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Based on staff interviews, review of hospital policies, and review of grievance-related documents, it was determined the hospital failed to provide either written responses or complete written responses to 5 of 8 patients (#62, #63, #66, #67, and #68) and/or patient representatives whose grievances were reviewed. This resulted in a lack of clarity about whether the grievances had been thoroughly investigated and resolved. It had the potential to interfere with patient understanding and satisfaction. Findings include:

A hospital policy titled, "PATIENT COMPLAINT & GRIEVANCE MANAGEMENT POLICY," last reviewed 1/05/10, contained a section describing the patient grievance resolution process. The policy stated, "Upon receipt of a grievance, the Executive Director of Risk Management (or designee) shall confer with the appropriate Department Director/Manager to review, investigate, and resolve the issue with the patient and/or patient representative within 30 days of the receipt of the grievance." Any written complaint was considered a grievance. Any verbal complaint was considered a grievance that could not be resolved at the time of the complaint by staff present, was postponed for later resolution, or required investigation or further action. Additionally, the policy stated the hospital must provide the complainant with a written notice of the decision, which included the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion of the investigation. The policy stated that any written complaint was considered a grievance.

This policy was not followed. Examples include:

1. Patient #62 was a 70 year old male, hospitalized on 12/22/09. A family member submitted a letter, dated 2/17/10, of grievance related to patient care issues. The hospital responded to the grievance in a letter, dated 3/12/10. However, the letter failed to describe the steps taken to investigate the grievance, the results of the investigation, and the date of the completed investigation.

In an interview on 9/21/10, beginning at 2:18 PM, the Executive Director of Risk Management reviewed the letter and confirmed the letter was incomplete.

2. Patient #63 was a newborn infant who was hospitalized on 12/12/09. A "PATIENT COMPLAINT REPORTING FORM," dated 12/15/09, documented a complaint alleging lack of nursing care and medical care, causing injury to Patient #63.

Email communication from the Director of Surgical Services, dated 4/01/10, to the Executive Director of Risk Management, reported having had conversations with the parent and having discussed the issue with a nurse that was involved with Patient #63's care.

There was no documentation of a written response to the parent who registered the complaint.

According to the Executive Director of Risk Management, during an interview on 9/21/10 beginning at 2:18 PM, the hospital should have sent a letter of response, but because the communication from the parent had been incorrectly classified as a complaint, rather than a grievance, a letter had not been sent. He explained it was not the hospital's policy to send letters of response on complaints. He also stated upon review of the complaint, he realized it should have been listed as a grievance and a letter of response should have been sent. The hospital's policy, referenced above, stated all written complaints were classified as grievances.

3. Patient #66 was admitted to the facility on 4/08/10 and discharged on 4/11/10. A "PATIENT COMPLAINT REPORTING FORM," dated 5/07/10, alleged a lack of nursing care. The complaint form was accompanied by a written complaint from Patient #66 on a form titled, "Notes for My Caregivers." The note detailed her concerns about care.

A letter addressed to the complainant, dated 5/18/10, from the the Executive Director of Risk Managment stated it was his understanding Patient #66's concerns had been addressed. Further, it stated the hospital would adjust the billing charges to the patient. However, the letter failed to describe the steps taken to investigate the grievance, the results of the investigation, and the date the investigation was considered complete.

In an interview with the Executive Director of Risk Management on 9/21/10 beginning at 2:18 PM, he stated he thought the letter that was sent was adequate.

4. Patient #67 had an infusion done at the hospital's Cancer Center on 6/15/10.

The hospital's grievance/complaint file contained a two-paged section with Patient #67's last name. The first page contained an e-mail dated 6/17/10 at 10:36 AM, from the Cancer Center Manager to the Risk/Quality Coordinator. It stated Patient #67 expressed a desire to file a formal complaint regarding the lack of care he received at the Cancer Center.

The second page contained a photocopy (date unreadable) of the hand written complaint from Patient #67.

There was no documentation to indicate a letter of response was sent to Patient #67.

During an interview on 9/21/10 starting at 2:18 PM, the Executive Director of Risk Management stated the investigation had not been completed and a letter had not yet been sent.

5. Patient #68 had back surgery on 6/23/10. An email communication, dated 7/21/10, from the Executive Director of Risk Management to another hospital staff member, documented Patient #68 alleged receiving an injury as a result of nursing care.

