HospitalInspections.org

A. Based on a review of Hospital policy, clinical record review and staff interview it was determined that for 1 of 3 (Pt. #6) clinical record reviewed, the Hospital failed to ensure less restrictive measures were determined to be ineffective prior to initiating restraints.

Findings include:

1. Hospital policy #300.75 entitled, "Restraints and Protective Devices-Usage for Non-Behavioral Health Units," was reviewed on 3/22/10 at approximately 1:00 P.M. The policy requires, "Restraint may only be used when less restrictive measures have been determined to be ineffective...to include: De-escalation techniques, orient patient, exit alarms, sitter... Documentation... Alternatives or other less restrictive interventions attempted..."

2. The clinical record record for Pt. #6 was reviewed on 3/22/10 at approximately 9:55 A.M. This was a 62-year-old female, admitted 3/19/10, with a diagnosis of Abscess Chest Wall. The record included documentation that restraints were initiated for Pt. #6 on 3/20/10 at 1:30 P.M for medical reasons to prevent pulling of tubes. The record lacked documentation that less restrictive interventions were attempted less than 4 hours prior to Pt. #6 being placed in restraints.

3. The above finding was confirmed during an interview with the 5 East Unit Manager, on 3/22/10 at approximately 10:00 A.M.

A. Based on a review of Hospital policy, clinical record review and staff interview it was determined that for 1 of 3 (Pt. #6) clinical record reviewed, the Hospital failed to ensure the order for restraints was complete.

Findings include:

1. Hospital policy #300.75 entitled, "Restraints and Protective Devices-Usage for Non-Behavioral Health Units," was reviewed on 3/22/10 at approximately 1:00 P.M. The policy requires, "restraints must be ordered by a physician..."

2. The clinical record record for Pt. #6 was reviewed on 3/22/10 at approximately 9:55 A.M. This was a 62-year-old female, admitted 3/19/10, with a diagnosis of Abscess Chest Wall. The "Physician's Orders for Restraints" dated 3/20/10 at 1:30 P.M., required that documentation be made by placing a check mark indicating the duration of restraints, as either "24 hours" or "other (specify)". The order lacked documentation to indicate the duration of restraints.

3. The above finding was confirmed during an interview with the 5 East Unit Manager, on 3/22/10 at approximately 10:00 A.M.

A. Based on a review of Hospital policy, clinical record review, and staff interview it was determined that for 2 of 2 clinical records reviewed for restraints, (Pt. #19 and #21) the Hospital failed to ensure restrained patients were monitored in accordance with policy.

Findings include:

1. Hospital policy #300.75 entitled, "Restraints and Protective Devices-Usage for Non-Behavioral Health Units," was reviewed on 3/22/10 at approximately 1:00 P.M. The policy requires, "All patients who are restrained should be monitored every 2 hours..."

2. The clinical record record for Pt. #19 was reviewed on 3/23/10 at approximately 8:25 A.M. This was a 92-year-old female, admitted 12/4/09, with a diagnosis of Agitated Dementia. The record included documentation that Pt. #19 was restrained from 12/4/09-12/8/09. The record lacked documentation of restraint monitoring every two hours on 12/6/09 at 4:00 P.M. and 10:00 P.M., and 12/7/09 at 12:00 P.M.

3. The clinical record record for Pt. #21 was reviewed on 3/23/10 at approximately 9:55 A.M. This was a 89-year-old female, admitted 11/18/09, with a diagnosis of Unwitnessed Fall versus Syncope. The record included documentation that Pt. #21 was restrained from 11/18/09-11/22/09. The last documented restraint monitoring for Pt. #21 was on 11/22/09 at 6:00 A.M. However, the record included documentation in the "Daily Patient Care & Assessment Flowsheet" for 11/22/09, that Pt. #21 remained in a Posey vest restraint as of 11/22/09 at 9:00 A.M. The record lacked documentation of restraint monitoring on 11/22/09 at 8:00 A.M.

