HospitalInspections.org

Based on record review and interviews, the hospital failed to ensure: 1) patients were informed of their rights by providing only the mental health rights and not including the rights required by the acute care hospital licensing regulations for 3 of 3 patients reviewed for patient rights from a total of 15 sampled patient records (#6, #7, #10) and 2) patients were provided with " An Important Message From Medicare " no more than 2 days prior to discharge for 4 of 4 patients reviewed for the Medicare message from a total of 15 sampled patients (#7, #8, #9, #12). Findings:

1) Patient Rights:
Review of the medical records of Patients #6, #7, and #10 revealed the patient rights presented included the mental health patient rights. There was no documented evidence that patients were presented the rights required by the acute care hospital licensing regulations.

Review of the " Patient Handbook " presented by Director of Nursing S2 as the hospital ' s current patient handbook, revealed, in part, " ...Patient Rights Your Rights as a member of this Program will be specifically addressed with you by your case manager and you will sign a form stating that you heard and understand these Rights. ... These rights are listed in the back of this Handbook ... " . Further review revealed no documented evidence of the list of rights at the back of the handbook presented by DON S2.

In a face-to-face interview on 08/27/10 at 9:35am, Registered Nurse (RN) Charge Nurse S3 confirmed the mental health rights were the only list of rights presented to the patients.

2) " Important Message From Medicare " :
Review of the medical records of Patient #7, Patient #8, Patient #9, and Patient #12 revealed no documented evidence that they had received the notice at discharge.

In a face-to-face interview on 08/27/10 at 9:35am, RN Charge Nurse S3 indicated they were not giving patients the " Important Message From Medicare " at discharge.

Based on record review and interview, the hospital failed to follow its policy for the time frame for review of a grievance and provision of a response by having no documented evidence of the date and time a grievance was made by a family member and by having no documented evidence of a response of the resolution by the CEO (chief executive officer) as required by hospital policy for 1 of 1 grievance reviewed from a total sample of 15 patients (#7). Findings:

Review of a " Grievance Report " documented by Registered Nurse (RN) S18 revealed the word " grievance " with several lines marked through the word and " complaint " written above the word " grievance " . Further review revealed the report was not documented on the " Complaint Report " form required by policy which includes the following areas to be completed: Statistical Data - date of complaint, time of complaint, date complaint received, department receiving complaint, complaint received from, data on complaint, state complaint, person receiving complaint; All Complaints Must Be Referred To The Department Manager For Review - department manager ' s findings, action taken, department manager signature, date; Following Review By Department Manager, The Complaint Must Be Referred To The Hospital CEO - findings, actions/recommendations, hospital CEO signature, date.

Review of the report documented by RN S18 revealed the following information: Filed by: " RN S18 a past verbal complaint from daughter " ; Complaint: " Patient #7 was noted to have skin breakdown to buttocks by daughter after discharge to nursing home " ; Investigation: " Pt. (patient) had excoriation to buttocks (after) diarrhea stools. Skin barrier cream and turning routines were completed here " ; Resolution: " Meeting was completed with daughter and pts care. (care giver) and physical changes were discussed. Also included in discussion was follow up care for pt ' s wife (pt was placed on hospice) and pt ' s daughter was encouraged to pursue care giver group 8/27/09 " ; Completed by: Signature of RN S18; Manager: no documented evidence of a signature by the manager. Further review revealed a note at the bottom of the form of " All forms are to be reviewed and signed by Director of Nursing (DON) S2 within 24 hours " . Further review of the report revealed the only documented date was at the top of the form and was " 8/09 " . Further review revealed no documented evidence that the family members were satisfied and felt that the problem was resolved.

In a face-to-face interview on 08/27/10 at 1:20pm, DON S2 confirmed the hospital policy was not followed as there was no accurate investigation, the time frame for resolution could not be determined because there were no dates documented, and there was no evidence that the CEO had reviewed it and provided a response of the resolution to the family.

Review of the hospital policy titled " Grievance Policy " , last reviewed 02/21/08 and submitted by DON S2 as 1 of 2 policies for grievances, revealed, in part, " Purpose: To state the steps a person must take to file a grievance. Policy: The Office for Civil Rights (OCR) of the U.S. Department of Health and Human Services is the federal agency which enforces Section 504 of the Rehabilitation Act of 1973 that prohibits the discrimination on the basis of handicap. In accordance with this regulation, Psychiatric Pavilion New Orleans has adopted a grievance procedure for any participant (patient), representative, or prospective participant who has reason to believe he or she was mistreated, denied services, or discriminated against because of a handicap ... " . Further review revealed no documented evidence that this policy referred to any complaint/grievance other than discrimination based on one ' s handicap.

Review of the hospital policy titled " Patient Complaints " , last reviewed 11/21/06 and submitted by DON S2 as 1 of 2 policies for patient grievances, revealed, in part, " ...Policy: Patient or patient family complaints occurring during the patient ' s hospitalization shall, whenever possible, be responded to by the designated Nursing Manager or responsible department manager closest to the problem causing the complaint. Procedure: Regardless of which manager responds, all complaints shall be reviewed by the Hospital CEO or his/her authorized representative. Responses to patient complaints shall be made as immediately as possible. Within forty-eight (48) hours, the problem should be resolved and each action documented. It should be noted that if the patient or patient ' s family continues to complain and in their view the problem is not resolved, the Hospital CEO must be apprised of the situation. Ongoing complaints or disenchantment with the services and/or patient care must be dealt with one-on-one by the Hospital CEO. ... Responses may be written or verbal, depending on the situation. ...Definition: A grievance is any written or verbal, complaint by a patient, relative, or any other representative relating to patient care or the quality of services provided. ... Procedure: 1. When a complaint of any kind is noted, the Complaint Report Form is used ... The top part of the form is completed by the person receiving the complaint. 2. The following information will be placed on the form by that individual completing the record: a. date the incident occurred; b. time the incident occurred; c. date the complaint was received; d. department receiving the complaint; e. the complaint as noted; f. name of person who received complaint; g. date the complaint form was completed; 3. The complaint form is then referred to the department manager for review and actions taken. The signature of the department manager and date completed. 4. The record is then forwarded within 24 hours of receipt of complaint to the Hospital CEO. ... 5. The Hospital CEO will then complete the bottom portion of the form. 6. Responses and appropriate resolutions to all complaints will be made within 48 hours ... " .

Based on record review and interview, the hospital failed to ensure the hospital policy required that resolution of the grievance be provided to the patient/representative in writing and contained the name of the hospital contact person, steps taken to investigate the grievance, the results of the grievance process, and the date of completion which resulted in a patient ' s representative not being notified in writing of the resolution of the grievance for 1 of 1 patient grievance reviewed from a total of 15 sampled patients (#7). Findings:

Review of a " Grievance Report " documented by Registered Nurse (RN) S18 revealed the word " grievance " with several lines marked through the word and " complaint " written above the word " grievance " . Further review revealed the following information: Filed by: " RN S18 a past verbal complaint from daughter " ; Complaint: " Patient #7 was noted to have skin breakdown to buttocks by daughter after discharge to nursing home " ; Investigation: " Pt. (patient) had excoriation to buttocks (after) diarrhea stools. Skin barrier cream and turning routines were completed here " ; Resolution: " Meeting was completed with daughter and pts care. (care giver) and physical changes were discussed. Also included in discussion was follow up care for pt ' s wife (pt was placed on hospice) and pt ' s daughter was encouraged to pursue care giver group 8/27/09 " ; Completed by: Signature of RN S18; Manager: no documented evidence of a signature by the manager. Further review revealed a note at the bottom of the form of " All forms are to be reviewed and signed by Director of Nursing (DON) S2 within 24 hours " . Further review of the report revealed the only documented date was at the top of the form and was " 8/09 " . Further review revealed no documented evidence that the family members were satisfied and felt that the problem was resolved.

In a face-to-face interview on 08/27/10 at 1:20pm, DON S2 confirmed the hospital policy was not followed as the correct form was not used, there was no accurate investigation, the time frame for resolution could not be determined because there were no dates documented, and there was no evidence that the CEO had reviewed it and provided a response of the resolution to the family.

Review of the hospital policy titled " Grievance Policy " , last reviewed 02/21/08 and submitted by DON S2 as 1 of 2 policies for grievances, revealed, in part, " Purpose: To state the steps a person must take to file a grievance. Policy: The Office for Civil Rights (OCR) of the U.S. Department of Health and Human Services is the federal agency which enforces Section 504 of the Rehabilitation Act of 1973 that prohibits the discrimination on the basis of handicap. In accordance with this regulation, Psychiatric Pavilion New Orleans has adopted a grievance procedure for any participant (patient), representative, or prospective participant who has reason to believe he or she was mistreated, denied services, or discriminated against because of a handicap ... " . Further review revealed no documented evidence that this policy referred to any complaint/grievance other than discrimination based on one ' s handicap.

Review of the hospital policy titled " Patient Complaints " , last reviewed 11/21/06 and submitted by DON S2 as 1 of 2 policies for patient grievances, revealed, in part, " ...Policy: Patient or patient family complaints occurring during the patient ' s hospitalization shall, whenever possible, be responded to by the designated Nursing Manager or responsible department manager closest to the problem causing the complaint. Procedure: Regardless of which manager responds, all complaints shall be reviewed by the Hospital CEO or his/her authorized representative. Responses to patient complaints shall be made as immediately as possible. Within forty-eight (48) hours, the problem should be resolved and each action documented. It should be noted that if the patient or patient ' s family continues to complain and in their view the problem is not resolved, the Hospital CEO must be apprised of the situation. Ongoing complaints or disenchantment with the services and/or patient care must be dealt with one-on-one by the Hospital CEO. ... Responses may be written or verbal, depending on the situation. ...Definition: A grievance is any written or verbal, complaint by a patient, relative, or any other representative relating to patient care or the quality of services provided. ... Procedure: 1. When a complaint of any kind is noted, the Complaint Report Form is used ... The top part of the form is completed by the person receiving the complaint. 2. The following information will be placed on the form by that individual completing the record: a. date the incident occurred; b. time the incident occurred; c. date the complaint was received; d. department receiving the complaint; e. the complaint as noted; f. name of person who received complaint; g. date the complaint form was completed; 3. The complaint form is then referred to the department manager for review and actions taken. The signature of the department manager and date completed. 4. The record is then forwarded within 24 hours of receipt of complaint to the Hospital CEO. ... 5. The Hospital CEO will then complete the bottom portion of the form. 6. Responses and appropriate resolutions to all complaints will be made within 48 hours ... " . Further review revealed no documented evidence that the policy required the response to be in writing and should include the hospital contact person, steps taken to investigate the grievance, the results of the grievance process, and the date of completion.

25065

Based on record review and interview, the hospital failed to ensure patients were provided the right to make informed decisions regarding their care by:
1) failing to ensure the consent of the patient's representative was obtained when he/she (the patient) was unable to make informed decisions regarding care and treatment for 3 of 4 patients reviewed for consent from a total of 15 sampled patients (#7, #8, #10).
2) failing to ensure "Do Not Resuscitate" (DNR) orders were based on properly obtained consents for 1 of 3 patients reviewed with DNR orders out of a total sample of 15 patients (#12). Findings:

1) Failing to ensure the consent of the patient's representative was obtained when he/she (the patient) was unable to make informed decisions regarding care and treatment:

Review of the medical records of Patient #7, Patient #8, and Patient #10 revealed they were admitted via Non-Contested Admission. Further review revealed no documented evidence a family member, guardian, or patient representative had signed the consent as evidenced by the line for the signature being blank. Further review revealed no documented evidence of attempts to obtain the signature of the family member or representative.

In a face-to-face interview on 08/25/10 at 12:30pm, Medical Director S15 indicated a non-contested admission meant that the patient was not able to make a valid decision due to dementia, but he/she was not contesting hospitalization. He further indicated a family member should sign/give consent for non-contested admissions.

Review of the Medical Staff Rules and Regulations, last revised 03/10/10 and submitted by Director of Nursing (DON) S2 as the current copy of the Medical Staff Rules and Regulations, revealed, in part, " ...Consent For Treatment 8.1 A general consent form, signed by or on behalf of every patient admitted to the Hospital, must be obtained at the time of admission. The admitting office shall notify the admitting physician whenever such consent has not been obtained. When so notified, it shall, except in emergency situations, be the staff member ' s obligation to obtain proper consent before the patient is treated in the Hospital. ... 8.2 When consent cannot be obtained, the reason shall be documented in the patient ' s record ... " .

Review of the hospital policy titled "Consents", developed 12/01/05 and submitted by DON S2 as their current policy for consents, revealed, in part, "...Policy: All patients receiving medical and surgical treatment must sign a consent form. ... Form of Consent. The following types of consents may be acceptable: a. Written. b. Telephone consent with two witnesses (document on chart who gave consent; witnesses should sign chart). c. Notarized Special Power of Attorney for medical and hospital care. d. Telegram consent: use at last resort when all other forms of consent for treatment have been tries. ... Incapacity to Consent: If a physician is of the opinion that a patient is incompetent, consent should be obtained from the patient's next-of-kin as indicated by state law...".

2) Failing to ensure "Do Not Resuscitate (DNR) orders were based on properly obtained consents:
Review of Patient #12's medical record revealed an order on 08/12/10 at 5:13pm for "DNR". Further review revealed an "Advanced Directive Do Not Resuscitate" form from Facility E in Patient #12's chart that was not dated and had no documented evidence of witnesses to the signature of someone whose relation to Patient #12 was not indicated.

During a face to face interview on 8/25/2010 at 12:40 p.m., Physician S15 indicated Do Not Resuscitate (DNR) orders should be based on properly obtained consents. S15 further indicated if a DNR order is continued from another facility, the rationale should be clearly documented in the transfer papers from the sending facility to include properly obtained witnessed consents for withholding resuscitation and/or properly obtained witnessed advanced directives. When asked to review the DNR from Facility E for Patient #12, Physician S15 confirmed the form was not dated and witnessed.

Review of the hospital policy titled, "Do Not Resuscitate, AM-02-009, developed 12/01/2005" presented by the hospital as their current policy revealed in part, "Competent Patient. A competent patient must request the DNR in writing or give his/her informed written consent to a DNR order. The writing must be witnessed. . . Incompetent Patients: Patients Previously Judicially determined Incompetent. If a patient has been adjudged to be mentally incompetent by a court, the discussion regarding DNR orders should be between the physician and the patient's legal guardian. Notwithstanding the patient's family wishes, the sole responsibility for concurrence with a physician requested DNR order rests with the legal guardian. For there protection of the patient, physician and hospital, DNR orders should be written only in accordance with accepted standards of medical practice. The medical record should contain documentation of: a. The discussion regarding the DNR decision. b. The patient's mental and physical condition. c. Where appropriate, any necessary authorization by the patient's family or the consent of a court, appointed guardian. . . Appropriate documentation supporting the DNR order should be in the progress notes. . .An authorization form from those legally authorized to act on behalf of the patient is also attached to a DNR order to document such persons' agreement and support of this approach. No other forms are necessary for a simple DNR order.. ."

Based on observations, record review and interview the hospital failed to ensure all staff had been assessed for competency in the application of physical restraints as evidenced by no documentation of demonstration for the application of restraints in 13 of 13 personnel files reviewed (S3, S4, S6, S7, S8, S10, S11, S13, S14, S16, S17, S18). Findings:

Review of the following forms: Position Activity Sheet, Nurse Core Competency Inventory, Position Description and Annual Appraisal, Validation of Competency to Perform Job Related Skills which are required to be completed on all hospital employees revealed no documented evidence competency assessment for the application of restraints had been included. Further review of the personnel files for RN (Registered Nurse) S3, RN S4, LPC (licensed Professional Counselor) Intern S6, LPC S7, Program Specialist S8, Social Worker S10, RN S11, RT (Recreational Therapist) S13, CNA S14, CNA S16, LPN (licensed practical nurse) S17, and RN S18 revealed no documented evidence competency in the application of restraints had been assessed.

In a face to face interview on 08/24/10 at 10:20am Director of Nursing (DON) S2 indicated physical restraints are not used in the facility because the population served is geri-psych. Further she indicated most of the patients are elderly and some are not ambulatory. According to the DON the patients can be talked down with soothing techniques when their behavior escalates.

Observation on 08/26/10 at 4:45pm in the hallway outside of the staff conference room revealed two random male patients, without any ambulatory problems noted walking up and down the hall. Further observation of one of the random patients revealed his height approximately 6 feet tall and weight >200 whose behavior was escalating as he started yelling at the staff they needed to do their jobs.

During a face to face interview on 8/27/2010 at 9:30 a.m., Registered Nurse S3 indicated there were no restraints available at the facility. S3 further indicated she would get an order for medication to decrease patient's agitation as needed and if the patient appeared to be at risk for violence she could call one of the male staff in to work if there were none on duty. S3 further indicated she did not know what she would do if a patient needed to be "taken down (placed in restraints)". S3 indicated she knew of one occasion where a patient was very close to needing restraints when agitated; however, she could not remember the patients name. S3 indicated the patient eventually responded to prn (as needed) medication.

Review of the hospital policy titled "Restraint And Seclusion Philosophy", last reviewed on 10/17/07 and submitted by DON S2 as the current policy for restraints, revealed, in part, "...Staff education focuses on: The impact of restraint/seclusion on the patient and his/her rights and dignity; Patient assessment strategies identifying potential patient behavioral risk factors; Care planning incorporating strategies to prevent or manage risk factors; The alternatives to restraint and seclusion effective for different patient behaviors; The correct application and removal when restraint is used; and Clinical strategies to identify and meet emergent patient needs during use of restraint and seclusion. ... This program identifies, educates and determines the competency of those staff members who apply or remove restraint or who initiate or terminate seclusion. Frequently repeated in-service education, including an understanding of manufacturer's instructions for use of restraint devices, helps assure safe use. ...". Review of the entire policy revealed no documented evidence of how competency would be determined for the use of restraints, such as observation of successful application of restraints by a competent health care professional.