The grievance file contained hand-written notes and email communication, indicating some investigation of Patient #68's allegation. There was no evidence a letter of response had been sent to Patient #68.

In an interview on 9/21/10 beginning at 2:18 PM, the Executive Director of Risk Management confirmed Patient #68's grievance file was incomplete and did not contain a letter of response regarding the investigation. He stated Patient #68 had changed her account of the alleged incident twice and threatened to hire an attorney.

The hospital failed to ensure written responses to grievances were sent to patients or patient representatives.

Based on observation, staff interview, and review of medical records, it was determined the hospital failed to ensure 2 of 2 patients (#4 and #5), who were restrained by net beds, were restrained only when assessments demonstrated less restrictive interventions had been determined to be ineffective. This resulted in the potential for unnecessary restraint use. Findings include:

1. Patient #4's medical record documented a 50 year old male who was admitted to the Rehabilitation Unit on 8/20/10 and was discharged to a Surgical Unit on 9/04/10. His diagnosis was stroke. He was readmitted to the Rehabilitation unit on 9/13/10 following prostate and bladder surgery. He was currently a patient as of 9/24/10. Physician orders, dated 8/20/10 but not timed, stated Patient #4 was to have a Vail Bed or 1 to 1 precautions. (Vail beds, net beds, and enclosed beds are all terms for a bed with a mesh enclosure from which a patient cannot get out. These terms were used interchangeably by the hospital.) Daily orders for an enclosed net bed restraint were documented from 8/21/10 through 8/29/10. These orders consisted of a sticker placed on the chart which contained boxes for the physician to check. Each of the orders included a checked box which stated "Reason for continued use: Patient unable to follow directions to avoid self-injury." An individualized assessment of the likelihood of Patient #4 being injured without restraints or of less restrictive measures that could be implemented instead of restraints was not documented.

The medical record documented the enclosed bed was utilized for Patient #4 from 8/20/10 through 8/29/10. The "Rehab History and Physical," dated 8/20/10, stated Patient #4's mood was appropriate and his mental status was awake, alert, and flat. The H&P did not include an assessment of the need for restraints nor did it indicate a reason for their use. Subsequent physician progress notes did not document an assessment of the need for restraints. An "Inpatient Rehabilitation Interdisciplinary Team Meeting Note," dated 8/24/10 and signed by social services, physical therapy, occupational therapy, speech therapy, nursing, and the physician, did not mention the need for restraints. The "ADMISSION ASSESSMENT" by the RN, dated 8/20/10 at 3:30 PM, stated Patient #4's "Affect appropriate for situation: Cooperative. responds appropriately: Maintains appropriate eye contact." An assessment of the need for restraints by nursing staff was not documented. Subsequent nursing notes did not document an assessment of the need for restraints.

The order to continue restraints for Patient #4 was not renewed on 8/30/10 and the restraint was discontinued. The physician progress note, dated 8/30/10 but not timed, stated the patient was confused and said "Will do 1:1 nursing." The progress note did not state why the restraint order was not renewed or contain an assessment of the need for restraints.

Patient #4 was readmitted to the Rehabilitation Unit on 9/13/10. He was not restrained but had an order for 1:1 nursing. On 9/15/19, untimed, an order to discontinue the 1:1 staffing was documented. At 1:00 PM on 9/15/10, an order written by the physician for a net bed restraint was documented. Daily orders to continue the net bed restraint were documented from 9/16/10 through 9/23/10. No assessment of the need for restraints was documented by physicians or nursing staff.

An observation of Patient #4 was made from 10:30 AM until 11:02 AM on 9/24/10. He was awake in the net bed at the beginning of the observation. The Physical Therapist arrived at 10:37 AM, assisted him out of bed, and performed therapy with him. Patient #4 was confused but pleasant and cooperative. He moved slowly and required repeated attempts to grasp objects and move purposefully. The need for restraints was not obvious.

The Co-Medical Director of the Rehabilitation Unit, was interviewed on 9/22/10 at 12:30 PM. He wrote the order for the net bed for Patient #4 on 9/21/10. He stated an assessment specific to the need for the restraint had not been performed.

Staff failed to assess the need to restrain Patient #4.

