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Based on observation and interviews the facility failed to provide confidentiality of the clinical telemetry information for 4 of the 4 sampled patients ( SP #14, #15, #21 and #25) in the Intensive Care Unit (ICU). The findings :

1. An initial visit was conducted of the ICU on August 18, 2015 at approximately 11:10 a.m. with the Chief Nursing Officer (CNO) during this observation and tour of the ICU. The CNO explained the patients in the ICU have cardiac monitoring on a continuum during their hospital stay in the unit. The ICU is divided into two sections (ICU Rooms 1-4 on the left section and and ICU Rooms 5-8 on the right section), Each section has a nursing station with telemetry/cardiac monitors. The names of sampled patients (SP) #14, #15, #21 and #25 were displayed on the monitors. The monitor screen contained clinical information including cardiac rate and a cardiac rhythm display.
The CNO commented the screens are available at the nurses station for ease of the nurse to monitor the condition of the patient. During the visit this surveyor stood to the right side of the nursing station in the hall adjacent to the monitor. During this observation it was possible to visualize the names and clinical information of each ICU patient and room number. The CNO continued to explain the screens are for the nurses to visualize and the family would not enter behind the nurses area.
2. On 08/19/2015 at approximately 10:00 a.m. outside of ICU room 4 an observation was conducted of the nursing station for rooms 1-4. At this time the hospital staff were observed either in the medication room or the station for rooms 5-8. At this time the nurses station was unsupervised and the monitor and nursing station was accessible. 3. An observation on 08/19/2015 at 10:15 a.m. was conducted. The Respiratory Director was assisting a staff member outside ICU room #4. The staff members access a computer located in a charting area /alcove located between ICU room #3 and ICU room #4. When asked the Respiratory Director explained the computer program visualized on the screen was for entering patient charges. The screens included the patient names, diagnostics tests, and equipment used in the care of SP #14. The screen did not have a confidentiality screen and information was visualized from the nursing station.

4. An observation was conducted on 08/20/2015 in the morning 11:45 a.m. in the ICU nursing station (ICU Rooms 1-4) area. The telemetry monitoring was visualized with the names of SP #14, 15, #21, and #25. During multiple random visits to both nursing stations in the ICU community visitors were observed at the both nursing stations during the survey.

Based on record review and interview, the facility failed to ensure that patient rights was not violated for 1 of 27 sampled patients (SP) # 24.

The findings:
Review of facility's policy "Restraint Usage" dated 02/15, showed that the practitioner will initiate a time-limited order for restraints that may not exceed 24 hours.
Review of SP # 24 "Physical Restraint Orders" form show that the order expires 24 hours after initiated.
Review of SP# 24 medical record show that the patient had a restraint order initiated on 04/25/15 at 10:00 AM. The next restraint order was initiated on 04/26/15 at 1:00 PM. Review of the nursing 24 hour care record showed that SP# 24 remained in restraints on 04/26/15 from 10:00 AM through 1:00 PM without a restraint order.
On 08/20/15 at 6:30 PM the Chief Clinical Officer stated that there was a short period that the patient was in restraints without an order.

Based on medical staff interview, medical record review and the facility bylaws , the facility failed to ensure healthcare providers enforced the bylaws in completing the medical records for 19 ( #1, #2, #3, #5, #6, #7, #8, #9, #11,#13, #14, #16, #17, #18, #20, #21, #23, #25 #26) of the 27 sampled patient's record reviewed.


The findings:
1. A review if the Medical Staff Bylaws was conducted with the Chief of Staff. In Section 10.6 on page 65 of the 2015 Medical Executive Committee Approved Bylaws contains the following:"Each medical record entry shall conclude with the legible signature of the provider, indicating the provider ' s professional credential, and shall be dated and timed. Medical records which have illegible or incomplete signatures, including date and time, will be deemed incomplete..."

An interview was conducted with the Chief of the Staff on 08/20/2015 at 12:20 p.m. During this interview with the physician, he verified his position as the Chief of Medical Staff. The Chief of Staff was asked to review a physician Progress Note dated 08/13/2015 for Sampled Patient (SP) #8.
An additional medical record review for SP #8 revealed a consultation note was not dated and did not include the time of the signature. The note contained a physician signature but was not dated and did not contain a time when the physician reviewed the Progress Note. The Chief of Staff was asked, what is the expectation of the medical staff regarding the date, time, and signature, according to the Medical Staff Bylaws? The Chief of Staff stated "This is considered incomplete. Every record entry requires a signature legible signature date and time." The Chief of Staff commented that is not complete and the physicians know what the expectation is for the medical record entries." 2. Review of sampled patient #6 medical record contain physician's Consultation dictated on 06/26/2015 which did not include a date and time of the physician signature.
3. Review of sampled patient #7 medical record contain physician's progress notes dictated on 06/12/2015, 07/17/2015 and 07/21/2015 which did not include a date and time of the physician signature.
4. Review of the sampled patient #9 medical record contain physician's progress notes dictated on 07/17/2015, 07/18/2015 and 07/20/2015 which did not include a signed date and time.


5. Review of sampled patient #14 medical record contain physician's Consultation notes dictated on 07/09/2015, which did not contain a physician signature date or time. A Consultation note was also dictated on 07/25/2015, which was signed but not dated or timed.




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6. Review of sampled patient # 13 medical record shows that the physician's progress notes dated 06/18/2015, 06/19/2015, 06/21/2015, and 06/20/2015 were signed but not dated showing when the notes were signed.

7. Review of sampled patient # 23 medical record show that the physician's progress notes dated 04/18/2015, 04/19/2015, 04/20/2015, 04/21/2015,04/22/2015,04/23/2015, 04/24/2015, 04/25/2015, 04/27/2015, 04/28/2015, 04/29/2015, 04/30/2015, 05/01/2015, were signed but not dated showing when the notes were signed.



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8. Record review for sampled patient #1 revealed a history and physical dictated 05/15/2015, physician's progress notes dictated 05/15/2015, 05/17/2015, 05/27/2015, 05/28/2015, and 05/29/2015, and a discharge summary dictated 06/17/2015. These documents were signed by the physicians, but not dated or timed to indicate when they were signed.

9. Record review for sampled patient #2 revealed a history and physical dictated 7/11/2015, physician's progress notes dictated 07/13/2015, 07/14/2014, 07/15/2015, 07/16/2015, 07/17/2015, 07/18/2015, 07/19/2015, 07/20/2015, 07/21/2015, 07/22/2015, 07/23/2015, 07/24/2015, 07/29/2015, 07/30/2015, and 07/31/2015 and a discharge summary dictated 08/04/2015. These documents were signed by the physicians, but not dated or timed to indicate when they were signed.

