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Based on record review and interview the hospital failed to ensure it met the Louisiana Licensing Regulation requiring that the Medical Records Department be supervised by a Medical Records Practitioner for 1 of 1 employee staffing the Medical Records Department of the hospital (S4) as per Louisiana Department of Health and Hospital's Hospital Licensing Standards, L0022/9387B which states, "Medical records shall be under the supervision of a medical records practitioner (i.e., registered record administrator or accredited record technician) on either a full-time, part -time or consulting basis." Findings:

Review of the personnel file for the only employee working in Medical Records Department; Medical Records Secretary S4, revealed no documented evidence of having any training as a medical records practitioner to include training as a Registered Record Administrator or Accredited Record Technician.

During a face to face interview on 3/01/2011 at 9:00 a.m., Medical Records Secretary S4 confirmed that she had no specialized training in the field of Medical Records.

During a face to face interview on 3/01/2011 at 9:00 a.m., Director of Nursing S2 indicated she (S2) had plans to hire a Registered Health Information Administrator to oversee/supervise the Medical Records Department; however, the plan had not been implemented.

Based on record review and interview the hospital failed to ensure their policy for Emergency Medical Conditions included management and/or oversight of the patient's care by the patient's physician and/or on-call physician until such a time as transport arrives outside of emergencies that require Cardio Pulmonary Resuscitation (CPR). Findings:

Review of the hospital's policy titled, "Emergency Medical Action, #PP-071, developed 12/09/05" presented by the hospital as their current policy revealed in part, "Beacon Behavioral Hospital staff may require assistance in the event of a medical emergency. The current environment in the surrounding community provides little resource for medical care (and) emergency treatment. In the event of a medical emergency, Unit licensed staff will perform CPR (Cardio Pulmonary Resuscitation) and basic life support while para-professional staff call for an ambulance and make arrangements to transfer the patient to the Emergency Department. Other staff will attend to the other patients. 1. It is a matter of calling for an ambulance and calling the ER (Emergency Room) to inform them of a pending arrival. . . 3. The patient's attending physician should be called immediately and the patient's family or caregivers, too. . . " Further review revealed no documented evidence of how the hospital would appraise and manage medical emergencies or the role of the patient's physician/on-call physician outside of emergencies requiring CPR.

During a face to face interview on 3/01/2011 at 2:15 p.m., Director of Nursing S2 indicated there was only one policy addressing appraisal and treatment of emergencies in the hospital. S2 presented the policy titled, "Emergency Medical Action, #PP-071". S2 confirmed the policy failed to address how medical emergencies occurring with patients, staff, or visitors within the hospital; other than those requiring CPR, would be appraised, managed, and transferred as needed. S2 confirmed the policy failed to address the patient's physician and/or on-call physician's role in providing management and/or oversight of the emergency medical condition until such a time as emergency transport arrives when the emergency can not be managed by the hospital and transfer was deemed necessary.

Based on record review and interview the hospital failed to ensure a written notice was provided to the complainant upon resolution of the grievance that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for 1 of 1 grievances reviewed (Patient #R1). Findings:

Review of the hospital's complaint log revealed a complaint of verbal abuse was submitted
by Patient R1 on 02/20/11. Review of the complaint/grievance investigation, signed by S1, Interim Administrator revealed Patient R1 informed S5, Licensed Counselor, a staff member had yelled at her and swung a vacuum cleaner at her. Review of the grievance investigation revealed no documented evidence a written response to Patient R1's grievance was made within 7 days following the initial complaint intake.

Review of the hospital policy entitled Patient/Complaints/Grievances #PSC-09-005 presented as the hospital s current policy revealed in part, "6. Written responses to patient grievances shall be made as immediately as possible by the CEO. Varying complexities associated with grievances may necessitate a prolonged investigation.. However, in no case shall a written response to the patient or patient's representative be made later than 7 days following the initial complaint. At a minimum, the written response will include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion."

Based on record review (medical record, hospital policy, grievances) and interview the hospital failed to ensure systems were in place to ensure a patient's verbal complaint/grievance of verbal abuse was investigated thoroughly for 1 of 1 random patients with an allegation of verbal abuse. (Patient #R1) Findings:

Review of the hospital's complaint log revealed a complaint of verbal abuse was submitted
by Patient R1 on 02/20/11. Review of the complaint/grievance investigation, signed by S1, Interim Administrator, revealed Patient R1 informed S5, Licensed Counselor, a staff member had yelled at her and swung a vacuum cleaner at her. Review of the grievance investigation by S1, Interim Administrator revealed the complaint allegations that occurred were not investigated thoroughly as evidenced by no documented evidence all staff members, present during the time of the alleged abuse incident, were interviewed as to the events that had occurred.

S2, DON was interviewed face to face on 03/01/11 at 10:45am. S2 indicated she had not interviewed all staff present who had witnessed the alleged verbal abuse because staff were not present when she was in the hospital.

Review of the hospital policy entitled Patient/Complaints/Grievances #PSC-09-005 presented as the hospital's current policy revealed in part, "4. Grievances about situations that endanger the patient, such as neglect or abuse shall be reviewed immediately, given the seriousness of the allegations and the potential for harm to the patient. If the hospital CEO does not feel that appropriate, sufficient, or timely action was taken, he or she will review the hospital-wide implications of the complaint."

Based on record review and interview the hospital failed to ensure all clinical staff were trained and demonstrated competency in the application of restraints upon orientation and/or periodically thereafter for 4 of 6 clinical nursing staff reviewed for restraint training (Registered Nurse S14, Registered Nurse S16, Certified Nursing Assistant S18, and Certified Nursing Assistant S19). Findings:

Personal Files of 6 employees (4 Registered Nurses and 2 Certified Nursing Assistants) were reviewed with Coordinator of Performance Improvement, S6. Review of Personnel files revealed no documented evidence of Restraint Training in the files of Registered Nurse (RN) S14, Registered Nurse S16, Certified Nursing Assistant (CNA) S18, and Certified Nursing Assistant S19.

During a face to face interview on 3/02/2011 at 12:20 p.m., Coordinator of Performance Improvement, S6, indicated the hospital had provided training on Restraints in 2008 and again in September and October of 2010. S6 indicated there was no evidence that RN S14, RN S16, CNA S18, or CNA S19 attended the training.

Based on record review and interview the hospital failed to ensure all clinical staff were trained and demonstrated competency regarding knowledge of the specific needs of the geriatric psychiatric population for techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require the use of a restraint or seclusion for 4 of 6 clinical nursing staff reviewed for training (Registered Nurse S14, Registered Nurse S16, Certified Nursing Assistant S18, and Certified Nursing Assistant S19). Findings:

Personal Files of 6 employees (4 Registered Nurses and 2 Certified Nursing Assistants) were reviewed with Coordinator of Performance Improvement, S6. Review of Personnel files revealed no documented evidence of Restraint Training in the files of Registered Nurse (RN) S14, Registered Nurse S16, Certified Nursing Assistant (CNA) S18, and Certified Nursing Assistant S19.

During a face to face interview on 3/02/2011 at 12:20 p.m., Coordinator of Performance Improvement, S6, indicated the hospital had provided training on Restraints in 2008 and again in September and October of 2010. S6 indicated there was no evidence that RN S14, RN S16, CNA S18, or CNA S19 attended the training.

