policy failed to detail how documentation should be done. The policy stated at number five, "The infusion pump is to be cleared and volumes documented at the end of each shift.

2. Record review for current Patient #36 conducted on 04/22/10 showed the patient had been admitted to the facility on 04/12/10. The physician history and physical said the reason for admission was due to malnutrition and for placement of a feeding tube. (Nutrition directly into the stomach by a tube) at 40 cc (cubic centimeters) per hour.
Physician orders dated 04/17/10 at 4:30 a.m. said to change the tube feeding to Glucerna to 75cc (cubic centimeters) an hour. The nursing documentation of the patient's tube feeding on 04/19/10 showed the following:
- 6:00 to 8:00 a.m. with no documentation.
- 8:00 - 10:00 a.m. at 200 cc.
- 10:00 a.m. - 12:00 p.m. with no documentation.
- 12:00 - 2:00 p.m. with no documentation.
- 2:00 - 4:00 p.m. at 200 cc.
- 4:00 - 6:00 p.m. at 300 cc.
- 6:00 - 8:00 p.m. at 100 cc.
No further documentation.
- The total intake was recorded at 790 cc. for the past 24 hours.

3. Record review for current Patient #37 conducted on 04/22/10 showed a physician order dated 04/19/10 at 12:45 p.m. for tube feeding goal rate to 40 cc. an hour with water flushes at 200 cc. every four hours. The nursing documentation of the patient's tube feeding on 04/20/10 showed the following:
- 6:00 to 8:00 a.m. with 1045 cc.
No further documentation.
- The total intake was recorded as 1,540 cc. for the past 24 hours.

The nursing documentation of the patient's tube feeding on 04/21/10 showed the following:
- No documentation until 6:00 - 8:00 p.m. with tube feeding 80 cc. an hour and flush at 200 cc.
- 8:00 - 10:00 p.m. with tube feeding at 80 cc.
- 10:00 p.m. - 12:00 a.m. with tube feeding at 80 cc.
- 12:00 - 2:00 a.m. with tube feeding at 80 cc. and water flush at 200 cc.
- 2:00 - 4:00 a.m. with tube feeding at 80 cc.
- 4:00 - 6:00 a.m. with tube feeding at 80 cc. and water flush at 200 cc.
- The total intake was recorded as 2,160 cc.

The nursing documentation of the patient's tube feeding on 04/22/10 showed the following:
- 6:00 - 8:00 am with tube feeding at 40 cc.
- 8:00 - 10:00 a.m. with tube feeding at 40 cc. and water flush at 200 cc.
- 10:00 a.m. - 12:00 p.m. with tube feeding at 40 cc.
No further documentation.
- The total intake was recorded as 2,260 cc.

Staff L, Director of Quality and Risk Management confirmed during an interview on 04/22/10 at 11:10 a.m. that the nursing documentation did not appear to be accurate.

It is not possible for the Registered Licensed Dietitian to have accurate assessment of tube feeding consumption and tolerance without detailed documentation of actual amounts consumed, as read from the tube feeding pump administration system.

Based on record review and interview, the facility failed to ensure medication orders were complete, accurate, and transcribed to the Medication Administration Record for three (Patient #4, #7, and #13) of eight patients observed during medication administration. The facility census was 92.

Findings included:

1. Review of the facility's policy titled, "Medication Order Process", revised 10/07, gave direction, in part, to include the following:
"The pharmacy will dispense medication after receipt of a complete, clear, and valid medication order. Unclear orders will be clarified with the prescriber."
"Incomplete, illegible, or inappropriate orders must be clarified with the prescriber."
"Medication order will be legibly written in ink and will include:"
"Dose, frequency, and route of administration"
"Directions for use, if applicable"

Review of the facility's document titled, Physician Orders", revised 07/08, gave direction at the top of the page to include the following:
"Do NOT" use ".5".
"DO write 0.5 (leading zero)"

2. Review of current Patient #4's medical record on 04/19/10 showed the following:
- A telephone order written for ".25 mg (milligrams) Xanax (medication to treat anxiety) q (every) hs (at bedtime) PRN (as needed). This order did not include a route and did not have a zero in front of the decimal point of the dose, which could result in the dose being read as 25 mg.
- A physician's order written for "Sinemet (medication for Parkinson's disease or Parkinson-like symptoms) is to be given q 3 hour". The previous order for Sinemet was not discontinued and a new complete order was not written.

During an interview on 04/22/10 at 1:15 p.m., Director of Pharmacy, staff R, stated that the Xanax order should have been clarified since there was no leading zero in the dose order. Staff R stated that the Sinemet order should have been rewritten.

