HospitalInspections.org

Based on review of facility policy, medical records, observation and interviews with facility staff, it was determined the facility failed to ensure the nursing staff:

1. Re-assessed 2 of 5 patients with altered skin integrity

2. Followed physician orders for wound care for 3 of 5 patients with wound care orders

3. Followed facility policy and documented care provided to Central Venous Access (CVC) devices for 1 of 1 record reviewed for a patient with a CVC.

4. Perform and document weights as ordered for 1 of 1 patients reviewed.



These deficient practices affected 5 of 21 in patient records reviewed, which included Medical Record (MR) # 1, 2, 7, 9, 12 and had the potential to negatively affect all patients admitted to this facility.


Findings include:

Facility policy:

Title: Wound Care: Care of the Patient with Loss of Skin Integrity, Skin Care and Wound Care

Effective date: 03/11
Revision Date: 5/14

I. Purpose: The purpose of this policy is to provide a plan of care for a patient whose skin assessment reveals abnormalities.

II. Scope: This policy applies to situations where the patient's primary nurse has assessed the patient's skin and found a loss of skin integrity. This applies to patients who are admitted with chronic wounds from home or possibly a loss of skin integrity. This policy outlines protocols used to treat Moisture Associated Dermatitis, skin tears, diabetic foot ulcers and pressure ulcers. The protocols are not intended to treat chronic dermatological conditions, or surgical wounds...

VI. Types of Wounds
...C. Pressure Ulcer ...

Stage II Pressure Ulcer: Partial thickness loss of dermis presenting as a shallow open ulcer with a red, pink wound bed, without slough ...

... VII. Procedure:

A. The patient's primary nurse will institute the appropriate wound care protocol when a skin abnormality is discovered. The protocol will be chosen based on the appearance of the wound as well as its location and history.
B. The licensed nurse will differentiate between the different types of loss of skin integrity. He/she will document the appearance of the skin/loss of skin integrity...
C. The nurse will document the following in the electronic chart: Size: (If able) Length x (by) width x depth in cm (centimeters)...
... D. The nurse will then choose the appropriate protocol for the skin care
The Wound Care Nurse provided the staff nurse with guidance in caring for and treating patients with partial thickness and superficial skin injury. The Wound Care Nurse or primary physician will be contacted if the wound does not progress towards healing.
... 3. Pressure Ulcers Stage I & Deep Tissue Injury
4. Pressure Ulcers Stage II and Partial thickness Wounds

The following Wound Care Protocols provide initial care of the wound/skin issue until it can be evaluated by a surgeon, the patient's primary physician or the Wound Care Nurse.
1. Pressure Ulcers Stages III, IV or Unstageable
2. Lower leg and Foot Wounds
3. Other Wounds Noted on Admission (such as abcess (abscess), cellulitis, previous surgical wound)...

VIII. Patients Admitted with a Wound
A. The staff nurse may initiate certain types of wound care based on the wound's appearance until the wound can be assessed by the appropriate physician or Wound Care Nurse...

Facility Policy:
Title: Peripherally Inserted Central Catheter (PICC)/Assisting with Insertion/Insertion by Registered Nurse/Catheter Care/Removal

Review Dates 5/14

...Monitoring and Care of the PICC
...6. Assess every 8 hours for external catheter length to check for migration of catheter.

7. Measure circumference of arm 2 inches above the insertion site and document every 8 hours.

Site Care

Policy
1. Injection caps shall be changed every 7 days ...

Procedure
1. Routine PICC and sterile dressing change every 7 days ...

Documentation
1. Condition of site
2. Care required
3. Type dressing required
4. Patient tolerance of procedure ..."



1. MR # 2 was admitted to the facility on 11/20/14 with diagnoses including Urinary Tract Infection. Review of the Physician's order dated 11/24/14 revealed orders for wound care to a sacral area decubitus every 12 hours, clean with 1/2 strength Dakins solution and apply 4 x 4, abdominal pad and secure with paper tape.

Review of the Electronic Health Record (EHR) revealed no documentation wound care was performed every 12 hours according to the above physician order on the following days:
11/29/14 - no documentation of the pm dressing change
11/30/14 - no documentation of the pm dressing change. The nurse documented the dressing was dry and intact.
12/2/14 (pm dressing change was not completed until 12/3/14 at 5:30 AM)
12/3/14 (pm dressing change was not completed until 12/4/14 at 3:30 AM)
12/4/14 (pm dressing change was not completed until 12/5/14 at 4:40 AM

On 1/7/15 at 1:30 PM, the medical record was reviewed and an interview was conducted with Employee Identifier (EI) # 5, Clinical Informatics Specialist, who verified the above.


