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Based on policy review, record review and interview, it was determined that the facility was unable to sustain a mechanism that identified medical errors, which prevented the analysis and potential reduction of those errors [in one of one record], which could potentially affect all inpatient. Findings include:

The Nursing Department policy titled "Medication Errors" states that errors will be reported or entered into the facility's quality improvement data collection under medication errors. The Medication Errors policy also states, "Findings and recommendations are also reported to the Quality Improvement Committee."

On 12/15/10 at 1305 patient #3's medical record was reviewed with employee #6 (Nursing Supervisor) who verified that patient #3 was admitted on 6/23/10 with a diagnosis of Urinary Tract Infection. On 6/25/10 a nursing note states: "Charge nurse found scripts in chart called Dr pt to be seen in Urgent Care (2015) and be started on Ultram 50 mg, Bactrim DS 800 mg/160 mg this pm." A nursing note dated 6/25/10 at 2115 states: Was started on Bactrim DS the order that came from (hospital name). Note left in Dr's Log for Dr (Dr's name.). Review of the MAR (Medication Administration Record) documentation in the clinical record revealed that the Bactrim DS was never started. These findings were verified by the Nursing Supervisor (employee #6.)

On 12/16/10 at 0955 the Recipient Rights Officer and Nurse Consultant (employee #9) verified that the two instances of medication omissions above should have been reported as Medication errors, per policy and that neither error had been reported or entered into the facility's quality improvement data collection under medication errors.

Based on interview and document/record review, it was determined that the facility failed to have organized and effective nursing service that could potentially affect all inpatients [56 on the date of the survey]. Findings include:

The facility failed to provide well organized nursing services under the direction of a RN. See A386.

The facility failed to provide nursing supervision and evaluation of each patient. See A395.

The facility failed to develop and/or keep current care plans by nursing. See A396.

The facility failed to demonstrate the orientation of a contract nurse to hospital policies and procedures. See A398

Based on interview and record review, the facility failed to ensure that one individual was clearly designated at the Director of Nursing services, responsible for supervising and evaluating nursing care. Findings include:

On 12/14/10 at approximately 1700 in the conference room of the administration building, Nursing Consultant #9, was asked whether he was the lead nursing staff member for the facility. The Nursing Consultant stated that he was not and does not directly provide clinical care at the facility. A review of Personnel file for Nursing Consultant #9 revealed the following: The Contractor Orientation Confirmation form identifies the role of Nursing Consultant #9 as a Clinical Consultant that is currently a Registered Professional Nurse in the State of New York. Nursing Consultant #9 confirmed that he is not licensed as a Registered Nurse in the State of Michigan.

On 12/15/10 at approximately 1145 in the conference room of the administration building, the Vice President of Regulatory Compliance (employee #1) was asked to identify the nurse in charge of facility nursing operations. Employee #1 named two individuals, Nurse Consultant #9 and Nurse Consultant #17, also a Nurse Consultant. Nurse Consultant #17 was not present during the survey. A review of Personnel file of Nurse Consultant #17 includes the following: Current license as a Registered Nurse in the State of Michigan. Professional Services Agreement signed 9/27/10 which states:
"General Description of Services: Services to be provided will include but are not limited to a) Clinical Consultation/Supervision, b) Nursing Education, c) Assisting with hospital orientation, d) special projects that may be assigned by the CEO and/or the Director of Nursing."

"Provider agrees... the provider will file a written (brief summary) outlining their activity on a monthly basis and submit this to the Director of Nursing."

"Compensation: the Client agrees... 16 hours a month are to be provided for clinical consultation/supervision. Any additional hours will be scheduled through the Director of Nursing."

On 12/15/10 at approximately 1215 in the first level hallway while accompanied by employee #1, employee #6 (Nursing Supervisor) was asked by surveyor who she calls if there is a question with regard to nursing at the facility. Employee #6 stated she would call Nurse Consultant #9 or Nurse Consultant #17 if they were on duty or available.

On 12/15/10 at approximately 1350 in the conference room of the administration building, employee #2 (CEO) was present during interview of employee #15 (Medical Director). Employee #15 was asked by surveyor who is serving as the Director of Nursing of the facility? Employee #15 stated Nurse Consultant #9.

There was no description in the personnel file of either Nurse Consultant #9 or Nurse Consultant #17 that they were to function as the Director of Nursing.

Based on interview and record review the facility failed to ensure that 3 of 6 patients (#3, #6 and #10) were provided with appropriate supervised nursing care. Findings include:

On 12/15/10 at 1305 patient #3's medical record was reviewed with employee #6 (Nursing Supervisor) who verified that patient #3 was admitted on 6/23/10 with a diagnosis of Urinary Tract Infection. On 6/25/10 a nursing note states: "Charge nurse found scripts in chart called Dr pt to be seen in Urgent Care (2015) and be started on Ultram 50 mg, Bactrim DS 800 mg/160 mg this pm." A nursing note dated 6/25/10 at 2115 states: Was started on Bactrim DS the order that came from (hospital name). Note left in Dr's Log for Dr (Dr's name.). Review of the MAR (Medication Administration Record) documentation in the clinical record revealed that the Bactrim DS was never started. These findings were verified by the Nursing Supervisor (employee #6.)

Patient #10's History & Physical (dated 6/3/10) indicated a diagnosis of "Brittle diabetes type 1. According to Nursing Department policy titled Management of Diabetes: "Every patient who is admitted to the BCA StoneCrest with a known diagnosis of diabetes will have their blood sugar tested by glucometer upon admission to the unit." This was verified by the by employee #6 on 12/15/10 at approximately 1320.

