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Based on 3 of 10 MR reviewed of patients receiving Medicare benefits (Pt. #2, 17, and 29) out of a total of 30 MR reviewed, and 1 of 1 staff interviews (A), the hospital failed to ensure that each Medicare beneficiary is informed of his/her right to appeal discharge from the facility which became effective July 13, 2007 per Survey and Certification memorandum 07-28 published by The Centers for Medicare and Medicaid (CMS). Failure to notify Medicare recipients of their right to appeal discharge from this facility affects all qualifying recipients admitted to the facility.

Findings include:
In an interview with Utilization Review Registered Nurse (UR RN) A on 8/8/12 at 10:30 a.m., UR RN A stated that either A or Social Worker (SW) J is responsible for informing patients of their right to appeal discharge if they are a Medicare recipient. UR RN A also stated that in the absence of A and J (i.e.: weekends, after hours) nursing is to explain the appeal form.

A MR review was completed on Pt. #2's closed MR on 8/8/12 at 10:25 a.m. Pt. #2 has a Medicare Discharge Appeal notice (MDA) that is not signed, dated, or timed. There is a note on page 2 from SW J regarding family member contact on 3/5/2012 but there is no further documentation regarding this.
UR RN A confirmed these findings at the time of the MR review.

A MR review was completed on Pt. #17's closed MR on 8/8/12 at 3:13 p.m. The MDA signed on admission (4/3/12) does not have a time it was signed and there is no evidence this information was presented to Pt. #17 at discharge on 4/9/12. UR RN A confirmed these findings during the MR review.

A MR review was completed on Pt. #29's closed MR on 8/9/12 at 8:34 a.m. Pt. #29 was admitted on 3/6/12 and discharged on 3/10/12. There is an MDA dated 2/9/12 in the MR but none to reflect the time period of within 48 hours of admission and discharge. UR RN A confirmed these findings during the MR review.

Based on observation and staff interviews, the facility did not construct and maintain the building systems to ensure a safe physical environment due to the cumulative effects of environment deficiencies and resulted in the hospital's inability to ensure a safe environment for the patients, which is a Condition of Participation. The facility did not have a facility free of life safety deficiencies. This deficiency occurred in all of the smoke compartments, and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On August 6th and 7th, 2012; surveyor #14105 observed that the facility had the following deficiencies:

K-18 (openings into the corridors),
K-25 (smoke compartments),
K-27 (openings in smoke compartments)
K-29 (hazardous areas),
K-38 (means of egress),
K-56 (sprinkler system),

Please refer to the full description of the deficient practice at the cited K-tags: This observed situation was not compliant with 42 CFR 485.623. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff E.

Based on observation and 2 of 2 staff interviews (E, D), the facility did not construct and maintain the building systems to ensure a safe physical environment due to the cumulative effects of environment deficiencies and resulted in the hospital's inability to ensure a safe environment for the patients, which is a Condition of Participation. The facility did not have a facility free of life safety deficiencies. This deficiency occurred in all of the smoke compartments, and had the potential to affect all of the 25 patients that the facility was licensed to serve, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:
On August 6th and 7th, 2012; surveyor #14105 observed that the facility had the following deficiencies:

K-18 (openings into the corridors),
K-25 (smoke compartments),
K-27 (openings in smoke compartments)
K-29 (hazardous areas),
K-38 (means of egress),
K-56 (sprinkler system),

Please refer to the full description of the deficient practice at the cited K-tags: This observed situation was not compliant with 42 CFR 485.623. The deficiency was confirmed at the time of discovery by a concurrent observation and interview with Staff E.



13469

Patient supplies and biohazard waste are not secure from unauthorized access.

Per observation, while touring the laboratory department with Lab Technician (D) on 8/6/12 at 2:00 PM, it was noted that a room for out-patient blood draws held a waiting room, with a door propped open to a public hallway, and an area for blood draws. The room contained all the equipment needed for this process including needles, syringes, glass tubes to hold blood specimens, biohazard needle disposal containers (that were open at the top and used needles could be removed), 70 containers of Bactec blood culture bottles with resin, and portable blood draw containers with supplies to go to the nursing home and draw blood there.

Per interview with (D), patients who come to the hospital for blood draws check in at the front desk and then come back to the blood draw room and sit in the waiting area. Per (D), there is not always laboratory staff in the blood draw room. As a result, patients and visitors would have access to all of the blood draw equipment, used needles and Bactec blood culture bottles with resin resulting in the potential for self-harm, removal, tampering or destruction of these supplies used for blood draws.

Based on 4 of 4 observations, and 3 of 3 staff interviews (F, S, N), the hospital failed to ensure that all medications are secured from unauthorized access, and labeled and stored appropriately. This deficiency had the potential to affect patients treated in the facility during the survey between 8/6/12 and 8/9/12.

Findings include:
Per observation, while touring the cardiac rehabilitation department with Rehab Manager (F) on 8/7/12 at 9:30 AM, it was noted that a crash cart which contained medications and IV solutions for medical emergencies had a breakaway device to alert staff if the cart had been breached. Per (F), the cart is not secured with a permanent locking device or placed in a secure area at the end of business day. Per (F), the area is cleaned by housekeeping staff after the department is closed. As a result, the lack of security of all drugs/IV solutions on the crash cart allows for removal, tampering, destruction or personal use by unauthorized personnel.

Per interview, with Pharmacist (S) on 8/9/12 at 7:55 AM, it was revealed that there is no hospital P&P that directs staff about the security and storage of medications, biological's, and IV solutions stored in the facility other than those in the Pyxis automated dispensing system.




26711

On 8/6/2012 from 2:30 p.m.-3:30 p.m. a tour of the nursing unit and adjacent areas was completed accompanied by Utilization Review RN (UR RN) A.

In a storage area between the Director of Nursing office and the nurse's station was a tall, open metal shelving unit which held numerous bags of intravenous (IV) fluids. On 8/8/12 at 8:50 a.m. while walking past this area with RN N, RN N stated that when the automated medication dispensing unit (Pyxis) was put in, the shelving unit was removed from that room and the extra bags of IV fluid that were in that medication room were put out on the shelf. RN N stated that the door to this area is not locked and anyone would have access to these IV fluids if they wanted to access them. This finding was confirmed on 8/8/2012 at 4:30 p.m. with UR RN A.