Based on record review and interview the hospital failed to ensure all clinical staff were trained and demonstrated competency in nonphysical intervention skills for 6 of 6 Clinical Staff reviewed (Registered Nurse S14, Registered Nurse S15, Registered Nurse S16, Registered Nurse S17, Certified Nursing Assistant S18, and Certified Nursing Assistant S19). Findings:

Personal Files of 6 employees (4 Registered Nurses and 2 Certified Nursing Assistants) were reviewed with Coordinator of Performance Improvement, S6. Review of Personnel files revealed no documented evidence of nonphysical intervention skills for 6 of 6 clinical staff reviewed: Registered Nurse (RN) S14, Registered Nurse S15, Registered Nurse S16, Registered Nurse S17, Certified Nursing Assistant (CNA) S18, and Certified Nursing Assistant S19.

During a face to face interview on 3/02/2011 at 12:20 p.m., Coordinator of Performance Improvement, S6, indicated the hospital had provided training in Crisis Prevention Interventions; however, she did not know the date of the training and had no documentation of attendance and or competency of any clinical staff in attendance.

Based on record review and interview the hospital failed to ensure all clinical staff were trained and demonstrated competency regarding knowledge of the specific needs of the geriatric psychiatric population for choosing the least restrictive intervention based on an individualized assessment of patient's medical or behavior status or condition for 4 of 6 clinical nursing staff reviewed for training (Registered Nurse S14, Registered Nurse S16, Certified Nursing Assistant S18, and Certified Nursing Assistant S19). Findings:

Personal Files of 6 employees (4 Registered Nurses and 2 Certified Nursing Assistants) were reviewed with Coordinator of Performance Improvement, S6. Review of Personnel files revealed no documented evidence of Restraint Training in the files of Registered Nurse (RN) S14, Registered Nurse S16, Certified Nursing Assistant (CNA) S18, and Certified Nursing Assistant S19.

During a face to face interview on 3/02/2011 at 12:20 p.m., Coordinator of Performance Improvement, S6, indicated the hospital had provided training on Restraints in 2008 and again in September and October of 2010. S6 indicated there was no evidence that RN S14, RN S16, CNA S18, or CNA S19 attended the training.

Based on record review and interview the hospital failed to ensure all clinical staff were trained and demonstrated competency regarding knowledge of the specific needs of the geriatric psychiatric population for safe application and use of all types of restraint or seclusion used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress such as positional asphyxia for 4 of 6 clinical nursing staff reviewed for training (Registered Nurse S14, Registered Nurse S16, Certified Nursing Assistant S18, and Certified Nursing Assistant S19). Findings:

Personal Files of 6 employees (4 Registered Nurses and 2 Certified Nursing Assistants) were reviewed with Coordinator of Performance Improvement, S6. Review of Personnel files revealed no documented evidence of Restraint Training in the files of Registered Nurse (RN) S14, Registered Nurse S16, Certified Nursing Assistant (CNA) S18, and Certified Nursing Assistant S19.

During a face to face interview on 3/02/2011 at 12:20 p.m., Coordinator of Performance Improvement, S6, indicated the hospital had provided training on Restraints in 2008 and again in September and October of 2010. S6 indicated there was no evidence that RN S14, RN S16, CNA S18, or CNA S19 attended the training.

Based on record review and interview the hospital failed to ensure all clinical staff were trained and demonstrated competency regarding knowledge of the specific needs of the geriatric psychiatric population for clinical identification of specific behavioral changes that indicate that restraint or seclusion is no longer necessary for 4 of 6 clinical nursing staff reviewed for training (Registered Nurse S14, Registered Nurse S16, Certified Nursing Assistant S18, and Certified Nursing Assistant S19). Findings:

Personal Files of 6 employees (4 Registered Nurses and 2 Certified Nursing Assistants) were reviewed with Coordinator of Performance Improvement, S6. Review of Personnel files revealed no documented evidence of Restraint Training in the files of Registered Nurse (RN) S14, Registered Nurse S16, Certified Nursing Assistant (CNA) S18, and Certified Nursing Assistant S19.

During a face to face interview on 3/02/2011 at 12:20 p.m., Coordinator of Performance Improvement, S6, indicated the hospital had provided training on Restraints in 2008 and again in September and October of 2010. S6 indicated there was no evidence that RN S14, RN S16, CNA S18, or CNA S19 attended the training.

Based on record review and interview the hospital failed to ensure all clinical staff were trained and demonstrated competency regarding knowledge of the specific needs of the geriatric psychiatric population for monitoring the physical and psychological well-being of the patient who is restrained or secluded, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and any special requirements specified by hospital policy associated with the 1 hour face to face evaluation for 4 of 6 clinical nursing staff reviewed for training (Registered Nurse S14, Registered Nurse S16, Certified Nursing Assistant S18, and Certified Nursing Assistant S19). Findings:

Personal Files of 6 employees (4 Registered Nurses and 2 Certified Nursing Assistants) were reviewed with Coordinator of Performance Improvement, S6. Review of Personnel files revealed no documented evidence of Restraint Training in the files of Registered Nurse (RN) S14, Registered Nurse S16, Certified Nursing Assistant (CNA) S18, and Certified Nursing Assistant S19.

During a face to face interview on 3/02/2011 at 12:20 p.m., Coordinator of Performance Improvement, S6, indicated the hospital had provided training on Restraints in 2008 and again in September and October of 2010. S6 indicated there was no evidence that RN S14, RN S16, CNA S18, or CNA S19 attended the training.

Based on record review and interview the hospital failed to ensure documentation in the personal files for all clinical staff revealed successful completion and competency regarding restraint education for 4 of 6 clinical nursing staff reviewed for training (Registered Nurse S14, Registered Nurse S16, Certified Nursing Assistant S18, and Certified Nursing Assistant S19). Findings:

Personal Files of 6 employees (4 Registered Nurses and 2 Certified Nursing Assistants) were reviewed with Coordinator of Performance Improvement, S6. Review of Personnel files revealed no documented evidence of Restraint Training in the files of Registered Nurse (RN) S14, Registered Nurse S16, Certified Nursing Assistant (CNA) S18, and Certified Nursing Assistant S19.

During a face to face interview on 3/02/2011 at 12:20 p.m., Coordinator of Performance Improvement, S6, indicated the hospital had provided training on Restraints in 2008 and again in September and October of 2010. S6 indicated there was no evidence that RN S14, RN S16, CNA S18, or CNA S19 attended the training.

Based on record review and interview, the hospital failed to implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program by failing to measure, analyze, and track quality indicators that assess processes of care, hospital services and operations. This was evidenced by the hospital's failure to implement quality indicators for all service areas including Radiology Services, Respiratory Services, Laboratory Services and the Physical Environment. Findings:

Review of the QAPI (Quality Assurance Performance Improvement) data revealed no evidence to indicate the implementation of quality indicators for Radiology Services, Respiratory Services, Laboratory Services and the Physical Environment.

The Coordinator of Performance Improvement and Education (S10) was interviewed on 3/01/11 at 12:50 p.m. S10 reviewed the QAPI data and confirmed that the QAPI data did not include quality indicators for all service areas of the hospital. S10 confirmed that there were no indicators for Radiology Services, Respiratory Services, Laboratory Services and the Physical Environment.