4. The above findings were confirmed during an interview with the Director of Nursing on 3/23/10 at approximately 1:30 P.M.

A. Based on clinical record review, stated Hospital policy and staff interview, it was determined that in 3 of 6 (Pt. #2, 7, and 20) clinical records reviewed, the Hospital failed to ensure all physician orders were completed, as required.

Findings include:

This finding was identified in the 1 of 2 clinical records reviewed 3 South Telemetry Unit:

1. The clinical record of Pt #2 was reviewed on survey date 3/22/10 at approximately 10:30 AM. Pt #2 was a 65 year old male admitted to the Hospital on 3/16/10 with diagnoses of End Stage Renal Disease and Near Syncope. The clinical record contained a physician order dated 3/16/10 at 4:20 PM that required Accuchecks TID (three times a day). The Blood Glucose/Insulin Administration/Hypoglycemia Treatment Flowsheet indicated that on 3/21/10 Pt #2 had two Accuchecks performed and not three as required.

2. The finding was verified by the Nurse Manager of the 3 South Telemetry Unit during an interview on survey date 3/22/10 at approximately 11:00 AM.


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This finding was identified in in 1 of 2 clinical records reviewed on the 5 East Unit:

3. The clinical record record for Pt. #7 was reviewed on 3/22/10 at approximately 10:45 A.M. This was a 36-year-old male, admitted to the 5 East Unit on 3/16/10, with diagnoses of Dyspnea, Bronchitis, Mild Pulmonary Edema, and End Stage Renal Disease. The record included a physician's order, dated 3/16/10 for accuchecks "bid" (twice daily) and Prandin (medication to control high blood glucose) 0.5 mg "bid" (twice daily) if blood sugar between 150-249. The "Blood Glucose/Insulin Administration/Hypoglycemia Treatment Flowsheet" failed to include documentation to indicate that Pt. #7's blood glucose was assessed twice daily at 9:00 A.M. and 9:00 P.M. in order to administer Prandin, as needed. Instead, Pt. #7's blood glucose was assessed on the following dates and times:

* 3/16/10 at 5:51 P.M.
* 3/17/10 at 6:00 A.M. and 4:00 P.M.
* 3/18/10 at 6:00 A.M. and 4:00 P.M.
* 3/19/10 at 6:00 A.M. and 6:00 P.M.
* 3/20/10 at 6:00 A.M., 4:00 P.M. and 9:00 P.M.
* 3/21/10 at 6:00 A.M., 4:00 P.M. and 9:00 P.M.
* 3/22/10 at 6:00 A.M.

4. An interview was conducted with the 5 East Unit Manager on 3/22/10 at approximately 11:00 AM. The Manager stated that the Hospital's practice for implementing "bid" is 9:00 A.M. and 9:00 P.M., as stated by the 5 East Nurse Manager.

5. The above findings were confirmed during an interview with the 5 East Unit Manager, on 3/22/10 at approximately 11:00 A.M.

This finding was identified in 1 of 2 closed records review of patients with wounds

6. The closed clinical record for Pt. #20 was reviewed on 3/23/10 at approximately 8:55 A.M. This was an 87-year-old female, admitted 1/12/10, with diagnoses of Sepsis, Early Dehydration, and Urinary Tract Infection. The record included documentation of a physician's order dated 1/14/10 to turn the patient every hour. The record lacked documentation from 1/14/10-1/24/10 to indicate that Pt. #20 was turned every hour as ordered.

7. The above finding was confirmed during an interview with the 5 East Unit Manager, on 3/23/10 at approximately 9:45 A.M.


B. Based on a review of Hospital policy, clinical record review, and staff interview it was determined that for 2 of 2 closed clinical records reviewed for wounds, (Pt. #20 and #23) the Hospital failed to ensure adherence to Hospital policy governing wound assessment and documentation.