On 8/6/2012 at 1:30 p.m. an interview with Pharmacist S was conducted along with a tour of the pharmacy. In the pharmacy Pyxis machine there is a drawer for outdated drugs to be stored waiting for pick up for disposal. According to Pharmacist S these drugs are all bar coded for tracking purposes. In this drawer Surveyor found injectable Lorazepam (an anti-anxiety medication) that had expired 1/30/12 that was not bar coded for tracking purposes. This finding was confirmed by Pharmacist S at the time of discovery.

On 8/7/12 at 7:40 a.m. an observation of RN L giving medications to Pt. #25 was made. Pt. #25 was admitted to the facility on 8/5/2012. RN L had removed an unmarked zip lock bag with 3 boxes of medications in it from the Pyxis unit. Two of these boxes were eye drops and one was a nasal spray. The box with the nasal spray did not have a label on to identify that it belonged to Pt. #25. When Surveyor asked RN L how L knew that was for Pt. #25 RN L admitted L would not know without a label and removed the spray from the room. This finding was discussed on 8/9/2012 at 9:30 a.m. with UR RN A.

Based on 2 of 6 medication administration error reports reviewed for 2012, and 1 of 1 staff interview (S), the hospital failed to ensure that the MD is notified of all medication administration errors. This deficiency had the potential to affect patients treated in the facility during the survey between 8/6/12 and 8/9/12.

Findings include:
Per review of 2012 medication administration errors on 8/9/12 at 8:50 AM, it was determined that 2 of 6 (a wrong dose given on 7/8/12 and a wrong medicine given on 7/7/12) were not reported to the MD. Per interview, with Pharmacist (S) at 9:00 AM, it was revealed that per hospital medication event and adverse drug reaction reporting program, all medication administration errors are to be reported to the MD.

Based on 12 of 12 observations, in 3 of 13 personnel and credential files reviewed (CC, DD, H), review of P&P, and 13 of 13 staff interviews (D, I, Q, F, H, E, G, K, L, M, N, X, Y), the hospital failed to ensure that the facility is kept clean, maintained, and arranged so as to provide a sanitary and safe environment for the prevention of potential cross-contamination or infection, that nursing staff follow universal precautions, that clean and dirty are kept separate, and that staff are screened for infections and communicable diseases. These deficiencies had the potential to affect patients treated in the facility during the survey between 8/6/12 and 8/9/12.

Findings include:

Per CDC Guidelines for preventing transmission of infectious agents in healthcare settings 2007: IV. Standard Precautions: washing/gloving standards are as follows: " IV.A.3.a Before having direct contact with patients. IV.A.3.b After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings. IV.A.3.c After contact with a patient's intact skin (e.g; when taking a pulse or blood pressure or lifting a patient). IV.A.3.d If hands will be moving from a contaminated-body site to a clean-body site during patient care. IV.A.3.e After contact with inanimate objects (including medical equipment in the immediate vicinity of the patient. IV.A.3.f After removing gloves.

Occupational Safety and Health Administration Bloodborne Pathogen standards at 29 CFR 1910.1030(d)(3)(ix) requires the following: " Gloves. Gloves shall be worn when it can be reasonably anticipated that the employee may have hand contact with blood, other potentially infectious materials, mucous membranes, and non-intact skin; when performing vascular access procedures except as specified in paragraph (d)(3)(ix)(D); and when handling or touching contaminated items or surfaces. "

Per CDC "Guideline for Hand Hygiene in Health-Care Settings" (MMWR 10/25/02) recommendations for glove use, page 33 #6 states, in pert: "Change gloves if moving from a contaminated body site to a clean body site. Decontaminate hands after removing gloves. Decontaminate hands after contact with inanimate objects." http:www.cdc.gov/mmwr/PDF/rr/rr5116.pdf.

Per observation, while touring the laboratory department with Lab Technician (D) on 8/6/12 at 2:00 PM, it was noted that a room for out-patient blood draws held a waiting room, with a door propped open to a public hallway, and an area for blood draws. This room was open to the laboratory itself. The door to the laboratory was held open with an electro-magnet plate and according to (D) was open to the hallway when the lab was open. Ventilation between the lab and public hallway is compromised, allowing dust and debris from the hallway to enter the lab and contaminants from the lab to enter the hallway.

Facility staff are not monitored for potential communicable disease. Per P&P review on 8/9/12 in the AM, the Employee Health Program P&P, last review date 2/08, directs the following: new employees "shall not begin work assignment until the employee is free of communicable disease (TB test administered and read.") and "Required testing during employment: "A. Mantoux TB test (1 step) required annually for all employees.") The following hospital staff files did not have evidence of annual tuberculosis testing per hospital P&P: MD (CC) who last was tested on 8/30/10, and MD (DD) who was last tested on 9/15/10. These examples were confirmed in interview with MR Supervisor (I) on 8/8/12 at 11:50 AM. Housekeeper (H) who was hired on 5/22/10 and did not have an initial screening at the time of hire. This example was confirmed in interview with ICO (Q) on 8/8/12 at 11:00 AM. Per (Q), all employees are required to be screened for tuberculosis annually and upon hire.

Staff are not protecting visitors and patients from cross-contamination. Per observation, while touring the laboratory department with Lab Technician (D) on 8/6/12 at 2:00 PM, it was noted that in the lab blood draw room two biohazard needle disposal containers were sitting on a counter with used needles which when turned upside down could be emptied thus causing exposure to blood. Per (D), patients are left unattended in the waiting room of the blood draw room and the door is propped open to the hallway allowing for anyone to enter the room and expose themselves to the used needles. This was confirmed by Lab Technician (D) during the observation.

Staff are not protecting themselves and patients from cross-contamination. Per observation, while touring the laboratory department with Lab Technician (D) on 8/6/12 at 2:00 PM, it was noted that in the lab blood draw room two biohazard needle disposal containers were sitting on a counter with used needles. Attached to both sharps containers were rolls of tape unwound and stuck to the edge of the sharps container where used/contaminated needles with blood are disposed of. Per (D), the tape is placed in this manner for easy access to tape gauze to the site of patient blood draws. (D) confirmed in interview that there is the potential of cross-contamination from the biohazard waste container to staff and then patient puncture sites.