Based on record review and interview the hospital failed to meet the Condition of Participation for Quality Assurance Performance Improvement by:

1) failing to track adverse patient events, analyze their causes and implement preventive actions and mechanisms that include feedback and learning throughout the hospital as evidenced by:

a) failing to follow hospital policy and procedure as evidenced by failing to complete an investigation of a sentinel event which resulted in the death of a patient (#10). See findings cited at A0288
b) failing to ensure a change in hospital policy relative to falls was monitored to ensure no further preventive actions were needed after determining that Orthostatic Blood Pressures should be monitored for patients post fall. See findings cited at A0288.
c) failing to ensure handwashing surveillance was monitored and documented in relation to an outbreak of a gastrointestinal virus at the hospital. See findings cited at A0288.

2) failing to ensure a Quality Assurance Performance Improvement Plan (QAPI) that defined the program was in place which included the hospital's scope of services with a plan specific to the hospital for monitoring hospital services and contracted services for quality of care, composition of the Quality Assurance Team, or how often the team was to meet. See findings cited at A0341.

20638

Based on record review and interview the hospital failed to track adverse patient events, analyze their causes and implement preventive actions and mechanisms that include feedback and learning throughout the hospital as evidenced by:
1) failing to follow hospital policy and procedure as evidenced by failing to complete an investigation of a sentinel event which resulted in the death of a patient (#10).
2) failing to ensure a change in hospital policy regarding falls was monitored to ensure no further preventive actions were needed after determining that Orthostatic Blood Pressures should be monitored for patients post fall.
3) failing to ensure handwashing surveillance was monitored and documented in relation to an outbreak of a gastrointestinal virus at the hospital. Findings:

1) Failing to follow hospital policy and procedure as evidenced by failing to complete an investigation of a sentinel event which resulted in the death of a patient:
Review of policy # EM-08-002 titled "Sentinel Event Guidelines" presented by the hospital as their current policy revealed in part, "In response to an identified sentinel event, Psychiatric Pavilion New Orleans will conduct a timely, thorough, and credible root cause analysis and will develop, implement, and monitor effectiveness of an appropriate plan of action which is designed to reduce the risk of the occurrence of similar events in the future.. . Event Determination Team Members: The Event Determination team will consist of: Human Resources Coordinator, AA/DON (Administrative Assistant/ Director of Nursing), Hospital CEO (Chief Executive Officer). This team will conduct a preliminary investigation sufficient to determine whether the reported event constitutes a sentinel event. If it does, the Event Determination Team will appoint an Investigation Team and determine whether the the sentinel event will be reported to outside agencies. Investigation Team Members: The following people, or their designees, will be considered as participants of the investigation team: Human Resources Coordinator, AA/DON, Chairperson of Medical Care Evaluation Committee, Hospital CEO, Department leadership of area where the event occurred, Person with technical knowledge of event, to be named by team members, Other ad hoc members to be determined by team members. . . Process: In accomplishing the foregoing, the Investigation Team will generally follow the following steps: Outline investigation plan, Collect information, Determine Sequence of Events, and Identify incident's causal factors. . . Characteristics of a thorough and credible root cause analysis. In a thorough root cause analysis: The proximate cause of the sentinel event is determined and the process (es) and systems related to it (')s occurrence are identified. Related systems and processes are analyzed. Possible common causes and their relative potential contributions to the event are identified. Potential improvement in processes or systems that would tend to decrease the likelihood of such events in the future is identified; or after analysis, a defensible determination is made that no such improvement opportunities exist. A plan to address identified opportunities for improvement or formulation of a rationale for not undertaking such changes is established. Where improvement actions are planned the following are identified ' Who is responsible for implementation; When the actions will be implemented - including any pilot testing; and How effectiveness of the actions will be evaluated. In a credible root cause analysis: The organization's leadership and the individuals most closely involved in the process and systems under review participate in the analysis. The analysis is internally consistent. The analysis includes consideration of any relevant literature."

Review of the hospital policy titled, "Significant Incident Reporting, PP-043, last reviewed 10/17/07" presented by the hospital as their current policy revealed in part, "It is the policy of the Psychiatric Pavilion of New Orleans to assure the reporting of all significant events/occurrences in order to maintain a safe environment for all clients, staff and visitors. The information reported is used to evaluate and identify risk areas so as to assure resolution and prevention of potential problems areas. . . When ever there is a significant occurrence the staff member involved in identifying the event will complete an Incident Report form. . . The report is to be turned in to the Nursing Director immediately and then is sent to Quality Management within 24 hours of the event or it(')s discovery. . . Quality Management will assist the program in investigating the incident, trending similar incidents and problem correction."

Review of the medical record for Patient #10 revealed he had been admitted via non-contested admission on 06/10/10 for demential with behavioral disturbances. Further review revealed he had a history of elevated liver function studies, malnutrition and low albumin levels.
Review of the Admit Nursing Assessment, Nutritional Screen section, dated 06/10/10 revealed Patient #10 had scored a "0" indicating no nutritional consult was needed. Further review of the Nutritional Screen revealed no documented evidence how #10's documented height and weight of 6 feet 137 pounds had been determined (Patient report, estimate or assessment). Review of the History & Physical (H&P) which the nurse documented to refer to for information on the patient's health history revealed the patient had a documented diagnosis of malnutrition. Review of the Physician's Admit Orders dated/timed 06/10/10 at 1600 (4:00pm) revealed an order for aspiration precautions. Using the hospital's Nutritional Screen Risk Criteria and the information documented in the Admit Orders and the H&P revealed the following: Diagnosis of malnutrition (8 points), Swallowing difficulty (8 points); Chronic Liver function Studies (3 points) Patient #10 indicating a score of "19" scoring the patient as a high risk for nutrition and triggering a dietitian referral. Further review revealed no documented evidence a referral had been made to the dietitian for Patient #10.

In a face-to-face interview on 08/25/10 at 12:30pm, Medical Director S15 indicated no dietary consult could be performed without a patient's weight.

In a face-to-face interview on 08/25/10 at 3:40pm, Registered Dietitian (RD) S22 indicated she completes the top portion of the initial assessment for nutrition therapy on each patient when she comes to the hospital, even if their nutritional screening score did not warrant a nutritional consult. She further indicated she only looked at the diet order to make sure the RDA was met with what diet was ordered. She confirmed that she did not look at physician orders, labs values, and the communication sheet. RD S22 indicated she did the nutritional assessment for Patient #10 on 06/10/10 without a documented height and weight. She further indicated she was not aware of the patient's confirmed aspiration by a barium swallow and indicated that swallowing difficulty was automatically a high risk and required a nutritional consult.

In a face-to-face interview on 08/26/10 at 4:00pm, Physician S9 indicated he would expect the nursing staff to watch what a patient eats during his/her feedings when he orders aspiration precautions.

Review of the Barium Swallow results for Patient #10 dated 12/11/2009 as performed at Facility D revealed in part, "Radiopaque liquids and solids administered orally using fluoroscopic monitoring by the speech pathologist demonstrating dysphagia judged moderate. Aspiration was also seen before swallow with very weak cough, found with thin and thick liquids. . . Speech Video Swallow: Aspiration noted (with) thin and nectar liquids, oral dysphagia noted esp (especially) (with) reg (regular) solids. Rec (Recommend) Level IV diet (mech (mechanical) soft...) (with) honey thick liquids. Aspiration precautions posted at bedside. Liquids to be honey thick. Sit upright as much as possible. Feed slowly. Alternate liquids and solids. Stop if coughing choking."

Review of the hospital's "Confidential Occurrence" dated 06/28/10 for the occurrence of 06/27/10 at 12:30pm revealed..... "Pt. (Patient #10) became choked on lunch (roast beef). Pt. did not respond to emergency procedures by nursing staff or EMS staff. Transported to Hospital "A"'s Emergency Room. Pt was pronounced at Hospital "A"." Further review revealed MD S15 and MD S33 were present on the unit at the time of the occurrence; the result of the occurrence was the death of the patient; the condition of the patient prior to the occurrence was confused, but cooperative; and the family was notified.

Review of a notebook presented by Quality Assurance (QA) Director S18 with the title page "Confidential and Privileged QA Assessment/ Improvement Information" with no documented date and time to indicated when the form was written revealed in part, "Initial Event- 6/27/2010 (61 days prior to the survey) Management: 12:30 (p.m.) Pt. (patient) had choking event during supervised meal - attempts made to dislodge food unsuccessful and CPR (cardiopulmonary resuscitation) started. (Dr. S15/ Dr. S33 present on unit) 12:34 (p.m.) EMS activated- attempts to dislodge progressed to CPR (Cardiopulmonary resuscitation) - O2 (oxygen) - AED (Automated external defibrillator) (Equipment present + verified as working) 1250 (p.m.) - Code per protocol per EMS (Emergency Medical Services) personnel- food matter removed with long forceps prior to intubation and emergency procedures progressed. 1325 (1:25 p.m.) - Transported to (Facility B). 1414- unit notified of pt's status - Nurse unable to reach family. - Administration notified. . Follow up- Review of Code Blue form - Occurrence Report completed. - Review of charts reported (indicated a 15 - 20 min response for EMS) and review of notes. - Event site (Dayroom/observation during meals), equipment present and functioning. - Documentation per nursing staff and medical staff completed. - Follow up calls made on Monday per social service (note in chart) and per Administration (note in chart) - Family did not desire autopsy- no unresolved issues were identified (family member did state that there was some difficulty getting information from the hospital- believed to be privacy policy. Review Analysis per (S18) was for further review. . . diet- Regular NAS (no added salt) ordered. Hx (history) of dysphagia since 1907 (as documented). 12/09 aspiration per modified Barium swallow, but tolerated Regular diet prior to admit. Admit 6/10/10 for aggressive behavior, refusing meds. hygiene - hit female peer in face. . staffing 2 RNs (Registered Nurses) / 2 LPNs (Licensed Practical Nurses) / 3 CNA (Certified Nursing Assistants) for 6/27/10 - (Physician S15 and S33) on unit during event. Pt. was being observed during meal some question if pt. had other event that precipitated choking (MI (Myocardial Infarction), CVA (Cerebrovascular Accident)) family did not desire autopsy. Extended time for EMS response (outside our control) due to increase volume (decreased) response time - discussed intake process (with) (Intake Coordinator S19) and verified diet and eating nutritional intake was discussed with routine assessment of pt. for admit. Summary of staff interviews- All efforts were made to dislodge food matter - no swallowing difficulty noted (.) prior to event tolerated Regular diet - both physicians present and assisted in response to pt. event. - increased response time for EMS was reported- staff members were confident in tx (treatment) given and documentation was completed. . . Case will be presented to Performance Improvement Committee in upcoming meeting for review and recommendations" Review of the entire document revealed no documented evidence to indicate where Patient #10 was located in the Day Room in relation to the location of staff members on the day of the incident, no documented evidence of interviews regarding the patient's ability to chop roast beef with a plastic knife, no documented evidence to indicate what utensils had been provided to the patient, no documented evidence to indicate if any assistance had been provided to the patient during meal time on the date of the incident. Further there was no documented evidence of the investigation from which the summary obtained to include no documentation of the names of staff on duty or the date, time, and information disclosed in interviews. Review revealed no documented evidence of identifying an inaccurate Nutritional Assessment performed upon admission to the hospital which resulted in a failure to consult the Dietician. Review revealed no documented evidence of identifying the absence of any policy regarding Aspiration Precautions. Further there was no documented evidence the information had been presented at the Performance Improvement Committee meeting for review.

Review of the entire Policy and Procedure Manuel revealed no documented evidence of a policy regarding "Aspiration Precautions". This finding was confirmed by Director of Nursing S2.

During a face to face interview on 8/26/2010 at 1:50 p.m., Quality Assurance Director S18 indicated the hospital had taken the death of Patient #10 seriously and had chosen to treat it as a sentinel event. S18 presented a notebook which contained a handwritten summary of her investigation (Review above). S18 indicated she did not have any documentation of the actual investigation from which the notebook summary was based. S18 indicated she thought the investigation was to be confidential and therefore had made no documentation regarding her interviews to include who she had interviewed, the date and time of interviews, or information gathered during the interviews. S18 further indicated she had recently been out on leave due to a medical illness and that although she had planned on presenting the summary of her investigation regarding the death of Patient #10 at the Performance Improvement committee meeting the month before (July 2010), she had not been able to. S18 confirmed that no one had performed this duty in her absence. S18 indicated she had planned on having the case reviewed by the Utilization Review Physician who admitted no patients to the facility; but it had not occurred at the time of the survey (event occurred 61 days prior to the survey). S18 indicated she had not identified the inaccuracy of Patient #10's admission nutritional screening which would have triggered a consult with the hospital's Dietician had it been correctly coded as "Swallowing Difficulty".

2) Failing to ensure a change in hospital policy regarding falls was monitored to ensure no further preventive actions were needed after determining that Orthostatic Blood Pressures should be monitored for patients post fall:

Review of the hospital's incident report log revealed the following number of patient falls by month: August 1, 2010 to present (08/24/10) - 3 falls; July 2010 - 3 falls; June 2010 - 5 falls; May 2010 - 2 falls; April 2010 - 5 falls; March 2010 - 5 falls; February 2010 - 7 falls; January 2010 - 3 falls.

Review of Patient #7's medical record revealed he experienced a fall on 08/11/09 at 5:45am and on 08/12/09 at 1:40am. Review of the entire medical record revealed no documented evidence that orthostatic blood pressures were assessed daily per policy for fall precautions.

Review of Patient #9's medical revealed he experienced a fall on 06/26/10 at 10:20pm. Review of the entire medical record revealed no documented evidence that orthostatic blood pressures were assessed daily per policy for fall precautions.

Review of Patient #11's medical record revealed she experienced a fall on 05/18/10 at 10:30am. Review of the entire medical record revealed no documented evidence that orthostatic blood pressures were assessed daily per policy for fall precautions.

During a face to face interview on 8/27/2010 at 1:20 p.m., Director of Nursing S2 indicated she had been involved in Quality Assurance's identification of the need for instituting Orthostatic Blood Pressure evaluations in response to falls. S2 indicated she could not recall the date that the changes were made; however, was able to confirm that the Fall Policy indicated the last revision was 5/08. S2 confirmed that after corrective action was implemented which involved daily assessments of Orthostatic Blood Pressure assessment post falls, there had been no monitoring to ensure staff were following the change in policy.

Review of the hospital policy titled, "Fall Precautions PP-036, last revised 5/22/08" presented by the hospital as their current policy revealed in part, "Patients recognized at High Risk for falls will be placed on fall precautions: . . . C. Daily vital signs will include orthostatic checks."

3) Failing to ensure handwashing surveillance was monitored and documented in relation to an outbreak of a gastrointestinal virus at the hospital:
During a face to face interview on 8/23/2010 at 10:00 a.m., Director of Nursing S2 indicated the hospital had a viral outbreak sometime in the recent past (could not recall date) where most of the nursing staff developed diarrhea and projectile vomiting.

During a face to face interview on 8/26/2010 at 1:50 p.m., Quality Assurance Director S18 indicated the hospital had an outbreak of some time virus in the recent past. S18 indicated several employees and a few patients developed diarrhea. S18 indicated all patients that became ill had cultures done and none were positive. S18 indicated ill staff members stayed home during the course of their illness. S18 indicated that although she did handwashing surveillance as part of her routine Quality Assurance monitoring that she did not keep any records (documentation) of the surveillance.




25065

Based on record review and interview the hospital failed to ensure a Quality Assurance Performance Improvement Plan (QAPI) that defined the program was in place which included the hospital's scope of services with a plan specific to the hospital for monitoring hospital services and contracted services for quality of care, composition of the Quality Assurance Team, or how often the team was to meet. Findings:

Review of the hospital's policy titled, "Quality Management Overview (no documented date)" presented by the hospital as their current policy revealed in part, "The goal of the Quality Management program is to continually improve the performance of the hospital's processes and services. To do this standards and criteria are established and the performance is monitored and measured against the standards through a planned, systematic, and ongoing approach. Data is collected for high risk areas including but not limited to: blood usage, drug usage, risk management, medical records, utilization review, and infection control. Once problems are identified they are assessed, corrective action taken and followed until resolution. This process will usually occur within the medical staff sub-committee meeting. All recommendations and actions will be reported to the medical executive committee and to the governing body who has the ultimate responsibility for quality management."

Review of the hospital policy titled, "Benchmark Indicators (no documented date)" presented by the hospital as current revealed in part, "Purpose: To focus on key indicators and allow benchmarking collaboration on best practice methods. " Further review revealed "ThinkQuality Indications/Benchmarks" to include Ventilator Wean Rate, Nosocomial Ventilator Pneumonia Rate, and Dialysis (Percent of positive water cultures for dialysis equipment per month and percent of positive endotoxin studies for dialysis equipment per month). Further review revealed no documented evidence of services offered by dietary and/or the dietician to have any indicators indicating monitoring of these services. This finding was confirmed by Director of Nursing S2 who indicated the policy was a corporate policy and most of the corporate owned facilities were medical facilities- not psychiatric facilities. S2 confirmed there was no dialysis unit in the hospital and no ventilators. S2 confirmed there was no QAPI plan specific to the services offered at Psychiatric Pavilion.

During a face to face interview on 8/26/2010 at 1:50 p.m., Director of Quality S18 indicated the Quality Assurance Performance Improvement Plan for the hospital was outlined in several different policies collectively. S18 confirmed there was no documentation revealing the hospital's scope of services, no documentation revealing the composition of the Quality Assurance Team, and no documentation indicating how often the team was to meet.