10. Record review for sampled patient #3 revealed a discharge summary dictated on 06/27/2015. This document was signed by the physician, but not dated or timed to indicate when it was signed.

11. Record review for sampled patient #5 revealed physician's progress notes dictated 05/18/2015, 05/19/2015, 05/20/2015, 05/21/2015, 05/22/2015, 05/27/2015, and 05/28/2015, a Neurology Consultation dictated 05/19/2015, and a discharge summary dictated 06/17/2015. These documents were signed by the physicians, but not dated or timed to indicate when they were signed.

12. Record review for sampled patient #26 for hospital stay from 04/16/2015 through 04/30/2015 with a history and physical dictated 04/17/2015, physician's progress notes dictated 04/18/2015, 04/19/2015, 04/20/2015, 04/21/2015, 04/21/2015, 04/22/2015, 04/23/2015, 04/25/2015, 04/27/2015 04/28/2015, 04/29/2015, and 04/30/2015, and an Infectious Disease Consultation dictated 04/20/2015.

Review of patient #26's medical record for hospital stay from 05/11/2015 through 06/02/2015 revealed a history and physical dictated 05/12/2015, physician's progress notes dictated 05/21/2015, 05/28/2015 and 06/02/2015 and a discharge summary dictated 06/17/2015. These documents were signed by the physicians, but not dated or timed to indicate when they were signed.



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13. Review of (SP) #17 medical record revealed a dictated Infectious Disease (ID) consultation report on 05/28/2015 that contained the physician's signature with no date of when it was signed.
14. Review of (SP) #18 medical record revealed a dictated Neurology consultation report on 04/29/2015 and a dictated Cardiology consultation report on 04/25/2015 that contained the physician's signatures with no date of when it was signed.
15. Review of (SP) # 20 revealed a dictated consultation report on 06/05/2015 that contained the physician's signature with no date of when it was signed.
16. Review of (SP) #21 medical record revealed a dictated cardiology consultation report on 06/04/2015 a dictated consultation report on 06/04/2015 06/06/2015, 06/07/2015, a dictated Infectious Disease ( ID ) consultation report on 06/12/2015,that contained the physician's signature with no date of when it was signed.


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17. Record review of SP# 11 medical record showed that the Physician progress notes were handwritten and illegible.
18. Record review of SP# 16 medical record showed that the H&P(history and physical) and Discharge Summary were handwritten and illegible.
19. On 08/20/15 at 8:45 AM, record review of SP# 25 showed that physician orders were not dated or timed when written.

Based on staff interview and record review the facility failed to ensure the care plans were appropriately developed, and updated to reflect the interdisciplinary care needs for 5 of the 27 sampled patients (SP) #5, #7, #9, #13, #14) medical records reviewed.


The findings:


1. The record review for Sampled Patient #7 reveal this patient had a diagnosis of respiratory distress and required the placement of a tracheotomy (A airway tube placed through a surgical incision at the base of throat in the trachea). The care plan review revealed the tracheotomy was not identified as a problem under the "Ineffective Breathing" section of the care plan. This section does include "Ineffective airway clearance" but does not mention the tracheotomy.
The section entitled "Altered in Skin Integrity" includes "Pressure Ulcer" but does not include the tracheotomy. The CNO verified the tracheotomy was not listed and commented the tracheotomy could have been listed under the section for surgical or stoma. The CNO commented the tracheotomy might have been place under the section "Problem" as a hand written entry on the care plan. The CNO commented the tracheotomy care and skin care around the tracheotomy was offered by the nursing and respiratory staff.

2. A review of the medical record for Sampled Patient #9 revealed this patient was admitted to the facility on 07/14/2015 for acute respiratory failure. The patient condition was determined as terminal and the patient expired on 07/19/2015. The review of the Interdisciplinary Care Plan contained one section completed for "Knowledge Deficit" and a section entitled "Activity Intolerance" was identified for a problem with endurance an shortness of breath. The care plan was reviewed with the CNO and she stated the care plan was "not complete' and was not indicative if the problems, goals or interventions needed for care.

3. A visit to the Intensive Care Unit (ICU) was conducted on 08/19/2015 at approximately 11:15 a.m. During this tour an observation was conducted of ICU Room #4, Sampled Patient #14 (SP#14) was observed in the hospital bed with tube feeding and respiratory ventilation equipment was visualized. A Interdisciplinary Care Plan review for SP#14 was completed on 08/20/2014. The section of the care plan entitled "Actual or Risk for Alteration in Nutrition" was blank (without entries) for the "tube feedings", The CNO verified the patient was receiving Tube Feedings and commented the care plans "need some help".

An interview was conducted with the Chief Nursing Officer on 08/20/2015 at 10:10 a.m. regarding the Interdisciplinary Care Plans for sampled patients #7, #9 and #14.




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4. Review of sampled patient #13 medical record show that the patient was admitted with a primary diagnosis of pneumonia on 06/16/2015. The progress notes show the patient was on intravenous antibiotics. Review of the LTAC(Longterm care acute care) Interdisciplinary Plan of Care show that the patient was not care planned for infections.


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5. Record review revealed sampled patient #5 was admitted to the facility on 05/15/2015. Review of the discharge summary dictated on 06/17/2015 revealed patient #5 had multiple diagnoses including Cellulitis, Urinary Tract Infection (UTI), and Perianal Cellulitis. Review of a Data Collection Tool for Wounds dated 05/18/2015 revealed wounds including sacral redness, perianal redness, heel redness, and skin tears to the right forearm and left upper arm. Review of the LTAC (Long Term Acute Care) Interdisciplinary Plan of Care revealed the care plans were implemented on 05/16/2015 and reviewed on 05/25/2015 and 05/31/2015. The care plan indicated patient #5 had the potential for infection, but did not indicate the Urinary Tract Infection or the Cellulitis. The care plan titled "Altered Skin Integrity" was blank.

During interview with the Chief Clinical Officer (CCO) on 08/20/15 at 5:52 PM, she said the Cellulitis would be addressed on the skin integrity care plan, not the infection care plan. Review of the clinical record with the CCO confirmed there was no care plan in place to address the UTI, Cellulitis or altered skin condition. She verified that the skin integrity care plan was blank and and stated she would have to speak to the nurses to make them understand this is a working tool, not just a piece of paper in the record.