Staff are not protecting themselves and patient lab results from cross-contamination. Per review, of hospital P&P for Laboratory staff dated 4/23/12, directs the following: "1. Smoking, eating and drinking: Viral infections can be transmitted to Laboratory personnel by infectious blood through either the oral or parenteral route. Therefore, there will be no smoking, eating or drinking in any Laboratory work area." Per observation, while touring the laboratory department with Lab Technician (D) on 8/6/12 at 2:00 PM, it was noted that food (an apple) and drink were found on a counter in the laboratory. Per interview at the time of the observation, (D) said food and drink are not allowed in the laboratory per hospital P&P.

Patient equipment is not kept clean from exposure to dust and debris. Per observation, while touring the therapy department with Rehabilitation Manager (F) on 8/6/12 at 9:30 AM, it was noted that in the occupational therapy equipment storage room there was patient equipment stored directly on the floor. The physical therapy equipment storage room had 4 jugs of distilled water used for therapy sessions that were stored directly on the floor. In addition, the area is not readily accessible for cleaning by housekeeping. These examples were confirmed by (F) during the tour.

Per interview, with housekeeper (H) and Maintenance Supervisor (E) on 8/7/12 at 10:30 AM, it was revealed that 4 of 4 automated dispensing systems used for the solutions to disinfect the facility during housekeeping activities are not being monitored by doing routine quality control checks to ensure appropriate concentrations. Per interview, with (E) on 8/9/12 at 11:00 AM, the manufacturer directs that test strips be used one time per week for each dispensing system once the pails are filled with the mixture of disinfectant and water.

Per interview, with Environmental Services staff (G) and Maintenance Supervisor (E) on 8/7/12 at 10:30 AM, it was revealed that the three soaking tanks with chlorine beach and water have not been tested for appropriate concentrations for the past two years as the hospital ran out of test strips. Per interview, with (E) on 8/9/12 at 11:00 AM, the manufacturer recommends that test strips be used daily for every load.






26711

The facility's policy titled, "Infection Prevention Policy Hand Hygiene," dated 2/12, was reviewed on 8/8/2012 at 9:45 a.m. The policy, which indicates it follows the Centers for Disease Control and Prevention (CDC) indicates that hands should be decontaminated before having direct contact with patients, after contact with inanimate objects (including medical equipment) in the immediate vicinity of a patient, and after removing gloves.

The following observations were made on tour of the nursing unit and observations of staff:

On 8/6/2012 from 2:30 p.m.-3:30 p.m. a tour of the nursing unit and adjacent areas was completed accompanied by Utilization Review Registered Nurse (UR RN) A. In a housekeeping closet, considered a dirty area, 3 partially consumed bottles of soda were found as well as clean supplies--paper towel and toilet paper for use in patient care and visitor areas. This does not demonstrate a separation of clean and dirty.

Throughout the patient care area several breeches in the integrity of walls, laminate on counter tops and doors, and vinyl furniture were noted. Breeches in the integrity of smooth surfaces which expose porous material underneath cannot be effectively cleaned and has the potential to harbor microorganisms. A few of these examples are: Room 203 has a vinyl reclining chair that has cracks and tears in the vinyl, Room 204 has gouges in the walls, Room 214 has tape over broken laminate which is dirty and frayed, Room 219 has a hole in the wall.

On 8/7/12 at 7:00 a.m. an observation of laboratory technician (lab tech) K was made. Lab Tech K did not wash hands on entry to Pt. #25's room before putting on gloves to obtain samples of blood.

On 8/7/12 at 7:40 a.m. an observation of RN L was made giving medications to Pt. #25. RN L, with gloved hands entered L's pockets to retrieve alcohol pads. The inside of pockets are considered dirty and the gloves should have been changed before proceeding with medication administration.

On 8/7/12 at 7:50 a.m. an observation of RN M putting in an intravenous (IV) line in an outpatient for IV fluids was done. This outpatient had a history of Methicillin-resistant Staphylococcus aureus (MRSA, a highly contagious, difficult to treat, bacteria). After inserting the IV into the outpatient's vein, RN M put gloved hands in M's pockets to retrieve a pen. Pockets are now potentially contaminated with MRSA.

On 8/7/12 at 8:10 a.m. an observation of RN N preparing medications was made. RN M opened Pt. #23's tablets in the medication room and used a pill cutter to cut one of them in half. Prior to opening the tablets (after using the computer key board to access the drawer of the electronic medication dispensing unit-Pyxis) and cutting them, RN N did not wash hands. After using the pill cutter RN N put the cutter in a dish on top of the Pyxis without washing it. On arrival to Pt. #23's room, RN N set the medication cups on the bedside table, without washing the table off with disinfectant towels, next to a paper towel that Pt. #23's urinal was sitting on. The scissors RN N brought along to open the medications was placed on the paper towel with the urinal on it.

On 8/8/12 at 7:10 a.m. an observation of Occupational Therapist (OT) X assisting Pt. #23 with morning cares and exercises was made. During the course of the cares OT X missed 3 opportunities for hand washing when gloves were changed. In all instances inanimate objects used for patient cares were touched before removal of the gloves.

On 8/8/12 at 7:50 a.m. an observation of Certified Nursing Assistant (CNA) Y assisting Pt. #26 with a sponge bath was made. CNA Y missed two opportunities for handwashing between glove changes during cares. Once when leaving the room and re-entering and once after glove removal after assisting Pt. #26 with perineal care before putting on new gloves.

These finding were discussed with UR RN A on 8/9/2012 at 9:30 a.m.

Based on observations on the tray line, P&P review, nationally recognized standards of practice, and 2 of 2 staff interview (C, S), this facility failed to follow recognized dietary practices by failing to, 1. Maintain a current diet manual that is approved annually by the Medical Director and Dietician, 2. Failed to properly identify open/discard dates on food in dry storage, 3. Failed to maintain an appropriate temperature on hot foods served to patients, and 4. Failed to keep trash/refuse receptacles covered . Failure to follow recognized dietary practices affects all patients, staff, and visitors who eat in the hospital.

Findings include:

Diet Manual:
In an interview with Dietician C on 8/6/12 at 11:15 a.m., Dietician C identified the diet manual used by the facility and stated that the evidence of approval of the manual by the Medical Director was in the Medical Records department with the documentation of the Medical Staff meeting minutes. On 8/7/2012 at 12:43 p.m. Medical Record Supervisor (MR S) I informed Surveyor that MR S I looked through the meeting minutes and could not find where the diet manual was approved.