2. MR # 1 was admitted on 1/4/15 with diagnoses including Dyspnea and Bilateral Pleural Effusions. Review of the Physician's order dated 1/6/15 revealed orders for daily wound care to the sacral area, clean with wound cleanser, pack with 4 x 4 and dress with Mepilex and a physician order for daily wound care to the right foot using Xeroform.

On 1/7/15 at 9:10 AM, the surveyor observed EI # 8, Registered Nurse (RN) perform wound care for MR # 1. During the observation of wound care, the surveyor observed EI # 8 apply 4 x 4s which were moistened with wound cleanser, and Medihoney was applied to the 4 x 4s and placed in the wound bed of both the sacral and right foot wounds.

Review of the Enterstomal Therapy Note dated 1/7/15 revealed the nurse documented both wounds were dressed with moisten 4 x 4 with Medihoney applied to both sacral and right foot wounds.

On 1/8/15 at 11:10 AM an interview was conducted with EI # 2, Chief Nursing Officer, who verified there was no documentation of a physician's order for Medihoney.


3. MR # 12 was admitted to the facility on 11/5/14 with diagnoses including Dehydration. Review of the History and Physical dated 1/5/14 revealed the physician documented the patient's past medical history included, "... Chronic sacral wound, stage 2-3..." and the skin assessment revealed, "... Stage 2-3 sacral decubitus noted..."

Review of the Physician's order dated 11/5/14 at 3:54 AM, revealed orders for a culture of the decubitus ulcer to the buttock. Review of the nurse assessment dated 11/5/14 at 8:45 AM revealed the patient had a wound to an undocumented area, which was documented as being clean, no redness or drainage, with well defined edges. The nurse documented dressing type was Mepilex Sacrum border. Review of the nurse assessment dated 11/5/14 at 8:15 PM revealed the patient had a wound to an undocumented area, which was documented as being clean, no redness or drainage and a dressing of Mepilex Sacrum border.

Review of the EHR through date of discharge on 11/10/14, revealed no further documentation of an assessment of the above wound.

An interview was conducted on 1/7/15 at 2:05 PM with EI # 1, Quality Manager, who verified there was no further documentation of an assessment of the above wound.




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4. MR # 7 was admitted to the facility 1/2/15 with diagnoses including Sepsis, Pneumonia and Lung Cancer. Record review revealed MR # 7 had an implanted Central Venous Catheter (CVC), an Infusaport.

Review of the 1/7/15 4:57 PM nurse documentation included the following: "...Infusaport Dressing Date Changed 1/7/15 11:00...Site Condition Infusaport Clean/Dry, No redness, No tenderness, Site Interventions Infusaport Site Care, Type Dressing Applied Infusaport 2x2's, Occlusive dressing".

The 1/7/15 nurse documentation for site care provided to MR # 7's Infusaport did not include the specific care provided.

An interview on 1/8/15 at 12:12 PM with EI # 2, Chief Nursing Officer confirmed the above.

5. MR # 9 was admitted to the facility 11/3/14 with diagnoses including Severe Protein Calorie Malnutrition and Possible Disseminated Histoplasmosis.

Record review revealed the physician's orders including the following:
11/3/14 9:17 PM: Wound care every other day (10 AM), sacral, apply Mepilex
11/7/14 2:55 PM: Measure external catheter length each shift and document
11/10/14 5:00 AM: Weight (Daily Weight)

Review of the 11/3/14 nurse documentation revealed a stage II sacral pressure ulcer, clean no redness, drainage, wound edges well defined, odor free, no drainage, cleaned with sterile saline, Mepilex Border Lite dressing applied, wound length 0.50 cm (centimeters), wound width 0.50 cm, wound depth 0.00 cm. There was no depth documented for the Stage II sacral pressure ulcer.

Review of the 11/9/14 3:56 PM nurse documentation included wound care with Mepilex dressing to right hip. There was no wound assessment or wound measurements documented.

Review of the 11/11/14 12:05 PM nurse documentation revealed the following wound assessment and care provided: Wound Assessed; Description/Assessment redness; Nonsurgical wound drainage small, Wound cleansed with soap...wound dressing type Mepilex Border Lite.

There were no wound measurements documented on 11/11/14.

Further review of the 11/11/14 1:35 PM nurse documentation included wound care to right hip with Duoderm dressing. There was no physician's order for Duoderm dressing.