Findings include:

1. Hospital policy #300.75 entitled, "Skin/Wound Assessment and Documentation" was reviewed on 3/23/10 at approximately 3:00 P.M. The policy requires, "Assessment and documentation of open wounds/lesions as noted upon admission and upon identification of new wounds and weekly will include the following... measurement in cm: length x width x depth... measurement in cm: tunneling or undermining... skin tears."

2. The clinical record for Pt. #20 was reviewed on 3/23/10 at approximately 8:55 A.M. This was an 87-year-old female, admitted 1/12/10, with diagnoses of Sepsis, Early Dehydration, and Urinary Tract Infection. The record lacked measurement documentation for the following wounds:

* sacral, stage IV (identified on admission 1/12/10, no wound measurements until 1/14/10 - 2 days later)
* back head, stage I (identified 1/14/10, no wound measurements)
* sacral skin tear (identified 1/15/10, no wound measurements)
* right and left heels, stage I (identified 1/20/10, no wound measurements).

3. The clinical record record for Pt. #23 was reviewed on 3/23/10 at approximately 11:15 A.M. This was a 50-year-old female, admitted 1/12/10, with diagnoses of Sepsis. The record included documentation of multiple wounds. The record lacked documentation of measurements for the following wounds:

* right ear, stage II (identified 1/22/10, no wound measurements)
* right and left buttocks, stage II (identified 1/22/10, no wound measurements).

4. The above findings were confirmed with the Director of Nursing on 3/23/10 at approximately 1:30 P.M. and 3/24/10 at approximately 9:15 A.M.


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C. Based on review of Hospital policy, observation and staff interview, it was determined that for 1 of 8 (Pt. #12) patients on monitoring in ICU, the Hospital failed to ensure the alarm volume on all electronic monitoring devices were loud enough to be heard by a nurse, as required by policy.

Findings include:

1. The Hospital policy titled, "Electronic Monitoring Device" was reviewed on 3/22/10 at 3:12 PM. The policy required, "Critical care Nurse Responsibilities: ...at all times, the volume on all electronic monitoring devices will be loud enough to be heard by a nurse who can respond to the alarm immediately....."

2. A tour of the Intensive Care Unit (ICU) was conducted on 3/22/10 between 1:40 PM and 2:25 PM. The audible alarm for Pt. #12's monitoring device, for the blood pressure was turned off.

3. The Clinical record of Pt. #12 was reviewed on 3/22/10 at 1:55 PM. Pt. #12 was a 55 year old female admitted in the ICU through the Emergency Department with Nausea, vomiting, diarrhea and uncontrolled Hypertension. Blood pressures in the ED ranged between 146/88 and 215/112. Pt. #12 was admitted to ICU with orders to "titrate NGT (nitroglycerin) drip to keep...BP 160 or less."

4. The above findings were confirmed with the Charge Nurse and the Director of the ICU North during an interview, on 3/22/10 at 2:20 PM.

A. Based on review of Hospital policy, patient interview, clinical record review and staff interview, it was determined that for 2 of 2 (Pt. #3 & 4) patients with a language barrier on the Medical/Surgical/Orthopedic Unit, the Hospital failed to ensure the language barrier identified in the admission assessments for Pt. #3 and 4 were included in the Nursing Care Plans.

Findings include:

1. The Hospital policy titled, "Plan of Hospital Services" was reviewed on 3/22/10 at 1:00 PM. The policy required, "Patient Plan of Care...patients...receive care that is planned for and provided...Procedures, treatments and interventions are individualized to each patient and are respectful of the patient's personal, cultural and spiritual belief..."

2. On 3/2/10 between 9:00 AM and 10:50 AM attempts were made to interview Pt. #3 and Pt. #4 during a tour of the Medical/Surgical/Orthopedic Unit on the 4th floor were unsuccessful because Pt. #3 only spoke Spanish and Pt. #4 only spoke Polish.