3. Review of current Patient #7's medical record on 04/20/10 showed the following:
- A physician's order written on 04/09/10 to "D/C (discontinue) Nitropaste (medication that dilate the arteries in the heart) following colonoscopy (procedure to examine the small bowel). The colonoscopy was completed on the same day. The document titled, "Medication Administration Record" (MAR), dated 04/20/10 showed Nitroglycerine 2% ointment (Nitropaste) scheduled and given every 6 hours. Director of Orthopedics, staff D, confirmed that the Nitropaste had been given without an order since 04/09/10.
- A physician's order written for "D/C IV Metoprolol, continue Metoprolol 12-5 BID (twice a day)". The order did not include the dose or route of administration.
- A physician's order for "Percocet (pain medication) 10/325 g (grams) one po (by mouth) q 6 hours PRN". The medication dose is in milligrams (mg), and does not come in grams (g). The MAR showed the following, "Percocet 325 mg - 5 mg one tab (tablet) orally every 6 hr (hours) PRN". The dose on the MAR was incorrect.
- A pre-printed form titled, "Diabetes Care Admission Order Sheet" with physician orders to "Notify me" hand written next to the treatment parameters for blood glucose (sugar) results 251-300, 301-350, and 351-400. The instructions to notify the physician were not on the MAR. Staff D stated that the instructions were not on their Kardex (information summary sheet used by nurses) so the nurses would not have known to call the physician.

During an interview on 04/22/10 at 1:15 p.m., Director of Pharmacy, staff R, stated that the page with the order to discontinue the Nitropaste did not get scanned to the pharmacy so was never seen by a pharmacist. Staff R stated that the elements for a complete medication order include the name of the medication, dose, frequency, route, justification (for some medications) and duration (for some medication). Staff R stated that if not elements are not present, the physician is to be called by the pharmacist of nurse. Staff R stated that the pharmacist could put "notify me" on the MAR to instruct the nurse to notify the physician as ordered but stated that it was not done.




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4. Review of current Patient #13's medical record on 04/20/10 showed a physician telephone order dated 04/03/10 at 2:40 p.m. written for Plavix (cardiovascular medication) by mouth daily. This order did not include the dosage of the medication.

Review of the medication administration record showed the patient received Plavix 75mg. by mouth on 04/03/10 at 8:09 p.m. and on 04/04/10 at 11:41 a.m.

A physician telephone order dated 04/04/10 at 11:10 a.m. was written for Plavix 75mg. daily.

Staff R, Director of Pharmacy said during an interview on 04/22/10 at 1:30 p.m. that a medication order must include the name of the drug, the route of administration, the frequency and the duration of administration. If the order is not complete, then pharmacy or nursing staff will call the physician for clarification of the order. In this case, the clarification process did not occur.

Based on observation and interview, the facility failed to ensure staff members performed hand hygiene for four (Patient #4, #5, #7, and #8) of sixteen patients observed during various care provided and failed to ensure equipment was cleaned after use for three (Patient #1, #4, and #7) of sixteen patients observed during various care provided. The facility census was 92.

Findings included:

1. Review of the facility policy titled, "Hand Washing and Nail Care", reviewed 03/07, gave direction, in part, to include the following:"Definition of Terms"
- "Decontaminate hands. To reduce bacterial counts on hands by performing antiseptic hand rub or antiseptic hand wash."
"Decontaminate hands before having direct contact with patients."
"Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient)."
"Decontaminate hands after contact with body fluids or excretions ..."
"Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient."
"Decontaminate hands after removing gloves."

Review of the facility policy titled, "Guidelines for Cleaning, Disinfecting, and Sterilizing Patient Care Equipment", reviewed 06/07, gave direction, in part, to include the following:
"Non disposable, patient care equipment, which does not come into contact with mucous membranes, will be cleaned by hospital staff between patient use, with a hospital approved disinfectant. Examples of products include, but are not limited to:
- Glucometer" (Accucheck)
- "Work Stations on Wheels (WOWs)"

Review of the facility policy titled, "Standard Precautions Isolation Policy", reviewed 01/07, gave direction, in part, to include the following:
"Standard Precautions apply to all patients regardless of their diagnosis or presumed infection status."
"Handwashing is the single most important means of preventing the spread of infection."
"Remove gloves promptly after use and wash hands thoroughly before touching non-contaminated items and environmental surfaces, and before going to another patient."
"Re-usable equipment is not to be used for the care of another patient until it has been cleaned and reprocessed appropriately."

2. Observation on 04/19/10 at 11:30 a.m. showed Patient Care Technician, staff C, perform a blood sugar check on Patient #1. The Accucheck machine (hand-held device that measures the blood sugar) was placed on Patient #1's bed covers during the test and then returned to the carrying case without cleaning the equipment.