Based on record review and interviews, the hospital failed to ensure the completion of a discharge summary was delegated to a qualified health practitioner who had been credentialed/privileged to coordinate and dictate the discharge summary and that the responsible physician timed and dated his authentication of the delegated discharge summaries for 4 of 5 patients reviewed for discharge summaries from a total of 15 sampled patients (#7, #8, #9, #11). Findings:

Review of Patient #7 ' s " Psychiatric Discharge Summary " revealed it was dictated on 09/27/09 by Registered Nurse (RN) S34. Further review revealed no documented evidence of the date and time Medical Director S15 signed the discharge summary.

Review of Patient #8 ' s " Psychiatric Discharge Summary " revealed it was dictated on 08/09/10 by RN S34. Further review revealed no documented evidence of the date and time Medical Director S15 signed the discharge summary.
Review of Patient #9 ' s " Psychiatric Discharge Summary " revealed it was dictated on 08/09/10 by RN S34. Further review revealed no documented evidence of the date and time Medical Director S15 signed the discharge summary.

Review of Patient #11 ' s " Psychiatric Discharge Summary " revealed it was dictated on 07/02/10 by RN S34. Further review revealed no documented evidence of the date and time Medical Director S15 signed the discharge summary.

In a face-to-face interview on 08/25/10 at 12:30pm, Medical Director S15 indicated RN S34 was not a nurse practitioner or physician assistant. He further indicated RN S34 had received verification from the LSBN (Louisiana State Board of Nursing) that he could dictate discharge summaries. S15 further indicated RN S34 should have a credentialing file.

In a face-to-face interview on 08/25/10 at 4:45pm, Medical Director S15 presented documentation from LSBN regarding the dictating of discharge summaries by RN S34.

Review of the documentation presented by Medical Director S15 from RN S34 and LSBN revealed the following e-mail communications:
E-mail sent to LSBN from RN S34 on 05/12/09 revealed, in part, " ...I am an RN and have worked extensively in clinical psychiatric nursing. One of the tasks that I have performed over the years is to dictate discharge summaries for several Psychiatrists. ... I have also been credentialed by the respective hospitals via their medical staffing requirements as an allied health professional where the summaries are dictated. ... Could you please clarify if doing a discharge summary is beyond the scope of practice for an RN? " .
E-mail sent to RN S34 by LSBN Director of Credentialing and Practice on 05/15/09 revealed, in part, " You may coordinate and dictate the discharge summary as long as you do not make a medical diagnosis. Your function is as a scribe and not as a clinician in this circumstance ... " .

In a face-to-face interview on 08/26/10 at 9:45am, Administrative Assistant S26 indicated she was responsible for credentialing for the hospital. She confirmed that RN S34 was not credentialed/privileged by the hospital medical staff and governing body. She indicated RN S34 works for Medical Director S15.

Review of the Medical Staff Rules and Regulations, last revised 03/10/10 with no documented evidence of approval by the Governing Board and last approved by the Medical Director in 12/27/08 and submitted by DON S2 as the hospital ' s current Medical Staff Rules and Regulations, revealed, in part, " ... A discharge summary shall be written on patients hospitalized. ... All summaries shall be signed by the responsible staff member. ... Allied Health Professional 14.1. Approved Allied Health Professionals The professionals that have been approved are: (no documented evidence of a list of approved allied health professionals) ... 14.3. Pre-Application Requirements Applications for practice prerogatives for Allied Health Professionals shall be provided only to individuals in disciplines or categories that have been recommended by the Medical Staff, approved by the Governing Board as listed in 14.1 ... " . Review of the entire rules and regulations revealed no documented evidence of which practitioners would be considered allied health professionals.

Based on record review and interview the hospital failed to ensure a Registered Nurse supervise and evaluate the nursing care for each patient by:
1) failing to have a policy that requires the RN to assess a patient upon admission, after a change in condition, and upon a patient's return from the ER (emergency room) for 4 of 4 patients reviewed for RN assessment at admission, with a change in condition, and after treatment in the ER from a total sample of 15 patients (#7, #9, #11#12).
2) failing to perform accurate assessments as evidenced by:
2a) failing to ensure patient's skin condition and wounds were properly assessed for 6 of 6 patients reviewed for skin/wound assessment out of a total sample of 15 ( #6, #7, #8, #9, #11, #12);
2b) failing to ensure accurate dietary screenings had been performed resulting in assessments which were not based on the patients' true weight for 2 of 5 patients reviewed for nutritional screening from a total of 15 sampled patients (#8, #10)
3) failing to ensure vital signs had been assessed before medications requiring vital signs were administered to a patient for 1 of 4 patients reviewed for medication administration from a total of 15 sampled patients (#8); and 7) failing to ensure all patients with orders to be turned every two hours had been turned and the intervention documented in the patients' chart for 1 of 3 patients reviewed with orders for turning from a total of 15 sampled patients (#8).
4) failing to ensure vital signs were taken at a frequency to determine if physician ordered prn (as needed) blood pressure medication should be administered for 1 of 1 patients reviewed with prn blood pressure medication (#2) out of a total sample of 15. Findings:

1) failing to have a policy that requires the RN to assess a patient upon admission, after a change in condition, and upon a patient's return from the ER (emergency room) for 4 of 4 patients reviewed for RN assessment at admission, with a change in condition, and after treatment in the ER:

Patient #7
Review of Patient #7's medical record revealed he was admitted to the hospital via a non-contested admission on 08/12/09 with the diagnosis of Dementia with Behavioral Disturbances. Further review revealed Patient #7 had a history of Anxiety, CABG (coronary artery bypass graft), CAD (cardiovascular artery disease), AFib (atrial fibrillation), CHF (congestive heart failure), Emphysema, AAA (abdominal aortic aneurysm) Repair, Carotid Endarterectomy, and Hypothyroidism. Review of the physician's orders revealed Patient #7 was to be have fall precautions instituted.

Review of Patient #7's "Treatment Team Progress Notes" revealed documentation by LPN S24 on 08/11/09 at 0545 (5:45am) that he was found lying on the floor in the hallway with bleeding to the forehead and to the right elbow, arm, and hand. Further review revealed he was sent to Facility B's ER. Review of the entire medical record revealed no documented evidence of an assessment by a RN.

In a face-to-face interview on 08/26/10 at 9:15am, LPN S24 confirmed there was no documented evidence of an assessment of Patient #7 by a RN.

Review of Patient #7's "Nursing Flow Sheet" for 08/11/09 (documentation from 7:00am on 08/11/09 through 6:59am on 08/12/09) revealed documentation at 1700 (5:00pm) by LPN S21 as follows: "Rec'd (received) per ambulance from Facility B ER - ambulatory - lg (large) Band-Aid over forehead dry & (and) intact - in day rm (room) - very anxious - redirected - unable to redirect pt (patient) trying to get up without assist - becomes angry - med (medicated) with Ativan 1 mg (milligram) - will monitor & maintain a safe & therapeutic environment - no c/o (complaints of) pain or discomfort no noted distress - pupil equal & reactive - orient x 1 (times 1)". Further review revealed no documented evidence of a complete neurological assessment including vital signs, evaluation of motor function and strength, movement, and reflexes, as well as an assessment of the wounds received as a result of the fall. Further review revealed the next documentation was by LPN S28 at 2300 (11:00pm). Review of the entire medical record revealed no documented evidence of an assessment upon return from the ER following a fall with a laceration to the head by a RN, no physician orders for treatment upon return from ER, and no continuing assessment after the initial assessment performed by the LPN (to include vital signs, level of consciousness, evaluation of motor function and strength, movement, and reflexes, pupils, and sensation of pain).

Review of Patient #7's "ED (emergency department) Education/Discharge Instructions" from Facility B dated 08/11/09 revealed the following: "1. Wake up patient every __ (no documented evidence of a number entered) hours throughout the night. 2. No alcohol or medication which causes sleepiness. 3. Tylenol may be used for pain or headache. 4. Return to the ED or call your doctor if: a. Any type of unusual behavior. B. Drainage or blood or fluid from ears or nose. C. Unequal pupils (one large, one small). D. Overly sleepy, disoriented or having problems with coordination. E. Vomiting more than 2 times. F. Very severe headache or headache which continues longer than 24 hours. G. Any seizure or suspected seizure. H. Any loss of strength, sensation or vision ...Other instructions: return to ER for fever, pus to wound or any evidence of infection. Keep wounds clean & dry. Neosporin to wounds twice a day. Cool compress to scalp ...".

In a face-to-face interview on 08/25/10 at 3:00pm, LPN S21, when asked by the surveyor to review her documentation for Patient #7 on 08/11/09 at 5:00pm, S21 indicated the "paragraph is short and sweet". She further indicated she did not document a full neurological assessment with vital signs. She confirmed there was no RN assessment, no physician orders for treatment upon return from ER, and no further assessments of Patient #7 for 6 hours. When asked to review the ER record from Facility B, S21 indicated she should not have administered Ativan according to the ER instructions.

Review of Patient #7's "Nursing Flow Sheet" for 08/11/09 (documentation from 7:00am on 08/11/09 through 6:59am on 08/12/09) revealed an entry at 0140 (1:40am on 08/12/09) by LPN S28 that Patient #7 was noted "on floor sitting next to bed, skin tears noted to bilateral lower forearms & sutures on forehead intact with blood draining from R (right) eye with hematoma above eye". Further review revealed Patient #7 was sent to Facility B's ER. Further review of the entire medical record revealed no documented evidence of an assessment performed by a RN.

Review of the "Treatment Team Progress Notes" for 08/10/09 through 08/11/09 revealed an entry dated 08/12/09 at 0520 (5:20am) by LPN S28 of the following: "Pt returned via stretcher ... awake, alert & combative, redirected several times to remain in bed, noncompliant, (arrow pointing up meaning up) in gerichair in dayroom, drsg (dressing) noted to bil (bilateral) (arrow pointing up meaning upper) shoulders, R forehead, bil arms, 148/82, P (pulse) 86, R (respirations) 18 ...". Further review revealed no documented evidence of an assessment by a RN of Patient #7's neurological status, to include assessment of pupils, evaluation of motor function and strength, movement, sensation of pain, and reflexes, as well as an assessment of the condition of the wounds received as a result of the fall. Review of the entire medical record revealed no documented evidence of a neurological assessment at any time after Patient #7's return from ER. Further review revealed no documented evidence of a physician's order for treatment upon return from the ER. Review of Patient #7's entire medical record revealed no documented evidence of daily orthostatic blood pressures taken as required by the hospital's fall precautions policy.

Review of Patient #7's "ED Education/Discharge Instructions" from Facility B dated 08/12/09 revealed he was to be awakened every 3 hours throughout the night. The instructions included the same instructions noted from the ER visit on 08/11/09 with the addition of a note to "please institute strict fall precautions and monitoring for patient".

In a face-to-face interview on 08/27/10 at 9:35am, RN Charge Nurse S3 indicated LPN S28 and RN S29 were not available for interview. After review of Patient #7's medical record, S3 confirmed there was no RN assessment after the patient ' s fall, upon Patient #7's return from ER, and no neurological assessments performed for Patient #7. She also confirmed there were no physician orders for treatment upon Patient #7's return from ER, and the nurse did not follow the ER physician's orders to wake the patient every 3 hours and to assess for changes in his condition. S3 indicated when fall precautions were ordered, the nurses should evaluate for mobility, monitor the patient closely, and check orthostatic blood pressures as required by policy. S3 confirmed there was no documented evidence of orthostatic blood pressures for Patient #7.

Patient #9
Review of Patient #9's medical record revealed he had been admitted to the hospital via a PEC (physician emergency certificate) on 06/26/10 at 7:00am with a diagnosis of Mood Disorder with a history of a pacemaker and CHF (congestive heart failure). Review of the
"Psychiatric Discharge Summary" revealed final diagnoses of dementia with behavioral problems, delusional disorder/psychosis, history of depression, hypertension, CHF, BPH (benign prostatic hypertrophy), coronary artery disease post pacemaker placement, and bladder problems.

Review of the "Daily Treatment Plan Update and Team Progress Note" and the "Treatment Team Progress Notes" for 06/26/10 written by RN S29 revealed Patient #9 slipped and fell backwards when he threw a chair. Further review revealed he struck his head on the corner of the wall causing a laceration to the back of his scalp. Further review revealed Patient #9 was sent to Facility B's ER.

Review of the "Physician Orders" for Patient #9 revealed an order on 06/12/27/10 at 3:30am to notify the physician if any redness, warmth, pain or drainage at site, unequal pupils, overly sleepy, vomiting more than 2 times, severe headache, seizures, and/or loss of strength.

Review of the "Daily Treatment Plan Update and Team Progress Note" for Patient #9 revealed he returned from ER on 06/27/10 at 3:30am. Further review revealed documentation by RN S29 that the dressing to bilateral elbows and wrists was intact. Further review revealed no documented evidence of an assessment of vital signs and presence or absence of pain. Further review revealed no documented evidence of further assessment of Patient #9 for 2 ? hours since his return from ER, the assessment include no documented evidence of his vital signs, including orthostatic blood pressure as required by hospital policy for fall precautions.

In a face-to-face interview on 08/27/10 at 9:35am, RN Charge Nurse S3 indicated RN S29 was not available for interview. After review of Patient #9's medical record, S3 confirmed there was no documented evidence of an assessment of vital signs by S29 upon Patient #9's return from ER, and there was no further assessment for 2 ? hours.

Patient #11
Review of Patient #11's medical record revealed she was admitted 05/07/10 with diagnoses of conduct disturbance, dementia with behavioral disturbances, hypothyroidism, GERD (gastroesophageal reflux disease), lower extremity edema, history of seizures, and malnutrition.

Review of the "Daily Treatment Plan Update and Team Progress Note" for Patient #11 on 05/18/10 documented by RN S20 revealed she fell at 10:30am which resulted in lacerations to the forehead above the right eye, and to the left hand. Further review revealed no documented evidence of the assessment of vital signs and neurological status prior to transporting Patient #11 to the ER.

Review of the "Daily Treatment Plan Update and Team Progress Note" for Patient #11 on 05/18/10 documented by RN S20 revealed she returned from Facility C's ER at 1830 (6:30pm). Further review revealed no documented evidence of a neurological assessment, vital signs, and appearance of wounds to the left hand. Further review revealed no documented evidence of an assessment of Patient #11 until 6:00am on 05/19/10, which was performed by a LPN and included no vital signs, including orthostatic blood pressure as required by the fall policy, and neurological assessment.

In a face-to-face interview on 08/25/10 at 2:40pm, RN S20 confirmed she did not document vital signs and a neurological assessment at the time of the fall. She further confirmed there was no documented evidence of another assessment of Patient #11 until 6:00am on 05/19/10, and this assessment did not include a neurological assessment and vital signs.

In a face-to-face interview on 08/27/10 at 1:20pm, DON S2 confirmed the hospital did not have a policy for the assessment of a patient following a change in condition and a policy for skin assessments.

Patient #12
Review of Patient # 12's medical record revealed she had been admitted to the hospital via a non-contested admission on 08/12/10 with the diagnosis of Dementia with Behavioral Disturbances. Review of the History and Physical revealed she had a history of Type 2 Diabetes Mellitus and Anemia and had multiple decubiti.

Review of Patient #12's "Admit Nursing Assessment Form" revealed the admission assessment was performed on 08/12/10 by LPN S27.

In a face-to-face interview on 08/27/10 at 9:35am, RN Charge Nurse S3 confirmed the admission assessment had been performed by the LPN.

Review of the hospital policy titled "Assessments", last reviewed 02/13/09 and submitted by Director of Nursing (DON) S2 as the hospital's current policy for assessments, revealed, in part, "...It shall be the policy ... that all assessments shall be completed within the specified time period and shall be maintained in the patient's medical record. ... Admission notes shall be completed within 24 hours. ... Nursing assessments shall be completed during the admission process within 8 (eight) hours of admission. The Nursing assessment shall include a nutritional screening .. ". Review of the entire policy revealed no documented evidence that the admission assessment must be performed by a RN.

Review of the hospital's policy titled "Fall Precautions", last revised 05/22/08 and submitted by DON S2 as their current policy for fall precautions, revealed, in part, "... Important Points: ... Implementation of fall prevention protocol does not require a physician order. ... Each patient ... will receive a Falls Assessment as part of the admission process and placed on appropriate precautions as a consequence. ... Procedure: 1. As part of the initial assessment process and prior to the development of the Initial Treatment Plan each patient will be given a Falls Assessment utilizing the functional screen. 2. Patients will be re-evaluated at least every 12 hours, or when a change in condition/status warrants determining if their risk level changed. 3. Patients recognized at High Risk for falls will be placed on fall precautions. ... Daily vital signs will include orthostatic checks. ... In the event of a patient fall 1. Prior to moving a patient that has fallen, an RN should assess for injury. ... 4. Record the details of the patient's fall in the record including: a. Any injuries or complaint of pain. b. Notification of physician(s) and orders received. c. Action taken. d. Patient's response. e. Reassessment of patient status within 4 hours. ... 6. Patients identified as Low Risk for falls who experience a fall, will be re-evaluated after the occurrence to determine if their risk has changed. If patient has a second fall for any reason during hospitalization, patient will be identified as a high fall risk for the remainder of the stay. Patient may be placed on one to one observation if needed".

Review of the hospital policy titled "Wound Assessment and Documentation", last revised 05/30/10 and presented by DON S2 as their current policy for assessment of wounds/skin tears, revealed, in part, "... All wounds will be assessed on admission and with each dressing change. ... Measure wound (area and depth) Length and width can be measured with a disposable guide/ruler, or wound can be traced with clear plastic sheet or bag. Depth can be measured by inserting sterile swab gently into the wound. ... Wound depth: for pressure ulcers the AHCPR staging system is used; for all others wounds the following definitions are used: superficial (involves the epidermis), partial-thickness (involves epidermis and some dermis), full-thickness (involves epidermis, dermis and possibly subcutaneous tissues, muscle or bone). 7. Assess wound edges, undermining, and tunneling. ... 8. Assess wound bed moisture. ... 9. Assess amount of devitalized tissue. ... 10. Assess amount of granulation tissue. ... 11/ Assess amount of epithelium. ... 12. Assess the surrounding skin for color and condition. ... 14. Document and date all information ...".