3. The clinical record of Pt. #3 was reviewed on 3/22/10 at 10:00 AM. Pt. #3 was a 79 year old female admitted on 3/20/10 with diagnosis of Upper Respiratory Infection. The Nursing assessment included identification of "language spoken" as Spanish. The Nursing Care Plan (NCP) failed to include that Pt. #3 spoke only Spanish, a potential for patient education and communication barrier.

4. The clinical record of Pt. #4 was reviewed on 3/22/10 at 10:50 AM. Pt. #4 was a 80 year old female admitted on 3/17/10 with diagnosis of Intractable Back Pain. The Nursing assessment included identification of "language spoken" as Polish. The NCP failed to include that Pt. #4 spoke only Polish, a potential for patient education and communication barrier.

5. The above findings were confirmed with the Nurse Manager of Med-Surg/Ortho Unit during interview on 3/22/10 at 11:15 AM.

A. Based on clinical record review and staff interview, it was determined that for 1 of 2 (Pt. #7) clinical records for patients on the 5 East Unit, the Hospital failed to ensure medication was administered in accordance with the physician's order.

Findings include:

1. The clinical record record for Pt. #7 was reviewed on 3/22/10 at approximately 10:45 A.M. This was a 36-year-old male, admitted 3/16/10, with diagnoses of Dyspnea, Bronchitis, Mild Pulmonary Edema, and End Stage Renal Disease. The record included a physician's order, dated 3/21/10 to change Levaquin (antibiotic) 500 mg intravenously every 48 hours to Levaquin 500 mg by mouth every 48 hours. However, the record lacked documentation that the oral Levaquin was administered on 3/21/10 as ordered.

2. The clinical record for Pt. #7 included a physician's order, dated 3/16/10, on the "Initial Medication Reconciliation," for Prandin (medication to control high blood glucose) 0.5 mg twice daily if blood sugar between 150-249. The record included documentation that Pt. #7's blood glucose was 195 on 3/21/10 at 6:00 A.M. The record lacked documentation that Pt. #7 received Prandin 0.5 mg until 3/21/10 at 9:00 A.M. (3 hours after the blood glucose was assessed).

3. The above findings were confirmed during an interview with the 5 East Unit Manager, on 3/22/10 at approximately 11:00 A.M.

A. Based on clinical record review and staff interview it was determined that for 2 of 2 (Pt. #19 and #21) clinical records reviewed for restraints, the Hospital failed to ensure the records included documentation when restraints were discontinued.

Findings include:

1. The clinical record record for Pt. #19 was reviewed on 3/23/10 at approximately 8:25 A.M. This was a 92-year-old female, admitted 12/4/09, with a diagnosis of Agitated Dementia. The record included documentation that Pt. #19 was restrained from 12/4/09-12/8/09, and discharged to the nursing home on 12/8/09 at 3:37 P.M. The record lacked documentation when or/if restraints were discontinued.

2. The clinical record record for Pt. #21 was reviewed on 3/23/10 at approximately 9:55 A.M. This was a 89-year-old female, admitted 11/18/09, with a diagnosis of Unwitnessed Fall versus Syncope. The record included documentation that Pt. #21 was restrained from 11/18/09-11/22/09, and discharged to the nursing home on 11.22.09 at 3:00 P.M. The record lacked documentation when or/if restraints were discontinued.

3. The above findings were confirmed during an interview with the Director of Nursing on 3/24/10 at approximately 9:00 A.M.

A. Based on a review of the Hospital's Medical Staff Rules and Regulations, a review of an attestation from the Medical Record's Department, and staff interview, it was determined that the Hospital failed to ensure completion of all medical records within 30 days post discharge.

Findings include:

1. The Hospital's Medical Staff Rules and Regulations were reviewed on 3/24/10 at approximately 1:30 P.M. The Rules and Regulations require, "The records of patients are completed within a period of time that in no event exceeds thirty (30) days following discharge."

