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Based on medical record review and staff interview it was determined the hospital failed to ensure the patient had the right to participate in the development and implementation of the plan of care for one (1) of one (1) patients reviewed who was admitted from an assisted living facility (patient #9). This failure has the potential to violate the rights of all patients who reside in this setting.

Findings include:

1. Review of the medical record for patient #9 revealed she was admitted to observation status through the Emergency Department on 9/23/11. Review of the 9/23/11 consent for treatment (Patient Agreement) revealed "Verbal Consent per nursing home" was documented on the line for patient signature. The record lacked documentation to reflect the patient lacked capacity or the "nursing home" was her legal decision maker. Therefore the record lacked documentation to reflect the patient was provided the right to participate in the admission consent process.

2. Review of the 9/23/11 physician orders for patient #9 revealed orders for the following: Do Not Resuscitate (DNR) and Do Not Intubate (DNI). Review of the medical record revealed no documentation to reflect the patient was consulted related to her wishes related to the DNR and DNI orders.

3. This record was reviewed and discussed with the 6S Nurse Manager in the late morning of 9/28/11. She agreed with these findings.

4. Review of the 9/23/11 physician orders for patient #9 revealed an order was triggered for an Assessment Risk Screen by the Social Worker related to discharge planning needs.

5. Review of the 9/24/11 physician orders for patient #9 revealed another order for a Social Services consult for making plans for a Rehab Facility placement. The record lacked any documentation to reflect the Social Worker consulted with the patient and provided her an opportunity to participate in the planning process for her post hospital needs.

6. The Director of Case Management was interviewed in the afternoon of 9/28/11. She stated the expectation was the Social Worker would see the patient within twenty-four (24) hours unless ordered on the weekend then the patient would be seen on Monday. She acknowledged the Social Worker should have consulted with the patient by 9/26/11 to provide assistance with planning for care.

Based on medical record review, policy review and staff interview it was determined the hospital failed to ensure the registered nurse measured wounds and obtained orders for treatment of wounds for two (2) of two (2) current patients reviewed with wounds (patient #8 and 10). This failure has the potential to adversely impact the care and condition of all patients with wounds.

Findings include:

1. Review of the medical record for patient #8 revealed the patient was admitted on 9/22/11 with multiple pressure ulcers. Review of the 9/22/11 nursing admission assessment revealed the nurse failed to measure these wounds. A consult with the wound care nurse was triggered by this assessment.

2. The record revealed the wounds were not measured until 9/27/11 when the wound care nurse assessed the patient. Review of physician's orders for patient #8 revealed an order for treatment of the wounds was not obtained until 9/26/11.

3. The policy "Procedure for Treatment of Pressure Ulcers," revised 3/11 was provided for review. The policy states in part: "Assess. Notify physician and obtain order for treatment...Document location, size, color, drainage, odor and perinuclear skin."

4. These findings were reviewed and discussed with the 6S Nursing Manager in the morning of 9/28/11. She agreed with these findings.

5. Review of the medical record for patient #10 revealed the patient was admitted on 8/31/11 and placed in full balanced skeletal traction. Review of the 9/19/11 nursing note documented at 0900 revealed the registered nurse noted a pressure area described as "necrosis." The record revealed this wound was not measured until 9/20/11 when the wound care nurse assessed the patient. On 9/28/11 the wound care nurse reassessed the patient and documented the patient now had three (3) wounds.

6. Review of the record in the midafternoon of 9/28/11 revealed the record of patient #10 lacked any orders for treatment of the wounds. This record was reviewed and discussed with the 6S Nurse Manager and she agreed with these findings.