Based on record review and staff interview, the facility failed to ensure medical records were complete, dated and timed for twenty-one sampled patients (SP) #1, #2, #3, #4, #5, #6, #7, #8, #9, #11, #12, #13, #14, # 16, #17, #18, #20, #21, #23, #25, #26); and were legible for two (SP# 16 and #11) of twenty seven medical records reviewed.



The findings:

1. Record review for sampled patient #1 revealed a history and physical dictated 05/15/2015, physician's progress notes dictated 05/15/2015, 05/17/2015, 05/27/2015, 05/28/2015, and 05/29/2015, and a discharge summary dictated 06/17/2015. These documents were signed by the physicians, but not dated or timed to indicate when they were signed.

Record review for sampled patient #1 revealed the IAA (Initial Admission Assessment) Social Services/Case Management form was dated 05/16. The assessment did not indicate the year it was completed. The assessment indicated patient #1 has no advanced directives. The section which indicated if information was provided; the patient declined opportunity; and/or the patient completed advanced directives was not completed. The section titled "Discharge Information" was dated 6/01, but no year was indicated.
2. Record review for sampled patient #2 revealed a history and physical dictated 7/11/2015, physician's progress notes dictated 07/13/2015, 07/14/2014, 07/15/2015, 07/16/2015, 07/17/2015, 07/18/2015, 07/19/2015, 07/20/2015, 07/21/2015, 07/22/2015, 07/23/2015, 07/24/2015, 07/29/2015, 07/30/2015, and 07/31/2015 and a discharge summary dictated 08/04/2015. These documents were signed by the physicians, but not dated or timed to indicate when they were signed.

Record review for sampled patient #2 revealed the " patient rights " form was signed by the patient's spouse, but the form was not dated to indicate when it was received and signed. The IAA Social Services/Case Management form was dated 07/11 and the section titled "Discharge Information" was dated 07/31, but no year was indicated.

3. Record review for sampled patient #3 revealed a discharge summary dictated 06/27/2015. This document was not signed by the physician.

4. Record review for sampled patient #5 revealed physician's progress notes dictated 05/18/2015, 05/19/2015, 05/20/2015, 05/21/2015, 05/22/2015, 05/27/2015, and 05/28/2015, a Neurology Consultation dictated 05/19/2015, and a discharge summary dictated 06/17/2015. These documents were signed by the physicians, but not dated or timed to indicate when they were signed.
Record review for sampled patient #5 revealed the IAA Social Services/Case Management form was dated 05/18. The assessment did not indicate the year it was completed. The assessment indicated patient #5 has no advanced directives. The section which indicated if information was provided; the patient declined opportunity; and/or the patient completed advanced directives was not completed. The section titled "Discharge Information" was dated 6/02, but no year was indicated.


5. Record review for sampled patient #26 for hospital stay from 04/16/2015 through 04/30/2015 with a history and physical dictated 04/17/2015, physician's progress notes dictated 04/18/2015, 04/19/2015, 04/20/2015, 04/21/2015, 04/21/2015, 04/22/2015, 04/23/2015, 04/25/2015, 04/27/2015 04/28/2015, 04/29/2015, and 04/30/2015, and an Infectious Disease Consultation dictated 04/20/2015. Review of patient #26's medical record for hospital stay from 05/11/2015 through 06/02/2015 revealed a history and physical dictated 05/12/2015, physician's progress notes dictated 05/21/2015, 05/28/2015 and 06/02/2015 and a discharge summary dictated 06/17/2015. These documents were signed by the physicians, but not dated or timed to indicate when they were signed.

6. During interview with the Director of Social Services (DSS) on 8/14/15 at approximately 7:00 PM, she said she usually puts the full date on the assessments. It is difficult without electronic medical records. I should put the year when I date my notes. In reference to the advanced directive section she reported "I take the advanced directive information into the room each time I complete an assessment. I should document on my assessment that I have offered them the service because" The DSS confirmed there is a place on the assessment to check whether the information was provided, declined, or completed.



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7. Review of sampled patient # 13 medical record show that the physician's progress notes dated 06/18/2015, 06/19/2015, 06/21/2015, and 06/20/2015 were signed but not dated showing when the notes were signed. Review of sampled patient # 13, "IAA Social Services/ Case Management" form, show the patient did not have any advanced directives. The forms show a check mark indicating " no " for advance directives. The form did not show that one of the following was checked: if information was provided; the patient declined opportunity; and/or the patient completed advanced directives.

8. Review of sampled patient # 23 medical record show that the physician's progress notes dated 04/18/2015, 04/19/2015, 04/20/2015, 04/21/2015,04/22/2015,04/23/2015, 04/24/2015, 04/25/2015, 04/27/2015, 04/28/2015, 04/29/2015, 04/30/2015, 05/01/2015, were signed but not dated showing when the notes were signed. Review of sampled patient # 23, " IAA Social Services/ Case Management" form, show the patient did not have any advanced directives. The forms show a check mark indicating " no " for advance directives. The form did not show that one of the following was checked: if information was provided; the patient declined opportunity; and/or the patient completed advanced directives.

On 08/20/2015 at 3:15 pm the Case Manager/Vice President of Physician Relations, Director of Admissions, and Social Services confirmed that the section for advance directives on the " IAA Social Services/ Case Management" form was not completed for sampled patient #13 and # 23.


9. On 08/20/2015 at 10:05 am, the Case Manager/Vice President of Physician Relations, Director of Admissions, and Social Services stated , the section for advance directives on the " IAA Social Services/ Case Management" form should show if the patient/family member have any advanced directives by a check mark for either "yes" or "no". If the answer is "no" , then one of the following should be checked: if information was provided; the patient declined opportunity; and/or the patient completed advanced directives.




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10. Review of sampled patient #4 Initial Social services/case management form on 05/01/2015 revealed that the patient did not have any Advanced Directives and would like some more information. Review of the form revealed that the box for: " If NO, INFORMATION PROVIDED" was not checked.
On interview with the social worker/case manager, on 08/20/2015 at 6: 03 PM, she confirmed that the patient did not have Advanced Directives at the time of the assessment. The patient asked for more information to be given to him, and that information was provided to the patient. She revealed that she should have checked the box for:" If NO, INFORMATION PROVIDED" on the form to show that the information was provided.
11. Review of (SP) #17 medical record revealed a dictated Infectious Disease (ID) consultation report on 05/28/2015 that contained the physician's signature with no date of when it was signed.
12. Review of (SP) #18 medical record revealed a dictated Neurology consultation report on 04/29/2015 and a dictated Cardiology consultation report on 04/25/2015 that contained the physician's signatures with no date of when it was signed.
13. Review of (SP) #20 revealed a dictated consultation report on 06/05/2015 that contained the physician's signature with no date of when it was signed.
14. Review of (SP) #21 medical record revealed a dictated cardiology consultation report on 06/04/2015 a dictated consultation report on 06/04/2015 06/06/2015, 06/07/2015, a dictated Infectious Disease (ID) consultation report on 06/12/2015,that contained the physician's signature with no date of when it was signed.