Review of the hospital policy titled "Care of Surgically Closed Wounds", last revised 05/30/10 and submitted by DON S2 as the current policy for wound assessment, revealed, in part, "...Purpose: To protect the wound against infection. To prevent trauma to the wound resulting in loss of sutures or staples. ... 8. Following the wound assessment policy and procedure, assess the wound and level of pain ...".

2) failing to perform accurate assessments as evidenced by:
2a) failing to ensure patient's skin condition and wounds were properly assessed for 6 of 6 patients reviewed for skin/wound assessment out of a total sample of 15 ( #6, #7, #8, #9, #11, #12);

Patient # 7
Review of Patient #7's medical record revealed he was admitted to the hospital via a non-contested admission on 08/12/09 with the diagnosis of Dementia with Behavioral Disturbances. Further review revealed Patient #7 had a history of Anxiety, CABG (coronary artery bypass graft), CAD (cardiovascular artery disease), AFib (atrial fibrillation), CHF (congestive heart failure), Emphysema, AAA (abdominal aortic aneurysm) Repair, Carotid Endarterectomy, and Hypothyroidism.

Review of Patient #7's admission assessment performed by RN S30 on 08/10/09 at 6:05pm revealed he had "multiple skin tears to bilateral forearms with scabs intact". Further review revealed no documented evidence of the specific number of skin tears with an assessment to include measurements, presence or absence of drainage, and the condition of surrounding skin.

Review of Patient #7's medical record revealed he fell on 08/11/09 at 5:45am which resulted in lacerations to the forehead above the right eye, the right elbow, right arm, and right hand. Further review revealed Patient #7 fell on 08/12/09 at 1:40am which resulted in skin tears to bilateral lower forearms. Review of the entire medical record for Patient #7's stay from the return from ER on 08/11/10 at 5:00pm through discharge on 08/26/09 revealed no documented evidence of the condition of the sutured laceration to the forehead that include a measurement. Further review of the entire medical record revealed no documented evidence of the number of skin tears, the exact location of the skin tears, and the assessment to include measurement, presence or absence of drainage, and the condition of the surrounding skin.

Review of Patient #7's nurses' notes for 08/25/09 revealed documentation of "excoriated buttock" with no documented evidence of the measurement of the affected area.

Review of Patient #7's wound documentation on 08/26/09, the day of discharge, revealed the following, with no documented evidence of who wrote the assessment at 8:00am: location: bil (bilateral) arms, drsg (dressing) dry & intact; R (right) eyebrow incision open to air well approximate; buttock; R heel sm (small) red streak open to air". There was no documented evidence of the number of wounds/skin tears, the measurement of affected areas, the amount of drainage, and the condition of the surrounding skin.

In a face-to-face interview on 08/25/10 at 3:00pm, LPN S21 confirmed documentation did not include the number and size of skin tears for Patient #7.

In a face-to-face interview on 08/27/10 at 9:35am, RN Charge Nurse S3 confirmed there was no documented evidence of the number, size, and condition of the skin tears for Patient #7. She further confirmed there was no documented evidence of the condition of his wounds at the time of discharge.

Review of the " Skin Report " dated 08/27/09 by the RN at Facility A revealed the following assessment of wounds (after re-admission from Psychiatric Pavilion New Orleans):
Right heel healing abrasion maroon, intact with scab, no drainage, no odor;
Right forearm skin tear 2cm x 0.5cm x 0.1cm 100% RVT (red vascular tissue), small amount serosanguineous drainage, mild odor, periwound bruised;
Right shoulder abrasion 2cm x 3cm x 0.1 cm 100% (per cent) pink bed (superficial), scant serous drainage, mild odor, periwound intact;
Left forearm skin tears 10cm x 7cm x 0.1cm cluster 30% RVT, 70% epithelium, small amount serosanguineous drainage, mild odor, periwound red;
Right elbow skin tear 1cm x 1cm x o.1cm 100% RVT, periwound red, amount serosanguineous drainage, mild odor;
Right 3rd knuckle skin tear 0.5cm x 1cm x 0.1cm 100% RVT, scant serous drainage, no odor, periwound bruised;
Right index finger skin tear scab dry, 1.0cm x 0.5cm, no drainage, no odor;
Left buttock Stage II 3cm x 1cm x 0.1cm, 100% RVT, periwound red, small amount serous drainage, mild odor;
Right buttock/scaral Stage II 9cm x 6cm x 0.1cm, 100% RVT, small amount serous drainage, mild odor, periwound red;
Right dorsal hand skin tear healing scab dry, 2cm x 0.5cm, no drainage, no odor, periwound bruised;
Left ankle (lateral) Stage II 0.5cm x 0.5cm scab, periwound intact, no drainage, no odor;
Right upper arm skin tear 0.5cm x 2.0cm scab, periwound bruised, no drainage, no odor;
Left upper arm scratches, multiple small scabs scattered, dry and intact, no drainage, no odor.

Patient #8
Review of the medical record for Patient # 8 revealed she had been admitted to the hospital via a non-contested admission on 06/17/10 with the diagnosis of Dementia and Behavioral Disturbances. Further review revealed she had a history of Hypertension, Gastrointestinal Reflux, Anemia, Hyperlipidemia, Congestive Heart failure and a recent Right Femur Fracture.

Review of the Daily Nursing Assessment form, Pressure Ulcer/ Wound Care Documentation for Patient #8 dated 06/17/10 through 06/27/10 revealed no documented evidence the nurse had identified any type of pressure ulcer had been identified.

Review of the Physician's Progress Notes for Patient #8 dated 06/26/10 (no time documented) revealed... "Patient has heel pressure sore 1/2cm (centimeter) 1st degree".

Review of the entire closed medical record for Patient #8 revealed no documented evidence Patient #8 had been assessed by a Registered Nurse for a pressure ulcer.

Charge Nurse S3 reviewed the medical record for Patient #8 on 8/27/2010 at 9:10 a.m. S3 indicated documentation regarding skin assessments for Patient #8 had been inconsistent and improvement in nursing assessments for wounds was evident.

Patient #9
Review of Patient #9's medical record revealed he had been admitted to the hospital via a PEC on 06/26/10 at 7:00am with a diagnosis of Mood Disorder with a history of a pacemaker and CHF. Review of the "Psychiatric Discharge Summary" revealed final diagnoses of dementia with behavioral problems, delusional disorder/psychosis, history of depression, hypertension, CHF, BPH, coronary artery disease post pacemaker placement, and bladder problems.

Review of Patient #9's medical record revealed he fell on 06/26/10 and sustained a laceration to his scalp. Further review revealed documentation by RN S29 upon his return from ER of "appearance: clean with staple scalp; skin tears clean bloody drainage bil (bilateral) elbow & wrists". Further review revealed no documented evidence of an assessment by RN S29 of the scalp to include the length of the laceration, the number of staples present, and the condition of the surrounding skin and the number, length, and condition of the skin surrounding the skin tears.

In a face-to-face interview on 08/27/10 at 9:35am, RN Charge Nurse S3 indicated RN S29 was not available for interview. After review of Patient #9's medical record, S3 confirmed there was no documented evidence of an assessment of the skin tears and scalp laceration to include size, number, and condition of the skin and drainage.

Patient #11
Review of Patient #11's medical record revealed she was admitted 05/07/10 with diagnoses of conduct disturbance, dementia with behavioral disturbances, hypothyroidism, GERD (gastroesophageal reflux disease), lower extremity edema, history of seizures, and malnutrition.

Review of Patient #11's medical record revealed she fell at 10:30am on 05/18/10 which resulted in lacerations to the forehead above the right eye and to the left hand.

Review of the"Daily Treatment Plan Update and Team Progress Note" for Patient #11 on 05/18/10 documented by RN S20 revealed she returned from Facility C's ER at 1830 (6:30pm). Further review revealed no documented evidence of an assessment of the wounds to the left hand and the forehead that include measurements and appearance of the skin.

In a face-to-face interview on 08/25/10 at 2:40pm, RN S20 confirmed she did not document an assessment of the condition of the wounds upon Patient #11's return from the ER.

Patient #12
Review of Patient #12's medical record revealed she was admitted to the hospital via a non-contested admission on 08/12/10 with a diagnosis of Dementia with Behavioral Disturbances. Review of her History and Physical revealed she had multiple decubiti and a history of Type 2 Diabetes Mellitus, Dementia, and Anemia.

Review of Patient #12's admission assessment revealed the following wound documentation: "sacral Stage II with dark red wound bed 1.5x2.0x0.3; left hip Stage II with pale pink with slough to wound bed 2.0x2.0x0.1; Stage I to B (bilateral) buttocks; multiple skin tears to B posterior lower legs and B hands". Further review revealed no documented evidence of an assessment of the skin tears to include the specific number and location of the skin tears, the measurement, presence or absence of drainage, and the condition of the surrounding skin.

In a face-to-face interview on 08/27/10 at 9:35am, RN Charge Nurse S3 confirmed there was no documented evidence of a RN assessment of Patient #12's skin tears.

In a face-to-face interview on 08/27/10 at 1:20pm, DON S2 confirmed the hospital did not have a policy for skin assessments other than what's addressed in the "Wound Assessment and Documentation" policy. Review of the "Wound Assessment and Documentation" policy revealed no documented evidence that the assessment of skin tears was addressed in the policy.

Review of the hospital policy titled "Wound Assessment and Documentation", last revised 05/30/10 and presented by DON S2 as their current policy for assessment of wounds/skin tears, revealed, in part, "... All wounds will be assessed on admission and with each dressing change. ... Measure wound (area and depth) Length and width can be measured with a disposable guide/ruler, or wound can be traced with clear plastic sheet or bag. Depth can be measured by inserting sterile swab gently into the wound. ... 7. Assess wound edges, undermining, and tunneling. ... 8. Assess wound bed moisture. ... 9. Assess amount of devitalized tissue. ... 10. Assess amount of granulation tissue. ... 11/ Assess amount of epithelium. ... 12. Assess the surrounding skin for color and condition. ... 14. Document and date all information ...".

Patient #6
Review of Patient #6's medical record revealed she was admitted to the hospital via a non-contested admission on 08/14/10 with the diagnosis of Dementia with Behavioral Disturbances. Further review revealed she had a history of dehydration, urinary tract infection, dementia, pulmonary edema, GERD, chronic knee pain, paraplegia, hard of hearing, and cataracts with decreased vision.

Review of Patient #6's Nursing Flow Sheet revealed documentation of the section titled "Pressure Ulcers/Wound Care Documentation" on 08/14/10 by RN S4 of appearance: #1 - "pink min (minimal) drainage; location: "sacrum" ; stage: "II" ; and size (cm) (centimeters) length x width: 3 area 1 cm dia (diameter); and #2 - "discolored area from buttocks - R (right) ischial". Further review revealed no documented evidence of an assessment of the wound edges, wound bed moisture, amount of devitalized tissue, and the condition of the surrounding tissue.

Review of the documentation on 08/16/10 at 6:20pm by RN 20 revealed "pt has broken skin in numerous areas in sacral and perineal area". Further review revealed no documented evidence of an assessment to include the measurement and skin condition of these areas as required by hospital policy.

Review of the documentation of the section titled "Pressure Ulcers/Wound Care Documentation" by RN S4 on 08/19/10 revealed appearance: "1-2-3-sacrum" ; stage: "II"; and size: "3 areas 2 cm diameter". Further review revealed no documented evidence of an assessment of the wound edges, wound bed moisture, amount of devitalized tissue, and the condition of the surrounding tissue as required by hospital policy.

In a face-to-face interview on 08/23/10 at 11:20am, RN S4 confirmed she did not document the assessment of a Stage 2 pressure ulcer for Patient #6 according to hospital policy.

Patient #8
Review of the medical record for Patient # 8 revealed she had been admitted to the hospital via a non-contested admission on 06/17/10 with the diagnosis of Dementia and Behavioral Disturbances. Further review revealed she had a history of Hypertension, Gastrointestinal Reflux, Anemia, Hyperlipidemia, Congestive Heart failure and a recent Right Femur Fracture.

Review of the Daily Nursing Assessment form, Pressure Ulcer/ Wound Care Documentation for Patient #8 dated 06/17/10 through 06/27/10 revealed no documented evidence the nurse had identified any type of pressure ulcer had been identified.

Review of the Physician's Progress Notes for Patient #8 dated 06/26/10 (no time documented) revealed... "Patient has heel pressure sore 1/2cm (centimeter) 1st degree".

Review of the entire closed medical record for Patient #8 revealed no documented evidence Patient #8 had been assessed by a Registered Nurse for a pressure ulcer.

During a face to face interview on 8/26/2010 at 1:50 a.m., Quality Assurance Director S18 indicated she had educated her staff to use the Staging done by previous facilities when a patient arrived at the hospital with a pressure wound. S18 indicated she had further educated her staff to document the pre-determined State and whether or not the wound was healing or not. S18 further indicated staff had been educated to do their own Staging of new wounds acquired at the facility.

Review of the hospital policy titled "Wound Assessment and Documentation", last revised 05/30/10 and presented by DON S2 as their current policy for assessment of wounds/skin tears, revealed, in part, "... All wounds will be assessed on admission and with each dressing change. ... Measure wound (area and depth) Length and width can be measured with a disposable guide/ruler, or wound can be traced with clear plastic sheet or bag. Depth can be measured by inserting sterile swab gently into the wound. ...Wound depth: for pressure ulcers the AHCPR staging system is used; for all others wounds the following definitions are used: superficial (involves the epidermis), partial-thickness (involves epidermis and some dermis), full-thickness (involves epidermis, dermis and possibly subcutaneous tissues, muscle or bone). 7. Assess wound edges, undermining, and tunneling. ... 8. Assess wound bed moisture. ... 9. Assess amount of devitalized tissue. ... 10. Assess amount of granulation tissue. ... 11/ Assess amount of epithelium. ... 12. Assess the surrounding skin for color and condition. ... 14. Document and date all information ...".

2b) failing to ensure accurate dietary screenings had been performed resulting in assessments which were not based on the patients' true weight:

Patient #6
Review of the Initial Assessment for Nutritional Therapy for Patient #6 (who was admitted 08/14/10) revealed the dietitian documented the following on 08/17/10: Heigh

Based on record review and interview the hospital failed to:
1) follow the Physician's orders for the Plan of Care as evidenced by a) failing to turn patients every 2 hours as evidenced by no documentation int he chart the patient had been turned (#8) for 1 of 3 patients with orders to be turned from a total sample of 15 patients: b) failing to obtain lab and EKG (electrocardiogram) as ordered for 1 of 5 patients reviewed for lab and EKG orders from a total of 15 sampled patients (#6); c) failing to provide wound care as ordered for 2 of 5 patients reviewed with wound care from a total of 15 sampled patients (#7, #12); and d) failing to obtain weights as ordered for 2 of 3 patients reviewed for weights as ordered by the physician from a total of 15 sampled patients (#7, #13, #14); and 2) ensure the patient ' s care plan identified patients' nursing needs and were updated in response to assessment of a change in condition for 4 of 4 patients' care plans reviewed from a total of 15 sampled patients (#6, #7, #9, #12). Findings

1a) Following physician's orders for failing to turn patients every 2 hours:
Patient #8
Review of the medical record for Patient # 8 revealed she had been admitted to the hospital via a non-contested admission on 06/17/10 with the diagnosis of Dementia and Behavioral Disturbances. Further review revealed she had a history of Hypertension, Gastrointestinal Reflux, Anemia, Hyperlipidemia, Congestive Heart failure and a recent Right Femur Fracture.

Review of the Physician's Progress Notes for Patient #8 dated 06/26/10 (no time documented) revealed... "Patient has heel pressure sore 1/2cm (centimeter) 1st degree".

Review of the Physician's Orders dated 06/26/10 revealed an order for Bactroban cream to the right heel TID (three times a day), pressure sore relief, turning every 2 hours to prevent pressure sores.

Review of the Nursing Notes and the MAR (Medication Administration Record) for 06/26/10 until discharge on 07/06/10 revealed no documented evidence Patient #8 had been turned every 2 hours as ordered.

In a face-to-face interview on 08/27/10 at 1:20pm, DON S2 confirmed the hospital had no policy for turning patients every 2 hours.

During a face to face interview on 8/27/2010 at 9:10 a.m., Charge Nurse S3 confirmed there was no documented evidence that Patient #8 had been turned every two hours.


1b) Obtaining lab and EKG:
Review of Patient #6's medical record revealed she was admitted to the hospital via a non-contested admission on 08/14/10 with the diagnosis of Dementia with Behavioral Disturbances. Further review revealed she had a history of dehydration, urinary tract infection, dementia, pulmonary edema, GERD, chronic knee pain, paraplegia, hard of hearing, and cataracts with decreased vision.

Review of Patient #6's "Physicians' Admit Orders & (and) Preliminary Treatment Plan" of 08/14/10 at 1:00pm revealed an order for RPR (rapid plasma regain), B12, Folate, and EKG.

Review of the laboratory results for Patient #6 revealed the RPR was collected on 08/16/10 at 8:23am, and the EKG was done on 08/22/10. Further review revealed no documented evidence that a B12 and folate had been collected.