Food dated:
During a tour of the kitchen area with Dietician C on 8/6/2012 at 11:30 a.m. the following items were noted to be opened and not dated in dry storage: one cake mix, and one package of Wild Rice. Dietician C confirmed these findings and stated staff are to date the food items when they are opened.

Food temperatures:
The facility's policy titled, "Food Preparation & Service," dated 7/18/12 was reviewed on 8/9/12 at 9:43 a.m. The policy indicates that meat (fish) should be at a minimum temperature of 145 degrees Celsius, and that food in the hot food holding trays should be maintained at a temperature of 140 degrees or above.

A test tray was put together by kitchen staff on 8/6/2012 at 12:00 p.m. Dietician C checked the temperature of the foods on the tray using the facility's equipment. The following items on the tray did not meet the minimal expectation for hot food items: Fish 130 degrees, Creamed peas 130 degrees, Potatoes 122-125 degrees. Dietician C agreed these temperatures were not adequate to maintain hot foods.

Trash/Refuse Receptacles:
According to the 2009 Food and Drug Administration Food Code, Receptacles and waste handling units for REFUSE, recyclables, and returnable's shall be kept covered:
(A) Inside the FOOD ESTABLISHMENT if the receptacles and units:
(1) Contain FOOD residue and are not in continuous use; or
(2) After they are filled;

During the tour of the kitchen area with Dietician C on 8/6/2012 at 11:30 a.m. several trash/refuse receptacles were noted not to have covers on them throughout the kitchen area. Dietician C confirmed these observations at the time they were made.

Based on Policy and Procedure (P&P) review and 4 of 4 staff interviews (A, B, I, S), the hospital failed to ensure that all departmental P&P are reviewed at least annually and that the content of the policies are adequate to guide facility personnel in their use. These deficiencies had the potential to affect patients treated in the facility during the time of the survey between 8/6-9/2012)

Findings include:

P&P review by surveyors #13469 and #26711 during the survey between 8/6/2012 and 8/9/2012 revealed that hospital departmental P&P are not reviewed annually.

In an interview with the Executive Director for Patient Services B on 8/6/2012 at 10:40 a.m. B stated that the facility is in the process of changing their policies and as a result some may not be up to the quality the facility would like them to be.

In an interview with Utilization Review Registered Nurse (UR RN) A on 8/8/12 at 10:00 a.m. UR RN A stated A is aware that not all policies have been updated and that the facility is in the process of switching to a company that publishes policies.

The hospital policies for the Swing Bed program have not been updated since 2002, with the exception of the nutrition program for Swing Bed which was updated in 2008.

The facility policy titled, "Advance Directives," dated 7/2012, was reviewed on 8/9/2012 at 7:15 a.m. The policy is one sentence long and reads as follows: "Every patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives." The policy is incomplete, for example it does not direct staff in what an Advanced Directive is, how a patient may be assisted with their Advanced Directive, or where to document in the patient's MR about an Advanced Directive.

UR RN A is aware of the need to re-do policies.





13469

Per interview, with UR RN (A) on 8/9/12 at 7:50 AM, it was revealed that there is no P&P for consents for treatment/procedures to identify what a consent should contain, for what procedures/treatments, how they should be completed and by whom etc.

Per interview, with HIM Manager (I) on 8/9/12 at 8:15 AM, it was revealed that there are no P&P developed for hospital staff about MR requirements except those in the Medical Staff Rules and Regulations.

Per interview, with Pharmacist (S) on 8/9/12 at 7:55 AM, it was revealed that there is no hospital P&P that directs staff about the security and storage of medications, biological's, and IV solutions stored in the facility other than those in the Pyxis automated dispensing system.

Based on 12 of 19 MR reviewed requiring nursing care plans out of a total of 30 MR reviewed, P&P review, and 2 of 2 staff interviews (A, P), this facility failed to develop nursing care plans (identified as nursing standards of care per policy) for patients admitted for acute care that are personalized to each patient's individualized needs and kept current as the needs of the patient change for 7 patients (Pt. #16, 17, 25, 26, 28, 29, and 30) with nursing care plans. Nursing staff failed to develop nursing care plans for 5 of 5 (Pt. #18, 19, 20, 21, 22) surgery and PACU (post-anesthesia recovery room) patients. Failure to individualize and update nursing care plans has the potential to affect all acute care inpatients and out patient surgery patients admitted to the facility during the time of the survey (8/6-9-2012).

Findings include:
The facility policy titled, "Nursing Standards of Care," dated 03/1990, was reviewed on 8/9/2012 at 9:45 a.m. The policy states in part, "A written, personalized, standards of care is developed for each patient by the nursing service and is available for use by all personnel caring for the patient." This policy also states that the care plan should have, "Measurable needs and goals of the patient/resident."

Surveyor began MR reviews on 8/7/2012 at 10:00 a.m. and noted that the nursing care plan (NCP) of the acute care inpatient was in a standardized format built into the computer system and was not individualized to the unique needs of the patients.

In an interview with UR RN A on 8/8/2012 at 10:30 during MR reviews, UR RN A stated, "If the patient has a special need beyond the standard care plan it will be personalized to the patient." This does not reflect the policy statement and the practice was not observed during the survey.

A MR review was completed on Pt. #25's open inpatient MR on 8/7/2012 at 10:00 a.m. Pt. #25 NCP was noted to be a standardized care plan generated from statements built into the computer upon admission to the facility on 8/5/2012. There had been no documentation regarding progress of the patient since admission. Utilization Review Registered Nurse (UR RN) A confirmed these findings at the time of the MR review. At 2:50 p.m. while working with RN N on MR reviews, Pt. #25's MR was revisited and the NCP had been updated and personalized. RN N stated that UR RN A came to the unit earlier in the day and, "Talked to the staff about the care plans."

MR reviews were completed on Pt. #16, 17, and 26 on 8/8/2012 between 1:15 p.m. and 3:30 p.m. accompanied by UR RN A. MR reviews were completed on Pt. # 28, 29, and 30 on 8/9/2012 between 7:51 a.m. and 9:15 a.m. accompanied by UR RN A. All of these patients had acute inpatient admissions and NCPs generated by predetermined computerized statements that had not been personalized to each of the patients unique needs and did not have measurable goals. These findings were confirmed by UR RN A during the MR reviews.