Review of the patient #6's clinical record revealed that he was admitted 6/1/10 and the first documentation of blood glucose testing was on 6/4/10. This was verified by the by employee #6 on 12/15/10 at approximately 1320.

Based on record review and interview the facility failed to develop nursing care plans that ensure the provision of comprehensive care to 4 of 11 patients (#1, #3, #10, and #11). Findings include:

1. On 12/15/10 at 1305 patient #3's medical record was reviewed with employee #6 (Nursing Supervisor) who verified that patient #3's care plan did not include interventions for a herniated disc or back pain (identified in History & Physical (dated 6/13/10) although the pain was described as "sharp and shooting radiates to both legs...mild bilateral leg edema...tenderness at lower lumbar region." There was no Nurse signature on the Master Treatment Plan (dated 6/23/10.) Patient #3 was admitted with a diagnosis of Urinary Tract Infection which was not treated or included in the Master Treatment Plan.

2. Patient #10's History & Physical (dated 6/3/10) indicated a diagnosis of "Brittle diabetes type 1. His Master Treatment Plan (completion date 6/8/10) had no care plan for management of Diabetes. This was verified by employee #6 on 12/15/10 at approximately 1320.


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1. On 12/14/10 at approximately 1600 at the nursing station of unit 2N, patient #1's medical record was reviewed with employee #6 employee Nursing Supervisor) and employee #4 present. The treatment plan does not identify any frequencies for implementation of interventions or state objectives in measurable terms.

2. Patient #11's History & Physical (dated 10/18/10) indicated a chronic medical history of possibly ulcerative colitis or Crohn disease. She was complaining constantly of emesis and bloody diarrhea. Her Master Treatment Plan (completion date 10/7/10) had no care plan for management of the identified chronic medical condition. This was verified by the by employee #15 (Medical director) on 12/15/10 at approximately 1345.

Based on document review and interview, the facility failed to provide effective nursing supervision to non-employee licensed nurses, as evidenced by the failure to provide medication for patient #3. Findings include:

Nursing Department policy titled "Medication Procedure: Administration of Medication" states: "The Medication nurse (RN/LPN) must check all charts for possible missed orders prior to the end of his/her shift." On 6/25/10 a contingent nurse (employee #16) wrote an order for Bactrim DS 800 mg/160, 1 table twice daily for patient #3.

A nursing note dated 6/25/10 at 2115 states: Was started on Bactrim DS the order that came from (hospital name). Note left in Dr's Log for Dr (Dr's name.). Review of the MAR (Medication Administration Record) documentation in the clinical record revealed that the Bactrim DS was never started. These findings were verified by the Nursing Supervisor (employee #6.)

Review of nurse #16's employee education record revealed no evidence of training in facility policy on Medication Administration. These findings were confirmed by the Human Resources Director (employee #7).

Based on record review and interview the facility uses verbal orders on a routine basis for patient admission orders. Findings include:

On 12/15/10, the facility policy for verbal orders [Department: Nursing, Policy: Verbal orders, Section 2.11] was reviewed. The policy does not govern the use of verbal orders, such as describing limitations or prohibitions for their use. The policy also states that verbal orders must be signed a physician within 24 hours of the transmittal of the verbal order.

On 12/15/10, two patients records (pt #1 dated 12/12/10 and pt #11 dated 12/12/10) were reviewed with employee #15 and found to contain the use of verbal orders to establish care for newly admitted patients.

On 12/15/10 at approximately 1345 in the administrative conference room, it was verified by employee #15 (Medical Director) that it is routine practice at the hospital to utilize verbal orders for patient admissions.

It was further verified by employee #15 that the verbal admission orders for patient #1 [admitted 3 days earlier] had not been signed by a physician.

Based on observation, interview and record review the facility failed to date, time and promptly authenticate physician orders for 4 of 11 records (patients #1, #2, #10 and #11). Findings include:

Nursing Department policy "Medication Procedure: Administration of Medication"states:
5.a Medications are ordered by the physician.
5.b "Telephone orders may only be taken by an RN/Pharmacist and read back to the Physician for verification."
5.c "All orders must be signed by the physician within 24 hours."

1. Review of patient #10's physician's orders revealed a verbal order written and read back on 6/18/10 at 0800. It appears that the physician authenticated the order 1 hour before it was written, on 6/18/10 at 0700, although legibility is questionable. A verbal order written on 6/15/10 was untimed by both the nurse and the physician.

2. Review of patient #2's clinical record revealed a physician's verbal order dated 7/17/10 with no time or date signed by the phsyician.




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1. On 12/15/10 at approximately 1345 in the administrative conference room, the physician order section of the medical records of patient #1 and patient #11 were reviewed with employee #15 (Medical Director). It was verified with employee #15 that the physicians orders (verbal orders) dated 12/13/10 for patient t#1 were not signed by a physician and did not include a read back, and that the physicians orders (verbal orders) dated 10/10/10 for patient t#11 were not signed by a physician.

Based on record review and interview the facility failed to ensure that the discharge summary always includes the outcome of hospitalization, disposition of care and provisions for follow-up as evidenced by the review of a closed record. Findings include:

On 12/15/10, the medical record for patient #4 was reviewed and indicated that the patient was discharged from the hospital on 11/2/10.

On 12/15/10 at approximately 1345 in the administrative conference room, employee #15 (Medical Director) verified that there was no discharge summary in the medical record of patient #4, and that this discharge summary had not been completed.