In a face-to-face interview on 08/23/10 at 11:20am, Registered Nurse (RN) S4 indicated the only lab work she requested was the RPR. She further indicated she would not order additional lab work or an EKG if there was a copy on the patient's chart. She confirmed she did not obtain a clarification order from the physician to cancel the EKG, B12, and folate orders. S4 further indicated the RPR was not drawn until 08/16/10, because when a patient was admitted on Saturday, the lab would be drawn on Monday. She further indicated the lab would come out on Saturday only for stat orders. She could offer no explanation for the EKG being done on 08/22/10.

Review of the hospital policy titled "Clinical Laboratory Tests", last reviewed 10/17/07 and submitted by Director of Nursing (DON) S2 as the hospital's current policy for lab tests, revealed, in part, "...It is the policy ... to record all laboratory work in an accurate and consistent manner ... Procedure: ...B. When lab function is to be performed, Nursing: 1. Checks copy of lab requisition form against the physician's order for accuracy. ... 5. Charts type of lab test(s) completed on the patient chart or reason why test was not completed. 6. Records in the progress notes the date and time lab was done. C. Upon receipt of lab results, Program Nurse: 1. Informs attending physician of any abnormal lab results. 2. Initials bottom of lab result sheets. 3. Place lab result sheet in the lab section of the patient chart ...".

1c) Wound care as ordered:
Patient #7
Review of Patient #7's medical record revealed he was admitted to the hospital via a non-contested admission on 08/12/09 with the diagnosis of Dementia with Behavioral Disturbances. Further review revealed Patient #7 had a history of Anxiety, CABG (coronary artery bypass graft), CAD (coronary artery disease), AFib (atrial fibrillation), CHF (congestive heart failure), Emphysema, AAA (abdominal aortic aneurysm) Repair, Carotid Endarterectomy, and Hypothyroidism.

Review of Patient #7's physician's orders revealed an order on 08/25/09 at 6:20pm for Zinc Oxide to buttocks area; keep client dry/clean.

Review of the MAR (medication administration record) and nurses' notes for 08/25/09 and 08/26/09 revealed no documented evidence that Zinc Oxide had been applied to Patient #7's wounds.

In a face-to-face interview on 08/27/10 at 9:35am, RN (registered nurse) Charge Nurse S3 confirmed there was no documented evidence Patient #7 had Zinc Oxide applied to his heel wound, a reason why it was not applied, or that the physician was notified.

Patient #12
Review of Patient #12's medical record revealed she was admitted to the hospital via a non-contested admission on 08/12/10 with a diagnosis of Dementia with Behavioral Disturbances. Review of her History and Physical revealed she had multiple decubiti and a history of Type 2 Diabetes Mellitus, Dementia, and Anemia.

Review of Patient #12's physician admit orders of 08/12/10 at 4:00pm revealed an order for Xenaderm to left hip and sacral area every other day.

Review of the MARs (medication administration record) for Patient #12 revealed the Xenaderm was applied on 08/13/10, 08/14/10, and 08/17/10 and not every other day as ordered.

In a face-to-face interview on 08/27/10 at 9:35am, RN Charge Nurse S3 confirmed the Xenaderm was not applied as ordered and confirmed there was no documented evidence why the order was not followed.

1d) Weights as ordered:

Patient #7:
Review of Patient #7's medical record revealed he was admitted to the hospital via a non-contested admission on 08/12/09 with the diagnosis of Dementia with Behavioral Disturbances. Further review revealed Patient #7 had a history of Anxiety, CABG (coronary artery bypass graft), CAD (cardiovascular artery disease), AFib (atrial fibrillation), CHF (congestive heart failure), Emphysema, AAA (abdominal aortic aneurysm) Repair, Carotid Endarterectomy, and Hypothyroidism.

Review of Patient #7's physician's admit orders revealed an order to obtain a weight weekly on Friday.

Review of the "Admit Nursing Assessment Form" completed on 08/10/09 by RN S30 revealed a weight of 126 pounds with no documented evidence of how the weight was obtained, whether it was reported, estimated, or assessed.

Review of Patient #7's "Graphic Sheet" for 08/10/09 through 08/26/09 (day of discharge) revealed a weight was documented for 08/14/09 (Friday). There was no documented evidence of another assessment of weight for the remainder of Patient #7's hospital stay.

In a face-to-face interview on 08/27/10 at 9:35am, RN Charge Nurse S3 confirmed there was no documented evidence of how the weight for Patient #7 was determined, and the order for weighing him weekly was not followed.

Patient #13:
Review of Patient #13's medical record revealed the patient was admitted to the hospital on 6/04/2010 with diagnoses that included Senile Dementia with behavior disturbances. Further review revealed #13's Admit Nursing Assessment Form to indicate weight: "350+" with "estimate" circled and a hand written notation of "scale goes to 350". Review of the entire medical record revealed no documented evidence that an accurate weight had ever been obtained on Patient #13. This finding was confirmed by Quality Assurance Director S18 on 8/25/2010 at 8:40 a.m. who further indicated that the hospital should have made arrangements to obtain a scale that was capable of weighing the patient.

Patient #14:
Review of Patient #14's medical record revealed the patient was admitted to the hospital on 8/25/2010 with diagnoses that included Dementia with Behavior Disturbances. Further review revealed #14's Admit Nursing Assessment for to indicate weight as estimated at "145" pounds. Further review revealed Patient #14's High Risk Assessment performed by the hospital's Registered Dietician on 8/25/2010 was based on the estimated weight of 145 pounds.


2) Care plan identified patients' nursing needs and was updated with change in condition:
Patient #6
Review of Patient #6's medical record revealed she was admitted to the hospital via a non-contested admission on 08/14/10 with the diagnosis of Dementia with Behavioral Disturbances. Further review revealed she had a history of dehydration, urinary tract infection, dementia, pulmonary edema, GERD, chronic knee pain, paraplegia, hard of hearing, and cataracts with decreased vision.

Review of Patient #6's Nursing Flow Sheet revealed documentation on 08/14/10 by RN S4 of a Stage II pressure ulcer to the sacrum.

Review of Patient #6's "Master Treatment Plan" revealed the primary problems to be treated were dementia with behavioral disturbance, CHF (congestive heart failure), sacral decubitus, dehydration, and hypertension. Further review revealed no documented evidence of nursing interventions to address the identified problems, measurable short-term and long-term goals with target dates to be met, and identification of staff responsible for the interventions.

In a face-to-face interview on 08/23/10 at 11:20am RN S4 confirmed the treatment plan did not have interventions and goals for the identified problems.

Patient #7
Review of Patient #7's medical record revealed he was admitted to the hospital via a non-contested admission on 08/12/09 with the diagnosis of Dementia with Behavioral Disturbances. Further review revealed Patient #7 had a history of Anxiety, CABG, CAD, AFib, CHF, Emphysema, AAA Repair, Carotid Endarterectomy, and Hypothyroidism.

Review of Patient #7's admission assessment performed by RN S30 on 08/10/09 at 6:05pm revealed he had "multiple skin tears to bilateral forearms with scabs intact". Further review of his medical record revealed Patient #7 experienced falls on 08/11/09 and 08/12/09 resulting in a laceration to the forehead and multiple skin tears to bilateral arms. The medical record revealed documentation of excoriation to the buttocks.

Review of the "Master Treatment Plan" revealed no documented evidence Patient #7's treatment plan had been updated to include fall precautions and wounds.

In a face-to-face interview on 08/25/10 at 12:30pm, Medical Director S15, after reviewing the treatment plan for Patient #7, indicated they would have to revise the treatment plans to include goals, interventions, target dates, and which staff would be responsible for each intervention.

Patient #9
Review of Patient #9's medical record revealed he had been admitted to the hospital via a PEC on 06/26/10 at 7:00am with a diagnosis of Mood Disorder with a history of a pacemaker and CHF. Review of the "Psychiatric Discharge Summary" revealed final diagnoses of dementia with behavioral problems, delusional disorder/psychosis, history of depression, hypertension, CHF, BPH, coronary artery disease post pacemaker placement, and bladder problems.

Review of Patient #9's medical record revealed he fell on 06/26/10 and sustained a laceration to his scalp and skin tears to bilateral elbow and wrists.

Review of the "Master Treatment Plan" revealed Patient #9's treatment plan identified the mood disorder and the medical conditions of hypertension and CAD. Further review revealed no documented evidence of nursing interventions to address the identified problems, measurable short-term and long-term goals with target dates to be met, and identification of staff responsible for the interventions. Further review revealed the treatment plan had not been updated to include fall precautions and the wounds.

In a face-to-face interview on 08/27/10 at 9:35am, RN Charge Nurse S3 confirmed the fall and wounds were not added to the treatment plan for Patient #9.

Patient #12
Review of Patient #12's medical record revealed she was admitted to the hospital via a non-contested admission on 08/12/10 with a diagnosis of Dementia with Behavioral Disturbances. Review of her History and Physical revealed she had multiple decubiti and a history of Type 2 Diabetes Mellitus, Dementia, and Anemia.

Review of Patient #12's physician admit orders of 08/12/10 at 4:00pm revealed an order for Xenaderm to left hip and sacral area every other day.

Review of the "Master Treatment Plan" revealed Patient #12's identified problems were dementia with behavioral disturbance and medical conditions of diabetes and anemia. Further review revealed no documented evidence of nursing interventions to address the identified problems, measurable short-term and long-term goals with target dates to be met, and identification of staff responsible for the interventions. Further review revealed the treatment plan had not been updated to include the wound to the hip and sacrum.

In a face-to-face interview on 08/27/10 at 9:35am, RN Charge Nurse S3 confirmed the wounds were not addressed in the treatment plan for Patient #12.

Review of the hospital policy titled "Treatment Planning", last reviewed 10/17/07 and submitted by DON S2 as the hospital's current policy for treatment planning, revealed, in part, "...It is the policy ... to utilize a multidisciplinary approach in the development and implementation of the Master Treatment Plan for each patient. Procedure: A. Each discipline will complete their assessments within the assigned time-frames, report their findings, and state their recommendations for the Preliminary and Master Treatment Plan for each patient. B. Preliminary Treatment Plans are completed within 24 hours of admission ... C. By the fifth day of treatment the rest of the Master Treatment Plan will be completed. This will incorporate the objectives, modalities for achieving the objectives, frequency of intervention, responsible party for each intervention, and projective date of goal achievement. D. Treatment Team meetings are held at least every week in order to monitor patient's progress, summarize and revise the plan as needed until patient is ready for discharge. However, the treatment plan may be altered at any time a patient's status indicates. ... F. The Master Treatment Plan will contain behavioral objectives written in measurable terms, the names of those individuals responsible for carrying out the interventions, and include target dates ... The problem definition is a description of the problem being addressed that conveys to the reader the observable behaviors the patient demonstrates. ... The discharge goal describes in behavioral terms what progress the patient needs to demonstrate prior to discharge. ... A short-term goal/objective describes the incremental step(s) that the patient must achieve in order to reach the discharge goal. These are not objectives for the staff, they are objectives for the patient. ... Interventions, Responsible Staff, and Frequency A. The intervention strategies are the actions and approaches to be taken by the staff in assisting the patient in resolving the identified problem and reaching the discharge goal. The frequency of the intervention is the number of times per day, per week ... that the interventions will occur. Intervention strategies must be very specific. B. The name and discipline of the party responsible for overseeing the intervention strategy. ... Target Date A. The staff and patient's estimate of when the Short Term Objective will be achieved ...".




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Based on record review and interview the hospital failed to:
1) ensure vital sign(s) had been assessed before administration of Metoprolol (Blood Pressure) and Lanoxin (Apical Pulse) as evidenced by no documented evidence of the vital signs being assessed for 1 of 1 patients on Metoprolol and Lanoxin out of 15 sampled medical records (# 8) .
2) ensure medications were administered as per physician orders for 1 of 15 sampled patients (#2). Findings:

1) ensure vital sign(s) had been assessed before administration of Metoprolol (Blood Pressure) and Lanoxin (Apical Pulse) as evidenced by no documented evidence of the vital signs being assessed:


Review of the medical record for Patient # 8 revealed she had been admitted to the hospital via a non-contested admission on 06/17/10 with the diagnosis of Dementia and Behavioral Disturbances. Further review revealed she had a history of Hypertension, Gastrointestinal Reflux, Anemia, Hyperlipidemia, Congestive Heart failure and a recent Right Femur Fracture. Review of the Physician's Admit Orders revealed an order for Metoprolol 25mg BID (twice a day) and Lanoxin 0.125mg every 0900 (9:00am).

Review of the MAR (Medication Administration Record for Patient #8 revealed the following:
Metoprolol 25mg had been administered on 07/10/10 @ 0900 (9:00am) and 1700 (5:00pm); 07/09/10 @ 9:00am and 5:00pm; 07/07/10 @ 9:00am and 5:00pm; 07/01/10 @ 9:00am and 5:00pm; 06/29/10 @ 9:00am and 5:00pm; 06/28/10 @ 9:00am and 5:00pm; 06/27/10 @ 9:00am and 5:00pm; 06/24/10 @ 9:00am and 5:00pm; 06/23/10 @ 5:00pm; 06/22/10 @ 9:00am; 06/21/10 @ 9:00am and 5:00pm; and 06/20/10 @ 9:00am and 5:00pm with no documented evidence the blood pressure had been assessed before administration of the medication; and Digoxin (Lanoxin) 0.125mg administered on 07/10/10 @ 0900 (9:00am); 07/09/10 @ 9:00am; 07/02/10 @ 9:00am; and 06/20/10 @9:00am with no documented evidence the heart rate hd been assessed before administration of the medication.

Review of the "Geriatric Dosage Handbook" 12th Edition by LexiComp, the official drug reference for the American Pharmacists Association revealed ....... Nursing Implications (for Digoxin) Check apical pulse before giving...". Further review of the handbook concerning the drug Metoprolol revealed..... "monitor orthostatic blood pressures, apical and peripheral pulse and mental status changes (i.e. confusion and depression)".

Review of the hospital policy titled "Oral Medications", developed 12/09/05 and submitted by DON S2 as the hospital's current policy for medication administration, revealed, in part, "...Purpose: To provide guidelines to safely and effectively administer oral medications...". Review of the entire policy revealed no documented evidence of a policy that required nurses to check an apical pulse before administering Digoxin and to check an orthostatic blood pressure, apical and peripheral pulses, and mental status changes prior to administering Metoprolol.

Review of the hospital policy titled "Medication General Policies", developed 12/09/05 and submitted by DON S2 as the hospital's current policy for medication administration, revealed, in part, "...Purpose: To provide guidelines for the accurate administration of medications...". Review of the entire policy revealed no documented evidence of a policy that required nurses to check an apical pulse before administering Digoxin and to check an orthostatic blood pressure, apical and peripheral pulses, and mental status changes prior to administering Metoprolol.

During a face to face interview on 8/27/2010 at 9:10 a.m., Charge Nurse S3 (after reviewing the medical record of Patient #8) indicated nursing staff may have been using the vital signs taken by the Mental Health Technicians/Certified Nursing Assistants at 8:00 a.m. prior to administering Metoprolol; however, there should be an apical pulse taken prior to the administration of Digoxin and she could see no evidence that anyone had taken an apical pulse prior to the administration of Digoxin on Patient #8.

2) ensure medications were administered as per physician orders:

Review of Patient #2's medical record revealed a physician's order dated 8/06/2020 for Geodon 20 milligrams intramuscular if patient refuses it by mouth. Further review revealed no documented evidence that patient #2 received any Geodon on 8/06/2010. Medication Administration Record revealed the patient refused the medication by mouth on 8/19/2010 at 7:30 a.m. and there was no documented evidence of administering the medication by mouth on 8/19/2010 at 4:30 p.m. Review of the entire medical record revealed no documented evidence that Patient #2 was administered Geodon intramuscularly when the patient failed to take the medication by mouth on 8/19/2010. This finding was confirmed by Charge Nurse S3 on 8/24/2010 at 3:20 p.m. who indicated Patient #2 should have been administered Geodon intramuscularly as ordered by the patient's physician.

Based on record review and interview the hospital failed to ensure accurate dietary consults had been performed as evidenced by the dietitian's use of weights not assessed by the hospital, inaccurate nursing assessments for nutritional risks and skin and no documented evidence blood work, medical history/diagnosis, physician's orders, History and Physical had been reviewed in order to recommend a diet to meet the needs of the patients for 6 of 6 patients reviewed for nutritional screening/nutritional consults from a total of 15 sampled medical records (#6, #7, #8, #10, #12, #14). Findings:

Patient #6
Review of the Initial Assessment for Nutritional Therapy for Patient #6 (who was admitted 08/14/10) revealed the dietitian documented the following on 08/17/10: Height 63 inches; Ideal Body Weight 115 plus or minus (+ or -) 10; Weight: NA (not available) BMI (basal metabolic index): no entry in blank; Diet ordered NCS (no concentrated sweets), NAS (no added salt), Mechanical Soft, Nectar Thick liquid; Nutrients served in diet plus supplement = (equals) 2000 calories, 85 g (grams) protein; RDAs (recommended daily allowance) for patient ' s condition : 1400 - 1500 calories, 50 - 55 g protein; the diet plus supplement met the RDA; and other: "obtain wt (weight)". Review of the Admission Nursing Assessment Form revealed the height and weight documented by the nurse was an estimate and not an actual assessed height and weight.

In a face-to-face interview on 08/25/10 at 3:40pm, Registered Dietitian (RD) S22 confirmed she did not have an accurate measured weight when she completed the initial assessment of Patient #6. She further indicated she was planning to check on her visit today (08/25/10, which was 8 days since her initial assessment) for a weight.

Patient #7
Review of the Admission Nursing Assessment Form for Patient #7 revealed the height of 6 feet 1 inch was a reported height. Further review revealed no documented evidence whether the documented weight of 126 pounds was a reported, estimated, or assessed weight.