Review of the nurse documentation from 11/8/14 to 11/13/14 did not include external catheter length measurements each shift performed and documented for a PICC catheter as per policy.

Review of 11/10/14 nurse documentation did not include a daily weight documented for 11/10/14.

An interview on 1/8/15 at 12:12 PM with EI # 2 confirmed the findings.

Based on medical record review, interviews and review of hospital policy and procedure, nursing staff failed to assess three of four patients receiving blood transfusions by failing to take and document vital signs 15 minutes after the blood was started as required by hospital policy and procedure. This negative practice affected 3 of 4 medical records reviewed of patients who received blood transfusions, including Medical Record (MR) # 26, 28, 9 and had the potential to negatively affect all patients who require blood transfusions.


Findings include:

Policy and Procedure:

A review of Blood and Blood Product Transfusion (process of receiving blood products into one's circulation intravenously, Wikipedia) Administration Policy and Procedure (issue date 12/02, review date 5/14) documented..."Death due to severe transfusion reactions can occur if established procedures for blood administration are not followed..."

Procedure:
A. Pre-transfusion
1. Complete baseline assessment prior to obtaining any transfusion product from the Blood Bank which includes:
a. Blood pressure and pulse
b. Respiratory Rate
c. Temperature...

C. Patient Assessment and Monitoring During Transfusion:
1. Enter the time the transfusion began...
4. Observe patient closely for 15 minutes. Obtain and document vital signs again...
7. Check patient frequently during administration. Observe for signs of transfusion reaction...


1. MR # 26 was admitted to the hospital on 12/29/14 with diagnoses to include Sickle Cell Crisis, Healthcare Associated Pneumonia and Anemia.

A physician order dated 12/30/14 revealed, "Type, cross and transfuse 2 units of PRC's (Packed Red Blood Cells) each over four hours."

A review of the nursing note revealed the second unit of blood was started on 12/30/14 at 19:36.

There were no vital signs documented at or around 19:51, fifteen minutes after the second unit of blood was initiated. The absence of fifteen minute vital signs was verified by the Informatics Manager, Employee Identifier (EI) # 11, on 1/7/15 at 15:05.


The next vital signs were documented at 20:52 on 12/30/14 two hours and 16 minutes after the second unit of blood was initiated.


2. MR # 28 was admitted to the hospital on 12/21/14 with a diagnosis of Malignant Carcinoid Tumor.

A physician order dated 12/21/14 revealed transfuse two units of blood.

Vital signs at 00:00 were 98.1, 79, 18 and 127/61.

A review of the nursing note revealed the second unit of blood was started on 12/22/14 at 00:04.

There were no vital signs documented at or around 00:19, fifteen minutes after the second unit of blood was initiated. This was verified by the Informatics Manager, EI # 11, on 1/7/15 at 15:10.

Vital signs (97.9, 80, 18 and 138/62) were documented at 03:20 on 12/22/14, three hours and 16 minutes after the second unit of blood was initiated.




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3. MR # 9 was admitted to the facility 11/3/14 with diagnoses including Severe Protein Calorie Malnutrition and Possible Disseminated Histoplasmosis.

Record review revealed the physician ' s orders including the following documentation: "...11/11/14 2:55 PM; Packed Red Cells, 2 (units)..."

Review of 11/14/14 nurse documentation revealed unit 2 of packed red cells were begun at 4:55 PM, vital signs were documented. The next set of vital signs were documented at 5:24 PM, 29 minutes later. The staff did not monitor and document vital signs 15 minutes after the packed red cells were initiated as per facility policy.

An interview on 1/8/15 at 12:12 PM with EI # 2, Chief Nursing Officer confirmed the findings.

Based on United States Health Public Food Code 2009 regulations, observations and interview, it was determined the hospital failed to ensure food was stored in a safe and sanitary manner.

This had the potential to negatively affect all patients.


Findings include:

United States Health Public Food Code 2009

3-501.17 Ready-to-Eat, Potentially Hazardous Food
(Time/Temperature Control for Safety Food),
Date Marking.
...commercially processed food open and hold cold
(B) Except as specified in (D) - (F) of this section, refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety...

(C) A refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) ingredient or a portion of a refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) that is subsequently combined with additional ingredients or portions of food shall retain the date marking of the earliest- prepared or first prepared ingredient.

(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include:...
(2) Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section;
(3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section...


