HospitalInspections.org

Based on review of hospital policies/procedures, Medical Staff Bylaws and Rules and Regulations, medical records and interviews, it was determined the hospital failed to protect and promote each patient's rights as evidenced by:

(A123) failing, in its resolution of a grievance, to provide the patient with written notice of the hospital's decision, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion of the grievance process;

(A166) failing to require the use of restraints in accordance with a written modification to the patient's plan of care;

(A168) failing to require that the use of restraints is in accordance with the order of a physician or other licensed independent practitioner;

(A169) failing to require that the use of restraint is never written as a standing order or on an as needed basis (PRN); and

(A174) failing to require that restraints are discontinued at the earliest possible time.

The cumulative effect of these systemic problems resulted in the hospital's failure to protect and promote each patients' rights.

Based on review of hospital policies/procedures, medical records, and interviews, it was determined the hospital failed to provide an organized nursing service 24-hours per day that provides for the RN supervision of nursing care required by each patient as evidenced by:

(A395) failing to require that an RN supervise and evaluate the nursing care for each patient;

(A396) failing to require that the nursing staff develops and keeps current a nursing care plan for each patient; and

(A404) failing to require that drugs are administered in accordance with complete orders of a practitioner.

The cumulative effect of these systemic problems resulted in the hospital's failure to provide an adequate, organized nursing service.

Based on review of hospital policy/procedure, Patient Handbook, other documents, and interview, it was determined that in its resolution of a grievance, the hospital failed to provide the patient with written notice of its decision, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for 2 of 2 patients (Pts #16 and 31).

Findings include:

Review of the hospital policy titled Complaint/Grievance Process revealed: "...Complaint:...A verbal or written concern or objection from a patient or the patient's designated representative regarding the quality or appropriateness of patient care that can be effectively addressed and resolved by informal means. Generally a complaint may be solved quickly by the staff member receiving the complaint...Grievance:...Verbal or written requests by a patient or designated representative to have the facility formally review the patient's concern or objection about the quality or appropriateness of patient care. Generally a grievance would require an investigation and/or may require management level personnel to resolve the grievance. The grievance can not be resolved promptly by staff present at the time of the grievance...Complaints are documented on an Occurrence Report and follow the occurrence management process...Grievances are documented on a Grievance Report by the employee as soon as the grievance is received and the report is immediately forwarded to the Department Manager/Supervisor...A 'Follow-up' response is provided to the patient within five (5) working days of the event...."

The hospital provided the Patient Handbook, titled: Promise Hospital of Phoenix A Guide to Patient Services. Review of this document revealed: "...Grievance Process...The Patient/Family should complete a Grievance Form and submit it to a patient advocate, or person acting on their behalf...Patient Advocacy shall submit the grievance to the Grievance Committee...The Grievance form shall be reviewed and addressed by the Grievance Committee...The complainant shall receive a written notice of the committee's review. The written response shall include the name of the contact person, the steps taken to investigate the grievance, a brief description of the Grievance Committee review, and the date of completion...."

On 12/12/11, the Director of Quality and Risk Management (DQRM) stated that the facility does not have a Grievance Committee, but utilizes the Performance Improvement Committee for that purpose.

On 12/12/11, the CCO provided an "Investigative Report" regarding a complaint expressed by Pt #16's Power of Attorney (POA). The complaint focused on a staff member's alleged rude and aggressive behavior. The documentation contained information that the COO had spoken with the patient's POA on 4/1/2011, regarding the complaint. She spoke with the staff member some time later and then on 4/6/22, the COO followed up with the POA verbally. The "Investigative Report" contained documentation of this verbal follow up.

The COO confirmed on 12/13/11, that she had not handled this complaint as a grievance. However, the complaint was not resolved at the time of the complaint and therefore met the definition of a grievance. The COO did not complete a grievance report; the PI Committee did not review it; and the POA did not receive a written response. In addition, if the complaint was considered to meet the definition of a complaint, rather than a grievance, an Occurrence Report was required per policy. An Occurrence Report was not completed.

On 12/13/11, the COO confirmed that the hospital policy/procedure for the Complaint/Grievance Process was not followed regarding the complaint/grievance expressed by Pt #16's POA.

On 12/12/11, the DQRM provided a Grievance Report completed by a Clinical Supervisor on 6/28/11, regarding Pt #31's grievance. The Quality and Risk Director stated that this Grievance Report was the only patient grievance that the hospital had received during the past year. The patient's grievance focused on a number of patient care issues.