Based on record review and interview, the hospital failed to implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program by failing to implement identified priorities for its performance improvement activities that are focused on high-risk or problem-prone areas that affect health outcomes, safety, and/or quality of care. This was evidenced by the hospital's failure to implement an effective system that included the monitoring of timely notification to practitioners of abnormal laboratory results on hospitalized patients after identifying delays in practitioner notification was occurring in regards to abnormal laboratory results. Findings:

Review of the QAPI (Quality Assurance Performance Improvement) data revealed that the hospital identified a breakdown in the hospital's ensuring that the physician/practitioner was notified timely of abnormal laboratory results. Documentation in the hospital's QAPI data revealed "Laboratory reports are currently signed by the nurse upon receipt but unclear if and how reported to the physician. Are both the medical physician and psychiatrist notified? How is this documented? What time frame is required for notification? What is the follow up procedure?". Documentation in the hospital's QAPI data revealed under the "TIER ONE" Audit, "24 Hours Audits of all cases will play a major role in finding deficiencies prior to our regular QAPI Audit. Audit Tools will be completed by each assigned personnel (whether Nurse, Social Services Staff, or Administrative Staff) to conduct select audits during the 24 hour period". Documentation in the hospital's QAPI data revealed "Charge Nurses will conduct 100% audits of charts each 24 hour period".

The medical record of Patient #7 was reviewed. This review revealed the patient was admitted to the hospital on 2/09/11 with an Axis I diagnosis of Dementia with Behavioral Disturbances. Review of the admission orders revealed an order dated 2/09/11 at 1:55 p.m. for a urinalysis. Review of the laboratory report revealed that the urinalysis was collected on 2/10/11 at 3:20 a.m. and the laboratory run time was 2/10/11 at 7:42 a.m. Results of the urinalysis indicated that the urine was cloudy with many white blood cells and the presence of bacteria. Review of the physician progress notes dated 2/11/11 revealed "Urine analysis shows evidence of urine tract infection". Review of the physician orders revealed an order dated 2/11/11 at 3:30 p.m. for the initiation of antibiotic therapy as Macrobid was started twice daily for 7 days. No documentation was found to indicate that the physician was notified of the results of the abnormal urinalysis on 2/10/11 which was the run date for the urinalysis.

S2 (Director of Nursing) and S3 (Registered Nurse) were interviewed on 2/28/11 at 1:45 p.m. S2 and S3 reviewed the medical record of Patient #7 and indicated that there was no documentation to indicate that the physician was notified of the results of the abnormal urinalysis on 2/10/11 which was the run date for the urinalysis

The Coordinator of Performance Improvement and Education (S10) and the Director of Nursing (S2) were interviewed on 3/01/11 at 12:50 p.m. A request was made for the 24 hour chart audits completed for Patient #7 for the dates of 2/09/11, 2/10/11 and 2/11/11 in an effort to determine if the hospital's QAPI audits had captured this delay in physician notification. S10 reported that she was unable to provide the 24 hour chart audits for the requested time period and stated that there was no indication that the audits had been done. S2 reported that the charge nurses failed to complete the 24 hour chart audits for the dates of 2/01/11 through 2/22/11 due to there being a miscommunication relating to who was going to be responsible for completing the 24 hours audits.

Based on record review and interview the hospital's medical staff failed to ensure it enforced it's bylaws by failing to ensure Medical Record were completed within 30 days of discharge for 47 of 47 delinquent records reviewed. Findings:

Review of the hospital's Medical Staff Bylaws, presented by the hospital as current, revealed in part, "(page 29) Medical Records: Members of the Medical Staff are required to complete medical records within 30 days of a patient's discharge. A temporary suspension in the form of withdrawal of admitting and other related Privileges until medical records are completed shall be imposed by the Medical Director, or his or her designee, after notice of delinquency for failure to complete medical records within that period." Further review revealed no time lines for notifying physicians of delinquent medical records regarding "notice of delinquency for failure to complete medical records" as indicated in the Medical Staff Bylaws and no timelines for "temporary suspension in the form of withdrawal of admitting and other related Privileges" as indicated in Medical Staff Bylaws.

Review of a handwritten list of delinquent medical records presented by Medical Records Secretary S4 revealed the 24 bed hospital had 47 delinquent Medical Records. Further review revealed 32 of the 47 delinquent records were greater than 30 days delinquent and 15 of the 47 delinquent Medical Records were greater than 60 days delinquent.

During a face to face interview on 3/01/2011 at 11:05 a.m., Medical Records Secretary S4 indicated there had been no formal system for ensuring Medical Records were completed. S4 indicated her practice had been to line up delinquent Medical Records on a shelf, track down physicians, and ask them to complete Medical Records. S4 indicated she (S4/ the only Medical Records employee) had never sent letters, email, or any formal documentation to physicians to alert them of delinquent Medical Records and had never known a physician on staff at the hospital to be suspended for failing to complete delinquent Medical Records.

During a telephone interview on 3/01/2011 at 3:20 p.m., Medical Director S8 indicated he (S8) believed suspension of physicians for delinquent Medical Records to be a "little rough"; however, he (S8) had reminded physicians of the need to complete Medical Records and would continue to remind them.

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Based on record reviews and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated each patient's care by failing to: 1) notify the physician of patients' refusal of medications for 2 of 2 patients who refused medications out of a total sample of 20 patients. (Patient #6 and Patient #12); 2) ensure the physician was notified of abnormal findings/changes in patient's condition for 2 of 20 sampled patients (Patient #7 regarding abnormal urinalysis results, Patient #20 regarding a 5 pound weight gain in one day). Findings:
1) Patient #6 : The medical record for Patient #6 was reviewed. Review of the History and Physical revealed Patient #6 was a 90 year old Vietnamese female admitted for the management of psychosis/aggressive combative behavior. Review of the Medication Administration records revealed Patient #6 refused the following medications on 02/22/11; Nexium 20mg, Century Vite Tablet, Folbic Tab, Vistaril 25mg, Macrodantin 50mg, Depakote, SR 250mg, Os-Cal500, Toprol XL 25mg at 9am and Depakote Sprinkles 500mg and K-Dur 20meq HS. There was no documented evidence in the patient's record the physician was notified of the patients refusal to take the medications. On 02/24/11, Patient #6 refused the following medications; Nexium 20mg, Century Vite Tablet, Folbic Tab, Vistaril 25mg, Macrodantin 50mg, Depakote, Sprinkles 500 mg, Os-Cal 500, Toprol XL 25mg at 9am and Depakote Sprinkles 500mg HS. There was no documented evidence in the patient's record the physician was notified of the patient's refusal to take the medications. On 02/27/11, Patient #6 refused the following medications; Nexium 20mg, Century Vite Tablet, Folbic Tab, Vistaril 25mg, Macrodantin 50mg, Depakote, Sprinkles 500 mg, Os-Cal 500, Toprol XL 25mg at 9am and Depakote Sprinkles 500mg HS. There was no documented evidence in the patient's record the physician was notified of the patient's refusal to take the medications.
S2, DON reviewed the medical record for Patient #6 and confirmed there was no documented evidence the physician was informed of the patient's non-compliance with the medication administration on 02/22/11, 02/24/11 and 02/27/11.
Patient #12: The medical record for Patient #12 was reviewed. Review of the Nursing Assessment dated 02/25/11 revealed Patient #12 was an 80 year old male admitted for Dementia with Behavioral Disturbances. Review of the Medication Administration records revealed Patient #12 refused the following medications on 02/27/11 at 9am; Tapazole 5 mg, Prilosec 20mg, Folic Acid 1 mg, Zyloprim 15mg, Keflex 500mg, Vitamin C, Toprol XL 25 mg ? tablet, Namenda 10 mg, Megace 40mg, Mucinex DM 30-600 ER, Cymbalta 60mg, and Carafate 10ml. There was no documented evidence in the patient's record the physician was notified of the patient's refusal to take the medications.
S2, DON reviewed the medical record for Patient #12 and confirmed on 02/28/11 at 2:50pm there was no documented evidence the physician was informed of the patient's non-compliance with the medication administration on 02/27/11.
The hospital had no policy for review addressing patients' non-compliance with medication administration.