2. Patient #5's medical record documented a 67 year old male who was admitted to the Rehabilitation Unit on 5/28/10 and was discharged on 6/18/10. His diagnosis was stroke. A physician order, dated 5/28/10 at 1:30 PM, stated Patient #5 was to have an Enclosed Bed restraint. Daily orders for an enclosed net bed were documented from 5/28/10 through 6/02/10. These orders consisted of a sticker placed on the chart which contained boxes for the physician to check. Each of the orders included a checked box which stated "Reason for continued use: Patient unable to follow directions to avoid self-injury." An individualized assessment of the likelihood of Patient #5 being injured without restraints or of less restrictive measures that could be implemented instead of restraints was not documented.

The medical record documented the enclosed bed was utilized for Patient #5 from 5/28/10 through 6/02/10. The "Rehab History and Physical," dated 5/29/10, stated Patient #5's mood and affect were flat. The H&P did not include an assessment of the need for restraints nor did it indicate a reason for the use of restraints. Subsequent physician progress notes did not document an assessment of the need for restraints. An "Inpatient Rehabilitation Interdisciplinary Team Meeting Note," dated 6/01/10 and signed by social services, physical therapy, occupational therapy, speech therapy, nursing, and the physician, did not mention the need for restraints. The initial "Nursing Assessment," dated 5/28/10 at 1:20 PM, stated Patient #5's "Affect appropriate for situation: Cooperative. responds appropriately: Maintains appropriate eye contact." An assessment of the need for restraints by nursing staff was not documented. Subsequent nursing notes did not document an assessment of the need for restraints.

The order to continue restraints for Patient #5 was not renewed on 6/03/10. Physician progress notes, dated 6/02/10 and 6/03/10 did not state why the restraint order was not renewed or contain an assessment of the need for restraints.

Patient #5's primary physician, was interviewed on 9/22/10 at 12:30 PM. He stated an assessment specific to the need for the restraint had not been performed.

Staff failed to assess the need to restrain Patient #5.

Based on staff interview and review of records and policies, it was determined the hospital failed to ensure restraints were used in accordance with valid physician orders for 4 of 7 restrained patients (#2, #6, #22, and #25) whose records were reviewed. This had the potential to interfere with coordination and safety of patient care. Findings include:

A hospital policy, "Restraint and/or Seclusion," dated 4/02/10, addressed restraint orders. It stated orders for restraints were to be obtained from an LIP/physician responsible for the care of the patient prior to the application of restraints. The order was to specify clinical justification for restraints, the date and time of the orders, the duration of use of restraints, the type of restraints to be used, and the criteria for release. The duration of restraint orders (for non-violent or non-self destructive behavior) could not exceed twenty-four hours. If reassessment indicated an ongoing need for restraint, a new order had to be written each calendar day by the LIP/physician.

This policy was not followed. Examples include:

a. Patient #6 was a 14 year old male admitted to the hospital's ICU on 8/07/10 after sustaining a head injury. Nursing restraint monitoring forms documented Patient #14 was being monitored for restraints from 8/15/10 through 8/19/10.

There was no initial order for restraints in the medical record. A sticker stating, "Restraint for Medical Management Re-order" was used when restraints were re-ordered after the initial order. There were three incomplete (undated and untimed) physician restraint re-order forms for bilateral upper extremity (wrist) restraints present in Patient #6's medical record. Two of the three restraint re-order forms were also not signed by a physician.

During an interview on 9/21/10 at 4:00 PM, the Nurse Educator for the ICU reviewed the record and stated she did not see an initial order for restraints in the record. She also confirmed the restraint re-order forms were incomplete and stated they should have been signed, dated, and timed.

b. Patient #22 was a 60 year old female who was a current patient in the hospital's ICU as of 9/21/10. Nursing notes, dated 8/31/10 and 9/04/10 from 6:00 AM to midnight, documented that soft wrist restraints were applied to Patient #22's because she was pulling at her tubes. However, Patient #22's medical record did not contain physician orders for restraints. This was confirmed on 9/21/10 at 1:52 PM during an interview with the ICU's Department Manager and the Director of Rehabilitation.

c. Patient #25 was a 42 year old male admitted to the hospital on 7/16/10 after sustaining a head injury.

A physician's order, dated 7/17/10 at 4:04 PM, was documented on a form titled "RESTRAINTS FOR MEDICAL MANAGEMENT - INITIAL ORDER." The order did not document the following elements required by hospital policy: the reason for use of the restraints, whether least restrictive measures were ineffective, the type of restraint, and the criteria for release.