2. The attestation letter from the Director of Health Information Management was reviewed on 3/23/10 at approximately 3:30 P.M. The letter included that as of survey date 3/23/10, there were 659 charts incomplete greater than 30 days post discharge.

3. The above finding was confirmed with the Director of Health Information Management during an interview on 3/23/10 at approximately 3:30 P.M.

A. Based on review of Hospital policy, clinical record review and staff interview, it was determined that in 1 of 1 (Pt #1) clinical record reviewed for patients on Parental Nutrition, the Hospital failed to ensure that all patients weight status was evaluated prior to initiation of parenteral nutrition.

Findings include:

1. Hospital policy entitled, "Parenteral Nutrition," reviewed on survey date 3/22/10 at approximately 12:00 PM required, "...All parenteral nutrition (PN) will be ordered by the physician...Registered dieticians:...4. The following will be assessed or considered before making a recommendation:...weight status/weight goals.."

2. Hospital policy entitled, "Intake and Output and Weights," reviewed on survey date 3/23/10 at 9:00 AM required, "...4. The following weight schedule will be followed for the following patient populations, unless specified by the physician...4.4. Enteral feeding patients weekly, 4.5 Hyperalimentation patients weekly."

3. The clinical record of Pt #1 was reviewed on survey date 3/22/10 at approximately 10:00 AM. Pt #1 was a 93 year old female admitted to the Hospital on 3/7/10 with diagnoses of Anemia and Renal Failure. The clinical record contained a physician order dated 3/20/10 that required Pt #1 be started on Parenteral Nutrition. The documented weight on admission for Pt #1 was 53.7 kilograms. As of survey date 3/22/10 at 10:00 AM, the record lacked an evaluation of Pt #1's current weight and/or weight goal, as required.

4. The finding was verified by the Nurse Manager of the 3 South Telemetry Unit during an interview on survey date 3/22/10 at approximately 11:00 AM.


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B. Based on review of Hospital policy, review of trayline temperature log and staff interview, it was determined that in 3 of 31 days in January 2010 (1/3, 1/8 and 1/19) the Hospital failed to ensure all trayline food temperature were documented according to policy and practice.

Findings include:

1. The Hospital policy titled "Food Temperature Monitoring-Trayline" was reviewed on 3/23/10 at 1:26 PM. The policy required, "All food products must be maintained (held) at the correct temperature prior to service and during service...Using the trayline Temperature Record, the early supervisor is responsible for taking the temperatures of all pertinent breakfast trayline items daily and recording it on the form...the late supervisor is responsible for recording the lunch and dinner trayline temperatures daily...."

2. During the tour of Food and Nutrition Services on 3/23/10 between 10:30 AM and 11:15 AM, the trayline temperature log was reviewed. Three of 31 days in January 2010 (1/3, 1/8, & 1/29), lacked documentation of trayline food temperature for either breakfast, lunch or dinner.

3. The Executive Chef/Production Manager was interviewed on 3/23/10 at 11:10 AM. The Manager stated that trayline food temperature are taken for breakfast, lunch and dinner. The above finding was confirmed with the Manager and the Director of Nutrition Services during interview on 3/23/10 at 11:15 AM.

A. Based on policy review, observation, environmental cleaning documentation and staff interview, it was determined that the Hospital failed to ensure, for 3 of 4 unoccupied rooms (rooms 304, 329 and 327) inspected on 3 North Telemetry, beds were clean and rooms did not contain personal belongings or equipment.

Findings include:

1. On 3/22/10 at approximately 1:00 PM, the Hospital's Discharge Cleaning policy was reviewed. The policy included, "Wash entire bed...wash entire frame...if any patient care equipment has been left in the room-go to desk and advise nursing of need to remove equipment to soiled utility room."