A tour of the facility's kitchen and food preparation area was conducted on 1/6/15 at 9:15 AM with Employee Identifier (EI ) # 6, Dietary Manager. During this tour, the surveyor observed located in the cooler was a large metal container, which contained a brown liquid. This container was not labeled with it's contents, date of preparation or expiration.

The surveyor observed scoops were lying in the bins, which contained flour and brown rice. During this observation time, EI # 6 verified the scoops should not be stored in the bins.

Located in the Dry storage room, the surveyor observed a gallon sized bottle of Teriyaki sauce, which was open, unlabeled with open date or expiration date. The original packaging on the bottle indicated, "Refrigerate after opening".

Also, stored in the Dry storage area, were 2 gallon bottles of Red Wine Vinegar, which were open and unlabeled and a bag of shredded coconut, which was open and labeled with an expiration date of 12/18/14.

During the tour on 1/6/15 at 9:15 AM, EI # 6 verified the above.

Based on review of facility policy, information obtained from the Wound, Ostomy Continence Nurses Society (WOCN) website, facility policy and procedure, observations and interviews with facility staff, it was determined the facility failed to ensure nursing staff followed acceptable standards for hand hygiene during 1 of 1 observation of wound care and 1 of 1 observation of Central Venous Catheter (CVC) care. This affected Medical Record # 1 and Medical Record (MR) # 7 and had the potential to affect all patients admitted to this facility with wounds.

Findings include:

Facility Policy
Infection Prevention
Hand Hygiene Effective date:6/7 Revision date: 5/14

I. Purpose: To decrease the risk of transmission of infection by use of appropriate hand hygiene.

II. Scope: To be used in all healthcare settings

III. Background/Rationale:

Hand hygiene is generally considered the single most important procedure for preventing healthcare associated infections. Antiseptics control and kill microorganisms contaminating skin and other superficial tissues and are sometimes composed of the same chemicals that are used for disinfection of inanimate objects. Although antiseptics and other hand hygiene agents do not sterilize the skin, they can reduce the microbial contamination depending on the type and amount of contamination, the agent used, the presence of residual activity, and the hand hygiene technique followed.

IV. Definitions:

... Hand hygiene - a general term that applies to either handwashing, antiseptic handwash, antiseptic hand rub, or surgical hand antisepsis.

V. Policy:
To disrupt the transmission of microorganisms, health care workers are to practice hand hygiene at key points in time such as the following
a. After contact with contaminated surfaces (even if gloves are worn)
b. After contact with blood or body fluids
c. After contact with contaminated surfaces (even if gloves are worn)...
e. After removing gloves (wearing gloves is not enough to prevent transmission of pathogens in health care settings)...

... VII. Other Aspects of Hand Hygiene
... c. Wear gloves when contact with blood or other potentially infectious materials...
e. Change gloves during patient care if moving from a contaminated body site fo (to) a clean site...


"WOCN Position Statement: Clean versus sterile: Management of Chronic Wounds...

Definitions...

... Clean technique involves strategies used in patient care to reduce the overall number of microorganisms or to prevent or reduce the risk of transmission of microorganisms from one person to another or from one place to another. Clean technique involves meticulous handwashing, maintaining a clean environment by preparing a clean field, using clean gloves and sterile instruments, and preventing direct contamination of materials and supplies..."


1. On 1/7/15 at 9:10 AM, the surveyor observed Employee Identifier (EI) # 8, Registered Nurse (RN) perform wound care for PI # 1 (MR # 1). During this observation time, EI # 8 stated that the wound care would be performed as a "clean" technique. Observation of the wound care: EI # 8 rolled the patient onto his/her left side, at which time, it was observed the patient had a bowel movement (BM). EI # 8 began cleaning the BM from the patient, removed the old dressing from the sacral area decubitus without removing her gloves or performing hand hygiene. EI # 8 continued to clean BM from the patient's bottom while wearing the same gloves. After removing her gloves, EI # 8 performed hand hygiene and donned clean gloves. EI # 8 performed wound care to the sacral area decubitus, applied Mepilex dressing, then performed wound care to the right outer foot. EI # 8 failed to remove her gloves or perform hand hygiene prior to performing wound care to the right outer foot wound.




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2. MR # 7 was admitted to the facility 1/2/15 with diagnoses including Sepsis, Pneumonia and Lung Cancer.

Record review revealed MR # 7 had an implanted Central Venous Catheter (CVC), an Infusaport.

An observation of site care to an implanted CVC, an Infusaport was conducted 1/7/15 at 10:55 AM with EI # 9, RN. EI # 3, Administrator was present.