A sticker stating, "Restraint for Medical Management Re-order" was used when restraints needed to be re-ordered. There were five incomplete (undated, untimed) physician restraint re-order forms present in Patient #6's medical record.

During an interview on 9/23/10 at 3:45 PM, the Director of Clinical Quality and Patient Safety reviewed Patient #25's medical record. She confirmed the physician orders for restraints were not complete.

d. Patient #2 was a 72 year old male admitted to the hospital on 8/08/10 with a diagnosis of "right subdural hematoma" (a collection of blood on the surface of the brain).

A physician's order, dated 8/09/10 at 7:00 AM, for bilateral/soft wrist restraints, was present on a form titled "RESTRAINTS FOR MEDICAL MANAGEMENT - INITIAL ORDER." The form did not document the reason for ordering the restraints, as required by hospital policy.

During an interview on 9/21/10 at 11:40 AM, the Nurse Educator for ICU reviewed the record and confirmed the restraint order was incomplete and stated the physician should have documented the reason for the restraint on the order form.

The hospital failed to ensure restraints were used in accordance with valid physician orders.

Based on staff interview and review of quality improvement documents, it was determined the hospital failed to ensure the causes of 3 of 3 adverse patient events (involving Patients #22, #71, and #72) in which patients removed their own endotracheal tubes, were analyzed. This prevented the hospital from developing plans to prevent further adverse patient events. Findings include:

"Risk Management Reports," from 9/09 through 9/10, documented 3 patients who self-extubated. Examples include:

a. The "Risk Management Report," dated 8/29/10, stated Patient #22 extubated herself on that date. The report stated the event was discovered when a Monitor Technician noticed her oxygen saturation levels dropping. The tube had to be replaced. A section of the report labeled "SPECIFIC CAUSES" stated, "IMPULSIVE BEHAVIOR, PATIENT MONITORING." Details of an investigation of the incident were not documented. The report also stated the Unit Manager had discussed the incident with the "Primary RN." The report did not state what had been discussed.

The report was reviewed with the Executive Director for Risk Management on 9/23/10 at 11:30 AM. He stated an investigation to determine the reasons Patient #22 was able to extubate herself, i.e. if staffing was adequate or if policies/orders were followed, was not documented.

b. The "Risk Management Report," dated 9/27/09, stated Patient #72 extubated himself on that date. The report stated the event was discovered when the ventilator alarmed. The tube had to be replaced. A section of the report labeled "SPECIFIC CAUSES" stated, "PERFORMANCE OF DUTIES." Details of an investigation of the incident were not documented. The report also stated the unit manager had discussed the incident with "STAFF."

The report was reviewed with the Executive Director for Risk Management on 9/23/10 at 11:30 AM. He stated an investigation to determine the reasons Patient #72 was able to extubate himself, was not documented.

c. The "Risk Management Report," dated 1/26/10, stated Patient #71 extubated himself on that date. The report did not state how the event was discovered. The tube had to be replaced. A section of the report labeled "SPECIFIC CAUSES" stated, "UNWILLING/UNABLE TO COOPERATE." Details of an investigation of the incident were not documented. The report also stated the unit manager had discussed the incident with "STAFF."

The report was reviewed with the Executive Director for Risk Management on 9/23/10 at 11:30 AM. He stated an investigation to determine the reasons Patient #71 was able to extubate himself, was not documented.

The hospital failed to analyze adverse patient events.

Based on record review and staff interview it was determined the hospital failed to ensure nursing staff supervised the care for 2 of 2 bone marrow biopsy patients (#21 and #52), and 2 of 4 blood transfusion patients (#22 and #23), and 1 of 5 patients (#22) whose procedures were observed. The lack of nursing supervision and failure to follow physicians' orders had the potential to compromise patients' health and recovery. Findings include:

1. The hospital failed to ensure nursing staff had assessed post procedural/post surgical bone marrow biopsy and aspiration patients. Examples include:

a. Patient #21 was a 60 year old male who was a current patient on the hospital's Oncology Unit as of 9/21/10. Patient #21's medical record contained a consent for a bone marrow biopsy, dated 9/20/10 that was not timed. Patient #21's "Operative Times - Operative Data" sheet, dated 9/20/10, noted the procedure ended at 11:08 AM. Patient #21 was taken directly to the "medical floor," by-passing the hospital's Post Anesthesia Care Unit. Patient #21 was given general anesthesia as noted on the "Consent for Anesthesia" dated 9/19/10. Patient #21 was discharged with the following physician orders, "Status post bone marrow core Bx + Asp [Bone marrow biopsy and aspiration]. Right post iliac crest. Pressure dressing in place. Check for bleeding q [every] 15 minutes for 1 hour, and then every 1 hour for 6 hours. If no bleeding after 8 hours replace dressing ..."