2) Patient #7: Medical record review revealed the patient was admitted to the hospital on 2/09/11 with an Axis I diagnosis of Dementia with Behavioral Disturbances. Review of the admission orders revealed that the patient's medical history included Hypertension, Borderline Diabetes, and Arthritis. Further review of the admission orders revealed an order dated 2/09/11 at 1:55 p.m. for a urinalysis. Review of the laboratory report revealed that the urinalysis was collected on 2/10/11 at 3:20 a.m. and the laboratory run time was 2/10/11 at 7:42 a.m. Results of the urinalysis indicated that the urine was cloudy with many white blood cells and the presence of bacteria. Review of the physician progress notes dated 2/11/11 revealed "Urine analysis shows evidence of urine tract infection". Review of the physician orders revealed an order dated 2/11/11 at 3:30 p.m. for the initiation of antibiotic therapy as Macrobid was started twice daily for 7 days. No documentation was found to indicate that the physician was notified of the results of the abnormal urinalysis on 2/10/11 which was the run date for the urinalysis resulting in a one day delay in the initiation of antibiotic therapy.

S2 (Director of Nursing) and S3 (Registered Nurse) were interviewed on 2/28/11 at 1:45 p.m. S2 and S3 reviewed the medical record of Patient #7 and indicated that there was no documentation to indicate that the physician was notified of the results of the abnormal urinalysis on 2/10/11 which was the run date for the urinalysis.

Patient #20: Review of Patient #20's medical record revealed the patient was admitted to the hospital on 12/31/2010 with diagnoses that included Bipolar Disorder, Mitral Valve Prolapse, Hypertension, Gastroesophageal Reflux Disease, Type 2 Diabetes with Renal Insufficiency, Congestive Heart Failure, Neuropathy Secondary to Diabetes, and Chronic Venous Insufficiency. Further review revealed a physician's order dated 1/12/2011 with no documented time which indicated Patient #20 was to have his weight monitored daily and for the on-call cardiology physician to be notified in the patient had a weight gain of more than 3 pounds in one day or 5 pounds in 3 days. Review of Patient #20's Nursing Graphic Sheet revealed the patient (#20) weighed 228 pounds on 1/23/2011 and 233 pounds on 1/24/2011 (a weight gain of 5 pounds in one day). Review of the entire medical record revealed no documented evidence that the on-call cardiologist had been notified of the patient's (#20) weight gain of 5 pounds in one day.

During a face to face interview on 3/01/2011 at 3:20 p.m., Licensed Practical Nurse S9 indicated she (S9) had been assigned to Patient #20 on 1/24/2011 when the Medical Record indicated the patient had gained 5 pounds in one day. S9 confirmed there was no documented evidence of the patient's physician or cardiologist being notified of a weight gain of 5 pounds in one day. S9 initially indicated she (S9) had no memory of the patient (#20) or the weight gain. Later, during the same interview, S9 indicated she (S9) thought she (S9) had called the patient's primary care physician only to receive a message indicating voice mail was full and could hold no other messages. S9 indicated she (S9) had not called the cardiologist, as the physician's order indicated, because the cardiologist did not have privileges at the hospital. S9 indicated she (S9) did not notify the Registered Nurse on duty of Patient #20's acute change in condition (weight gain of 5 pounds in one day in a patient with Renal Disease and Heart Disease) so that a Registered Nurse assessment could be performed on Patient #20 nor did she (S9) inform anyone in administration that she(S9) had been unable to reach the patient's primary care physician because of full voice mail. S9 indicated she should have documented her attempt to reach Patient #20's primary care physician in the medical record, should have informed the Charge Nurse of the patient's change in condition, and should have alerted Administration of her inability to reach the patient's physician.

Based on record reviews and interview, the hospital failed to: 1) ensure the nursing staff developed interventions and measurable goals for a patient with behaviors of refusing medications for 2 of 2 patients refusing medications (Patient #6 and Patient #12) and for a patient who had a language barrier and required an interpreter to communicate for 1 of 1 patients with a language barrier (Patient ( #6) out of a total sample of 20 patients. Findings:
Patient #6
The medical record for Patient #6 was reviewed. Review of the History and Physical revealed Patient #6 was a 90 year old Vietnamese female admitted on 02/17/11 for the management of psychosis/aggressive combative behavior. Review of the Medication Administration records revealed Patient #6 refused the following medications on 02/22/11; Nexium 20mg, Century Vite Tablet, Folbic Tab, Vistaril 25mg, Macrodantin 50mg, Depakote, SR 250mg, Os-Cal500, Toprol XL 25mg at 9am and Depakote Sprinkles 500mg and K-Dur 20meq HS. There was no documented evidence in the patient ' s record the physician was notified of the patients refusal to take the medications. On 02/24/11 Patient #6 refused the following medications; Nexium 20mg, Century Vite Tablet, Folbic Tab, Vistaril 25mg, Macrodantin 50mg, Depakote, Sprinkles 500 mg, Os-Cal500, Toprol XL 25mg at 9am and Depakote Sprinkles 500mg HS. There was no documented evidence in the patient's record the physician was notified of the patient's refusal to take the medications. On 02/27/11 Patient #6 refused the following medications; Nexium 20mg, Century Vite Tablet, Folbic Tab, Vistaril 25mg, Macrodantin 50mg, Depakote, Sprinkles 500 mg, Os-Cal 500, Toprol XL 25mg at 9am and Depakote Sprinkles 500mg HS.
There was no documented evidence in the patient's Multidisciplinary Master Treatment Plan at review of the record on 02/28/11 interventions and goals were established and implemented for the patient's behavior of refusing medications.
S2, DON reviewed the medical record for Patient #6 and confirmed on 02/28/11 at 2pm Patient #6 ' s noncompliance with medication administration was not addressed and interventions and goals established and implemented for the patient's behaviors of refusing medications.
Further review of Patient #6's Social Service's Note dated 02/17/11 revealed in part, "Pt speaks Korean and it is difficult for the staff to communicate with her." Further review of the record revealed the LCSW was unable to determine the patient's mental status due to the language barrier and her inability to speak English. There was no documented evidence in the patient's Multidisciplinary Master Treatment Plan at review of the record on 02/28/11 interventions and goals were established and implemented for the patient's language barrier and her inability to speak English.
S2, DON reviewed the medical record for Patient #6 and confirmed on 02/28/11 at 2pm Patient #6's language barrier was not addressed in the Multidisciplinary Master Treatment Plan and interventions and goals established and implemented for the patient's inability to speak English.
S7, LCSW was interviewed face to face on 03/01/11 at 1pm. S7 indicated Patient #6 spoke Korean and he was unable to establish her mental status because of the language barrier. Further he had attempted to find an interpreter who could assess the patient for delusions and her orientation to person, place time date but the hospital was not budgeted to pay the $70.00 per hour fee. Further S7 indicated at this time Patient #6's language barrier was not addressed in the Multidisciplinary Master Treatment Plan and interventions and goals established and implemented for the patient's inability to speak English.
Review of the policy entitled "Treatment Planning" Policy #PP-018 presented as the hospital's current policy revealed in part, Procedure: C. By the 5th 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 interventions, responsible party for each intervention, and projective date of goal achievement. 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."