15. Record review of SP# 11 medical record showed that the Physician progress notes were handwritten and illegible. The date on the IAA Social Service/Case Management form was not complete. The year that the form was signed is not indicated.
16. Record review of SP# 12 showed that the date on the IAA Social Service/Case Management form is not complete. The year that the form was signed is not indicated.
17. Record review of SP# 16 medical record showed that the H&P(history and physical) and Discharge Summary were handwritten and illegible.

18. Record review of SP# 25 medical record show that photos documenting wound progression were not dated.
On 08/20/15 at 8:45 AM, record review of sampled patient (SP) # 25 medical record show that an" Informed Consent to Surgery/Special Procedures/Anesthesia" consent form was completed by the physician on 07/22/14 at 1:20 PM. The procedure that the consent was executed for is not documented on the form. The form was signed by the proxy, but there is no date or time that indicates when it was signed.
On 08/20/15 at 6:30 PM the Chief Clinical Officer stated that she is not sure as to why the consent is not completed. She stated that this is an issue that she will follow up on to ensure that it doesn't happen again.
19. Review of Patient Rights in the Patient Handbook stated that the patient has a right to complete and understandable information from your physician concerning your diagnosis, treatment, procedure, outcome and complications.



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20. An interview was conducted with the Chief of the Staff on 08/20/2015 at 12:20 p.m. During this interview with the physician, he verified his position as the Chief of Medical Staff. The Chief of Staff was asked to review a physician Progress Note dated 08/13/2015 for Sampled Patient (SP) #8.
An additional medical record review for SP #8 revealed a consultation note was not dated and did not include the time of the signature. The note contained a physician signature but was not dated and did not contain a time when the physician reviewed the Progress Note. The Chief of Staff was asked, what is the expectation of the medical staff regarding the date, time, and signature, according to the Medical Staff Bylaws? The Chief of Staff stated "This is considered incomplete. Every record entry requires a signature legible signature date and time." The Chief of Staff commented that is not complete and the physicians know what the expectation is for the medical record entries." 21. Review of sampled patient #6 medical record contain physician's Consultation dictated on 06/26/2015 which did not include a date and time of the physician signature.
22. Review of sampled patient #7 medical record contain physician's progress notes dictated on 06/12/2015, 07/17/2015 and 07/21/2015 which did not include a date and time of the physician signature.
23. Review of the sampled patient #9 medical record contain physician's progress notes dictated on 07/17/2015, 07/18/2015 and 07/20/2015 which did not include a signed date and time.


24. Review of sampled patient #14 medical record contain physician's Consultation notes dictated on 07/09/2015, which did not contain a physician signature date or time. A Consultation note was also dictated on 07/25/2015, which was signed but not dated or timed.


25. A review if the Medical Staff Bylaws was conducted with the Chief of Staff. In Section 10.6 on page 65 of the 2015 Medical Executive Committee Approved Bylaws contains the following: "Each medical record entry shall conclude with the legible signature of the provider, indicating the provider ' s professional credential, and shall be dated and timed. Medical records which have illegible or incomplete signatures, including date and time, will be deemed incomplete..."

Based record review and interview, the facility failed to properly execute an informed consent for 1 of 27 sampled patients (SP) # 25.
The findings:
Review of Patient Rights in the Patient Handbook stated that the patient has a right to complete and understandable information from your physician concerning your diagnosis, treatment, procedure, outcome and complications.
On 08/20/15 at 8:45 AM, record review of sampled patient (SP) #25 medical record show that an" Informed Consent to Surgery/Special Procedures/Anesthesia" consent form was completed by the physician on 07/22/14 at 1:20 PM. The procedure that the consent was executed for is not documented on the form. The form was signed by the proxy, but there is no date or time that indicates when it was signed.
On 08/20/15 at 6:30 PM the Chief Clinical Officer stated that she is not sure as to why the consent is not completed. She stated that this is an issue that she will follow up on to ensure that it doesn't happen again.

Based on staff interview and record review the facility failed to secure medications brought in from home for one of the sampled patient (SP#8) of the 27 patient's sampled for medication review.


The findings:

A medical record review and medication reconciliation was conducted on 08/20/2015 for sampled patient #8 at 3:00 p.m. The Medication (medication) requested by MD in Pyxis Room". An interview was conducted with ICU Nurse B at approximately 3:10 p.m. The nurse stated the wife was elderly and was unable to communicate the medications her husband SP #8 was taking at home prior to this hospital admission. The ICU Nurse explained the wife brought in the containers of medications and these were stored in the locked medication room. The nurse denied the medications that were brought in were inventoried by the staff. The nurse denied the medications were listed or counted on each shift to ensure the medication was maintained in an accurate and safe manner. The ICU Nurse did admit the medications from home were readily available on the counter for any staff member with access to the medication room.

A review of the Hospital Policy entitled "Patient Home Medications" Policy Number "PS.69 with an approval date of 03/15 was conducted on 08/20/2015. The procedure section contains the following:"Procedure: *Nursing:
1. Encourage the family member, significant other, or guardian to take the medications home.2. If a family member cannot take medications home: inventory the medications on the "Home Medication Inventory" form, and deliver to Pharmacy as soon as possible.
a. Complete patient name, account number, date admitted, and physicianb. List all medications by name strength and quantity
3. Deliver medications and inventory to the Pharmacy.4. Sign the inventory form.

* Pharmacy:
1. Upon receipt of medications and "Home Medication Inventory" form review for completeness.
2. Accurately count all controlled substances prior to nursing personnel leaving. Seal Vial /package with tamper tape and initial by Pharmacist.
3. Sign Inventory form.
4. Hand a copy of the "Home Medication Inventory" form to the Nursing personnel.
5. Seal the medications in a plastic bag and affix the "Home Medication Inventory" form to the outside of the package.
6. Log the required information in the home meds. log.
7. Store home medications in the designated area within Pharmacy.

The ICU Nurse commented this policy was not followed.

Based on observation, interview and staff interview, the facility failed to ensure therapeutic diets were provided in accordance with physician's orders for one (SP #15) of one patient receiving food by mouth out of a total census of four patients. This was evidenced by failure to provide liquids at honey thickened consistency as ordered.