Patient #21's nursing notes, dated 9/20/10, were reviewed. A nursing note, dated 9/20/10 at 11:20 AM, written by a student nurse was the only documented physical assessment of Patient #21 after the procedure. This note did not include an assessment of the surgical dressing or site. Patient #21's vital signs sheet, dated 9/20/10, documented his vital signs were taken by the student nurse at 11:55 AM and then repeated at 4:30 PM.

The registered nurse who was in charge of Patient #21's post-operative care on 9/20/10 was interviewed on 9/21/10 starting at 3:00 PM. She stated post-operative patients that were intubated were to have vital signs every 15 minutes for 1 hour, every 30 minutes for 2 hours, and then every hour for 4 hours. She stated that if a patient was not intubated, the vital signs were to be taken every 15 minutes for ? hour and then every 30 minutes for 1 hour. She also stated patients were to have a head to toe assessment by a registered nurse upon arrival to the unit. None of the above nursing assessments or vital signs were documented in Patient #21's medical record, including dressing checks as ordered by the physician. The registered nurse stated she did do the assessments and vital signs for Patient #21 but the information had been written on a napkin that she could not find.

b. Patient #52 was a 33 year old female who was admitted to the hospital on 8/27/10. Patient #52 had a bone marrow biopsy and aspiration on 9/01/10. Patient #52's 9/01/10 "Operative Times - Operative Data" sheet stated the procedure ended at 11:06 AM, and he was taken directly to the surgical floor, by-passing the hospital's Post Anesthesia Care Unit. Patient #52's 9/01/10 nursing notes documented that vital signs were not obtained until 4:00 PM (almost 5 hours post procedure), and there was no nursing assessment of the patient's surgical site.

An interview was conducted with the Director of the Medical/Surgical/Oncology floor on 9/23/10 starting at 12:00 PM. She reviewed Patient #52's record. She confirmed that vital signs were not obtained until 4:00 PM, and that nursing did not document an assessment of the patient's procedural site. She stated that her expectations of post procedural/surgical patients were that vital signs were obtained upon the patient's arrival from surgery, and that a head to toe assessment would be done by a registered nurse which included an assessment of the surgical/procedural site.

The hospital failed to ensure nursing staff had assessed patients after bone marrow biopsy and aspiration.

2. The hospital failed to ensure nursing staff followed physician's orders. Examples include:

a. Patient #23 was a 56 year old female who was a current patient in the hospital's ICU as of 9/21/10. Patient #23's record contained a physician's order, dated 9/11/10 at 7:00 AM. The order was to infuse 2 units of blood. The order specified that each unit was to be infused over 2 hours. Patient #23's "Transfusion Record," dated 9/11/10 documented the first unit of blood was infused from 10:30 AM to 11:15 AM (45 minutes). The second unit of blood was documented as being given from 10:30 AM (during the first infusion) to 1:30 PM (2 ? hours). The ICU's Department Manager reviewed Patient #23's record and was interviewed on 9/21/10 starting at 2:26 PM. He confirmed the nurse did not follow the physician's orders.

Additionally, Patient #23's record contained a physician's order, dated 9/17/10 that was not timed. The order was to infuse 2 unit of blood. Patient #23's medical record did not contain documented evidence that the blood was administered.

The ICU's Department Manager reviewed Patient #23's record and was interviewed on 9/21/10 starting at 2:26 PM. He stated nursing staff should have filled out the hospital's "Transfusion Record" for the units of blood ordered on 9/17/10. He stated he could not find documented evidence that the nurse gave the units of blood as ordered on 9/17/10.