In a face-to-face interview on 08/27/10 at 9:35am, RN Charge Nurse S3 confirmed she could not determine if the weight used the nutritional status of Patient #7 was an accurate weight.

Patient #8
Review of the Initial Assessment for Nutritional Therapy for Patient #8 revealed the dietitian documented the following information: Height and Weight of 64 inches and 231 pounds indicating a BMI of 39.9. (Review of the Nursing Admit Assessment revealed the height and weight of 54 inches and 231 pounds had been estimated. Review of the graphics sheets used by the hospital to document vital signs, input and output revealed no documented evidence the #8 had been weighed on admit.); Regular diet with 1 can of Ensure if <50% of meal consumed; and the nutrients contained in the diet 1900 calories and 85 grams or Protein which met the daily requirements. Further review revealed no documented evidence the dietitian had reviewed the History & Physical dated 06/18/10 for Patient #8 which revealed she had a low Hemoglobin and Hematocrit, low protein level and low albumin and was recovering from surgery for a broken femur.

In a face-to-face interview on 08/25/10 at 3:40pm, RD S22 confirmed her nutritional assessment of Patient #8 was not based on a measured weight.

Patient #10
Review of the Initial Assessment for Nutritional Therapy for Patient #10 revealed the dietitian documented the following information: Height, Weight , Ideal Body Weight and BMI (Body Mass Index) -NA (Not applicable); Diet- NAS (No Added Salt); Supplement Ensure tid (three times a day); Nutrients served in diet: 2950 calories and 112 protein; and other - obtain height. Further review of the Nutritional Assessment revealed an entry dated 06/14/10 (no time documented) revealed a height of 72 inches, weight 137 pounds, IBW of 178 and a BMI of 18.8 and to continue Ensure supplement. There was no documented evidence the dietitian had reviewed the H&P, the abnormal lab values, the Physician's Orders for Aspiration Precautions, the results of the Barium Swallow Study indicating abnormal results, a previous choking episode at the nursing home, or skin condition. The patient was placed and kept on a regular diet.

Patient #12
Review of the Admission Nursing Assessment Form completed by LPN (licensed practical nurse) S27 on 08/12/10 revealed no documented evidence whether the documented weight of 90 pounds and height of 5 feet were a reported, estimated, or assessed weight and height. Further review revealed no documented evidence that the following questions in the nutritional screen had been assessed: is patient on restricted diet; does the medical history indicate nutritional problems; and are there ethnic/cultural/religious variations to the diet.

Review of the Initial Assessment for Nutritional Therapy for Patient #12 revealed RD S22 completed the assessment on 08/17/10, 5 days after admission.

Patient #13:
Review of Patient #13's medical record revealed the patient was admitted to the hospital on 6/04/2010 with diagnoses that included Senile Dementia with behavior disturbances. Further review revealed #13's Admit Nursing Assessment Form to indicated weight: "350+" with "estimate" circled and a hand written notation of "scale goes to 350". Review of the entire medical record revealed no documented evidence that an accurate weight had ever been obtained on Patient #13. This finding was confirmed by Quality Assurance Director S18 on 8/25/2010 at 8:40 a.m. who further indicated that the hospital should have made arrangements to obtain a scale that was capable of weighing the patient.

Review of Patient #13's initial assessment performed by the dietician on 6/06/2010 revealed the Recommended Daily Allowance for the Patient's condition to be 1800 - 1600 calories and 55 - 60 grams of protein. Further review revealed a notation in the section of other to be "obtain wt (weight)". Documentation dated 6/10/2010 revealed "wt: 350 # . . . continue modified diet."

During a face to face interview on 8/25/2010 at 3:40 p.m., Registered Dietician S22 indicated she had no knowledge that the weight she had received on 6/10/2010 of 350# had been an estimated weight. S22 further indicated she had not been told that the hospital scale's maximum weight assessment was 350 pounds.

Patient #14:
Review of Patient #14's medical record revealed the patient was admitted to the hospital on 8/25/2010 with diagnoses that included Dementia with Behavior Disturbances. Further review revealed #14's Admit Nursing Assessment for to indicate weight as estimated at "145" pounds. Further review revealed Patient #14's High Risk Assessment performed by the hospital's Registered Dietician on 8/25/2010 was based on the estimated weight of 145 pounds.

In a face-to-face interview on 08/25/10 at 12:30pm, Medical Director S15 indicated no dietary consult could be performed without an accurate patient's weight.

In a face-to-face interview on 08/25/10 at 3:40pm, RD S22 indicated she was responsible for the nutritional consults performed at the hospital. She further indicated she was at the hospital 1 or 2 times a week. S22 indicated, in order to meet her time requirements for starting the nutritional assessment, the nurses would fax their admission assessment that included their nutritional screening of the patient. She would then complete the top portion of the assessment (includes patient height, weight, ideal body weight, BMI [basal metabolic index], diet order, supplement, nutrients served in diet plus supplement in number of calories and grams of protein, RDAs [recommended daily allowance] for patient's condition in calories and grams of protein, whether diet plus supplement meets RDAs, recommendation if not meeting RDA, change calorie level to, and other) and fax it back to the hospital. S22 indicated if she received a nutritional screening for a patient who scored high risk and she was not at the hospital, she would complete the top portion, fax it back to hospital, and complete the high risk assessment on her next visit to the hospital. She further indicated she would perform the assessment for a patient who scored at moderate risk on the nutritional screening on her weekly visit to the hospital. She further indicated she did not know what was the time interval required for her to complete the nutritional consult. S22 indicated she completes the top portion of the initial assessment for nutrition therapy on each patient when she comes to the hospital. She indicated she only looks at the diet order to make sure the RDA was met with what diet was ordered. She confirmed that she does not look at physician orders, labs values, and the communication sheet. S22 indicated she did the nutritional assessment for Patient #10 on 06/10/10 without a documented height and weight. She further indicated she was not aware of the patient's confirmed aspiration by a barium swallow and indicated that swallowing difficulty was automatically a high risk.

Review of the hospital policy titled "Nutritional Assessment", developed 12/09/05 and submitted by Registered Dietitian (RD) S22 as the current policy for nutritional assessment, revealed, in part, "...All patients ... will receive a nutritional screening as a component of the Nursing Assessment. In addition, those patients identified on admission by nursing staff and/or during hospitalization by the Treatment Team as potentially in need of nutritional counseling may be referred to the dietitian for assessment. Nursing staff and, when indicated in collaboration with the dietitian, will collect the data necessary to plan the nutritional care of the patient. This information may be obtained from physician and nursing history and physical data, social history and family contact, laboratory findings, evaluation of weight changes, factors influencing selection and consumption of food including dentition and dysphagia, and food allergies or intolerances...". Review of the entire policy revealed no documented evidence of what criteria or score would be used to determine when the nurse should request a consult by the dietitian.

Review of the hospital policy titled "Comprehensive Nutrition Consult/Assessment", developed 12/09/05 and submitted by RD S22 as the current policy for nutritional consults, revealed, in part, "... 1. An order must be written by patient's physician prior to nutrition consult. ... 3. The Dietitian will assess the nutritional status of the patient using patient's medical record (diagnosis, lab values, height, weight, and medical history) and diet history. 4. After the assessment, the Dietitian will make recommendations on patient's nutrition care plan in the progress notes of the patient's medical record. 5. Dietitians will begin with consult within 48 hours of request...". Review of the entire policy revealed no documented evidence of the time that the assessment should be completed and how an assessment of a moderate risk nutritional assessment would differ from a high risk assessment.

Review of the hospital policy titled "Assessments", last reviewed 02/13/09 and submitted by Director of Nursing (DON) S2 as the hospital's current policy for assessments, revealed, in part, "...It shall be the policy ... that all assessments shall be completed within the specified time period and shall be maintained in the patient's medical record. ... Admission notes shall be completed within 24 hours. ... Nursing assessments shall be completed during the admission process within 8 (eight) hours of admission. The Nursing assessment shall include a nutritional screening .. ". Review of the entire policy revealed no documented evidence that the admission assessment must be performed by a RN.

Based on record review and interview the hospital failed to meet the Condition of Participation for Special Medical Records requirements for Psychiatric Hospitals by:

1) failing to ensure patient's written plan of care (Master Treatment Plan) included short-term and long range goals as indicated in hospital policy for 5 of 5 patients reviewed for Treatment Planning out of a total sample of 15 (#1, #2, #3, #4, #5). (See findings cited at B121)

2) failing to ensure patients' written plan of care (Master Treatment Plan) included specific treatment modalities utilized as indicated in hospital policy for 5 of 5 patients reviewed for treatment planning out of a total sample of 15 (#1, #2, #3, #4, #5). (See findings cited at B122)

3) failing to ensure patients' written plan of care (Master Treatment Plan) included the responsibilities of each member of the treatment team for 5 of 5 patients reviewed for Treatment Planning out of a total sample of 15 (#1, #2, #3, #4, #5). (See findings cited at B123)

4) failing to ensure patients' written plan of care (Master Treatment Plan) included the responsibilities of each member of the treatment team for 5 of 5 patients reviewed for Treatment Planning out of a total sample of 15 (#1, #2, #3, #4, #5). (See findings cited at B125)

5) failing to ensure progress notes contain recommendations for revisions in the treatment plan as indicated for 5 of 5 patients reviewed for Treatment Planning out of a total sample of 15 (#1, #2, #3, #4, #5). (See findings cited at B131)

Based on record review and interview the hospital failed to ensure a Psychiatric Evaluation was completed within 60 hours of admission for 2 of 15 sampled patients (#4, #5). Findings:

Review of Patient #4's medical record revealed the patient was admitted to the hospital on 8/11/2010. The medical record was reviewed on 8/24/2010 and there was no documented evidence of a Psychiatric Evaluation in the Record. This finding was confirmed by Charge Nurse S3 on 8/24/2010 at 3:50 p.m. who further indicated some of the psychiatrist dictate or type their own psychiatric evaluations; however, they should have made them available for placement in the medical record in a timely manner.

Review of Patient #5's medical record revealed the patient was admitted to the hospital on 8/16/2010. The medical record was reviewed on 8/24/2010 and there was no documented evidence of a Psychiatric Evaluation in the Record. This finding was confirmed by Charge Nurse S3 on 8/24/2010 at 8:40 a.m.

Review of the hospital policy titled, "Medical Record, last revised 6/15/2010" presented by the hospital as their current policy revealed in part, "Assessments will be completed by each member of the multi-disciplinary team in a timely manner so designated: Psychiatric Evaluation within 60 hours of admission."

Based on record review and interview the hospital failed to ensure patient's written plan of care (Master Treatment Plan) included short-term and long range goals as indicated in hospital policy for 5 of 5 patients reviewed for Treatment Planning out of a total sample of 15 (#1, #2, #3, #4, #5). Finding:.

Patient #1:
Patient #1 was admitted to the hospital on 8/05/2010 with diagnoses that included Psychosis NOS (not otherwise specified), Tourette Syndrome, Hypertension, and Chronic Lower Back Pain. Review of Patient #1's Master Treatment Plan revealed signatures to include Physician S15 dated 8/06/2010. Review of Patient #1's Master Treatment Plan revealed problems identified as Psychosis NOS (not otherwise specified), confused, hallucinating, sleep disturbance, medical conditions (Tourette, hypertension, chronic lower back pain). Further review revealed no documented evidence of short or long term measurable goals This finding was confirmed 8/25/2010 at 2:45 p.m..

Patient #2:
Patient #2 was admitted to the hospital on 8/06/2010 with diagnoses that included Chronic Paranoid Schizophrenia in acute exacerbation, Schizoaffective Disorder, Hypertension, Urinary Incontinence, Neurogenic Bladder Hyperlipidemia, Hypothyroidism, Gastro Esophageal Reflux Disease, Anemia, and Type 2 Diabetes. Review of Patient #2's Master Treatment Plan revealed signatures to include Physician S15 dated 8/10/2010. Review of Patient #2's Master Treatment Plan revealed problems identified as Schizophrenia as evidenced by agitation, cursing, positive paranoia, hallucinations, poor compliance with care, medical Conditions: Hypertension, Diabetes, GERD, and Hyperlipidemia. Further review revealed no documented evidence of short or long term measurable goals. This finding was confirmed by Social Services Director S10 on 8/25/2010 at 2:45 p.m.

Patient #3:
Patient #3 was admitted to the hospital on 8/09/2010 with diagnoses that included Senile Dementia with Behavioral Disturbances, Carotid Artery Disease, Hyperlipidemia, Anemia, and Osteoporosis. Review of Patient #3's Master Treatment Plan revealed signatures to include Physician S9 dated 8/13/2010. Review of Patient #3's Master Treatment Plan revealed problems identified as Dementia with Behavior Disturbances as evidenced by refusing care, agitation, increases confusion, and aggression, Medical Condition: Hypertension, Carotid Artery Disease, Hyperlipidemia, Overactive Bladder, and Osteoporosis.. Further review revealed no documented evidence of short or long term measurable goals. This finding was confirmed by Social Services Director S10 on 8/25/2010 at 2:45 p.m.

Patient #4:
Patient #4 was admitted to the hospital on 8/11/2010 with diagnoses that included Major Depression and Multiple Sclerosis. Review of Patient #4's Master Treatment Plan revealed signatures to include Physician S15 dated 8/16/2010. Review of Patient #4's Master Treatment Plan revealed problems identified as Major Depression: depressed and hoarding pills. Further review revealed no documented evidence of short or long term measurable goals. This finding was confirmed by Social Services Director S10 on 8/25/2010 at 2:45 p.m.

Patient #5:
Patient #5 was admitted to the hospital on 8/16/2010 with diagnoses that included Chronic Paranoid Schizophrenia with exacerbation and hallucinations, Hypertension, Anemia, Gastritis, Chronic Low back pain, and Non-pitting edema of lower extremities. Review of Patient #5's Medical Record revealed no documented Master Treatment Plan (8 days after admission to the hospital). This finding was confirmed by Charge Nurse S3 on 8/24/2010 at 8:40 a.m. who further indicated that one of the Social Services staff should have initiated the Patient's Master Treatment Plan. This finding was confirmed by Social Services Director S10 on 8/25/2010 at 2:45 p.m.

An interview was conducted with Recreational Therapist S13 on 8/25/2010 at 11:00 a.m. S13 indicated the hospital had instituted new forms for documenting Master Treatment Plans sometime in the past; although she could not recall the exact date. S13 indicated that the new forms failed to require Short Term or Long Term Goals and staff had not been documenting this Treatment Planning Data since the form had been changed.

During a face to face interview on 8/25/2010 at 3:30 p.m., Licensed Practical Counselor S7 and Licensed Practical Counselor Intern S6 confirmed there had been no short or long term goals identified in the Plan of Care (Master Treatment Plan) for patients being treated in the hospital.

Review of the hospital policy titled, "Treatment Planning, last reviewed 10/17/07" presented by the hospital as their current policy revealed in part, "By the fifth day of treatment the rest of the Master Treatment Plan will be completed. . .The Master Treatment Plan will contain behavioral objectives written in measurable terms. . . and include target dates. Discharge Goal (also called Long Term Goals) The discharge goal describes in behavioral terms what progress the patient needs to demonstrate prior to discharge. The discharge goals should be realistically achievable during treatment. Short Term Goals: A short term goal objective describes the incremental steps that the patient must achieve in order to reach the discharge goal. These are not objectives for the staff, they are objectives for the patient. Each short term objective should be achievable prior to discharge. Short term objectives are written in a language that describes the patient's observable behavior."

Based on record review and interview the hospital failed to ensure patients' written plan of care (Master Treatment Plan) included specific treatment modalities utilized as indicated in hospital policy for 5 of 5 patients reviewed for treatment planning out of a total sample of 15 (#1, #2, #3, #4, #5). Findings:

Patient #1:
Patient #1 was admitted to the hospital on 8/05/2010 with diagnoses that included Psychosis NOS (not otherwise specified), Tourette Syndrome, Hypertension, and Chronic Lower Back Pain. Review of Patient #1's Master Treatment Plan dated 8/10/10 revealed problems identified as Psychosis NOS, confused, hallucinating, sleep disturbance, medical conditions (Tourette, hypertension, chronic lower back pain). Further review revealed no documented evidence of any treatment modalities/interventions to be implemented in order to assist the patient in reaching the goal of discharge or the frequency of interventions. This finding was confirmed by Social Services Director S10 on 8/25/2010 at 2:45 p.m.


Patient #2:
Patient #2 was admitted to the hospital on 8/06/2010 with diagnoses that included Chronic Paranoid Schizophrenia in acute exacerbation, Schizoaffective Disorder, Hypertension, Urinary Incontinence, Neurogenic Bladder Hyperlipidemia, Hypothyroidism, Gastro Esophageal Reflux Disease, Anemia, and Type 2 Diabetes. Review of Patient #2's Master Treatment Plan dated 8/10/2010 revealed problems identified as Schizophrenia as evidenced by agitation, cursing, positive paranoia, hallucinations, poor compliance with care, medical Conditions: Hypertension, Diabetes, GERD, and Hyperlipidemia. Further review revealed no documented evidence of any treatment modalities/interventions to be implemented in order to assist the patient in reaching the goal of discharge or the frequency of interventions. This finding was confirmed by Social Services Director S10 on 8/25/2010 at 2:45 p.m.


Patient #3:
Patient #3 was admitted to the hospital on 8/09/2010 with diagnoses that included Senile Dementia with Behavioral Disturbances, Carotid Artery Disease, Hyperlipidemia, Anemia, and Osteoporosis. Review of Patient #3's Master Treatment Plan dated 8/13/2010 revealed problems identified as Dementia with Behavior Disturbances as evidenced by refusing care, agitation, increases confusion, and aggression, Medical Condition: Hypertension, Carotid Artery Disease, Hyperlipidemia, Overactive Bladder, and Osteoporosis. Further review revealed no documented evidence of any treatment modalities/interventions to be implemented in order to assist the patient in reaching the goal of discharge or the frequency of interventions. This finding was confirmed by Social Services Director S10 on 8/25/2010 at 2:45 p.m.