The findings:

1.Observation on 8/10/15 at approximately 12:40 PM revealed a Registered Nurse (RN) deliver a lunch tray to sampled patient #15. The tray contained pureed food as ordered. The beverages included iced tea which was pre-thickened in the kitchen prior to delivery and a unopened 8 ounce carton of fat free milk which was not thickened. The tray contained four packets of food thickener. The instructions on the commercial food thickener were to add 2 packets for each 4 ounces of liquid to reach a honey thickened consistency.

The RN placed the tray at the bedside, but did not add the thickener to the milk prior to leaving the room.

2. Observation on 08/18/2015 at approximately 1:00 PM revealed a family member at the bedside feeding patient #15. The family member poured the milk into a glass and added one packet of thickener. After stirring the product into the milk, he added a portion of a second packet. After mixing the thickener into the milk, he offered the beverage to patient #15. The milk was slightly thickened, but did not appear to be honey consistency. All four packages of thickener were not added.

3. Record review for sampled patient #15 revealed a diet order dated 08/17/2015 for a Cardiac diet, Pureed with Honey Thickened Liquids

4. During interview with the family member (patient #15's cousin) on 08/20/2015 at approximately 1:05 PM, he said had some experience with thickening liquids because he used to thicken them for his mother. He said for his cousin, he just added enough thickener so he could feel that the milk was a little thicker than regular milk. When asked if he had been trained by staff to thicken the liquids to honey thick consistency, he responded "no" stating that his cousin had been receiving a tube feeding for about six weeks and had just started to eat by mouth yesterday.

5. During interview with the Registered Nurse (staff B) on 08/19/2015, she said the nurse who delivers the tray is responsible for thickening all liquids at the time the tray is delivered if they are not thickened in the kitchen. We do try to educate patients and family members on the procedure in the event they are discharged on thickened liquids. Staff B confirmed the milk for patient should have been thickened when the tray was delivered and the family had not been educated on the procedure.

6. During interview with the Registered Dietitian (RD) on 08/20/15 at 11:39 AM, She said the protocol for provision of thickened liquids to patients has been for dietary to thicken any open items (iced tea/coffee) and if the liquid is closed (milk, juice) we sent the item closed with the correct number of thickener packets to reach the proper consistency based on volume of the item and consistency ordered. The nursing staff is responsible for thickening the closed items at the bedside. The thickener product is also available on the units for use by nursing and ST (speech therapy) is responsible for training patients/families regarding procedures for thickening liquids as appropriate.

7. Review of the Food and Nutrition Services Policy and Procedure Manual approved 02/27/2015 revealed there was no policy and procedure in place to address the provision of thickened liquids. This was verified by the RD.

Based on observation and staff interview the facility failed to ensure the work room in the Intensive Care Unit (ICU) was locked to provide a safe and secure environment in a manner to protect the patients, staff and visitors population in the ICU.

The findings:

On 08/2015 at 10:05 a.m. a visit to the Intensive Care Unit (ICU) was conducted accompanied by the Chief Nursing Officer. A clean work room located in the ICU hallway was observed open (without locked entry). The CNO commented that the surveyors could enter as the door was not locked. Inside the room was a phlebotomy carry tray. The tray contained syringes, syringe needles and laboratory blood collection tubes. The room contained a warmer for bathing towelettes. The warmer temperature was observed at 125 degrees. The Director of Respiratory Therapy was available for interview and he explained the large tool box contained respiratory equipment including respiratory scopes and equipment used for difficult intubation procedures. The director verified the door was always open for easy access to the equipment.

Observation and entry into this room was made by the surveyors on 08/19/2015 and 08/20/2015 at various times in the morning, afternoon and evening.
Observations and entry was conducted into this room was made when community visitors were in the hallway and making their way to the patient rooms in the ICU.

Based on observation, interview, and record review the facility failed to ensure the Infection Control Program provide interventions that include cleaning and sanitizing of a multi-user device glucometer for two (SP# 14 and SP# 25) sampled patients; the sanitizing of the dial stem food thermometers; the cleaning of the microwave ovens, ice machine, and refrigerators; the preparation of one patient (SP # 15) medications of 2 sampled patients under sanitary conditions. The facility failed to provide thermometer gauges in the kitchen and ICU (Intensive Care Unit) refrigerators; and the facility failed to ensure there is no improper storage in the ICU medication refrigerator.

The findings:

1. During the medication administration observation on 08/19/2015 at 10:06 am for sampled patient #15 showed the registered nurse retrieved the following medications from the Pyxis: Furosemide 10 mg/ml, Famotidine 20 mg tablet, Folic Acid 1 mg tablet, Labetalol 100 mg tablet, Lactobacillus Acidoph/Bulgaricus 1 tablet, Multivitamin 5 ml, Triple Antibiotic ointment 30 gm, Quetiapine Fumarate 50 mg tablet, Silver Sulfadiazine 1% cream 50 gm. The nurse then placed two medicine cups on the counter. The nurse than opened each tablet and placed one in one of the medicine cup on the counter, then took the other cup off the counter and placed it over the opened medication in the first cup. The nurse then crushed the medication. The nurse repeated this for each tablet.

On 08/19/2015 at the Nurse confirmed the above findings. She stated that I do it that way so I can make sure the patient get all of the medications.



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2. A visit to each floor was conducted on 08/19/2015 at 9:11 a.m accompanied by the Chief Nursing Officer (CNO). The Intensive Care Unit medication room refrigerator was opened by the staff. The refrigerator did not have a temperature gauge to determine appropriate temperatures. A "Cath Flow" and a sterile water vial was observed in the refrigerator. The Director of Pharmacy was outside the med room and stated this was "not normally stored in the refrigerator.
3. At 10:12 the ICU refrigerator was opened and dark unknown particles were observed on the refrigerator shelves. The microwave was opened and dried dark particle were noted on the microwave revolving plate and door. The top inside surface of the microwave was observed with dried dark particles. The ICU ice machine catch plate was with dark particles. An ICU staff member was asked who was in charge of cleaning these food preparation equipment and refrigerator. The staff member stated "housekeeping". An interview with a member of the housekeeping staff was conducted at 10:21 a.m. The staff member stated it was not on her list to clean and she stated it was nursing responsibility. the CNO verified the refrigerator, ice and microwave food are used for both patients and visitors.