13469

Per MR review between 8/8/12 at 2:00 PM and 8/9/12 at 10:40 PM the following surgical patients did not have a nursing care plan developed by the RN to ensure safe and optimal care: Pt. #18 who had cataract surgery on 4/10/12, Pt. #19 who had a lipoma removal on 4/19/12, Pt. #20 who had a colonoscopy on 6/14/12, Pt. #21 who had tonsil and adenoid removal on 5/1/12 and Pt. #22 who had tonsil and adenoid removal on 12/6/11. The above examples were confirmed at the time of the MR review by LPN (P).

Based on MR review in 3 out of 30 MR reviewed (Pt's. #27, 5, 8) and 2 of 2 staff interviews (A, P), this facility failed to ensure that the information in the MR is accurate and complete. Failure to maintain accurate, complete medical records has the potential to affect all patients who receive care in this facility.

Findings include:
A MR review was completed on Pt. #27's closed ED MR on 8/9/2012 at 7:22 a.m. Pt. #27 left this facility to go to another facility for specialized services. Prior to leaving this facility Pt. #27 supplied a urine sample. The urine sample would be a key piece of evidence in the the tests Pt. #27 would require upon examination for these specialized services. Pt. #27 left this facility for the other facility without taking the urine sample along. In the ED note from the provider, the provider indicated the urine sample was sent with Pt. #27. This documentation is inaccurate. Utilization Review Registered Nurse A confirmed these findings during the MR review.




13469

The following MR were reviewed between 10:25 AM on 8/8/12 and 10:40 AM on 8/9/12: Pt. #5 who was seen in the ED and transferred on 4/3/12, and Pt. #8 who was seen in the ED and transferred on 4/2/12.

Pt. #5 ED nursing notes indicate that the patient was stable at the time of discharge. The note was entered into the EMR at 11:19 PM on 4/3/12. Pt. #5 was not discharged until 12:15 AM on 4/4/12. This evaluation of Pt. #5 was completed prematurely.

Pt. #5 ED nursing notes, entered into the EMR at 12:47 AM, indicate that Pt. #5 was admitted into the "inpatient unit." This information is inaccurate as this patient was transferred from the ED to another hospital.

Pt. #8 ED nursing notes indicate that the patient was "alert and oriented, stable, continued discomfort, no further complications" at the time of discharge. The note was entered into the EMR at 7:55 PM on 4/2/12. Pt. #8 was not discharged until 9:23 PM. This evaluation of Pt. #8 was completed prematurely.

The above examples were confirmed at the time of the MR review by LPN (P).

Based on 13 of 22 MR reviewed requiring general consents for care (Pt. #1, 2, 3, 9, 11, 15, 16, 23, 24, 25, 28, 29, and 30), and 3 out of 6 requiring transfer consents from the ED (Pt. #15, 27, 5) out of a total of 30 MR reviewed, P&P review, and 2 of 2 staff interviews (A, P), the hospital failed to ensure that consents for treatment are properly executed to include dates, times, and/or complete signatures from the witness and/or the patient/representative. In 5 of 5 surgical patient MR reviewed (Pt. #18, 19, 20, 21, 22) and 2 of 2 patients admitted to the facility (#17 and 26) out of total of 30 MR reviewed, the hospital failed to ensure that discharge instructions specify actions the patient should take in the immediate post-discharge period to promote their recovery from the surgery or admission to the facility and include warning signs of complications. These deficiencies had the potential to affect all patients treated in the facility during the time of the survey between 8/612 and 8/9/12.

Findings include:
The facility's policy titled, "Consent: Who May Sign," dated 9/2001 was designed to define to the Emergency Department staff who can sign consents for treatments. The policy states in part, "B. Patient under Guardianship: All persons under legal custody shall have consents/permits signed by legal guardian and certified copy of official letter of guardianship shall be placed in the medical record. D. Person Legally Incompetent: If a person has been declared legally incompetent by a court of law, the person appointed by the court as personal representative must sign except when an emergency exists."

The policy does not address what to do in the event that the patient is unaccompanied at the time of arrival to the facility for follow up attempts for obtaining consent.

A MR review was completed on Pt. #1's closed MR on 8/7/2012 at 3:05 p.m. Pt. #1 came through the facility ED on 3/1/2012 and was sent back to a skilled nursing facility 4 hours after arrival, accompanied by a family member. Pt. #1's consent for treatment indicates that a signature could not be obtained because Pt. #1 had a guardian. In the ED note dictated by the MD, the note indicates the [family member] and POA (Power of Attorney) is at the bedside. There is no indication on the consent of who the guardian is, if the family member present was able/not able to legally sign the consent, or evidence of attempts to contact the guardian or mail the consent to the guardian. This finding was confirmed by Utilization Review Registered Nurse (UR RN) on 8/8/12 at 10:10 a.m.

A MR review was completed on Pt. #2's closed MR on 8/8/2012 at 10:25 a.m. Pt. #2 came through the ED on 3/4/2012 and was admitted as an inpatient. The consent for treatment indicates it could not be signed due to Pt. #2 having a POAHC. There is no evidence that further attempts were made to obtain a signature on the consent. This finding was confirmed by UR RN at the time of the MR review.

A MR review was completed on Pt. #3's closed MR on 8/8/2012 at 10:37 a.m. Pt. #3 came through the ED on 3/6/2012 and was transferred to a facility for a higher level of care due to an emergent situation. The consent for treatment indicates it could not be signed due to Pt. #3 having a POA. There is no indication on the consent form that it could not be signed because of the need for an emergent transfer. This finding was confirmed by UR RN at the time of the MR review.

A MR review was completed on Pt. #9's closed MR on 8/8/2012 at 11:00 a.m. Pt. #9 came through the ED on 6/2/2012 and was discharged to home. Pt. #9's consent for care does not indicate a time Pt. #9 signed the form and does not indicate a date the witness signed the form. This finding was confirmed by UR RN at the time of the MR review.

A MR review was completed on Pt. #11's closed MR on 8/8/2012 at 11:30 a.m. Pt. #11 came through the ED on 6/8/2012 and was admitted for observation. Pt. #11's consent for care does not indicate a time the patient signed the consent. This finding was confirmed by UR RN at the time of the MR review.

A MR review was completed on Pt. #15's closed MR on 8/8/2012 at 2:33 p.m. Pt. #15 came through the ED on 3/4/2012 and was admitted to the facility as an inpatient. Pt. #15's consent for care does not indicate a time the patient signed the consent or a date the witness signed the form. This finding was confirmed by UR RN at the time of the MR review.