2. On 3/22/10 at 9:30 AM 3 North Telemetry unit was toured.

* The bed in unoccupied room 304 contained siderails that were stained with a brownish/yellow substance. The bedside table was also stained with a black colored substance. Room 304 was last occupied and cleaned on 3/20/10 according to documentation provided by the Manager of Environmental Services on 3/22/10 at approximately 11:30 AM.

* Unoccupied bed 329-1 contained a wrist watch in the bedside drawer. The room was last occupied and cleaned on 3/20/10 according environmental cleaning documentation.

* The unoccupied bed 327-2 contained patient equipment (a fall sensor) that was dangling from the siderail. The room was last occupied and cleaned on 3/18/10 according to environmental documentation.

3. The above findings were confirmed by the Manager of Environmental Services during an interview on 3/22/10 at approximately 10:30 AM.

B. Based on review of Hospital policy, observation, clinical record review, and staff interview, it was determined that in 2 of 2 (Pt #1 and #12) clinical records reviewed of patients requiring isolation precautions, the Hospital failed to ensure all precautions were implemented and maintained, as required.

Findings include:

1. Hospital policy entitled," Transmission-Based Precautions," reviewed on survey date 3/22/10 at approximately 1:00 PM required, "Purpose: The purpose of this policy is to delineate the management of transmission-based precautions. Transmission-based precautions are used for all patients known or suspected to be infected or colonized with epidemiologically important pathogens that can be transmitted ...or by contact with dry skin or contaminated surfaces. Process: 1. In addition to Standard Precautions that apply to all patients there are three types of Transmission-Based Precautions: 1.1 Contact Precautions: Disease requiring Contact Precautions are outlined by Type and Duration in Attachment 1. Place the patient in a private room...Special contact precautions are used for C-difficile infections. Traditional hand washing will only be used before and after patient care..Documentation:..Enter Contact Precautions in the computer...apply sign on patient's door..."

2. Hospital policy entitled, "Recommendations for Isolation Precautions in Hospitals," reviewed on survey date 3/22/10 at approximately 1:00 PM required, "...Infection/condition: Enterocolitis, Clostridium difficile...Precautions Type - Contact."

3. On survey date 3/22/10 between approximately 9:00 AM and 10:00 AM, the 3 South Telemetry Unit was toured. During the tour, it was observed that Pt #1 (room #324 bed 2) was in a semiprivate room with a roommate.

4. The clinical record of Pt #1 was reviewed on survey date 3/22/10 at approximately 10:00 AM. Pt #1 was a 93 year old female admitted to the Hospital on 3/7/10 with diagnoses of Anemia and Renal Failure. The clinical record contained a physician order dated 3/20/10 that required the collection of a C-Diff (Clostridium difficile) sample. As of survey date 3/22/10 at 11:00 AM, the sample had not been collected to rule out C-Diff infection, Pt #1 had not been isolated as required, and was in a semi-private room with a roommate.

5. The finding was verified by the Nurse Manager of the 3 South Telemetry Unit during an interview on survey date 3/20/10 at approximately 11:00 AM


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6. A tour of the Intensive Care Unit (ICU) was conducted on 3/22/10 between 1:40 PM and 2:25 PM. There were no patients identified with infectious disease requiring isolation precaution, thus no signage or equipment for isolation was noted in any of the patients rooms.

7. The Clinical record of Pt. #12 was reviewed on 3/22/10 at 1:55 PM. Pt. #12 was a 55 year old female admitted in the ICU through the Emergency Department on 3/21/10 at 3:30 PM, with Nausea, vomiting, diarrhea and uncontrolled Hypertension. ED Nursing notes included documentation that Pt.#1 had moderate to small amount of liquid diarrhea at 5:35 PM and 8:30 PM on 3/21/10. A Physicians order dated 3/21/10 at 10:50 PM included "...Stool for C-Diff...." Pt. #12 was not placed in isolation precaution. As of survey date 3/22/10 at 1:30 PM the sample was not collected to rule out C-Diff infection.