Patient #12
The medical record for Patient #12 was reviewed. Review of the Nursing Assessment dated 02/25/11 revealed Patient #12 was an 80 year old male admitted for Dementia with Behavioral Disturbances. Review of the Medication Administration records revealed Patient #12 refused the following medications on 02/27/11 at 9am; Tapazole 5 mg, Prilosec 20mg, Folic Acid 1 mg, Zyloprim 15mg, Keflex 500mg, Vitamin C, Toprol XL 25 mg ? tablet, Namenda 10 mg, Megace 40mg, Mucinex DM 30-600 ER, Cymbalta 60mg, and Carafate 10ml.
There was no documented evidence in the patient ' s Multidisciplinary Master Treatment Plan, at review of the record on 02/28/11, interventions and goals were established and implemented for the patient's behavior of refusing medications.
S2, DON reviewed the medical record for Patient #12 and confirmed on 02/28/11 at 2pm Patient #12's noncompliance with medication administration was not addressed and interventions and goals established and implemented for the patient's behaviors of refusing medications

Based on record review and interview the hospital failed to ensure:
1) patient's heart rate was monitored prior to the administration of Metoprolol as ordered by the patient's physician and indicated in the hospital's drug reference book for 1 of 1 patients reviewed receiving the medication Metoprolol out of a total sample of 20 (Patient # 17).
2) physician's orders were clarified when no parameters were ordered regarding when medication was to be administered by mouth versus intramuscularly for 2 of 20 sampled patients (#5, #15). Findings:

1) Review of Patient #17's medical record revealed the patient was admitted to the hospital on 12/26/2010 with diagnoses that included Major Depressive Disorder, Anxiety Disorder, Chronic Obstructive Pulmonary Disease, Hyperlipidemia, Positive Bronchitis, and Atherosclerosis. Further review revealed a physician's order dated 12/31/2010 at 10:30 a.m. for Metoprolol 12.5 milligrams by mouth two times per day; hold for blood pressure less than 90/60 or heart rate less than 60.

Review of the hospital's Drug Reference Book titled, "Nursing 2010 Drug Handbook" revealed on page 387; regarding administration of Metoprolol, "Nursing Considerations: Always check patient's apical pulse rate before giving drug. If it's slower than 60 beats/minute, withhold the drug and call prescriber immediately."

Review of Patient #17's entire medical record; to include Patient #17's Medication Administration Record, for the dates of 1/1/2011, 1/3/2011, and 1/4/2011 revealed no documented evidence of monitoring Patient #17's apical pulse prior to the administration of Metoprolol.

During a face to face interview on 3/01/2011 at 9:50 a.m., Director of Nursing S2 confirmed there was no documented evidence of nursing staff monitoring Patient #17's apical pulse prior to the administration of Metoprolol on 1/1/2011, 1/3/2011, and 1/4/ 2011. Director of Nursing S2 further indicated nursing staff should have monitored the patient's heart rate apically prior to the administration to ensure it did not drop below the rate of 60 as indicated by the patient's physician and the hospital's drug reference book.

2) Patient #5: Review of Patient #5's medical record revealed physician's orders dated 2/23/2011 at 1745 (5:45 p.m.) for Ativan 1 milligram by mouth every 6 hours as needed agitation or Ativan 1 milligram intramuscularly every 6 hours as needed for agitation. Review of the entire medical record revealed no documented evidence of physician ordered parameters to indicate when Ativan was to be administered by mouth versus when it was to be administered intramuscularly. Further review revealed no documented evidence of clarification of Patient #5's Ativan order regarding parameters as to when the patient was to receive Ativan by mouth and when the patient was to receive the medication intramuscularly.

Patient #15: Review of Patient #15's medical record revealed physician's orders dated 1/31/2011 at 8:15 a.m. for Ativan 0.5 milligrams by mouth or intramuscularly every six hours as needed agitation, 1/23/2011 with no documented time for Ativan 0.5 milligrams by mouth or intramuscularly every eight hours as needed agitation, and 1/24/2011 at 6:10 p.m. for Ativan 0.25 milligrams by mouth or intramuscularly every eight hours as needed for agitation. Further review of the entire medical record revealed no documented evidence of clarification of the above listed Ativan orders for Patient #15 regarding parameters as to when the patient was to receive Ativan by mouth and when the patient was to receive the medication intramuscularly.

During a face to face interview on 3/01/2011 at 9:50 a.m., Director of Nursing S2 confirmed that Patient #15 did not have any documented parameters to indicate when Ativan should be administered by mouth versus intramuscularly. S2 indicated nursing staff should have called the ordering physician for clarification of the medication order.

Review of the hospital policy titled, "Authentication of Drug Orders, #XV:09" presented by the hospital as their current policy revealed in part, "Orders for any medication, diagnostic test, or case management must be written out specific to the patient and status."

Based on record review and interview the 24 bed hospital failed meet the Condition of Participation for Medical Records Services by failing to ensure:
1) an effective system was in place to ensure Medical Records were completed within 30 days of discharge as required by the hospital's Medical Staff Bylaws for 47 of 47 delinquent records reviewed: 32 of the 47 delinquent records were greater than 30 days delinquent and 15 of the 47 delinquent records were greater than 60 days delinquent (See findings cited at A0438). Review of the hospital's Medical Staff Bylaws, presented by the hospital as current, revealed in part, "(page 29) Medical Records: Members of the Medical Staff are required to complete medical records within 30 days of a patient's discharge. A temporary suspension in the form of withdrawal of admitting and other related Privileges until medical records are completed shall be imposed by the Medical Director, or his or her designee, after notice of delinquency for failure to complete medical records within that period." Further review revealed no time lines for notifying physicians of delinquent medical records regarding "notice of delinquency for failure to complete medical records" as indicated in the Medical Staff Bylaws and no timelines for "temporary suspension in the form of withdrawal of admitting and other related Privileges" as indicated in Medical Staff Bylaws.

2) Medical Records Services were appropriate to the scope and complexity of the services performed by failing to ensure the Medical Records Department was supervised by a Medical Records Practitioner for 1 of 1 employee staffing the Medical Records Department of the hospital (S4) as per Louisiana Department of Health and Hospital's Hospital Licensing Standards, L0022/9387B which states, "Medical records shall be under the supervision of a medical records practitioner (i.e., registered record administrator or accredited record technician) on either a full-time, part -time or consulting basis (See findings cited at A0022 and A0432)."

3) Medical Records were properly filed and protected from water in the event that the sprinkler system were to be triggered for 6 of 6 cardboard boxes containing medical records stored in the Medical Records Storage Room (all stored in-patient medical records in the facility were located in these 6 cardboard boxes) and 34 of 34 Medical Records located in a locked Nursing Office (See findings cited at A0438).

Based on record review and interview the hospital failed to ensure Medical Records Services were appropriate to the scope and complexity of the services performed by failing to ensure the Medical Records Department was supervised by a Medical Records Practitioner for 1 of 1 employee staffing the Medical Records Department of the hospital (S4) as per Louisiana Department of Health and Hospital's Hospital Licensing Standards, L0022/9387B which states, "Medical records shall be under the supervision of a medical records practitioner (i.e., registered record administrator or accredited record technician) on either a full-time, part -time or consulting basis (See findings cited at A0022)." Findings:

Review of the personnel file for the only employee working in the Medical Records Department; Medical Records Secretary S4, revealed no documented evidence of having any training as a medical records practitioner to include training as a Registered Record Administrator or Accredited Record Technician.