A MR review was completed on Pt. #16's closed MR on 8/8/2012 at 2:49 p.m. Pt. #16 was admitted as an inpatient to the facility on 3/7/2012 and discharged on 3/10/2012. Pt. #16's consent for care indicates it could not be signed because of Pt. #16's condition, a possible stroke. There is no evidence that further attempts were made to obtain a signature on the consent from someone throughout the hospitalization. This finding was confirmed by UR RN at the time of the MR review.

A MR review was completed on Pt. #24's closed MR on 8/8/2012 at 3:32 p.m. Pt. #24 was admitted to the Swing Bed program on 3/30/12. The consent for care does not indicate the time the patient or the witness signed the consent. This finding was confirmed by UR RN at the time of the MR review.

A MR review was completed on Pt. #23's open MR on 8/7/2012 at 10:42 a.m. Pt. #23 was admitted to the Swing Bed program on 7/19/12. The consent for care has a date of 9/13/2012 which is not possible at the time of this admission, and there is no date for the witness signature and no times that either party signed the form. This finding was confirmed by UR RN at the time of the MR review.

A MR review was completed on Pt. #24's closed MR on 8/8/2012 at 3:32 p.m. Pt. #24 was admitted to the Swing Bed program on 3/30/12. The consent for care does not indicate the time the patient or the witness signed the consent. This finding was confirmed by UR RN at the time of the MR review.

A MR review was completed on Pt. #25's open MR on 8/8/2012 at 10:25 a.m. Pt. #25 was admitted as an inpatient on 8/5/2012. The consent for treatment indicates it could not be signed due to Pt. #25 not having an available POA. There is no evidence that further attempts were made to obtain a signature on the consent even though the Social Worker contacted the POA on 8/6/2012 by phone. This finding was confirmed by UR RN at the time of the MR review.

A MR review was completed on Pt. #28's closed MR on 8/9/2012 at 7:51 a.m. Pt. #28 was admitted as an inpatient on 3/3/2012 and discharged on 3/5/2012. The consent for care is not signed by the patient or a representative and indicates this is due to the patient being confused. There is no evidence that a signature for the consent for treatment was sought during the hospitalization. This finding was confirmed by UR RN at the time of the MR review.

A MR review was completed on Pt. #29's closed MR on 8/9/2012 at 8:34 a.m. Pt. #29 was admitted as an inpatient on 3/6/2012 and discharged on 3/10/2012. The consent for care, which is dated 3/9/2012 for the patient signature does not indicate a time the patient signed the form and does not indicate a date or time the witness signed the form. This finding was confirmed by UR RN at the time of the MR review.

A MR review was completed on Pt. #30's closed MR on 8/9/2012 at 8:54 a.m. Pt. #30 was admitted as an inpatient on 6/2/2012 and discharged on 6/5/2012. The consent for care is not signed by the patient or a representative and states "Pt. unable to sign at this time." There is no evidence that follow up attempts were made to obtain a signature. This finding was confirmed by UR RN at the time of the MR review.

Emergency Medical Treatment and Active Labor Act (EMTALA) consents:
A MR review was completed on Pt. #15's closed MR on 8/8/12 at 2:33 p.m. Pt. #15 was transferred to a higher level of care on 3/5/2012. The EMTALA transfer form does not include a date or time the physician signed it. UR RN A confirmed these findings during the MR review.

A MR review was completed on Pt. #27's closed MR on 8/9/2012 at 7:22 a.m. Pt.#27 was in the process of being transferred to an alternate facility for specialized care when #27 left without notifying staff. The physician to physician phone call had been made, however there is no documentation of the date and time this was done. UR RN A confirmed these findings during the MR review.

Pt. #17 and #26 did not have Discharge Instructions (DC) on file in their closed MRs.
Pt. #17's MR review was conducted on 8/8/12 at 3:13 p.m. and Pt. #26's MR review was conducted on 8/8/12 at 3:15 p.m. UR RN A accompanied Surveyor during MR review and confirmed these findings.




13469

The MD and RN failed to develop patient specific discharge instructions to ensure safe and optimal aftercare. Per MR review between 8/8/12 at 2:00 PM and 8/9/12 at 10:40 PM the following surgical patients did not have evidence in their MR that discharge instructions specific to the type of surgery they had, to include warning signs of complications and who to contact, were given to the patient/representative at the time of discharge: Pt. #18 who had cataract surgery on 4/10/12, Pt. #19 who had a lipoma removal on 4/19/12, Pt. #20 who had a colonoscopy on 6/14/12, Pt. #21 who had tonsil and adenoid removal on 5/1/12 and Pt. #22 who had tonsil and adenoid removal on 12/6/11. The above examples were confirmed at the time of the MR review by LPN (P).

Emergency Medical Treatment and Active Labor Act (EMTALA) consents:
Per MR review, on 8/8/12 at 10:50 AM, Pt. #5 was transferred to another hospital after being stabilized in the ED on 4/3/12. The "Patient's Request/Refusal/consent to Transfer" agreement section #2 is blank. This section identifies the MD accepting transfer, the name of the receiving facility and person making contact, as well as other transfer information. The form indicates that a nurse, social worker or provider complete all fields. This example was confirmed at the time of the MR review by LPN (P).

Based on MR review in 23 out of 30 MRs reviewed (Pt. #1, 2, 3, 9, 10, 11, 12, 15, 16, 17, 24, 25, 27, 28, 30, 4, 5, 6, 7, 8, 19, 21, 22) and 2 of 2 staff interviews (A, P), this facility failed to maintain MRs that were complete and contained chronologically authenticated information (times/dates/signatures) regarding patient care. Failure to maintain a complete and informative MR has the potential to affect all patients receiving care in the facility.

Findings include:
ED Provider Notification:
An interview was conducted with Utilization Review Registered Nurse (UR RN) A on 8/8/2012 at 10:15 a.m. regarding not documenting the time the ED provider was notified that a new patient came in to be seen. UR RN A stated that A was under the impression that the regulations stated this did not have to be documented if the provider was in house (in the facility).