8. The above findings were confirmed with the Charge Nurse and the Director of the ICU North during an interview, on 3/22/10 at 2:20 PM.














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A. Based on policy review, observation and staff interview, it was determined that the Hospital failed to ensure, in 1 of 12 rooms (310-1) inspected on 3 North Telemetry, blood was cleaned from environmental surfaces in accordance with policy.

Findings include:

1. On 3/24/10 at approximately 1:00 PM the policy titled, "Blood and Body Fluid Clean Up" was reviewed. The policy included, "All blood and body fluids...will be cleaned up by the nursing staff."

2. On 3/22/10 at approximately 9:30 AM, room 310 was observed with a penny size bright red stain on the floor next to bed 310-1

3. The above finding was confirmed by the Manager of Environmental Services on 3/22/10 at 9:30 AM, during an interview.

A. Based on review of Hospital policy, clinical record review and staff interview, it was determined that in 1 of 2 (Pt #2) clinical records reviewed on the 3 South Telemetry Unit, the Hospital failed to ensure that discharge evaluations were conducted as per policy.

Findings include:

1. Hospital policy entitled, "Case Management: Discharge Planning Process," reviewed on survey date 3/22/10 at 12:45 PM required, "...7. Any member of the team may make a referral to Social Service when case complexity is high or psychosocial needs present. 7.1 Social Service will respond to a referral within 72 hours or the next business day."

2. The clinical record of Pt #2 was reviewed on survey date 3/22/10 at approximately 10:30 AM. Pt #2 was a 65 year old male admitted to the Hospital on 3/16/10 with diagnoses of End Stage Renal Disease and Near Syncope. The clinical record contained Emergency Department documentation dated 3/16/10 at 12:09 PM that indicated a SS (social service) referral had been made. As of survey date 3/22/10 (seven days) at 10:45 AM, the clinical record lacked an evaluation by the SS department.

3. The finding was verified by the Nurse Manager of the 3 South Telemetry Unit during an interview on survey date 3/20/10 at approximately 11:00 AM.

A. Based on review of Hospital policy, clinical record review and staff interview, it was determined that in 2 of 2 (Pt #1 and 2) clinical records reviewed of patients with orders for Occupational Therapy referrals, the Hospital failed to ensure all patients were evaluated as required.

Findings include:

1. Hospital policy entitled, "Assessment/Reassessment of Patients-Rehabilitation Services," reviewed on survey date 3/22/10 at 12:00 PM required, "3.1. Inpatient Assessments: In PT and OT, the inpatient assessments is attempted within 24 hours of receipt of the inpatient order in the department...If the inpatient assessment for some reason cannot be completed within the stipulated time frame (i.e. patient refusal, testing, etc.), the therapist will make every attempt to document the reason in the medical record."

2. The clinical record of Pt #1 was reviewed on survey date 3/22/10 at approximately 10:00 AM. Pt #1 was a 93 year old female admitted to the Hospital on 3/7/10 with diagnoses of Anemia and Renal Failure. The clinical record contained a physician order date 3/16/10 that required an Occupational Therapy (OT) evaluation. As of survey date 3/22/10 at 11:00 AM the clinical record lacked an OT evaluation and/or reason the evaluation had not been completed.

3. The clinical record of Pt #2 was reviewed on survey date 3/22/10 at approximately 10:30 AM. Pt #2 was a 65 year old male admitted to the Hospital on 3/16/10 with diagnoses of End Stage Renal Disease and Near Syncope. The clinical record contained a physician order date 3/16/10 that required an Occupational Therapy (OT) evaluation. As of survey date 3/22/10 at 11:00 AM the clinical record lacked an OT evaluation and/or reason the evaluation had not been completed.

4. The findings were verified by the Nurse Manager of the 3 South Telemetry Unit during an interview on survey date 3/22/10 at 11:00 AM.