3. Observation on 04/19/10 at 3:20 p.m. showed Registered Nurse, staff G, administer medications to Patient #4. Staff G did not perform hand hygiene when entering the patient's room, assisted the patient by holding his/her glass and straw, put the medications from the cup directly into the patient's mouth with his/her hands, then document the medications on the WOW (Workstation On Wheels [mobile computer that is transported to patient rooms]). The WOW was not cleaned when leaving Patient #4's room.

4. Observation on 04/19/10 at 3:00 p.m. showed Patient Care Technician, staff F, provide care to Patient #5. The first two times Staff F left the room, he/she was in the process of providing the foley (tube inserted into the bladder to drain urine) care, took the gloves off while separating the curtain around the patient, did not perform hand hygiene, and then he/she went to the linen cart in the main hallway to get additional washcloths. The third time Staff F left the room, he/she was in the middle of repositioning the patient, left the room without performing hand hygiene, and then went into the main hallway to the blanket warmer. The fourth time staff F left the patient area without performing hand hygiene and retrieved a pillow from a closet. Upon entering the curtained area around Patient #5, staff F stated that he/she should change the pillow slip so left and returned holding the pillow in one hand and a pillow slip in the other. He/she placed the pillow on the patient's bed cover. The pillow was yellowed and had three round red spots, approximately the size of quarters. After this surveyor asked if those spots were possibly blood stains, Staff F stated that they looked like blood and he/she would try to wipe them off. Staff F took the pillow to a sink in the four-bed patient ward and used a antimicrobial wipe to try and remove the blood. After this surveyor came out of the curtain area to watch staff F attempt to remove the blood, staff F stated that he/she would get a different pillow.

During an interview on 04/21/10 at 11:00 a.m., Nurse Manager, staff E, stated that the pillow was disposable and should have been thrown away.

5. Observation on 04/20/10 at 9:25 a.m. showed Registered Nurse, staff I, administer medications to Patient #7. Staff I did not perform hand hygiene upon entering the patient's room, administered medications, left the room to retrieve additional medication from the medication room and did not perform hand hygiene when leaving the patient's room or upon re-entering. Staff I then donned gloves to administer IV (intravenous [catheter inserted into a vein for administering medications and fluid]). Staff I did not wipe off WOW when leaving Patient #7's room.

During an interview on 04/21/10 at 12:00 noon, Director of Clinical Quality, staff A, stated that he/she had observed some lack of hand hygiene during the medication administration to Patient #7.

6. During an interview on 04/21/10 at 12:00 noon, Director of Quality and Risk Management, staff L, stated that the WOW should be wiped off after use. He/she stated that the Accucheck machine should be wiped off after use.



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7. Observation of a dressing change to Patient #8's left foot on 04/20/10 at 11:30 a.m. showed the following:
- Staff K, Registered Nurse removed the dressing from the left foot. The dressing contained a moderate amount of drainage.
- Staff K, cleaned the wound.
- Staff K then removed his/her right glove, but did not perform hand hygiene.
- Staff K then applied the dressing to the left foot.

Staff O, wound care nurse said during an interview on 04/21/10 at 2:00 p.m. that hand hygiene should be performed after removing the dressing and before applying a new dressing to the wound.

Based on medical record review, facility policy review, and interview, the facility failed to follow facility policy to ensure post-operative anesthesia reports were completed on two outpatients (Patient #27 and Patient #28) out of two outpatient medical records reviewed. The facility census was 92.

Findings included:

1. The facility Medical Staff Rules and Regulations last revised 11/09 stated at number 16 on page 22, "A post-operative anesthesia follow-up report must be documented in the medical record and be completed within 48 hours after surgery. The report must include: cardiopulmonary status, level of consciousness, any follow-up care and/or observation and patient instructions, any complications occurring during post-anesthesia recovery, and the condition of the patient at the time of discharge".

2. Medical record review conducted on 04/21/10 at 4:30 p.m. showed discharged Patient #28 underwent a colonoscopy on 04/21/10. The medical record did not contain a post-operative anesthesia evaluation.

3. Medical record review conducted on 04/21/10 at 4:30 p.m. showed closed Patient #27 underwent a colonoscopy on 04/21/10. The post-operative evaluation was checked as no complications, but was not timed or dated.

4. Staff L, RN, Director of Quality and Risk Management said during an interview on 04/21/10 at 4:00 p.m. that the Medical Staff Rules and Regulations do not differentiate between outpatient and inpatient surgeries. The post-operative evaluations should have been completed on these two patients.