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Based on MR review and interview with staff, in 2 of 3 inpatient MRs reviewed (1) out of a total of 6 MR reviewed, the facility failed to enure the IM notice is provided and signed by the patient and/or representative within 48 hours of admission. This deficiency directly affects 2 Pt (1 and 6) and potentially affects all Pts treated at the facility.

Findings include:

Pt #1's MR reviewed on 1/7/12 at 10:00 AM revealed the IM intended for Pt #1's admission on 9/29/12 is not signed by the Pt or representative. This is confirmed in interview with PI A on 1/7/12 at 4:00 PM.

Pt #6's MR reviewed on 1/7/12 at 1:55 PM revealed there is no copy of the IM presented and signed by the Pt prior to discharge. This is confirmed in interview with PI A on 1/7/12 at 4:00 PM.

Based on MR review, review of P&P and interview with staff, in 1 of 6 MR (1) the facility failed to ensure Pt CPs are completed and kept current based on Pt needs. This deficiency directly affected Pt #1 and potentially affects all Pts at the facility.

Findings include:

Review of facility policy on 1/7/12 at 3:00 PM titled Care Planning dated 4/11, it states under #1 "Upon admission, the nurse will assess the patient for active problems or needs based on information obtained from the admission assessment. 2. The RN or other licensed healthcare provider will select nursing care plans that are most appropriate to address the patient's needs and individualize it as necessary...4. The care plan shall be updated (goals evaluated) for each patient daily by the RN, LPN, Nurse Intern or other licensed healthcare provider caring for the patient. 5. Nursing care plans and/or goals will be added as new problems are identified."

Pt #1 MR review on 1/7/12 at 10:00 AM revealed Pt #1 was admitted from a Nursing Home on 9/29/12 with suspected urinary tract infection, and intermittant mental status changes. The NA dated 9/29/12 at 6:30 M, states Pt #1 is high risk for skin breakdown. A nursing note on 9/29/12 at 10:36 PM states a DuoDerm dressing was applied to a reddened area on Pt #1's coccyx."

The nursing notes dated 9/29/12 at 5:50 PM state "Patient screaming out in pain with transfer and vital signs. Patient stated she has fibromyalgia and that she was in pain from staff touching her." At 7:10 PM a nursing note states "Patient yelling in pain with assisting on and off bedpan. Husband reminded staff that patient has fibromyalgia and to be careful with movement."

The CP dated 9/29/12 has three nursing diagnoses: Alternation in comfort, Confusion /Disorientation and Alternation in thought process. There is no intervention that describes how to care for the patient, specific to Pt #1's fibromyalgia. There is no CP for skin breakdown although there was DuoDerm applied to Pt #1 coccyx. There were no changes to the CP during Pt #1's stay with the daily evaluation of the CP by nursing staff.

The above information is confirmed in interviews with PI A and RN M on 1/7/12 at 12:25 PM and 10:15 AM respectively.

Per interview with CO B on 12/17/12 at 10:24 AM, CO B stated specific instructions including demonstrations were given on how to move Pt #1 to reduce pain and prevent skin tears.

Per interview with admitting RN M on 1/7/12 at 1:15 PM, she stated she was told Pt #1 had fibromyalgia and to move her slowly. RN M said she passed that information on to her CNA. RN M confirmed there was no CP for skin breakdown, and no CP related to the fibromyalgia stating it was covered with the alteration in comfort. RN M acknowledged there were no specific interventions related to the fibromyalgia, and stated the alteration in comfort covered prevention of pain and skin breakdown. RN M could not point out the interventions that applied to prevention of pain and skin breakdown.

Based on MR review, review of R&R and interview with staff, in 2 of 6 MR (1, 6) the facility failed to ensure VOs and TOs are written, and authenticated with MD signature, date and/or time. This deficiency potentially affects all Pts treated at the facility.