b. Patient #22 was a 60 year old female who was a current patient in the hospital's ICU as of 9/21/10. A physician's order, dated 8/29/10 at 4:00 AM, requested Patient #22 be administered 2 units of blood. Patient #22's "Transfusion Record" documented that 1 single unit of blood was given on 8/29/10 from 6:05 AM to 7:38 AM. The ICU's Department Manager and the Director of Rehabilitation researched the missing unit on 9/21/10 at 10:46 AM. They found the laboratory had only released 1 unit of blood during that time. They stated they were unable to explain why Patient #22 had not received the second unit of blood as ordered. However, a "Transfusion Record," dated 9/01/10 at 2:30 PM, documented Patient #22 had received a unit of blood. The ICU's Department Manager and the Director of Rehabilitation, during an interview starting on 9/21/10 at 10:46 AM, stated the 9/01/10 2:30 PM blood could have been the second unit that was ordered on 8/29/10 at 4:00 AM. Additionally, consent for blood products was not obtained by nursing staff until 9/01/10 at 6:45 PM, after the blood products had been administered. This was also confirmed by the ICU's Department Manager and the Director of Rehabilitation during an interview starting on 9/21/10 at 10:46 AM.

The ICU's Department Manager and the Director of Rehabilitation, were interviewed on 9/21/10 starting at 10:46 AM. They reviewed the medical record and were unable to find an order for the units of blood that were transfused on 9/22/10. The only order that was located was dated 9/03/10 at 7:10 PM. However, they confirmed no blood had been released from the laboratory at that time. The blood was transfused on 9/01/10 without a physician's order.

The hospital failed to ensure nursing staff had followed physician's orders.

3. The hospital failed to ensure patient safety. The example includes:

Patient #22 was a 60 year old female who was a current patient in the hospital's ICU as of 9/21/10. An observation of a procedure was conducted on 9/21/10 from 8:30 AM to 9:51 AM. Patient #22 was on an air mattress, intubated and semi responsive. The registered nurse was observed preparing Patient #22 for the procedure. This included, but was not limited to, raising the bed to approximately 3 feet off the ground and lowering the right side rails to the down position. At 8:37 AM, the registered nurse left the room with the patient in the above described position. The ICU's Department Manager came into the room shortly after the registered nurse had left. He asked if everything was ok. The issue of the patient's safety was pointed out and he stated the nurse should have put the side rails up before leaving Patient #22's bedside. He then placed the side rails in an up position.

The hospital failed to ensure nursing staff supervised the care of bone marrow biopsy and aspiration patients, blood transfusion patients, and the safety of an observed patient.

Based on staff interview, observation, and record review, it was determined the hospital failed to ensure accurate and promptly completed medical records were maintained for 4 of 14 patients (#2, #13, #25, and #55) whose records were reviewed for completeness of documentation. This resulted in a lack of clarity related to the actual course of patient events and had the potential to interfere with quality and coordination of patient care. Findings include:

1. Patient #2 was a 72 year old male admitted to the hospital on 8/08/10 with a diagnosis of "right subdural hematoma" (a collection of blood on the surface of the brain).

A surgical consent form, dated 8/08/10 at 1:30 PM, stated Patient #2 was consenting to "left craniotomy and removal of blood clot." There was a line drawn through the word "left." The word "right" was handwritten above the crossed out word. There was no date or time for the change. It could not be determined if the change had been made before or after Patient #2's representative signed the consent for surgery.

A physician's consultation report, dated 8/08/10 at 8:31 PM, referenced Patient #2's left subdural hematoma. Two of the references in the report to "left" subdural hematoma had lines drawn through the word "left." The word "right" was handwritten above the crossed out area. One reference to a left acute subdural hematoma, under the section of the report "REASON FOR CONSULTATION," was not corrected.

During an interview on 9/21/10 at 10:30 AM, the Nurse Educator for ICU reviewed Patient #2's record. She confirmed the crossed out areas in the record and replacement of the word "left" with the word "right."

During an interview on 9/21/10 at 11:30 AM, the Director of Quality Management was asked for the hospital's policy for correction of errors in documentation in the medical record. After looking for the policy, he stated he did not believe the hospital had such a policy.

The hospital failed to have a procedure to ensure consistent documentation of correction of documentation errors.

2. Patient #25 was a 42 year old male who was admitted to the hospital on 7/16/10 after sustaining a head injury. A physician's consultation report, dictated 7/19/10 at 7:56 AM, had a notation on the first page "*Dictation is garbled from this point forward, unable to transcribe.* BLANKS WITHIN REPORT, PLEASE CLARIFY*." There was no documentation to indicate the dictation had been clarified to finish the consultation report.