4. Review of the facility's Super Sani-Cloth Germicidal Disposable Wipe Technical Bulletin showed that some organisms are removed from the surface by thoroughly wiping the surface with the wipe. Most remaining organisms are killed within two minutes by exposure to the liquid in the wipe. Multi-Drug Resistant Bacteria must be exposed to the liquid for two minutes.
On 08/18/15 at 11:30 a.m., observation showed that the glucometer used for SP# 14 was cleaned with a Super Sani-Cloth Germicidal Disposable Wipe for approximately 5 seconds before and after use.
On 08/18/15 at 11:50 a.m., observation showed that the same glucometer was cleaned with a Super Sani-Cloth Germicidal Disposable Wipe for approximately 5 seconds before use for SP# 25 who is on contact precautions for Multi-drug Resistant Bacteria. The glucometer was taken into the room and placed on a table that was not cleaned prior to placing the glucometer on the table. It was removed from the table and placed on the clean protective barrier to perform the blood glucose testing. After the test was completed the glucometer was wiped for approximately 5 seconds and placed into the container for transport. The glucometer was then placed in the charger in the medication room.
On 08/20/15 at 8:45 a.m., record review of SP# 25 chart showed that upon admission labs were collected on 07/03/15 at 3:42 p.m.. Results showed that SP# 25 was positive for Methicillin Resistant Staphylococcus Aureus (MRSA) and Enterobacter Cloacae (CRE). Labs collected on 08/07/15 at 08:17 a.m. showed that SP# 25 was positive for MRSA and Pseudomonas Aeruginosa.
On 08/18/15 at 12:05 p.m. Staff B stated that the proper way to clean equipment using the Super Sani-Cloth Germicidal Disposable Wipe is to wipe the surface for about 10 seconds and let it air dry.
An interview was conducted with the Chief Nursing Officer (CNO) and Chief Executive Officer (CEO) on 08/18/2015 at 12:20 p.m. The CNO commented the glucometer would be pulled from service and each surface area in contact with the contaminated glucometer would be cleaned using the appropriate contact wet time including the suitcase -like container for the glucometer. The CNO verbalized the equipment is cleaned with the purple top Sani -Wipe and then left to air dry. The CEO stated "That is about a 2 minute process from start to finish." The label information was reviewed with the CNO and she stated "we will do whatever it takes". Later in the afternoon the CNO was Observed at the nursing station providing an instructional service to the nurses and nursing aides regarding the cleaning of equipment and the appropriate use of the Sani-Wipe as a sanitizer/disinfectant.
At approximately 5:40 p.m. on 08/18/2015 an interview with the CNO was conducted. She stated instructions for the appropriate cleaning was conducted on the day shift and will be conducted for night shift until 100% of the staff had completed the training.
On 08/19/2015 an interview with the Director of Respiratory was conducted at approximately 11:00 a.m. He commented the respiratory equipment was cleaned and kept "juicy" and wet for at least 2 minutes and left to air dry. He explained that if needed additional wipes are used to keep the equipment wet for the 2 minute timeframe. He explained once the equipment was dry a clear plastic bag was placed over the equipment indicating that piece of equipment was "cleaned and ready for use."A review was conducted on 08/19/2015 at 8:30 a.m. of the hospital policy entitled "Glucose Monitoring, Bedside Point of Care Testing" approval date February 2015, on page number 5 includes : "Safety, Maintenance, and Cleaning"
Maintain standard precautionsRemove, clean, and dry test strip holder daily and as necessary with warm water. Clean the lens area and contact point with a cotton swab dampened with tap water. Do not scratch the lens or get water inside the meter. Clean the exterior surface of the meter with the manufacturers' recommended agent after each usage.replace batteries when the status screen indicates low battery."
A review of the Respiratory Therapy Policy entitled "Equipment and Cleaning, Respiratory Equipment" approval date 12/14 was reviewed at 9;00 a.m. on 08/20/2015. The policy includes: on page 1 the following: "Procedure: Only clean equipment is stored in the clean equipment area. Clean equipment will be covered with a clear plastic bag to ensure cleanliness. Equipment is not to be stored on or immediately around the sink to avoid contamination from the water. All other equipment that is not or cannot be cleaned immediately after use is covered in a red bag and placed in the dirty equipment area... All agents and or procedures used for cleaning, disinfecting, or sterilizing equipment must be approved by the Infection Control Committee
Page 2: Shared patient equipment shall be wiped down using hospital approved wipe between uses.

On 08/19/15 at 2:20 p.m., the Chief Clinical Officer was interviewed regarding the infection control program and to evaluate the hospital acquired infections. A review of the tracking and trending information graphic and reports were conducted. The reports and graphics indicate the hospital did not experience hospital acquired infections and the CNO stated that she had no hospital acquired infections to date.
On 08/20/15 at 1:40 p.m., the Chief Clinical Officer stated that hospital acquired infections are those not present on admission but present after three days during the hospital stay.



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5.Observation during an initial tour of the kitchen on 08/18/2015 beginning at 9:17 AM revealed a single door reach in refrigerator used for storage of potentially hazardous food items including milk. The exterior built in thermometer registered 43 degrees Fé and there was no thermometer inside the unit. Observation in the ICU (Intensive Care Unit) at approximately 10:00 AM revealed individual yogurts stored in a refrigerator dated 08/11/2015. The Chef (staff M) confirmed the refrigerator was stocked with food for patient consumption and stated the yogurt should have been removed. Staff M said dietary is responsible for rotating the stock in the refrigerator.

Review of the Food and Nutrition Service policy and procedure titled "Storage", approved February 2015 revealed refrigerated food shall be stored at or below 41 degrees Fé. Thermometers are maintained in all refrigerators and freezers. Food shall be dated with the date received and the "use by" or "expiration date". Personnel look for and follow "use by" or "expiration" dates.


6. The microwave located in this area contained food splatter on the interior base, sides and top of the unit. Staff M confirmed the microwave was used to heat food for patients. Staff M said she thought housekeeping was responsible for cleaning the microwave.

7. Observation on 08/18/2015 beginning at approximately 11:50 AM, revealed the chef (staff M) preparing a lunch tray for delivery to the nursing unit. The Chef removed food from a heat source and used a food processor to blenderize sausage with beans, rice, and a vegetable medley to a pureed consistency. Once blenderized, the Chef removed a dial stem thermometer from a protective sleeve. The dial stem thermometer was not sanitized prior to use. Staff M stated she had sanitized the thermometer earlier. Staff M was observed placing the tip of the thermometer into each food item. The temperatures of the entree, starch and vegetable registered between 110 and 120 degrees Fahrenheit (Fé). The food items were placed into a warmer set at 180 degrees. Staff M continued to check the food temperatures placing only the tip of the dial stem thermometer into the food items. The food were reheated on the stove, but when tested with the dial stem thermometer they continued to register between 110-120 degrees Fé. The Sausage and beans were observed to be boiling when removed from the stove, but registered 120 degrees Fé when tested. The thermometer was placed into ice water and registered 32 degrees Fé. This process was repeated three times when the Registered Dietitian instructed staff M to dispose of the food and prepare an alternate meal. Staff M repeated the procedure blenderizing roast pork, rice, and green beans to a pureed consistency. Again, only the tip of the dial stem thermometer was placed into each food item.

