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Based on documentation, and an interviews with the facility staff, it was determined that the facility failed to complete an occurrence report on patient # 1, for leaving the facility against medical advice.

Findings were:
Review of the medical record of patient #1, revealed that patient #1 was admitted to the facility on 01/17/12 and left against medical advice on 01/18/12.
Review of progress note 01/18/12 per the Nurse Practitioner stated,"Patient called her daughter and left against medical advice because she felt that I was accusatory, rude, and refused an explanation for the rationale, for her treatment modality."

Review of Policy # PCSO40, Against Medical Advice/Elopement, Leaving, without Treatment, revised 05/11. AMA/ELOPEMENT 7. "An occurrence report is completed on all AMA's/elopements and sent to the Department Director."

In a telephonic interview conducted with the Family Nurse Practitioner on 03/13/12 at 2:20 pm at the facility, it was confirmed that an occurrence report had not been completed for patient #1, who was admitted to the facility on 01/17/12 and left against medical advice on 01/18/12.
In an interview with the Vice President of Quality on the afternoon of 03/13/12 at the facility, it was confirmed that an occurrence report had not been completed for patient #1 who was admitted to the facility on 01/17/12 and left against medical advice on 01/18/12.

Based on review of facility documentation, policies, and an interview with the Quality Improvement Coordinator, it was determined, the nursing staff failed to change the dressing of patient # 2 each shift, as ordered by the physician.

Findings were:
Review of the medical record patient #2, revealed an exploratory laparotomy was performed on 11/04/11 with findings of ischemic right colon and a right colectomy was performed. The physician ordered 11/07/11 stated "Can change abdominal dressing q (every) shift with dry gauze".

Review of the clinical documentation record 11/10/11 and 11/11/11 revealed the dressing was not changed each shift, as ordered by the physician.

Review of facility policy, Diagnostic and Therapeutic Orders of Medical Staff: Acknowledgement, Coordination and Implementation # PCSO24, stated, "registered nurses will coordinate the implementation of the physician's orders. Physicians' orders for patient care are processed in a timely manner to ensure that each patients needs are assessed and met. Based on each patient's presenting needs, orders are prioritized and implemented."

In an interview with the Quality Improvement Coordinator on the afternoon of 03/13/12, clinical records 11/10/11 and 11/11/11 were offered to the surveyor, revealing the dressing had been changed on 11/10/11 and 11/11/11. No other documentation was offered to the surveyor indicating that the dressing had been changed each shift as ordered by the physician.

Based on review of documentation, and an interview with the director of 1 East, it was determined, the facility failed to follow their own policy; patient #2 and his wife were not given discharge instructions for care of the abdominal incision.

Findings were:
Review of facility policy # PC8017, Discharge Planning, II, stated " It is the policy at MCA, based upon patient admission requirements and assessments, the registered nurse initiates discharge planning on admission, writes an ongoing discharge plan, makes referrals to the case manager/social worker and coordinates discharge planning with the patient case manager, and family throughout the hospitalization. Prior to discharge, any post-discharge continuing nursing care needs are assessed and noted in the medical record."

Review of the patient clinical discharge education 11/11/11 revealed there was no documentation instructing the patient #2 and his wife on the care of the incision.

In an in-person interview with director of 1 East on the afternoon of 03/13/12, it was confirmed the facility failed to provide discharge instructions to patient #2 and his wife, for care of the abdominal incision.