The following patients came in through the ED and do not have documentation regarding the ED provider being notified of their arrival: Pt.s #1, 2, 3, 9, 10, 11, 12, 15, 16, 17, and 25. MR reviews were completed on these patients from 8/7/2012-8/9/2012 throughout each day accompanied by UR RN A who confirmed these findings.

UR RN A stated that there will not be any documentation on any of the ED patients regarding the ED provider being notified of a new patient as this facility does not document this.

ED Provider Evaluation:
A MR review was conducted on Pt. #9's closed ED MR on 8/8/2012 at 11:00 a.m. accompanied by UR RN A. There is no documentation of the ED Provider seeing the patient (indicated in this facility as Assigned Attending in the computer) even though there are MD orders. UR RN A confirmed these findings during the MR review.

Missing Provider Orders:
A MR review was conducted on Pt. #11's closed ED MR on 8/8/2012 at 11:30 a.m. Pt. #11 came to the ED with chest pain on 6/8/2012. There is documentation that the RN was changing the rate of the Nitroglycerin intravenous drip medication on 6 occasions however there were no orders to change the rate of this medication. According to UR RN A, this nursing action was done per Nitroglycerin drip protocol, however there are no orders from a provider to start this protocol. This finding was confirmed by UR RN A at the time of the MR review.

Improper Authentication, Missing Documentation:
A MR review was conducted on Pt. #12's closed MR on 8/8/12 at 12:50 p.m. accompanied by UR RN A. Pt. #12 did not have a date or time Pt. #12 signed the DC instructions, and there was no signature, date or time of the staff member who discussed the instructions with Pt. #12. UR RN A confirmed these findings during the MR review.

A MR review was conducted on Pt. #2's closed MR on 8/8/12 at 10:25 a.m. accompanied by UR RN A. There are DC instructions on file for Pt. #2 however they are not signed, dated or timed by either the Pt. or the staff member who discussed them with the Pt. UR RN A confirmed these findings during the MR review.

Pt. #24 and #30's DC instructions do not indicate the time or date the Pt. signed them.
Pt. #24's MR was reviewed on 8/8/12 at 3:32 p.m. and Pt. #30's MR was reviewed on 8/9/12 at 8:54 a.m. UR RN A confirmed these findings at the time of the MR review.

Pt. #9, 10, and 28 did not have the time indicated that the DC instructions were signed.
Pt. #9's MR was reviewed on 8/8/12 at 11:00 a.m., Pt. #10's MR was reviewed on 8/8/12 at 11:15 a.m., and Pt. #28's MR was reviewed on 8/9/12 8:34 p.m. UR RN A confirmed these findings during the MR review.





13469

The following MR were reviewed between 10:25 AM on 8/8/12 and 10:40 AM on 8/9/12: Pt. #4 who was seen in the ED and discharged on 3/8/12, Pt. #5 who was seen in the ED and transferred on 4/3/12, Pt. #6 who was seen in the ED and discharged on 4/5/12, Pt. #7 who was seen in the ED and transferred on 3/6/12, Pt. #8 who was seen in the ED and transferred on 4/2/12, Pt. #19 who had a lipoma removal on 4/19/12, Pt. #21 who had tonsil and adenoid removal on 5/1/12 and Pt. #22 who had tonsil and adenoid removal on 12/6/11.

ED Provider Notification: The following patients came in through the ED and do not have documentation regarding the ED provider being notified of their arrival: Pt.s #4, 5, 6, 7, and 8.

Pt. #4 ED notes indicate that a foreign body was removed from her right eye. MD and nursing documentation does not identify the time the foreign body was removed or the time the tetracaine and fluoroscein were administered.

Pt. #5 nursing notes entered into the EMR at 12:10 AM indicate that "wound interventions" included "antibiotic ointment applied." The MR does not contain an order for the antibiotic nor identify the type of antibiotic used on Pt. #5 wound.

Pt. #6 nursing notes entered into the EMR at 11:10 PM indicate that Bacitracin and Vaseline gauze were applied to his laceration. The MR does not contain orders for the Bacitracin and Vaseline gauze. The notes do not identify the time the medication, gauze, and 7 stitches were applied to Pt. #6 laceration.

Pt. #19 post-anesthesia note completed on 4/19/12 does not include the time the note was entered into the MR. The nursing intra-operative note does not identify the time the patient entered the OR, the time surgery started, the time surgery ended, or the time the patient was discharged from the OR.

Pt. #21 nursing PACU notes do not identify the time this patient left the PACU on 5/1/12.

Pt. #22 nursing PACU notes do not identify the time this patient left the PACU on 12/6/11.

The above examples were confirmed by LPN (P) at the time of the MR review.

Based on 4 of 5 surgical MR reviewed (#18, 19, 21, 22) out of total of 30 MR reviewed, P&P review, and 4 of 4 interviews (P, R, W, Z), the hospital failed to ensure that a comprehensive H&P is completed prior to the day of surgery to allow assessment of the patient's readiness for surgery. and that sterilization and disinfection procedures are supervised and completed per manufacturers directions.

Findings include:
P&P review on 8/9/12 in the AM of "Guidelines for Surgical H&H" (dated 6/26/10) directs the following: "Procedure: 1. H&P will consist of the following: a. patient complaint, b. past and present history of illness, c. family and social history, d. results of the physical exam, and e. diagnosis."

The following MR were reviewed between 10:25 AM on 8/8/12 and 10:40 AM on 8/9/12: Pt. #18 who had cataract surgery on 4/10/12, Pt. #19 who had a lipoma removal on 4/19/12, Pt. #21 who had tonsil and adenoid removal on 5/1/12 and Pt. #22 who had tonsil and adenoid removal on 12/6/11. The above examples were confirmed at the time of the MR review by LPN (P).

A comprehensive H&P was not done to determine if the patient has any underlying conditions that would put the patient at risk for having such a procedure or to identify any new or existing comorbid conditions that would require additional interventions for surgical Pt's. #18, 19, 21, and 22. A comprehensive H&P would include a medical, social, and family history, vital signs, allergies, and a head to toe examination to include palpation, auscultation, and percussion, appropriate lab, x-ray, work up and evidence of a release for the surgical procedure to be performed. The H&P may defer neuro and/or pelvic/genital exams if not pertaining to the procedure.

Pt #19 H&P did not include the following: medical and surgical histories, social history, and a list of current medications.

Pt. #18 H&P did not include the following: medical and surgical histories, social history, allergies, and a list of current medications.