The DQRM provided documentation of her verbal follow-up to the patient's grievance dated 6/29/11. This documentation included the patient's request to review the written report of his original grievance. The hospital was unable to provide documentation that the patient received any written response to his grievance; the steps taken to investigate the grievance or any documentation that the grievance was reviewed by the PI Committee.

The DQRM and CCO confirmed during an interview conducted on 12/13/11, that the patient did not receive a written response to his grievance and that the PI Committee minutes did not contain documentation that the grievance was reviewed at a PI Committee meeting.

Based on review of hospital policy/procedure, medical records and staff interview, it was determined that the hospital failed to require that the use of restraints be in accordance with a written modification to the patient's plan of care for 2 of 2 patients (Pts #2 and 3).

Findings include:

Review of the hospital policy/procedure titled Restraints revealed the hospital's policy did not include the CMS requirement that the use of restraints be in accordance with a written modification to the patient's plan of care.

Patient # 2's medical record contained physician orders for restraints: right wrist only on 11/22/11; upper extremities nights only 11/23/11; mitts and 4 side rails on 11/24/11, 11/26/11, and 11/27/11; Right upper extremity on 11/25/11, 12/1/11, and 12/2/11; and upper extremity on 11/28/11, 11/29/11, and 12/3/11 through 12/8/11. Patient #2's Interdisciplinary Plan of Care did not contain any mention of restraints.

Patient # 3's medical record contained physician orders for restraints: upper extremities on 11/23/11, 11/25/11, 11/27/11 and 11/28/11 through 12/8/11. Pt #3's Interdisciplinary Plan of Care did not contain any mention of restraints.

RN # 8 confirmed during an interview on 12/8/11 at 1215 hours, that patient #3's Interdisciplinary Plan of Care was incomplete and missing documentation regarding restraints.

The day shift RN Supervisor confirmed during an interview on 12/8/11 at 1515 hours, that patients #2 and 3's Interdisciplinary Plan of Care were incomplete and missing documentation regarding restraints.

Based on review of hospital policy and procedure, Medical Staff Bylaws/Rules/Regulations, facility documents, medical records and interview with staff, it was determined the administrator failed to require that the use of restraints be in accordance with an order from the physician or other licensed independent practitioner for 3 of 3 patients that were restrained (Pts # 2, 3 and 8).

Findings include:

Review of the hospital policy/procedure titled Restraints revealed: "...Restraints are only used...when they are therapeutically necessary and ordered by the physician for the safety of patients and others...use of restraints will be monitored for appropriateness and patient safety outcomes...Standing or PRN orders for restraints are not valid...MD must in-person evaluate patient...if need for restraint continues, a new order is written...RN- if the MD does not perform an in-person evaluation before the order expires, the restraint must be removed...RN&LVN...ensures that patient care is provided and data collected about patient behavior every 2 hours for patients restrained by medication or in one or two point restraints...."

Review of Medical Staff Bylaws revealed: "...basic responsibilities of individual staff membership...each member of the Medical Staff shall...abide by the Medical Staff Bylaws and by all other lawful standards, policies and rules of the Hospital...."

Review of Medical Staff Rules and Regulations revealed: "...the use of mechanical restraints shall require clinical justification and shall be used only to prevent a patient from injuring himself or others or to prevent serious disruption of the therapeutic environment...Restraint orders shall be renewed every twenty-four (24) hours...each written order for a mechanical restraint shall be time limited...PRN orders shall not be used to authorize the use of restraints."

Patient # 2's medical record contained a form titled Restraint Physician Orders. The form contained three sections for the physician to complete: "...Reason for Restraint...Type of Restraint...Monitor the patient every:...1 hour...2 hours...." The medical record contained Restraint Physician Order forms for every calendar day from 11/22/11 through 12/8/11.

On 11/22/11, at 0800 hours a physician wrote an order for right wrist only.
On 11/23/11, at 0800 hours a physician wrote an order: "...night shift need only- day prn...Physical restraint: Upper Extremities...."
The medical record also contained physician orders for restraints for the following dates and times: 11/24/11 at 1200 noon, 11/25/11 at 1410 hours, 11/26/11 at 1500 hours, 11/27/11 through 11/30/11 at 0800 hours, 12/1/11 and 12/2/11 at 0900 hours, 12/3/11 at 1100 hours, and 12/4/11 through 12/8/11 at 0800 hours

Patient # 2's medical record contained a form titled 24-HR Care Record. The form contained nursing documentation that the patient was in a right wrist restraint on 11/22/11 from 0700 through 1100 hours. "Restraints off" on 11/22/11 from 1300 hours through 1900 hours. "Restraints reapplied" on 11/22/11 at 2000 hours through 0600 hours on 11/23/00. The 24-HR Care record contained nursing documentation that the patient was out of restraints on 11/23/11 from 0700 hours through 1100 hours, and the patient was placed back in restraints on 11/23/11 at 1300 hours.