During interview with staff M on 8/18/2015 at approximately 12:20 PM, she stated the thermometer was calibrated because it was at 32 degrees Fé when placed into the ice water. She continued to say she did not understand why the food was not hot enough. When asked if she knew where the sensor was located on the dial stem thermometer, she said she was not sure. When asked if there was any portion of the thermometer that had to be immersed into the food, she said she did not understand the question. When asked if she was aware the dial stem thermometer had a dimple (sensor), she said no. She continued to take food temperatures immersing only the tip of the dial stem into the food until corrected by the facility RD. Only after intervention was staff M able to demonstrate proper technique using the dial stem thermometer to ensure proper temperatures.

Observation on 08/18/2015 at approximately 12:15 PM revealed the Chef (staff L) checking the temperature of the pork, rice, and green beans selected as the alternate meal for sampled patient #15. These food items were being held on the cafeteria steam table. She was observed to place entire length of the dial stem into the food including the protective sleeve used to hold the thermometer. The sleeve which had not been sanitized was immersed into each food item.

During interview with the RD on 08/20/15 at 11:11 AM, she revealed the dietary staff receives an initial orientation to the facility and the department. The competency evaluations are done at 90 days and then annually unless needed sooner. In-service training is done minimally monthly and as needed. On Monday, the first day of the survey I did an in-service on proper use of thermometers and temperature monitoring. This in-service has not been scheduled yet, but due to the concerns on Monday the in-service was conducted for all 3 cooks the same day. The in-services included a post test and a sign in sheet. As part of the in-service related to thermometer use, I also covered proper food temperatures.

During interview with the RD on 08/20/15 at 12:20 PM, she confirmed that all refrigeration units should have thermometers maintained inside each unit. They have been purchased and placed in all units.


Review of a Food and Nutrition Service policy and procedure titled "Food Preparation" approved February 2015 revealed food is cooked and/or reheated to required temperatures. Food shall be cooked to heat all parts of the food to an internal temperature for a time that is at least 165 degrees Fé or above for 15 seconds.

Review of in-service material titled "Correct Use of Thermometers dated 11/08 revealed the importance of a thermometer is to assure that foods are cooked, served and stored at proper temperatures and to help prevent food-borne illness related to ability to check temperatures with the thermometer. Manufacturer's guidelines will state how far to insert the thermometer, where the indentation (sensing device) is located and how long to leave in the product. Review of the manufacturer's instructions for using an instant read, bimetal (dial stem) thermometer revealed speed 15-20 seconds, placement 2-2/1/2 deep in the thickest part of the food. Be sure the thermometer is placed in the thickest part of the food and that the small "eye" on the stem is placed in the food whose temperature you are taking.

Based on interview and record review the facility failed to ensure that the initial evaluations were completed on a timely basis for 2 sampled patients (SP) # 17, and # 19 of 27 medical records reviewed.
The findings:
1. Review of sampled patient (SP# 17) medical record revealed that the patient was admitted on 05/22/2015, the initial Social Services / Case Manager assessment was completed on 05/27/2015 (5 days after admission).
The Social Worker/ Case Manager on 08/20/2015 at 2: 36 PM confirmed that the initial social worker assessment was completed 5 days after the patient's admission to the hospital. She added that she could not complete the assessment prior to that date because when she went to see the patient the day before, the patient was sleeping.
2. Review of sampled patient (SP# 19) medical record revealed that the patient was admitted on 05/22/2015, the initial Social Services / case manager assessment was completed on 05/26/2015 (4 days after admission).
The Social Worker/ Case Manager on 08/20/2015 at 2: 29 PM confirmed that the initial social worker assessment was completed 4 days after the patient ' s admission to the hospital. She added that the patient was admitted on Friday 05/22/2015 at 9:00 PM, she had up to 72 hours not including weekends to do the assessment.
The hospital policy revealed: The case manager (CM) should meet each patient and family the day of admission or within 24 hours and 72 - hours for weekend admissions and provide them with an explanation of the role of case manager. The CM should perform an InterQual admission assessment forty-eight (48) hours post admission and verify that the patient meets appropriate continued stay requirements.

Based on record review and interview the facility failed to ensure the rehabilitation services are appropriate to the scope of the services offered in 3 sampled patients (#1, # 2, #3) of 27 medical records reviewed.

The findings:

1. Review of the Rehabilitation Therapy Services Agreement show (the [named] agency has an agreement with the facility) is a rehabilitation therapy services provider that employs therapy personnel who furnish physical and occupational therapy and speech-language pathology services to inpatients of the hospital. The agreement further state that [named ] will provide rehabilitation services to patients of the Hospital pursuant to this agreement upon [named] receipt of a request or referral, or when require by applicable law, a written order of an attending physician.



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2. Record review for sampled patient #1 revealed a physician's order dated 05/15/2015 for a PT/OT (Physical Therapy/Occupational Therapy) evaluation. Review of the closed medical record revealed no documentation to indicate an OT evaluation was completed. There was no OT evaluation on file in the medical record.

During interview via telephone with the Director of Rehabilitation Services on 08/20/2015 at 5:07 PM, he said there may have been an order for the OT evaluation to be discontinued and for PT to take over the upper extremity treatment. He said there should be an order to discontinue the OT evaluation.

Review of patient #1's medical record with the Chief Clinical Officer (CCO) confirmed there was no physician's order to discontinue the OT evaluation.


3. Record review for sampled patient #2 revealed a PT evaluation dated 07/10/2015. The documentation indicated patient #2 received skilled PT services from 07/10/2015 through 07/31/2015. Patient #2 was discharged from the facility on 08/01/2015. Review of the physician's orders revealed no orders for skilled PT evaluation and treatment. The PT discharge summary on file in the medical record was blank. Review of a Neurology Consultation dictated on 07/11/2015 revealed a plan which included PT, PT, and ST (Speech Therapy) evaluation and treatment to continue. There were no orders on file for patient #2 to received any of these skilled therapy modalities.