During an interview on 9/23/10 at 3:45 PM the Director of Clinical Quality and Patient Safety reviewed the record and stated she would check with the Medical Record Department and see if the consultation was ever completed. At 9/24/10 at 8:35 AM, she stated the consultation was not completed or clarified.

The medical record was incomplete.



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3. Patient #55 was a newborn infant transferred to the facility on 8/27/10 for evaluation of seizures. Patient #55 underwent a lumbar puncture on 8/27/10 at approximately 9:30 PM. The admission note, dictated by the Neonatal Nurse Practitioner at 9:20 PM on 8/27/10, and signed by the physician, indicated the father was updated at the bedside regarding the plan for care (including the lumbar puncture). In addition, nursing notes from 8/27/10 at 9:00 PM, documented the physician discussed the plan of care with the father prior to performing the lumbar puncture. However, a signed consent for the lumbar puncture was not located in Patient #55's medical record.

The Director of Women's and Children's Services reviewed Patient #55's record and stated she could not locate a signed consent. She stated that even if the procedure was completed in an urgent manner, she would still expect to see a completed consent form for the lumbar puncture in the medical record.

The medical record did not contain all appropriate consent forms and was therefore incomplete.

4. Patient #13 was an 11 year old girl admitted to the pediatric unit on 9/15/10 for evaluation of diarrhea and dehydration. As a precaution, she was placed in contact isolation which indicated the need to don a gown and gloves for interactions that involved contact with Patient #13 or potentially contaminated areas in her room.

The pediatric unit was toured on 9/21/10 at approximately 11:30 AM. While waiting at the nurses' station, the surveyor, and the RN caring for Patient #13 on 9/21/10, observed Patient #13's mother approach the nurses' station with bare feet and without a gown or gloves.

Patient #13's mother was interviewed on 9/21/10 at 1:50 PM. She stated that she was aware of the recommendation to observe isolation precautions, including wearing a gown and gloves while caring for her daughter, however she chose not to. She explained that she did not believe an infectious disease was causing her daughter's diarrhea and therefore saw no need for isolation precautions. She did confirm that nursing staff had on various occasions educated her on the proper protective equipment.

The RN, who cared for Patient #13 on 9/21/10, was interviewed on 9/22/10 at 2:45 PM. The RN confirmed the family was educated about the importance of following isolation precautions. The RN stated she, and other nurses caring for Patient #13, had addressed this issue with the family on numerous occasions during the hospitalization. She stated the family was encouraged to wear a gown and gloves while caring for Patient #13. The RN specifically stated she repeatedly addressed the issue of the mother's insistence on not wearing socks and shoes. She did acknowledge the lack of family compliance with proper isolation precautions and admitted she did not always document her conversations with the family regarding the need to follow these precautions.

The Director of Women's and Children's Services reviewed Patient #13's medical record for documentation related to nursing management of the isolation precautions in relation to family members. She was interviewed on 9/23/10 at 9:50 AM. She reported that she was not able to locate nursing documentation related to the noncompliance of Patient #13's family with isolation precautions.

Patient #13's medical record lacked documentation addressing the noncompliance to isolation precautions and the response of staff to this noncompliance.

The facility failed to ensure complete and accurate medical records were maintained for all patients.

Based on medical record review, review of hospital policies, and staff interview it was determined the facility failed to ensure all patient medical records were completed with date, time, and/or physician signature for 6 of 14 patients (#2, #4, #5, #6, #53, and #54) whose inpatient records were reviewed for completeness of physician order documentation. Failure to ensure physician orders were dated, timed, and signed had the potential to interfere with the clarity of when orders were given and/or authentication of the orders. Findings include:

The facility policy, "Physicians Orders," dated 5/27/09, specified that medication orders would contain the time and date of the order and the prescriber's signature. It was unclear whether or not other types of orders, such as diagnostic and non-medicinal therapeutic orders, were to contain the date and time of the order along with the physician's signature as required by federal regulations. In addition, the policy addressed the protocol for verbal orders, including who could give and receive orders, the need for repeat verification of the verbal order, and what documentation was to be included when the verbal order was transferred into the medical record. The policy failed to address the physician co-signature of orders to verify accuracy, and the need to date and time this co-signature.

1. Patient #53 was a 33 year old female admitted to the facility on 6/28/10 to deliver her baby. The following orders were incomplete:

- Patient #53's medical record contained a "STANDARDIZED POST-PARTUM ORDERS" form. The top of the form was dated 6/28/10, 7:20 AM. The bottom of the form contained a line for the physician's signature, date, and time. The physician had signed on the line, but failed to include the date and time the orders were signed.