Patient #4:
Patient #4 was admitted to the hospital on 8/11/2010 with diagnoses that included Major Depression and Multiple Sclerosis. Review of Patient #4's Master Treatment Plan dated 8/16/2010 revealed problems identified as Major Depression: depressed and hoarding pills. Further review revealed no documented evidence of any treatment modalities/interventions to be implemented in order to assist the patient in reaching the goal of discharge or the frequency of interventions. This finding was confirmed by Social Services Director S10 on 8/25/2010 at 2:45 p.m.

Patient #5:
Patient #5 was admitted to the hospital on 8/16/2010 with diagnoses that included Chronic Paranoid Schizophrenia with exacerbation and hallucinations, Hypertension, Anemia, Gastritis, Chronic Low back pain, and Non-pitting edema of lower extremities. Review of Patient #5's Medical Record revealed no documented Master Treatment Plan. This finding was confirmed by Charge Nurse S3 on 8/24/2010 at 8:40 a.m. who further indicated that Social Services Staff should have initiated the Patient's Master Treatment Plan. This finding was confirmed by Social Services Director S10 on 8/25/2010 at 2:45 p.m. who further indicated the patient's Master Treatment Plan (plan of care) should have been completed in the time frame indicated in hospital policy and with treatment modalities and frequency specified.

An interview was conducted with Recreational Therapist S13 on 8/25/2010 at 11:00 a.m. S13 indicated the hospital had instituted new forms for documenting Master Treatment Plans sometime in the past; although she could not recall the exact date. S13 indicated that the new forms failed to require Treatment Modalities or the frequency of interventions and staff had not been documenting this Treatment Planning Data since the form had been changed.

During a face to face interview on 8/25/2010 at 3:30 p.m., Licensed Practical Counselor S7 and Licensed Practical Counselor Intern S6 confirmed that Master Treatment Plans in the facility failed to include the Modalities/Interventions to be implemented or their frequency. S6 and S7 indicated hospital policy should have been followed.

Review of the hospital policy titled, "Treatment Planning, last reviewed 10/17/2010" revealed in part, "By the fifth day of treatment the rest of the Master Treatment Plan will be completed. This will incorporate the objectives, modalities for achieving the objectives, frequency of intervention, responsible party for each intervention, and projective date of goal achievement. The intervention strategies are the actions and approaches to be taken by the staff in assisting the patient in resolving the identified problem and reaching the discharge goal. The frequency of the intervention is the number of times per day, per week, etc. that the interventions will occur. Intervention strategies must be very specific. The name and discipline of the party responsible for overseeing the intervention strategy."

Based on record review and interview the hospital failed to ensure patients' written plan of care (Master Treatment Plan) included the responsibilities of each member of the treatment team for 5 of 5 patients reviewed for Treatment Planning out of a total sample of 15 (#1, #2, #3, #4, #5). Findings:

Patient #1:
Patient #1 was admitted to the hospital on 8/05/2010 with diagnoses that included Psychosis NOS (not otherwise specified), Tourettes Syndrome, Hypertension, and Chronic Lower Back Pain. Review of Patient #1's Master Treatment Plan dated 8/10/10 revealed problems identified as Psychosis NOS, confused, hallucinating, sleep disturbance, medical conditions (Tourettes, hypertension, chronic lower back pain). Further review revealed no documented evidence identifying the staff member responsible for implementing patient care interventions to assist the patient in reaching the goal of discharge. This finding was confirmed by Social Services Director S10 on 8/25/2010 at 2:45 p.m.

Patient #2:
Patient #2 was admitted to the hospital on 8/06/2010 with diagnoses that included Chronic Paranoid Schizophrenia in acute exacerbation, Schizoaffective Disorder, Hypertension, Urinary Incontinence, Neurogenic Bladder Hyperlipidemia, Hypothyroidism, Gastro Esophageal Reflux Disease, Anemia, and Type 2 Diabetes. Review of Patient #2's Master Treatment Plan dated 8/10/2010 revealed problems identified as Schizophrenia as evidenced by agitation, cursing, positive paranoia, hallucinations, poor compliance with care, medical Conditions: Hypertension, Diabetes, GERD, and Hyperlipidemia. Further review revealed no documented evidence identifying the staff member responsible for implementing patient care interventions to assist the patient in reaching the goal of discharge. This finding was confirmed by Social Services Director S10 on 8/25/2010 at 2:45 p.m.


Patient #3:
Patient #3 was admitted to the hospital on 8/09/2010 with diagnoses that included Senile Dementia with Behavioral Disturbances, Carotid Artery Disease, Hyperlipidemia, Anemia, and Osteoporosis. Review of Patient #3's Master Treatment Plan dated 8/13/2010 revealed problems identified as Dementia with Behavior Disturbances as evidenced by refusing care, agitation, increases confusion, and aggression, Medical Condition: Hypertension, Carotid Artery Disease, Hyperlipidemia, Overactive Bladder, and Osteoporosis. Further review revealed no documented evidence identifying the staff member responsible for implementing patient care interventions to assist the patient in reaching the goal of discharge. This finding was confirmed by Social Services Director S10 on 8/25/2010 at 2:45 p.m.

Patient #4:
Patient #4 was admitted to the hospital on 8/11/2010 with diagnoses that included Major Depression and Multiple Sclerosis. Review of Patient #4's Master Treatment Plan dated 8/16/2010 revealed problems identified as Major Depression: depressed and hoarding pills. Further review revealed no documented evidence of any treatment modalities/interventions to be implemented in order to assist the patient in reaching the goal of discharge or the frequency of interventions. This finding was confirmed by Social Services Director S10 on 8/25/2010 at 2:45 p.m.

Patient #5:
Patient #5 was admitted to the hospital on 8/16/2010 with diagnoses that included Chronic Paranoid Schizophrenia with exacerbation and hallucinations, Hypertension, Anemia, Gastritis, Chronic Low back pain, and Non-pitting edema of lower extremities. Review of Patient #5's Medical Record revealed no documented Master Treatment Plan. This finding was confirmed by Charge Nurse S3 on 8/24/2010 at 8:40 a.m. who further indicated that Social Services Staff should have initiated the Patient's Master Treatment Plan. This finding was confirmed by Social Services Director S10 on 8/25/2010 at 2:45 p.m. who further indicated the patient's Master Treatment Plan (plan of care) should have been completed in the time frame indicated in hospital policy and should have specified the staff responsible for implementing interventions to assist the patient reach the goal of discharge.

An interview was conducted with Recreational Therapist S13 on 8/25/2010 at 11:00 a.m. S13 indicated the hospital had instituted new forms for documenting Master Treatment Plans sometime in the past; although she could not recall the exact date. S13 indicated that the new forms failed to require identification of staff responsible for implementing interventions to assist the patient reach the goal of discharge and staff had not been documenting this Treatment Planning Data since the form had been changed.

During a face to face interview on 8/25/2010 at 3:30 p.m., Licensed Practical Counselor S7 and Licensed Practical Counselor Intern S6 confirmed that Master Treatment Plans in the facility failed to include identification of the staff responsible for implementing interventions to assist the patient reach the goal of discharge. S6 and S7 indicated hospital policy should have been followed.

Review of the hospital policy titled, "Treatment Planning, last reviewed 10/17/2010" revealed in part, "By the fifth day of treatment the rest of the Master Treatment Plan will be completed. This will incorporate the objectives, modalities for achieving the objectives, frequency of intervention, responsible party for each intervention, and projective date of goal achievement. The intervention strategies are the actions and approaches to be taken by the staff in assisting the patient in resolving the identified problem and reaching the discharge goal. The frequency of the intervention is the number of times per day, per week, etc. that the interventions will occur. Intervention strategies must be very specific. The name and discipline of the party responsible for overseeing the intervention strategy."

Based on record review and interview the hospital failed to ensure treatment received by the patient was documented in such a way as to assure all therapeutic efforts were included for 6 of 6 patients reviewed for Treatment Planning out of a total sample of 15 (#1, #2, #3, #4, #5, #7). Findings:

Patient #1:
Patient #1 was admitted to the hospital on 8/05/2010 with diagnoses that included Psychosis NOS (not otherwise specified), Tourettes Syndrome, Hypertension, and Chronic Lower Back Pain. Patient #1's medical record was reviewed with Recreational Therapist S13 on 8/25/2010 at 2:50 p.m. This review revealed Patient #1 was provided Recreational Therapy on the following dates/times: 8/10/2010 at 9:00 a.m., 8/19/2010 at 9:00 a.m., and 8/20/2010 at 9:00 a.m. Review revealed no documented evidence Patient #1 received Recreational Therapy on the following days: 8/06/2010, 8/09/2010, 8/11/2010, 8/12/2010, 8/12/2010, 8/13/2010, 8/16/2010, 8/17/2010, and 8/18/2010. Review of Patient #1's Master Treatment Plan revealed no documented evidence of revision of Plan due to the patient ' s failure to participate in group services. Review of Patient #1's entire medical record revealed no documented evidence that any Recreational Therapy was provided outside of Group Sessions for this patient that did not consistently attend Group Sessions (confirmed by Social Services Director S10 on 8/25/2010 at 2:45 p.m.).

Patient #2:
Patient #2 was admitted to the hospital on 8/06/2010 with diagnoses that included Chronic Paranoid Schizophrenia in acute exacerbation, Schizoaffective Disorder, Hypertension, Urinary Incontinence, Neurogenic Bladder Hyperlipidemia, Hypothyroidism, Gastro Esophageal Reflux Disease, Anemia, and Type 2 Diabetes. Review of Patient #2's Psychosocial dated 8/09/2010 revealed the patient's brother and sister were contacted to obtain information for completion of the psychosocial assessment. Further review of the entire medical record revealed no documented evidence that Patient #2 was assessed for the desire to include his family members in treatment planning or to obtain his consent to include his family with treatment planning. Record review revealed no documented evidence of any family contact other than to gather information for the psychosocial evaluation. Patient #2's medical record was reviewed with Recreational Therapist S13 on 8/25/2010 at 2:50 p.m. This review revealed Patient #2 was provided Recreational Therapy on the following dates/times: 8/17/2010 at 9:00 a.m.. Further review revealed no documented evidence Patient #2 received Recreational Therapy on the following days: 8/09/2010, 8/10/2010, 8/11/2010, 8/12/2010, 8/13/2010, 8/16/2010, 8/18/2010, 8/19/2010, 8/20/2010, 8/23/2010, or 8/24/2010.. Patient #2's medical record was reviewed with Licensed Practical Counselor S7 and Licensed Practical Counselor Intern S6 on 8/25/2010 at 3:30 p.m. This review revealed Patient #2 was provided Social Services Group Therapy on the following dates/times: 8/09/2010 at 2:00 p.m. and 8/25/2010 at 2:00 p.m. Review revealed no documented evidence Patient #2 received Social Services Therapy on the following days: 8/10/2010, 8/11/2010, 8/12/2010, 8/13/2010, 8/16/2010, 8/17/2010, 8/18/2010, 8/19/2010, 8/20/2010, 8/23/2010, or 8/24/2010. Review of Patient #2's Master Treatment Plan revealed no documented evidence of revision of Plan due to the patient's failure to participate in group services. Review of Patient #2's entire medical record revealed no documented evidence of Individual Therapy Sessions in lieu of Group Therapy or that any Recreational Therapy was provided outside of Group Sessions for this patient that did not consistently attend Group Sessions (confirmed by Social Services Director S10 on 8/25/2010 at 2:45 p.m.).

Patient #3:
Patient #3 was admitted to the hospital on 8/09/2010 with diagnoses that included Senile Dementia with Behavioral Disturbances, Carotid Artery Disease, Hyperlipidemia, Anemia, and Osteoporosis. Review of Patient #3 ' s Psychosocial dated 8/10/2010 revealed the patient's daughters were involved in information gathering to complete the psychosocial assessment. Further review of the entire medical record revealed no documented evidence that Patient #3 was assessed for the desire to include his family members in treatment planning or to obtain his consent to include his family with treatment planning. Record review revealed no documented evidence of any family contact other than to gather information for the psychosocial evaluation. Record review revealed no documented evidence of any family contact other than to gather information for the psychosocial evaluation. Patient #3's medical record was reviewed with Recreational Therapists S13 on 8/25/2010 at 2:50 p.m.. This review revealed Patient #3 was provided Recreational Therapy on the following dates/times: 8/16/2010, 8/17/2010, 8/19/2010, 8/20/2010, 8/23/2010, and 8/24/2010. Review revealed no documented evidence Patient #3 received Recreational Therapy on the following days: 8/10/2010, 8/11/2010, 8/12/2010, 8/13/2010, and 8/18/2010. Patient #3's medical record was reviewed with Licensed Practical Counselor S7 and Licensed Practical Counselor Intern S6 on 8/25/2010 at 3:30 p.m.. This review revealed Patient #3 was provided Social Services Group Therapy on the following dates/times: 8/10/2010 at 1:00 p.m., 8/17/2010 at 2:00 p.m., 8/19/2010 at 1:00 p.m., 8/24/2010 1:30 p.m., and 8/25/2010 at 2:00 p.m.. Review revealed no documented evidence Patient #3 received Social Services Therapy on the following days: 8/11/2010, 8/12/2010, 8/13/2010, 8/16/2010, 8/18/2010, and 8/20/2010. Review of Patient #3 ' s Master Treatment Plan revealed no documented evidence of revision of Plan due to the patient's failure to participate in group services. Review of Patient #3's entire medical record revealed no documented evidence of Individual Therapy Sessions in lieu of Group Therapy or that any Recreational Therapy was provided outside of Group Sessions for this patient that did not consistently attend Group Sessions (confirmed by Social Services Director S10 on 8/25/2010 at 2:45 p.m.).

Patient #4:
Patient #4 was admitted to the hospital on 8/11/2010 with diagnoses that included Major Depression and Multiple Sclerosis. Review of Patient #4 ' s psychosocial dated 8/13/2010 revealed the patient's father was included in obtaining information to complete the Psychosocial Assessment. Further review of the entire medical record revealed no documented evidence that Patient #4 was assessed for the desire to include his family members in treatment planning or to obtain his consent to include his family with treatment planning. Record review revealed no documented evidence of any family contact other than to gather information for the psychosocial evaluation. Patient #4 ' s medical record was reviewed with Recreational Therapist S13 on 8/25/2010 at 11:10 a.m. This review revealed Patient #4 was provided Recreational Therapy on the following dates/times: 8/13/2010 at 9:00 a.m., 8/16/2010 at 9:00 a.m., 8/17/2010 at 9:00 a.m., 8/19/2010 at 9:00 a.m., 8/20/2010 at 9:00 a.m., 8/23/2010 at 9:00 a.m., and 8/24/2010 at 9:00 a.m. Review revealed no documented evidence Patient #4 received Recreational Therapy on the following days: 8/12/2010 and 8/18/2010. Patient #4 ' s medical record was reviewed with Licensed Practical Counselor S7 and Licensed Practical Counselor Intern S6 on 8/25/2010 at 3:30 p.m. This review revealed Patient #4 was provided Social Services Group Therapy on the following dates/times: 8/13/2010 at 9:00 a.m., 8/16/2010 at 2:00 p.m., 8/17/2010 at 1:00 p.m., 8/19/2010 at 1:00 p.m., 8/24/2010 at 1:30 p.m., and 8/25/2010 at 2:00 p.m.. Further review revealed no documented evidence Patient #4 received Social Services Therapy on the following days: 8/12/2010, 8/18/2010, 8/20/2010, and 8/23/2010. Review of Patient #4 ' s Master Treatment Plan revealed no documented evidence of revision of Plan due to the patient's failure to participate in group services. Review of Patient #4's entire medical record revealed no documented evidence of Individual Therapy Sessions in lieu of Group Therapy or that any Recreational Therapy was provided outside of Group Sessions for this patient that did not consistently attend Group Sessions (confirmed by Social Services Director S10 on 8/25/2010 at 2:45 p.m.).

Patient #5:
Patient #5 was admitted to the hospital on 8/16/2010 with diagnoses that included Chronic Paranoid Schizophrenia with exacerbation and hallucinations, Hypertension, Anemia, Gastritis, Chronic Low back pain, and Non-pitting edema of lower extremities. Review of Patient #5's Psychosocial dated 8/17/2010 revealed the patient's friend was involved in obtaining information for completion of the patient's psychosocial assessment. Further review of the entire medical record revealed no documented evidence that Patient #5 was assessed for the desire to include her friend in treatment planning or to obtain her consent to include her friend in treatment planning. Record review revealed no documented evidence of any contact with the patient's support system (friend) other than to gather information for the psychosocial evaluation. Patient #5 ' s medical record was reviewed with Recreational Therapists S13 on 8/25/2010 at 2:50 p.m. This review revealed Patient #5 was provided Recreational Therapy on the following dates/times: 8/17/2010 at 9:00 a.m., 8/20/2010 at 9:00 a.m., 8/23/2010 at 9:00 a.m., and 8/24/2010 at 9:00 a.m. Review revealed no documented evidence Patient #5 received Recreational Therapy on the following days: 8/18/2010 and 8/19/2010. Patient #5's medical record was reviewed with Licensed Practical Counselor S7 and Licensed Practical Counselor Intern S6 on 8/25/2010 at 3:30 p.m. This review revealed Patient #5 had never received Social Services Group Therapy.