During a face to face interview on 3/01/2011 at 9:00 a.m., Medical Records Secretary S4 confirmed that she had no specialized training in the field of Medical Records.

During a face to face interview on 3/01/2011 at 9:00 a.m., Director of Nursing S2 indicated she (S2) had plans to hire a Registered Health Information Administrator to oversee/supervise the Medical Records Department; however, the plan had not been implemented.

Based on record review and interview the 24 bed hospital failed to:
1) ensure an effective system was in place to ensure Medical Records were completed within 30 days of discharge for 47 of 47 delinquent records reviewed, and
2) ensure Medical Records were properly filed and protected from water in the event that the sprinkler system were to be triggered for 6 of 6 cardboard boxes containing medical records stored in the Medical Records Storage Room (all stored in-patient medical records in the facility were located in these 6 cardboard boxes) and 34 of 34 Medical Records located in a locked Nursing Office. Findings:

1) Review of a handwritten list of delinquent medical records presented by Medical Records Secretary S4 revealed the 24 bed hospital had 47 delinquent Medical Records. Further review revealed 32 of the 47 delinquent records were greater than 30 days delinquent and 15 of the 47 delinquent Medical Records were greater than 60 days delinquent.

During a face to face interview on 3/01/2011 at 9:00 a.m., Medical Records Secretary S4 indicated she (S4) did not keep a formal log regarding delinquent medical records; although she (S4) did keep an informal listing on her computer. S4 indicated there had been no tracking or trending of delinquent Medical Records at the hospital.

During a face to face interview on 3/01/2011 at 11:05 a.m., Medical Records Secretary S4 indicated there had been no formal system for ensuring Medical Records were completed. S4 indicated her practice had been to line up delinquent Medical Records on a shelf, track down physicians, and ask them to complete Medical Records. S4 indicated she (S4/ the only Medical Records employee) had never sent letters, email, or any formal documentation to physicians to alert them of delinquent Medical Records and had never known a physician on staff at the hospital to be suspended for failing to complete delinquent Medical Records.

Review of the hospital's Medical Staff Bylaws, presented by the hospital as current, revealed in part, "(page 29) Medical Records: Members of the Medical Staff are required to complete medical records within 30 days of a patient's discharge. A temporary suspension in the form of withdrawal of admitting and other related Privileges until medical records are completed shall be imposed by the Medical Director, or his or her designee, after notice of delinquency for failure to complete medical records within that period." Further review revealed no time lines for notifying physicians of delinquent medical records regarding "notice of delinquency for failure to complete medical records" as indicated in the Medical Staff Bylaws and no timelines for "temporary suspension in the form of withdrawal of admitting and other related Privileges" as indicated in Medical Staff Bylaws.

During a telephone interview on 3/01/2011 at 3:20 p.m., Medical Director S8 indicated he (S8) believed suspension of physicians for delinquent Medical Records to be a "little rough"; however, he (S8) had reminded physicians of the need to complete Medical Records and would continue to remind them.

2) Observations on 3/01/2011 at 9:00 a.m. revealed storage of Medical Records in the 24 bed hospital to be stored in 6 cardboard boxes located on top of wooden crates on the floor in the Medical Records Storage Room (all stored in-patient medical records in the facility were located in these 6 cardboard boxes) . Further observation revealed a sprinkler system located in the center of the ceiling. Observations revealed no protection of Medical Records from water damage should the sprinkler be activated. Further observations revealed an additional 34 medical records stored on open wooden shelves and desk tops in a locked nursing office with no protection from water should the sprinkler system in the office be triggered.

This finding was confirmed by Medical Records Secretary S4 on 3/01/2011 at 9:00 a.m. S4 further indicated Medical Records were stored in cardboard boxes based on the year of patient's admission to the hospital. S4 confirmed indicated the only filing system/containers at the facility for completed medical records was cardboard boxes. S4 indicated the hospital maintained about three years of medical records in the facility and the remainder had been sent to an outside Medical Record Storage facility. S4 indicated the reason 34 Medical Records were located in the locked Nursing Office, was because she had placed them there for nursing staff to review after she had processed them post patient discharge. S4 confirmed the Medical Records were not protected from the possibility of water damage should the sprinkler be triggered.

20638


Based on record review and interview, the hospital failed to ensure all patient medical record entries were legible, complete, dated, timed, and authenticated by the person making the entry. This was noted in the medical records for 10 of 20 sampled patients (#1, #2, #3, #4, #7, #12, #15, #16, #17, #18). Findings:Patient #1: Medical record review revealed physician orders dated 2/24/2011 and 2/27/2011 that were not timed by the ordering practitioner and physician progress notes dated 2/22/2011, 2/23/2011, 2/24/2011, 2/25/2011, and 2/27/2011 that were not timed. In an interview on 2/28/2011 at 11:15 a.m., Director of Nursing S2 confirmed that all entries had not been timed.
Patient #2: Review of the record for Patient #2 revealed the Physician's Progress Notes for 02/23/11, 02/24/11, 02/25/11, 02/26/11, 02/27/11, and 02/28/11 were not timed.
Patient #3: Medical record review revealed physician orders dated 2/27/11 that were not timed by the ordering practitioner and physician progress notes dated 2/25/11, 2/26/11, 2/27/11 and 2/28/11 that were not timed. In an interview on 2/28/11 at 1:10 p.m., S2 (Director of Nursing) confirmed that all entries are not timed.
Patient #4: Medical record review revealed physician orders dated 2/24/11 and 2/27/11 that were not timed by the ordering practitioner and physician progress notes dated 2/24/11, 2/26/11, 2/27/11 and 2/28/11 that were not timed. In addition, the psychiatric evaluation dated 2/24/11 was not timed and the psychosocial assessment dated 2/24/11 was not timed. In an interview on 2/28/11 at 1:10 p.m., S2 (Director of Nursing) confirmed that all entries are not timed.

Patient #7: Medical record review revealed physician orders dated 2/09/11, 2/15/11, 2/20/11, 2/24/11 that were not timed by the ordering practitioner and physician progress notes dated 2/10/11, 2/14/11, 2/15/11, 2/22/11, 2/23/11, 2/24/11 and 2/27/11 that were not timed. In an interview on 2/28/11 at 1:10 p.m., S2 (Director of Nursing) confirmed that all entries are not timed.

Patient #12: Review of the record for Patient #12 revealed the Physician's Progress Notes for 02/26/11 and 02/27/11 were not timed.

Patient #15: Medical record review revealed physician's progress notes dated 1/15/2011, 1/16/2011, 1/17/2011, 1/18/2011, and 1/20/2011 that were not timed. In an interview on 3/01/2011 at 9:50 a.m., S2 (Director of Nursing) confirmed that all entries were not timed and should be.

Patient #16: Medical record review revealed physician's progress notes dated 1/23/2011, 1/24/2011, 1/25/2011, 1/26/2011, 1/27/2011, 1/29/2011, 1/30/2011, and 1/31/2011 that were not timed. In an interview on 3/01/2011 at 9:50 a.m., S2 (Director of Nursing) confirmed that all entries were not timed and should be.

Patient #17: Medical record review revealed #17's Psychiatric Evaluation which was dictated on 12/28/2010 by Physician S13 and transcribed on 12/28/2010. Further review revealed no documented evidence of authentication by Physician S13 either through handwritten or electronic signature. In an interview on 3/01/2011 at 9:50 a.m., S2 (Director of Nursing) confirmed Physician S13's failure to authenticate the patient's Psychiatric Evaluation.