EI # 9 performed hand hygiene and donned gloves. EI # 9 removed the Infusaport's old dressing. EI # 9 removed his/her gloves. EI # 9 failed to perform hand hygiene after glove removal.

EI # 9 donned a mask and sterile gloves. EI # 9 cleansed the Infusaport site with alcohol swabs, chlorahexidine sponge stick then applied a stat lock and Tegaderm dressing. EI # 9 removed gloves. EI # 9 did not perform hand hygiene after glove removal.

In an interview on 1/7/15 at 11:06 AM with EI # 3, confirmed staff did not follow procedure and perform hand hygiene following glove removal.








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Based on review of facility policies and procedures, observation and interviews, it was determined the facility failed to ensure staff performed terminal cleaning of Operating Room (OR) suites per facility policies and procedures and Hand Hygiene. This had the potential to negatively affect all patients and staff.

Findings include:

Facility Policy:
Title: Cleaning of Surgical and Special Procedure Room
Review Dates 8/11

Purpose:
...Special cleaning is required in areas where surgical and other procedures are being performed. These include the operating room ...Cleaning in these rooms at a minimum includes ...and terminal cleaning at the end of each procedure day. All cleaning ...is done in accordance with AORN (American Operating Room Nurse) guidelines ...
1. Housekeeping is responsible for ...terminal cleaning in the surgical suites ...

In accordance with AORN guidelines the following will define the EVS (Environmental Services) team Terminal cleaning process of all perioperative areas at Baptist Health.
a. All floors will be terminally cleaned with either a wet vacuum or single use mop; and disinfectant solution ...The floor should be wet with the disinfectant for the dwell time indicated on the manufacturer ' s instructions for use.
a. Cleaning should progress from the cleanest to dirtiest areas of the floor.
b. Floor surfaces at the perimeter of the room should be disinfected before ...
c. The entire floor should be disinfected, including areas under the OR bed and mobile equipment.
b. All mobile equipment should be rolled from one half of the room after the floor has been flooded to ensure that wheels have been coated in the disinfectant solution. The first half should be scrubbed/mopped, then equipment moved to the other half f the room and the process repeated. After the whole floor has been scrubbed/mopped the equipment should be placed in the original position ... "

Facility Policy #: 59:00
Title: Surgical Attire
Revised:04/14

Surgical Attire
Purpose: To provide guideline for attire worn in...restricted areas in Surgical Services.

General Information:
Personnel must comply with the facility policy on...Dress Code...
8. Personal protective equipment is available for personnel in the surgical suite:
c. Additional available attire includes: fluid resistant gown..."

Facility Policy:
Title: Hand Hygiene
Review Dates 8/11
Purpose:
To decrease the risk of transmission of infection by use of appropriate hand hygiene
" V. Policy
To disrupt the transmission of microorganisms, health care workers are to practice hand hygiene at key points in time such as the following
a. After contact with contaminated surfaces (even if gloves are worn)
b. After contact with blood or body fluids
...e. After removing gloves (wearing gloves is not enough to prevent transmission of pathogens in health care settings) ... "

On 1/7/15 at 2:25 PM an observation of the terminal cleaning of OR # 1 by Employee Identifier (EI) # 10, Housekeeping staff member was conducted. EI # 3, Administrator was present.

EI #10 donned all required personnel protective equipment, however EI # 10 did not close the front of the fluid resistant disposable gown. Gown ties were allowed the flow free. During terminal cleaning in OR # 1, the bottom of the gown and ties were observed several times touching the floor.

During cleaning of the walls, EI #10's right glove tore in the palm area. EI # 10 removed his/her right glove and donned another glove. EI # 10 did not perform hand hygiene following removal of the right glove.

EI # 10 applied A- 456 II disinfectant cleaner 3 to disposable cloths and wiped down each piece of mobile equipment. After wiping down each individual piece of mobile equipment in OR # 1, EI # 10 then rolled the each piece of equipment into the hallway outside OR # 1.

EI # 10 completed cleaning the stationary equipment, then mopped the walls. EI #10 reported to the surveyor after the floor was mopped, the mobile equipment would be rolled back to OR # 1.

EI #10 did not follow AORN guidelines and facility policy for terminal cleaning of OR # 1. EI # 10 failed to ensure the wheels of the mobile equipment were coated in disinfectant solution when he/she moved the equipment out of the OR prior to mopping the floor.