- A physician's verbal order was documented in the medical record by an RN on 6/28/10 at 11:55 AM. Beneath the orders was a space for the physician's signature and the date and time. The physician signed the order but failed to document the date and time.

- The Physician Assistant wrote discharge orders, including a prescription for a narcotic, on 6/30/10 at 8:00 AM. There was a space beneath the written orders for the physician's signature and the date and time. The physician signed the order but failed to document the date and time.

The Director of Clinical Quality and Patient Safety reviewed Patient #53's medical record on 9/23/10 at 8:45 AM. She confirmed that the date and time the physician signed, or co-signed, his orders was not clear.



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2. Patient #2 was a 72 year old male admitted to the hospital on 8/08/10 with a diagnosis of "right subdural hematoma" (a collection of blood on the surface of the brain).

The following physician orders were incomplete:

- A physician's verbal order, dated 8/08/10 at 5:55 PM, was not co-signed by the physician.

- Preprinted physician's orders for "INPATIENT ADMISSION," dated 8/08/10 at 5:00 PM, were signed by a physician on 8/09/10. The time the physician signed the order was not documented.

- Pre-printed physician's orders on a form titled "POST ANESTHESIA" were signed by a physician. However, the date and time of the orders was not documented.

During an interview on 9/21/10 at 11:40 AM, the Nurse Educator for ICU reviewed the record and confirmed the incomplete physician orders. She stated physician orders should be signed, dated, and timed.

3. Patient #6 was a 14 year old male admitted to the hospital on 8/07/10 after a head injury. The following physician orders were incomplete:

- An untimed "ED TRAUMA ORDER FORM," dated 8/07/10, was not signed by the physician.

- Physician orders, dated 8/15/10 at 10:00 AM, were not signed by the physician.

- A physician's verbal order, noted by an RN on 8/16/10, was signed by the physician but not dated or timed.

- Physician orders, dated 8/16/10 at 11:30 AM, were not signed by the physician.

- Physician orders, noted by an RN on 8/22/10, were not signed by the physician.

During an interview on 9/21/10 at 4:00 PM, the Nurse Educator for ICU reviewed the record and stated physician orders should be signed, dated, and timed.

4. Patient #54 was a 49 year old female admitted to the hospital on 6/17/10 for surgery. The following physician orders were incomplete:

- Physician's pre-printed orders on a form titled "POST ANESTHESIA," page 1, failed to include Patient #54's name, the date or time of the orders or the date or time the orders were noted.

- Physician's pre-printed orders on a form titled "PRE-OP VAGINAL or ABDOMINAL HYSTERECTOMY, LAPAROTOMY..." were signed by the physician. There was no date or time for the orders or when the physician signed the orders.

During an interview on 9/24/10 at 10:00 AM, the Director of Clinical Quality and Patient Safety reviewed the record and confirmed the physician's orders were incomplete.



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5. Patient #4's medical record documented a 50 year old male who was admitted to the Rehabilitation Unit on 8/20/10 and was discharged to a Surgical Unit on 9/04/10. His diagnosis was stroke. Daily orders for an enclosed net bed restraint were documented from 8/20/10 through 8/29/10. The orders on 8/20/10, 8/23/10, 8/26/10, 8/27/10, 8/28/10, and 8/29/10 were not timed.

The Director of the Rehabilitation Center was interviewed on 9/29/10 at 3:40 PM. She stated the orders for Patient #4 were not timed.

Staff failed to time restraint orders for Patient #4.

6. Patient #5's medical record documented a 67 year old male who was admitted to the Rehabilitation Unit on 5/28/10 and was discharged on 6/18/10. His diagnosis was stroke. A physician order, dated 5/28/10 at 1:30 PM, stated Patient #5 was to have an Enclosed Bed restraint. Daily orders for an enclosed net bed were documented from 5/29/10 through 6/02/10. None of these orders included the time the order was written.

The Director of the Rehabilitation Center was interviewed on 9/29/10 at 3:40 PM. She stated the orders for Patient #5 were not timed.

Staff failed to time restraint orders for Patient #5.

The hospital failed to ensure medical records were complete and included physician orders that contained the physician's signature along with the date and time the order was signed.