Patient #18: Medical record review revealed #18's Psychiatric Evaluation which was dictated on 12/28/2010 by Physician S13 and transcribed on 12/28/2010. Further review revealed no documented evidence of authentication by Physician S13 either through handwritten or electronic signature. In an interview on 3/01/2011 at 9:50 a.m., S2 (Director of Nursing) confirmed Physician S13's failure to authenticate the patient's Psychiatric Evaluation.

Review of the hospital policy titled, "Legible and Complete Medical Records, Errors, Late Entries, Verbal and Telephone Orders, Authentication of Orders, # XV:10" presented by the hospital as their current policy revealed in part, "All patient medical records entries are legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided."

Based on record review (patient medical records, medical staff bylaws) and interview, the hospital failed to ensure a medical history and physical examination (H&P) was completed, documented, and placed in the patients' medical records within 24 hours after admission by having H&Ps conducted and/or transcribed greater than 24 hours after admission. Findings:

Review of Patient #10's medical record revealed an admit date of 02/24/11. Further review revealed the H&P was dictated on 02/25/11 but was not filed in the record as of 02/28/11. This was confirmed by S2, DON on 02/28/11 at 2:50pm.


20638

Based on record review and interview the hospital failed to ensure radiology services were available to meet the needs of the patients on weekends for 1 of 20 sampled patients (Patient #16). Findings:

Review of the hospital's Radiology Contract revealed in part, "hereby agrees to provide at its sole cost and expense the following services: Scheduled routine services for client as needed Monday through Friday between the hours of 8:00 a.m. and 4:00 p.m. excluding weekends and holidays. . . will provide services within 24 hours of notification within the service days and times. All procedures performed outside of scheduled services hours are considered "emergency services or stat" and will be performed within 24 hours of notification."

Review of Patient #16's medical record revealed a physicians order dated 1/28/2011 (Friday) for an x-ray of the patient's left hip. Further review revealed the x-ray ordered on 1/28/2011(Friday) was not taken until 1/30/2011 (Sunday, 2 days after the x-ray had been ordered).

This finding was confirmed in an interview by Director of Nursing S2 on 3/01/2011 at 9:50 a.m. S2 further indicated the x-ray should have been taken within 24 hours of the date of order as indicated in the Radiology Contract.

Based on record review (employee personnel files) and interview, the hospital failed to have a full-time employee who was qualified to serve as the dietary manager. Findings:

Review of the active employee list revealed no documented evidence of a dietary manager.

S2, DON was interviewed face to face on 02/28/11 at 2:445pm. S2 indicated the registered dietitian is contracted and comes to the hospital regularly on consultant basis. She further indicated the full-time dietary manager is an employee of Nursing Home A and the hospital contracts dietary services with Nursing Home A.

Based on record review and interview the hospital failed to have a current therapeutic diet manual approved by the medical staff that was readily available to all medical , nursing and food service personnel. Findings:

Review of the hospital policy and procedure manuals revealed no current therapeutic diet manual approved by the medical staff that was readily available to all medical , nursing and food service personnel.

This was confirmed on 02/28/11 at 3:05pm who indicated she could not locate a dietary manual on the hospital premises so had gotten the manual from Nursing Home A adjacent to the hospital.

Based on observations and interviews, the hospital failed to maintain all facilities, supplies, and equipment in a manner to ensure an acceptable level of safety and quality. This was evidenced by failing to ensure that the building and equipment in all patient care areas were in good repair. Findings:

Observations on 2/28/11 between 9:40 a.m. and 10:30 a.m. revealed the following:

- Sections of rust and flaking paint were noted on the surface of the metal grid that was attached to the windows throughout the hospital (Affected areas included, but not limited to, Room #'s S17, S18, S19, S20). In addition, the bolts securing the metal grid to the window frame were noted to be loose in Room #S20.
- Sections of rust and flaking paint were noted on the door frames throughout the hospital (Affected areas included, but not limited to, Room #'s S17, S18, S19, S20).
- Sections of the panels were noted to be separating from the door frame on several doors throughout the hospital resulting in uneven surfaces and splintering wood. (Affected areas included, but not limited to, Room #'s S1, S2, S4).
- Sections of rust were noted on a wheelchair used to transport patients within the hospital.
- Sections of peeling sheetrock and flaking paint were noted on the ceiling in the bathroom in Room #S15.
- Four plastic bags containing soiled linen were noted on the floor (not in a leak proof container) in the soiled linen room.

In an interview at the time of the above observations, S3 (Registered Nurse) confirmed the above findings.

Based on record review (personnel file) and interview the hospital failed to ensure the Infection Control Officer was qualified through current ongoing education, training, experience and/or certification. Findings:

Review of the personnel file for S2, Director of Nursing/Infection Control Officer revealed no documented evidence of current educational training, experience or certification in the development of the Infection Control processes in hospitals in order to implement the Infection Control Program.

In a face to face interview on 03/02/11 at 8:45am S2, DON/Infection Control Nurse indicated she was not currently enrolled in ongoing educational training in infection control and her experience had been through direct patient care and as the DON in Long Term Care at her previous employment.

Based on record review and interview the hospital failed to ensure there was a qualified credentialed physician assigned as the Director of Respiratory Care Services. Findings:

Review of the hospitals files of Credentialed Physicians revealed no documented evidence of a qualified physician functioning as the Director of Respiratory Care Services.

During a face to face interview on 3/01/2011 at 3:30 p.m., Director of Nursing S2 and Administrative Assistant S11 indicated there had been no physician assigned to the position of Director of Respiratory Care Services at the hospital. Director of Nursing S2 confirmed there were patients in the hospital that received supplemental oxygen and/or nebulizer treatments.