Findings include:

Review on 1/7/12 at 4:00 PM of facility R&R approved 9/12, under #6 it states "All clinical entries in the patient's medical record shall be legible, complete, dated timed and authenticated promptly by the person who is responsible for ordering, providing or evaluating the service furnished."

Per interview with PI A on 1/7/12 at 10:00 AM VOs and TOs are to be authenticated by the MD within 48 hours.

Pt #1's MR reviewed on 1/7/12 at 10:00 AM revealed there are VOs and TOs written between 9/29/12 and 10/3/12 that are not authenticated by the MD with a signature, date and time, and within 48 hours. This is confirmed in interview with PI A on 1/7/12 at 10:00 AM.

Pt #6's MR reviewed on 1/7/12 at 1:55 PM revealed is a TO written on 9/4/12 that is written as "TO (name) RN/ (MD)/ (name) RN", and not authenticated by the MD with a date and time. RN's may not give an order to an RN. This is confirmed in interview with PI A on 1/7/12 at 1:55 AM.

Based on MR review, review of R&R and interview with staff, in 3 of 6 MR (1, 3 and 5) the facility failed to ensure progress notes of assessments are included in the MR to reflect the Pt condition, and/or are timed when completed. This deficiency potentially affects all Pts treated at the facility.

Findings include:

Review on 1/7/12 at 4:00 PM of facility R&R approved 9/12, under #4 it states "The medical record must contain information to justify admission and continued hospitalization, support diagnosis, and describe the patient's progress and response to medications and services."

Pt #1's MR review on 1/7/12 at 10:00 AM revealed Pt #1 developed a severe skin tear on 10/3/12. Nursing notes dated 10/3/12 at 10:45 AM stated MD J was present and assessed Pt #1 for the injury. There is no progress note by MD J related to this examination. This is confirmed in interview with PI A on 1/7/12 at 12:25 PM.

Pt #3's MR review on 1/7/12 at 12: 10 PM revealed Pt #3 arrived in the ED on 10/27/12 at 2:10 AM. The MR indicated the MD acknowledged notification of the Pt at 2:30 AM. Pt # 3 was discharged at 3:46 AM. The examination is timed at 9:01 AM, after Pt #3 left the facility. This is confirmed in interview with DIR L on 1/7/12 at 12:55 PM

Pt #5's MR review on 1/7/12 at 12:40 PM revealed Pt #5 arrived in the ED on 09/29/12 at 1:38 AM. The MR indicated the MD acknowledged notification of the Pt at 1:39 AM. Pt #5 was discharged at 3:54 AM. The examination is timed at 3:57 AM, after Pt #5 left the facility. This is confirmed in interview with DIR L on 1/7/12 at 12:55 PM

Based on MR review, review of R&R and interview with staff, in 2 of 6 MR (1 and 6) the facility failed to ensure MRs are complete within 15 days per facility policy. This deficiency potentially affects all Pts treated at the facility.

Findings include:

Review on 1/7/12 at 4:00 PM of facility R&R approved 9/12, under #10 it states "...Records not completed within 15 days after discharge of the patient shall be considered delinquent."

Pt #1's MR reviewed on 1/7/12 at 10:00 AM revealed Pt #1 was discharged on 10/3/12. The DS is authenticated by the MD on 12/2/12, greater than 15 days per R&R. An Interim Summary (handoff to another physician), and H&P are authenticated on 12/19/12, greater than 15 days per R&R. There are TOs and VOs written between 9/29/12 and 10/3/12 that are not authenticated with a signature date and time, and/or signed on 12/19/12, ,greater than the 15 days per R&R. This is confirmed in interview with PI A on 1/7/12 at 12:25 PM.

Pt #6's MR reviewed on 1/7/12 at 1:55 PM revealed Pt #6 was discharged on 9/10/12. The DS is authenticated by the MD on 12/19/12, greater than 15 days per R&R; and there is an order written on 9/4/12 that is not authenticated with a date and time, per R&R. This is confirmed in interview with DIR O on 1/7/12 at 3:30 PM.