Pt #21 H&P did not include the following: medical and surgical histories. The MD indicates there is none "on file" but does not indicate if the patient was cleared for past medical and surgical history at the time of the exam.

Pt. #22 MD note dated 12/5/11 indicates that the "H&P is located in EPIC (EMR) dated 11/28/11. There was no evidence found in the MR that a H&P was completed on 11/28/11.

The above examples were confirmed at the time of the MR review by LPN (P).



26711

Due to no surgeries scheduled during the week of the survey (8/6/12-8/9/12) no surgical observations could be made.

During a tour of the Surgical Suite which includes an adjacent procedure room for Endoscopies (colonoscopy and esophageal [throat] scoping) on 8/7/2012 at 2:15 p.m. accompanied by Surgical Technician (ST) W, ST W stated that the Endoscopies are done in this facility by non-direct staff and that the cleaning of the scopes is also done by non-direct staff.

The staff who perform the Endoscopies, conscious Intravenous (IV) Sedation, and disinfection of the scopes all come from a different facility and they bring their own equipment with them.

ST W, who is a lead for this facility in the disinfection/sterilization department, has no oversight of the Gastrointestinal Therapeutic assistant (GI assist) who comes from the other facility to perform the high level disinfection process for the patients of this facility. ST W is not aware if the scopes that are used on patients from this facility are cleaned before use on the patients (after traveling from one hospital to another), or if proper protocol for this facility is being followed.

In an interview with Supervisor of Surgical Services R on 8/8/12 at 8:15 a.m., Supervisor R is aware of the non-direct staff using the facility but states R also does not have any oversight over them.

In a phone interview with GI assist. Z on 8/8/12 at 8:57 a.m., GI assist. Z stated the scopes are not cleaned prior to use on the patient's in this hospital because they are cleaned after each use at the facility they are being brought from. When asked how GI assist. Z knows how much Aseptizyme (cleaning enzyme for surgical instruments) to use when cleaning scopes in this facility, Z replied, "It's so much per gallon and I'm assuming the sink is like 4-6 gallons because its smaller than the one in our hospital." GI assist Z pumps a few times with the Aseptizyme in an unmarked sink and states test strips are not done to determine if there is enough cleaning enzyme to be effective. GI assist Z was unsure of the manufacturers directions.

GI assist Z states that the only hospital oversight in this facility is that, "They make sure the machines are set up and ready to go." If Z has any questions Z knows who to call. GI assist Z does not submit data to the Quality Assurance committee of this hospital. Z stated the only thing for Quality Assurance is that Z checks the solution in the hi level disinfection machine and logs it in a log book which stays in the room with the machine.

These findings were reported to Utilization Review Registered Nurse A, Executive Director of Patient Care Services B, and Chief Executive Officer BB on 8/8/2012 at 4:30 p.m.

The cumulative effect of these problems resulted in the facilities inability to ensure safe and optimal care to it's surgical patients.

Based on review of the QI program, P&P review, and 4 of 4 staff interviews (K, Q, S, R), the hospital failed to ensure that it's quality improvement program include all hospital departments and services furnished under contract or arrangement. This deficiency had the potential to affect patients treated in the facility during the survey between 8/6/12 and 8/9/12.

Findings include:
Review of the QI P&P on 8/9/12 in the AM, the policy directs that "QI Committee and Responsibilities: All departments will be represented" in the QI program.

Per review of the hospital QI program and interview with QI Supervisor (K) on 8/8/12 at 8:00 AM, it was revealed that not all of the hospital departments participate in the QI program. Examples include the dietary and medical record departments. In addition, contracted services are not evaluated to ensure they are providing safe and effective services.

Per interview, with Maintenance Supervisor (E) on 8/7/12 at 10:30 AM, "Bandbox" is a contracted service that launders patient bedpads and is not evaluated annually as part of the QI program.




26711

An interview with Infection Control Preventionist (ICP) Q was conducted on 8/8/12 at 9:03 a.m. ICP Q is currently collecting data regarding surgical site infections, infections from foley catheters, and other infection prevention data. This information is tracked and trended but not forwarded to the overall Quality Improvement (QI) plan for the facility.

An interview with Pharmacist S was conducted on 8/6/2012 at 2:00 p.m. Pharmacist S collects data on hood testing sterility, antibiograms, and sensitivities and looks for trends then compiles the data which is forwarded to the Medical Staff and Pharmacy and Therapeutics committee, however Pharmacist S stated S is not sure how this data is is rolled into the overall QI plan for the facility. Pharmacist S does not supply this information directly to QI.

An interview with Surgical Services Supervisor (Sup.) R was conducted on 8/8/2012 at 8:15 a.m. Since December 2011 Sup. R oversees Surgery/Operating rooms and the Post Anesthesia Care Unit (PACU). Sup. R states for QI the Surgical department is working on improving discharge instructions but is not tracking, trending, or analyzing any data for national indicators. Sup. R also stated that for the PACU nothing is being done for QI.

Based on review of the facility's Swing Bed (known in this facility as Transitional Care Unit-TCU) Admission Agreement, 1 of 2 Swing Bed MR (Pt. #24) out of a total of 30 MR reviewed, and 2 of 2 staff interviews (Staff A and J), this facility does not ensure that Swing Bed patients have the required information needed at the time of transfer or discharge. This deficiency will affect all Swing Bed patients that enter this facility.

Findings include:
An interview with Utilization Review Registered Nurse (UR RN) A and Social Worker J was conducted on 8/7/2012 at 11:08 a.m. It was determined during the interview that the facility does not have a transfer/discharge agreement for the Swing Bed (TCU) patients and asked if this was a new requirement.

The facilities Admission Agreement for TCU, which is undated, was reviewed on 8/9/2012 at 5:55 a.m. The agreement includes the language from the State Operations Manual regarding the need for the transfer notice and its contents however the facility has not developed a notice for transfer or discharge that would inform the patient of the right to know the reason, effective date, or where they would be discharged or transferred should this occur.

The facility also does not give the patient contact information about the Long Term Care Ombudsman, or include information regarding who to contact for patients with developmental disabilities or mental illness, since this would be located on the transfer/discharge notice.

A MR review was done on the closed Swing Bed MR for Pt. #24 on 8/8/2012 at 3:32 p.m. There was no transfer/discharge notice on file in the MR. This finding was confirmed by UR RN A at the time of the MR review.