Based on record reviews and interview, the hospital failed to: 1) ensure the nursing staff developed measurable goals for a patient with behaviors of refusing medications for 2 of 2 patients refusing medications (Patient #6 and Patient #12) and for a patient who had a language barrier and required an interpreter to communicate for 1 of 1 patients with a language barrier (Patient ( #6) out of a total sample of 20 patients. Findings:
Patient #6
The medical record for Patient #6 was reviewed. Review of the History and Physical revealed Patient #6 was a 90 year old Vietnamese female admitted on 02/17/11 for the management of psychosis/aggressive combative behavior. Review of the Medication Administration records revealed Patient #6 refused the following medications on 02/22/11; Nexium 20mg, Century Vite Tablet, Folbic Tab, Vistaril 25mg, Macrodantin 50mg, Depakote, SR 250mg, Os-Cal500, Toprol XL 25mg at 9am and Depakote Sprinkles 500mg and K-Dur 20meq HS. There was no documented evidence in the patient ' s record the physician was notified of the patients refusal to take the medications. On 02/24/11 Patient #6 refused the following medications; Nexium 20mg, Century Vite Tablet, Folbic Tab, Vistaril 25mg, Macrodantin 50mg, Depakote, Sprinkles 500 mg, Os-Cal500, Toprol XL 25mg at 9am and Depakote Sprinkles 500mg HS. There was no documented evidence in the patient's record the physician was notified of the patient's refusal to take the medications. On 02/27/11 Patient #6 refused the following medications; Nexium 20mg, Century Vite Tablet, Folbic Tab, Vistaril 25mg, Macrodantin 50mg, Depakote, Sprinkles 500 mg, Os-Cal 500, Toprol XL 25mg at 9am and Depakote Sprinkles 500mg HS.
There was no documented evidence in the patient's Multidisciplinary Master Treatment Plan at review of the record on 02/28/11 measurable short and long term goals were established for the patient's behavior of refusing medications.
S2, DON reviewed the medical record for Patient #6 and confirmed on 02/28/11 at 2pm Patient #6's noncompliance with medication administration was not addressed and contained no measurable short and long term goals for the patient's behaviors of refusing medications.
Further review of Patient #6's Social Service's Note dated 02/17/11 revealed in part, "Pt speaks Korean and it is difficult for the staff to communicate with her." Further review of the record revealed the LCSW was unable to determine the patient's mental status due to the language barrier and her inability to speak English. There was no documented evidence in the patient's Multidisciplinary Master Treatment Plan at review of the record on 02/28/11 that measurable short and long term goals were established for the patient's language barrier and her inability to speak English.
S2, DON reviewed the medical record for Patient #6 and confirmed on 02/28/11 at 2pm Patient #6's language barrier was not addressed in the Multidisciplinary Master Treatment Plan and interventions and goals established and implemented for the patient's inability to speak English.
S7, LCSW was interviewed face to face on 03/01/11 at 1pm. S7 indicated Patient #6 spoke Korean and he was unable to establish her mental status because of the language barrier. Further he had attempted to find an interpreter who could assess the patient for delusions and her orientation to person, place time date but the hospital was not budgeted to pay the $70.00 per hour fee. Further S7 indicated at this time Patient #6's language barrier was not addressed in the Multidisciplinary Master Treatment Plan and interventions and goals established and implemented for the patient's inability to speak English.
Review of the policy entitled "Treatment Planning" Policy #PP-018 presented as the hospital's current policy revealed in part, Procedure: C. By the 5th 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 interventions, responsible party for each intervention, and projective date of goal achievement. 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."

Patient #12
The medical record for Patient #12 was reviewed. Review of the Nursing Assessment dated 02/25/11 revealed Patient #12 was an 80 year old male admitted for Dementia with Behavioral Disturbances. Review of the Medication Administration records revealed Patient #12 refused the following medications on 02/27/11 at 9am; Tapazole 5 mg, Prilosec 20mg, Folic Acid 1 mg, Zyloprim 15mg, Keflex 500mg, Vitamin C, Toprol XL 25 mg ? tablet, Namenda 10 mg, Megace 40mg, Mucinex DM 30-600 ER, Cymbalta 60mg, and Carafate 10ml.
There was no documented evidence in the patient's Multidisciplinary Master Treatment Plan, at review of the record on 02/28/11, measurable short and long term goals were established for the patient's behavior of refusing medications.
S2, DON reviewed the medical record for Patient #12 and confirmed on 02/28/11 at 2pm Patient #12's noncompliance with medication administration was not addressed and interventions and goals established and implemented for the patient's behaviors of refusing medications

Based on record reviews and interview, the hospital failed to: 1) ensure the nursing staff developed interventions with specific treatment modalities to be utilized for a patient with behaviors of refusing medications for 2 of 2 patients refusing medications (Patient #6 and Patient #12) and for a patient who had a language barrier and required an interpreter to communicate for 1 of 1 patients with a language barrier (Patient ( #6) out of a total sample of 20 patients. Findings:
Patient #6
The medical record for Patient #6 was reviewed. Review of the History and Physical revealed Patient #6 was a 90 year old Vietnamese female admitted on 02/17/11 for the management of psychosis/aggressive combative behavior. Review of the Medication Administration records revealed Patient #6 refused the following medications on 02/22/11; Nexium 20mg, Century Vite Tablet, Folbic Tab, Vistaril 25mg, Macrodantin 50mg, Depakote, SR 250mg, Os-Cal500, Toprol XL 25mg at 9am and Depakote Sprinkles 500mg and K-Dur 20meq HS. There was no documented evidence in the patient ' s record the physician was notified of the patients refusal to take the medications. On 02/24/11 Patient #6 refused the following medications; Nexium 20mg, Century Vite Tablet, Folbic Tab, Vistaril 25mg, Macrodantin 50mg, Depakote, Sprinkles 500 mg, Os-Cal500, Toprol XL 25mg at 9am and Depakote Sprinkles 500mg HS. There was no documented evidence in the patient's record the physician was notified of the patient's refusal to take the medications. On 02/27/11 Patient #6 refused the following medications; Nexium 20mg, Century Vite Tablet, Folbic Tab, Vistaril 25mg, Macrodantin 50mg, Depakote, Sprinkles 500 mg, Os-Cal 500, Toprol XL 25mg at 9am and Depakote Sprinkles 500mg HS.
There was no documented evidence in the patient's Multidisciplinary Master Treatment Plan at review of the record on 02/28/11 interventions with specific treatment modalities were established and implemented for the patient's behavior of refusing medications.
S2, DON reviewed the medical record for Patient #6 and confirmed on 02/28/11 at 2pm Patient #6's noncompliance with medication administration was not addressed to include interventions with specific treatment modalities for the patient's behaviors of refusing medications.
Further review of Patient #6's Social Service's Note dated 02/17/11 revealed in part, "Pt speaks Korean and it is difficult for the staff to communicate with her." Further review of the record revealed the LCSW was unable to determine the patient's mental status due to the language barrier and her inability to speak English. There was no documented evidence in the patient's Multidisciplinary Master Treatment Plan at review of the record on 02/28/11 interventions with specific treatment modalities were established and implemented for the patient's language barrier and her inability to speak English.
S2, DON reviewed the medical record for Patient #6 and confirmed on 02/28/11 at 2pm Patient #6's language barrier was not addressed in the Multidisciplinary Master Treatment Plan and interventions with specific treatment modalities established and implemented for the patient's inability to speak English.
S7, LCSW was interviewed face to face on 03/01/11 at 1pm. S7 indicated Patient #6 spoke Korean and he was unable to establish her mental status because of the language barrier. Further he had attempted to find an interpreter who could assess the patient for delusions and her orientation to person, place time date but the hospital was not budgeted to pay the $70.00 per hour fee. Further S7 indicated at this time Patient #6's language barrier was not addressed in the Multidisciplinary Master Treatment Plan and interventions with specific treatment modalities established and implemented for the patient's inability to speak English.
Review of the policy entitled "Treatment Planning" Policy #PP-018 presented as the hospital's current policy revealed in part, Procedure: C. By the 5th 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 interventions, responsible party for each intervention, and projective date of goal achievement. 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."

Patient #12
The medical record for Patient #12 was reviewed. Review of the Nursing Assessment dated 02/25/11 revealed Patient #12 was an 80 year old male admitted for Dementia with Behavioral Disturbances. Review of the Medication Administration records revealed Patient #12 refused the following medications on 02/27/11 at 9am; Tapazole 5 mg, Prilosec 20mg, Folic Acid 1 mg, Zyloprim 15mg, Keflex 500mg, Vitamin C, Toprol XL 25 mg ? tablet, Namenda 10 mg, Megace 40mg, Mucinex DM 30-600 ER, Cymbalta 60mg, and Carafate 10ml.
There was no documented evidence in the patient's Multidisciplinary Master Treatment Plan, at review of the record on 02/28/11, interventions with specific treatment modalities were established and implemented for the patient's behavior of refusing medications.
S2, DON reviewed the medical record for Patient #12 and confirmed on 02/28/11 at 2pm Patient #12's noncompliance with medication administration was not addressed nor were interventions with specific treatment modalities established and implemented for the patient's behaviors of refusing medications