Patient #7:
Patient #7 was admitted to the hospital on 08/10/09 with diagnoses that included Dementia with Behavioral Disturbances and a history of Anxiety, CABG (coronary artery bypass graft), CAD (cardiovascular artery disease), AFib (atrial fibrillation), CHF (congestive heart failure), Emphysema, AAA (abdominal aortic aneurysm) Repair, Carotid Endarterectomy, and Hypothyroidism. Review of the "Psychosocial History" documented on 08/13/09 revealed Patient #7 was unable to answer questions, and the family was not available for contact. Further review revealed the following areas of the assessment were answered with "unknown": outpatient treatment attempted and reasons for this level of care; family constellation (genogram, family of origin, history of losses, significant events and problems, relationships, history of physical abuse); significant developmental history; previous psychiatric treatment; history of substance use and abuse; educational history; vocational history; military history; legal history; financial and environmental concerns; and patient and family attitude toward the current situation, treatment process, reliability of reported information, and plans for post-discharge. Further review revealed Patient #7's strengths/assets were listed as family and Facility A. Review of the entire medical record revealed no documented evidence of any attempt to contact the family to obtain information for the psychosocial assessment, and there was no documented evidence of involvement of the family or Facility A, Patient #7's identified strengths, in his treatment planning. Further review revealed no documented evidence that Patient #7 had received Social Services Group or Individual Therapy. Review of the medical record revealed Patient #7 received Activity Group Therapy on 08/17/09 at 12:50pm, 08/18/09 at 11:39am, 08/20/09 at 11:41am, 08/24/09 at 11:36am, and 08/25/09 at 11:24am. There was no documented evidence Patient #7 received Activity Group Therapy on 08/11/09, 08/12/09, 08/13/09, 08/14/09, 08/19/09, and 08/21/09.

An interview was conducted with Recreational Therapist S13 on 8/25/2010 at 11:00 a.m. S13 indicated she had not made it her practice to document individual sessions with patients or any activities provided for patients that had not been done in group. S13 indicated she would sometimes include family members in education and/or planning; however, she had not made it her practice to document these sessions and would not be able to recall what interventions had occurred with family members. S13 indicated she would have to document individual and family sessions in order to recall what information had been discussed and how it related to achieving the patient's short and long term goals.

During a face to face interview on 8/25/2010 at 3:30 p.m., Licensed Practical Counselor S7 and Licensed Practical Counselor Intern S6 indicated they had provided individual and family interventions with patients currently in the hospital; however, it had not been their practice to document these sessions and without documentation would not be able to recall the dates, times, or information discussed in these sessions.

Review of the hospital's "Daily Patient Schedule" presented by the hospital as their current treatment schedule revealed in part that the Recreational Therapist was scheduled to provide "Community Meetings" from 9:00 a.m. - 10:30 a.m. Monday through Friday in addition to "Exercise" from 1:00 p.m. - 1:30 p.m. Monday through Friday. Further review revealed "Social Services" group activity was scheduled from 1:30 p.m. - 2:30 p.m. Sunday through Wednesday and from 10:40 a.m. - 11:30 a.m. Thursday and Friday.

Review of the hospital policy titled, "Treatment Team Progress Notes, last revised 6/15/2010" presented by the hospital as their current policy revealed in part, "Each patient shall have a separate hospital record to provide an accurate record of progress, to use as a reference for continuity of care, and to use as a guide to further evaluate patient care. The charting shall. . . Reflect all treatment rendered to the patient. Reflect the implementation of the treatment plan. . . Describe responses to and outcome of treatment both psychiatric and/or medical. . . Patient, Patient's family, and/or significant others' response to treatment/intervention as indicated. . . As Treatment Planning is implemented (i.e. related conferences with patient, family and continuing care resources or placement, and pre-discharge visits), the primary therapist/case manager shall document the occurrence and significant responses of the patient, family, etc.. . "

Review of the hospital policy titled, "Patient/Family Education, PP-024, last reviewed 10/17/07" presented by the hospital as their current policy revealed in part, "Purpose: To ensure that patients and families will receive necessary education as specific needs are identified. . . The following eduction programs may be provided: Patient/Family needs to know about the illness, treatment, and management of the illness in the community. Medication education. Basic nutritional needs for wellness. Education regarding any medical problems. Family dynamics that impact the patient's wellness. The needs, plans and implementation of patient/family teaching are to be documented in patients' medical record and on the Patient/Family Education Form. . ."

Based on record review and interview the hospital failed to ensure progress notes contain recommendations for revisions in the treatment plan as indicated for 5 of 5 patients reviewed for Treatment Planning out of a total sample of 15 (#1, #2, #3, #4, #5). Findings:


Patient #1:
Patient #1 was admitted to the hospital on 8/05/2010 with diagnoses that included Psychosis NOS (not otherwise specified), Tourettes Syndrome, Hypertension, and Chronic Lower Back Pain. Patient #1's medical record was reviewed with Recreational Therapist S13 on 8/25/2010 at 2:50 p.m. This review revealed Patient #1 was provided Recreational Therapy on the following dates/times: 8/10/2010 at 9:00 a.m., 8/19/2010 at 9:00 a.m., and 8/20/2010 at 9:00 a.m. Review revealed no documented evidence Patient #1 received Recreational Therapy on the following days: 8/06/2010, 8/09/2010, 8/11/2010, 8/12/2010, 8/12/2010, 8/13/2010, 8/16/2010, 8/17/2010, and 8/18/2010. Review of Patient #1's Master Treatment Plan revealed no documented evidence of revision of Plan due to the patient's failure to participate in group services. Review of Patient #1's entire medical record revealed no documented evidence that any Recreational Therapy was provided outside of Group Sessions for this patient that did not consistently attend Group Sessions or that a change in the treatment modality was indicated (confirmed by Social Services Director S10 on 8/25/2010 at 2:45 p.m.).

Patient #2:
Patient #2 was admitted to the hospital on 8/06/2010 with diagnoses that included Chronic Paranoid Schizophrenia in acute exacerbation, Schizoaffective Disorder, Hypertension, Urinary Incontinence, Neurogenic Bladder Hyperlipidemia, Hypothyroidism, Gastro Esophageal Reflux Disease, Anemia, and Type 2 Diabetes. Review of Patient #2's Psychosocial dated 8/09/2010 revealed the patient's brother and sister were contacted to obtain information for completion of the psychosocial assessment. Further review of the entire medical record revealed no documented evidence that Patient #2 was assessed for the desire to include his family members in treatment planning or to obtain his consent to include his family with treatment planning. Record review revealed no documented evidence of any family contact other than to gather information for the psychosocial evaluation. Patient #2's medical record was reviewed with Recreational Therapist S13 on 8/25/2010 at 2:50 p.m. This review revealed Patient #2 was provided Recreational Therapy on the following dates/times: 8/17/2010 at 9:00 a.m.. Further review revealed no documented evidence Patient #2 received Recreational Therapy on the following days: 8/09/2010, 8/10/2010, 8/11/2010, 8/12/2010, 8/13/2010, 8/16/2010, 8/18/2010, 8/19/2010, 8/20/2010, 8/23/2010, or 8/24/2010.. Patient #2's medical record was reviewed with Licensed Practical Counselor S7 and Licensed Practical Counselor Intern S6 on 8/25/2010 at 3:30 p.m. This review revealed Patient #2 was provided Social Services Group Therapy on the following dates/times: 8/09/2010 at 2:00 p.m. and 8/25/2010 at 2:00 p.m. Review revealed no documented evidence Patient #2 received Social Services Therapy on the following days: 8/10/2010, 8/11/2010, 8/12/2010, 8/13/2010, 8/16/2010, 8/17/2010, 8/18/2010, 8/19/2010, 8/20/2010, 8/23/2010, or 8/24/2010. Review of Patient #2's Master Treatment Plan revealed no documented evidence of revision of Plan due to the patient's failure to participate in group services. Review of Patient #2's entire medical record revealed no documented evidence of Individual Therapy Sessions in lieu of Group Therapy or that any Recreational Therapy was provided outside of Group Sessions for this patient that did not consistently attend Group Sessions. Further there was no documented evidence that a change in treatment modality was indicated (confirmed by Social Services Director S10 on 8/25/2010 at 2:45 p.m.).

Patient #3:
Patient #3 was admitted to the hospital on 8/09/2010 with diagnoses that included Senile Dementia with Behavioral Disturbances, Carotid Artery Disease, Hyperlipidemia, Anemia, and Osteoporosis. Review of Patient #3 ' s Psychosocial dated 8/10/2010 revealed the patient's daughters were involved in information gathering to complete the psychosocial assessment. Further review of the entire medical record revealed no documented evidence that Patient #3 was assessed for the desire to include his family members in treatment planning or to obtain his consent to include his family with treatment planning. Record review revealed no documented evidence of any family contact other than to gather information for the psychosocial evaluation. Record review revealed no documented evidence of any family contact other than to gather information for the psychosocial evaluation. Patient #3's medical record was reviewed with Recreational Therapists S13 on 8/25/2010 at 2:50 p.m.. This review revealed Patient #3 was provided Recreational Therapy on the following dates/times: 8/16/2010, 8/17/2010, 8/19/2010, 8/20/2010, 8/23/2010, and 8/24/2010. Review revealed no documented evidence Patient #3 received Recreational Therapy on the following days: 8/10/2010, 8/11/2010, 8/12/2010, 8/13/2010, and 8/18/2010. Patient #3's medical record was reviewed with Licensed Practical Counselor S7 and Licensed Practical Counselor Intern S6 on 8/25/2010 at 3:30 p.m.. This review revealed Patient #3 was provided Social Services Group Therapy on the following dates/times: 8/10/2010 at 1:00 p.m., 8/17/2010 at 2:00 p.m., 8/19/2010 at 1:00 p.m., 8/24/2010 1:30 p.m., and 8/25/2010 at 2:00 p.m.. Review revealed no documented evidence Patient #3 received Social Services Therapy on the following days: 8/11/2010, 8/12/2010, 8/13/2010, 8/16/2010, 8/18/2010, and 8/20/2010. Review of Patient #3 ' s Master Treatment Plan revealed no documented evidence of revision of Plan due to the patient's failure to participate in group services. Review of Patient #3's entire medical record revealed no documented evidence of Individual Therapy Sessions in lieu of Group Therapy or that any Recreational Therapy was provided outside of Group Sessions for this patient that did not consistently attend Group Sessions. Further there was no documented evidence to indicated that a change in treatment modality was indicated (confirmed by Social Services Director S10 on 8/25/2010 at 2:45 p.m.).

Patient #4:
Patient #4 was admitted to the hospital on 8/11/2010 with diagnoses that included Major Depression and Multiple Sclerosis. Review of Patient #4 ' s psychosocial dated 8/13/2010 revealed the patient's father was included in obtaining information to complete the Psychosocial Assessment. Further review of the entire medical record revealed no documented evidence that Patient #4 was assessed for the desire to include his family members in treatment planning or to obtain his consent to include his family with treatment planning. Record review revealed no documented evidence of any family contact other than to gather information for the psychosocial evaluation. Patient #4 ' s medical record was reviewed with Recreational Therapist S13 on 8/25/2010 at 11:10 a.m. This review revealed Patient #4 was provided Recreational Therapy on the following dates/times: 8/13/2010 at 9:00 a.m., 8/16/2010 at 9:00 a.m., 8/17/2010 at 9:00 a.m., 8/19/2010 at 9:00 a.m., 8/20/2010 at 9:00 a.m., 8/23/2010 at 9:00 a.m., and 8/24/2010 at 9:00 a.m. Review revealed no documented evidence Patient #4 received Recreational Therapy on the following days: 8/12/2010 and 8/18/2010. Patient #4 ' s medical record was reviewed with Licensed Practical Counselor S7 and Licensed Practical Counselor Intern S6 on 8/25/2010 at 3:30 p.m. This review revealed Patient #4 was provided Social Services Group Therapy on the following dates/times: 8/13/2010 at 9:00 a.m., 8/16/2010 at 2:00 p.m., 8/17/2010 at 1:00 p.m., 8/19/2010 at 1:00 p.m., 8/24/2010 at 1:30 p.m., and 8/25/2010 at 2:00 p.m.. Further review revealed no documented evidence Patient #4 received Social Services Therapy on the following days: 8/12/2010, 8/18/2010, 8/20/2010, and 8/23/2010. Review of Patient #4 ' s Master Treatment Plan revealed no documented evidence of revision of Plan due to the patient's failure to participate in group services. Review of Patient #4's entire medical record revealed no documented evidence of Individual Therapy Sessions in lieu of Group Therapy or that any Recreational Therapy was provided outside of Group Sessions for this patient that did not consistently attend Group Sessions. Further there was no documented evidence that a change in treatment modality was indicated (confirmed by Social Services Director S10 on 8/25/2010 at 2:45 p.m.).

Patient #5:
Patient #5 was admitted to the hospital on 8/16/2010 with diagnoses that included Chronic Paranoid Schizophrenia with exacerbation and hallucinations, Hypertension, Anemia, Gastritis, Chronic Low back pain, and Non-pitting edema of lower extremities. Review of Patient #5's Psychosocial dated 8/17/2010 revealed the patient's friend was involved in obtaining information for completion of the patient's psychosocial assessment. Further review of the entire medical record revealed no documented evidence that Patient #5 was assessed for the desire to include her friend in treatment planning or to obtain her consent to include her friend in treatment planning. Record review revealed no documented evidence of any contact with the patient's support system (friend) other than to gather information for the psychosocial evaluation. Patient #5 ' s medical record was reviewed with Recreational Therapists S13 on 8/25/2010 at 2:50 p.m. This review revealed Patient #5 was provided Recreational Therapy on the following dates/times: 8/17/2010 at 9:00 a.m., 8/20/2010 at 9:00 a.m., 8/23/2010 at 9:00 a.m., and 8/24/2010 at 9:00 a.m. Review revealed no documented evidence Patient #5 received Recreational Therapy on the following days: 8/18/2010 and 8/19/2010. Patient #5's medical record was reviewed with Licensed Practical Counselor S7 and Licensed Practical Counselor Intern S6 on 8/25/2010 at 3:30 p.m. This review revealed Patient #5 had never received Social Services Group Therapy. Review of Patient #4's entire medical record revealed no documented evidence of Individual Therapy Sessions in lieu of Group Therapy or that any Recreational Therapy was provided outside of Group Sessions for this patient that did not consistently attend Group Sessions. Further there was no documented evidence that a change in treatment modality was indicated (confirmed by Social Services Director S10 on 8/25/2010 at 2:45 p.m.).

An interview was conducted with Recreational Therapist S13 on 8/25/2010 at 11:00 a.m. S13 indicated she had not made it her practice to document individual sessions with patients or any activities provided for patients that had not been done in group. S13 indicated she would sometimes include family members in education and/or planning; however, she had not made it her practice to document these sessions and would not be able to recall what interventions had occurred with family members. S13 indicated she would have to document individual and family sessions in order to recall what information had been discussed and how it related to achieving the patient's short and long term goals.

During a face to face interview on 8/25/2010 at 3:30 p.m., Licensed Practical Counselor S7 and Licensed Practical Counselor Intern S6 indicated they had provided individual and family interventions with patients currently in the hospital; however, it had not been their practice to document these sessions and without documentation would not be able to recall the dates, times, or information discussed in these sessions.

Review of the hospital's "Daily Patient Schedule" presented by the hospital as their current treatment schedule revealed in part that the Recreational Therapist was scheduled to provide "Community Meetings" from 9:00 a.m. - 10:30 a.m. Monday through Friday in addition to "Exercise" from 1:00 p.m. - 1:30 p.m. Monday through Friday. Further review revealed "Social Services" group activity was scheduled from 1:30 p.m. - 2:30 p.m. Sunday through Wednesday and from 10:40 a.m. - 11:30 a.m. Thursday and Friday.

Review of the hospital policy titled, "Treatment Team Progress Notes, last revised 6/15/2010" presented by the hospital as their current policy revealed in part, "Each patient shall have a separate hospital record to provide an accurate record of progress, to use as a reference for continuity of care, and to use as a guide to further evaluate patient care. The charting shall. . . Reflect all treatment rendered to the patient. Reflect the implementation of the treatment plan. . . Describe responses to and outcome of treatment both psychiatric and/or medical. . . Patient, Patient's family, and/or significant others' response to treatment/intervention as indicated. . . As Treatment Planning is implemented (i.e. related conferences with patient, family and continuing care resources or placement, and pre-discharge visits), the primary therapist/case manager shall document the occurrence and significant responses of the patient, family, etc.. . "

Based on record review and interview the hospital failed to ensure the Director of Social Services monitor and evaluate the quality and appropriateness of social services furnished in the hospital resulting in the hospital's failure to document individual therapy sessions, document family sessions, indicate individualized short term patient goals, indicate individualized long term patient goals, indicate treatment modalities utilized for Patient Treatment Planning, or identify the responsible staff for carrying out treatment interventions. Findings:

Review of medical records for Patients #1, #2, #3, #4, #5, and #7 revealed no documented evidence of attempts to include family/support system in Treatment Planning, identify alternative treatment interventions for patients not attending group therapy sessions (Recreational and Psychosocial), Short Term Goals, Long Term Goals, Treatment Modalities, or to identify responsible staff for implementing treatment interventions in the Master Treatment Plan (Cross reference findings cited at B121, B122, B123, B125, and B131).

During a face to face interview on 8/25/2010 at 2:45 p.m., Licensed Certified Social Worker S10 indicated he was the person designated as Social Services Director for the hospital; however, he provided no direct supervision. S10 further indicated his primary function at the hospital was to attend monthly meetings where he provided In-service Education. S10 indicated he would be available to answer questions from Licensed Practical Counselors as needed. S10 indicated he had not been aware that the facility had changed forms and did not know the new Treatment Plans failed to contain short or long term goals, treatment modalities, or list staff responsible for implementing interventions. S10 further indicated he had not been aware that social services staff were no documenting individual or family sessions or that disclosure of information had not been formalized with consents for cognitively intact patients.