In an interview on 1/8/15 at 3:55 PM with EI # 3, the finding was confirmed.

Based on review of facility policy, medical record and interview with facility staff, it was determined the facility failed to ensure outpatient services were ordered by a practitioner for 1 of 2 outpatient records reviewed. This affected Medical Record (MR) # 29 and had the potential to affect all outpatient therapy patients served by this facility.


Findings include:

Facility Policy

Outpatient Therapy Medical Record Documentation Requirements

Effective date 4/13

I. Purpose: The purpose of this policy is to ensure that all patient charts are standardized while maintaining certain required documentation.

II. Scope: This policy applies to all outpatient therapy charts.

III. Background: This policy has been established to meet the Medicare documentation requirements for the coding and billing of patient services.

IV. Policy with Definitions:

... Plan of Care (POC) - can be established by a physician/practitioner who consults with the therapist, the PT (Physical Therapist), OT (Occupational Therapist) or SLP (Speech Language Pathologist) who will provide the service. Treatment should not begin before the POC is written unless it is performed or supervised by the therapist who establishes the plan.

It must contain by not limited to:
... The treatment type, amount (number of times a day) frequency (number of times in a week) and duration (number of weeks) for the services to be provided.

Certification (Physician/ NP (Nurse Practitioner) signature & date required)
Acceptable documentation may be a physician's progress note, a physician/practitioner order or a POC that is signed and dated by the physician/practitioner.

Initial Certification - Lasts for the duration of the therapy or 90 calendar days from the date of initial treatment. Timely certification is considered a signed or verbal order that is dated within 30 days following the evaluation. A verbal order must be signed within 14 days. Documentation of sending the POC to the physician must be maintained in the medical record...


Review of MR # 29 revealed a faxed copy of a physician's prescription for PT/OT evaluate and treat for left birth brachial plexis palsy and to consider left elbow extension serial casting and adaptive equipment. MR # 29 was initially evaluated by OT on 7/29/14 for therapy services for the treatment of Nerve Root/ Plexis. Review of the Initial Occupational Therapy Evaluation dated 7/29/14 revealed the OT's assessment revealed, "... To facilitate a more functional grasp and increased flexion of the left hand digits, a wrist cock-up splint is recommended. Skilled Occupational Therapy services are indicated for once per week for 30 minutes to address the above-identified problems areas and increase (patient's) ability to function independently in age-appropriate functional activities..."

The initial OT evaluation was faxed to the physician on 8/11/14. There was no documentation the physician/practitioner signed this document.

A thorough review of the patient's medical record revealed no documentation the physician agreed with the patient's plan of care for 30 minute treatments once weekly.

An interview was conducted on 1/8/15 at 11:45 AM with Employee Identifier # 7, Patient Service Manager who stated they only obtain physician signatures for Medicare patients.

Based on review of medical records (MR), policy and procedure and interview, the facility failed to ensure therapy staff established and documented a Plan of Care that included all required elements for care. This did affect MR # 7, 1 of 1 records reviewed with inpatient Physical Therapy services. This had the potential to negatively affect all patients receiving therapy services.

Findings include:
Facility Policy:
Subject Title: Physical Therapy Patient Care Assessment/Reassessment
Review Dates: 3/12
... III. Procedure:
B. Plan of Care
1. Plan of care will be established for all patients being seen for inpatient treatment ...It will coincide with the assessment/reassessment and will include:
a. Duration of treatment
b. Frequency of treatment
c. Long terms goals
d. Short term goals

...4. Goals will be periodically reassessed by the Physical Therapist
a. Inpatients will have ongoing assessment during their stay with modifications in goals as needed.
b. Goals should be numbered, e.g., STG (short term goal) # 1, LTG (long term goal) # 1 ... "

1. MR # 7 was admitted to the facility 1/2/15 with diagnoses including Sepsis, Pneumonia and Lung Cancer.

Review of the record revealed a 1/3/15 physician's order for a Physical Therapy (PT) consult.

Review of the 1/5/15 Physical Therapy evaluation included documentation of the problem identified, the PT treatment plan and 6 goals of the PT treatment plan.

The PT evaluation documentation did not include the frequency and duration of treatment. The goals were not documented as either short term or long term goals.

An interview on 1/8/15 at 12:12 PM with Employee Identifier (EI) # 2, Chief Nursing Officer confirmed the above. EI # 2 reported the Physical Therapist does not document a treatment frequency and duration because the therapist would be required to then provide treatments according to the documented frequency and duration. There is only one full time Physician Therapist.