During interview via telephone with the Director of Rehabilitation Services on 08/20/2015 at 5:15 PM, he said there should be a physician's order for the physical therapy evaluation and treatment. He said maybe the physician just asked me to do an evaluation on this patient and I did not write the verbal order. He said the discharge summary is usually done the next day if it is during the week. If the patient is discharged on a Friday, the discharge summary is done on Monday. He had no explanation for the discharge summary being blank. He said "I guess the discharge summary on the patient is missing". In reference to the Neurology Consult indicating the patient should continue to receive PT, OT and ST services, he stated the primary physician is the person who orders the therapy. The admitting physician will write the therapy orders. The specialist may think the patient is receiving a therapy that has not been ordered.

During interview with a Registered Nurse (staff B) on 08/20/2015 at 5:51 PM, she said if there is a physician's order a referral is made to therapy, but the note written by the Neurologist was just a progress note, not an order for therapy.

During interview withe the COO on 08/20/2015 at 5:55 PM, she stated the attending physician should have reviewed the results of the Neurology consult and the addressed the notation regarding the PT. OT and ST.


4. Record review for sampled patient #3 revealed a physician's order for a PT evaluation dated 06/02/2015. The PT evaluation was dated 06/01/2015. Documentation indicated patent #3 received services from 06/01/2015 through 06/08/2015.
During interview via telephone with the Director of Rehabilitation Services on 08/20/2015 at 5:36 PM, he said he has to have a physician's order before conducting a PT evaluation. I can do a screening without an order, but not an evaluation. I may complete a screening and then request an order. Maybe I put the wrong date on the evaluation.
Review of patient #3's medical record with the CCO confirmed the PT evaluation was dated 06/01/2015 and the physician's order was received 06/02/2015.

Review of a Rehab Care policy and procedure titled "Physician's Orders", dated 09/01/2014 revealed "the therapist visually confirms that an order to evaluate and treat exists in the medical record before initiating the evaluation and treatment. If there is an evaluation order only, an order to treat must be obtained before treating the patient.

Based on record review and staff interview, the facility failed to ensure orders for physical therapy were written by the practitioner responsible for the care of the patient for 2 ( SP#2, and # 3) out of twenty seven medical records reviewed.

The findings:


1. Record review for sampled patient #2 revealed a PT evaluation dated 07/10/2015. The documentation indicated patient #2 received skilled PT services from 07/10/2015 through 07/31/2015. Patient #2 was discharged from the facility on 08/01/2015. Review of the physician's orders revealed no orders for skilled PT evaluation and treatment.

During interview via telephone with the Director of Rehabilitation Services on 08/20/2015 at 5:17 PM, he said there should be a physician's order for the physical therapy evaluation and treatment. He said maybe the physician just asked me to do an evaluation on this patient and I did not write the verbal order.

Review of patient #2's medical record by the CCO confirmed there was not an order for the PT services that were provided.

2. Record review for sampled patient #3 revealed a physician's order for a PT evaluation dated 06/02/2015. The PT evaluation was dated 06/01/2015. Documentation indicated patent #3 received services from 06/01/2015 through 06/08/2015.
During interview via telephone with the Director of Rehabilitation Services on 08/20/2015 at 5:36 PM, he said he has to have a physician's order before conducting a PT evaluation. I can do a screening without an order, but not an evaluation. I may complete a screening and then request an order. Maybe I put the wrong date on the evaluation.
Review of patient #3's medical record with the CCO confirmed the PT evaluation was dated 06/01/2015 and the physician's order was received 06/02/2015.
Review of a Rehab Care policy and procedure titled "Physician's Orders", dated 09/01/2014 revealed "the therapist visually confirms that an order to evaluate and treat exists in the medical record before initiating the evaluation and treatment. If there is an evaluation order only, an order to treat must be obtained before treating the patient.

Based on interview, and record review the facility failed to ensure the Occupational Therapy (OT) services were provided as ordered by the physician and documented in the patient's medical record for 4 sampled patients (SP) # 1, # 2, # 4, and # 13) of 27 medical records reviewed.
The findings:
1. Review of the Facility's policy revealed that all therapists must have a physician's order (s) before initiating the evaluation of the patient.

Review of sampled patient (SP # 4)revealed an admission physician order for OT (Occupational Therapy) evaluation on 04/29/2015.There was no documentation in the patient's medical record that the OT services were provided.
The Rehabilitation Director on 08/20/2015 at 5:31 pm, via a telephone interview stated that the patient was seen by the Physical therapist but not by OT.
The Director of Nursing (DON) on 08/20/2015 at 5: 30 pm, also confirmed that there was an order for the patient to receive OT services but there was no documentation that the services were provided and there was no order to discontinue the OT services.



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2. Review of sampled patient # 13 medical record show a physician's order for PT (physical Therapy) and OT (Occupational Therapy) evaluation. Review of the medical record did not show the patient was evaluated by an Occupational Therapist.

On 08/20/2015 at 6:30 pm via telephone the Director of Physical Therapy confirmed that there was no OT (Occupational Therapy) evaluation completed for sampled patient # 13, and there were no orders to discontinue the OT evaluation.


3. Review of the Rehabilitation Therapy Services Agreement show (the [named] agency has an agreement with the facility) is a rehabilitation therapy services provider that employs therapy personnel who furnish physical and occupational therapy and speech-language pathology services to inpatients of the hospital. The agreement further state that [named ] will provide rehabilitation services to patients of the Hospital pursuant to this agreement upon [named] receipt of a request or referral, or when require by applicable law, a written order of an attending physician.








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4. Record review for sampled patient #1 revealed a physician's order dated 05/15/2015 for a PT/OT (Physical Therapy/Occupational Therapy) evaluation. Review of the closed medical record revealed no documentation to indicate an OT evaluation was completed. There was no OT evaluation on file in the medical record.

During interview via telephone with the Director of Rehabilitation Services on 08/20/2015 at 5:07 PM, he said there may have been an order for the OT evaluation to be discontinued and for PT to take over the upper extremity treatment. He said there should be an order to discontinue the OT evaluation.

Review of patient #1's medical record with the Chief Clinical Officer (CCO) confirmed there was no physician's order to discontinue the OT evaluation.

5. Record review for sampled patient #2 revealed a PT evaluation dated 07/10/2015. The documentation indicated patient #2 received skilled PT services from 07/10/2015 through 07/31/2015. Patient #2 was discharged from the facility on 08/01/2015. The PT discharge summary on file in the record was blank.

During interview via telephone with the Director of Rehabilitation Services on 08/20/2015 at 5:17 PM, he said the discharge summary is usually done the next day if it is during the week. If the patient is discharged on a Friday, the discharge summary is done on Monday. He had no explanation for the discharge summary being blank. He said "I guess the discharge summary on the patient is missing".

Review of the medical record with the CCO the PT discharge summary was blank.