RN # 8 confirmed in an interview conducted on 12/8/11 at 1215 hours, that patient # 2 had one PRN order for restraints on 11/23/11.

RN # 30 confirmed in an interview on 12/9/11 at 1100 hours that patient # 2 did not have restraint orders renewed every 24 hours as required by Medical Staff Rules and Regulations. She also confirmed that the nurse discontinued restraints and reapplied restraints without a new physician's order.

The "CCO" (Chief Clinical Officer) confirmed in an interview on 12/12/11, that restraint orders for patient # 2 were not ordered every 24 hours as required by Medical Staff Rules and Regulations.

Patient # 3's medical record contained Restraint Physician Orders forms. A physician ordered restraints on 11/27/11 at 0800 hours. A physician reordered restraints daily at 0800 hours from 11/27/11 through 12/1/11. On 12/2/11, a physician reordered restraints at 0900 hours. On 12/3/11, the physician reordered restraints at 1015 hours. Pt #3's medical record contained documentation that the patient remained in restraints continuously from 11/27/11 through 12/3/11.

Patient # 3's medical record contained Restraint Physician Orders forms for 11/25/11 and 11/27/11. On 11/25/11, the physician did not record the type of physical restraint that patient # 3 required due to disorientation/confusion and risk of injury to self. On 11/27/11, the physician did not record the reason for the restraint or the type of physical restraint for Pt # 3.

RN # 30 confirmed in an interview on 12/9/11 at 1100 hours, that patient # 3's medical record contained incomplete physician restraint orders for 11/25/11 and 11/27/11.

Patient # 8's medical record contained Restraint Physician Orders forms. The physician recorded the initial order for restraints on 11/20/11 at 1200 hours. The form contained documentation that the patient required physical restraints to his/her upper extremities due to the patient being at risk for injury to self and due to disorientation/confusion. The physician documented restraint orders on subsequent dates from 11/21/11 through 11/23/11, but the physician did not record the time of the orders on each of these dates.

The CCO confirmed in an interview conducted on 12/14/11 at 1215 hours, that the restraint orders for patient # 8 were incomplete and did not meet the requirement of the Medical Staff Rules and Regulations to be renewed every 24 hours.

Based on review of policy and procedure, facility documents, medical records and staff interviews, it was determined the administrator failed to assure that orders for restraints were never written as a standing order or on an as needed basis (PRN) for 1 of 3 patients who was restrained (Pt #2).

Findings include:

Cross reference Tag (A168) for information regarding hospital policy and procedure, Medical Staff Bylaws, Rules and Regulations for restraints and PRN orders for Patient # 2.

Employee # 8 confirmed in an interview conducted on 12/8/11 at 1215 hours, that patient # 2 had one order for restraints PRN on 11/23/11.

The "CCO" (Chief Clinical Officer) confirmed in an interview on 12/12/11 that patient # 2 had a physician restraint order for restraints PRN on 11/23/11.

Based on review of hospital policy and procedure, medical record and staff interviews, it was determined the administrator failed to require that restraints were discontinued at the earliest possible time regardless of the length of time identified in the order for 1 of 3 patients who were in restraints (Pt #3).

Findings include:

Cross reference Tag (A168) for information regarding policy and procedure titled Restraints.

Patient # 3's medical record contained a form titled 24-HR Care Record. The form contained nursing documentation that the patient was in soft bilateral wrist restraints on 12/2/11 from 0700 through 12/3/11 at 0600 hours, and on 12/3/11 from 0700 hours through 12/4/11 at 0400 hours. Documentation on this form revealed that on 12/2/11, the patient was calm, quiet, and resting comfortably at 0800, 1200 noon, 1600 hours, 2000 hours, and 2200 hours; and on 12/3/11 from 0100 hours through 0600 hours and from 1400-2000 hours; and on 12/4/11 at 0000 (midnight) through 0400 hours.

RN # 8 confirmed in an interview conducted on 12/8/11 at 1430 hours, that the patient remained in restraints while calm, quiet and resting comfortably and that restraints were not discontinued at the earliest possible time.

Based on review of Medical Staff Bylaws/Rules/Regulations, hospital policies and procedures, medical records and interviews, it was determined the hospital failed to require that the Medical Staff enforce bylaws to carry out its responsibilities as evidenced by:

1. failing to require that physicians' restraint orders comply with the requirements of the Medical Staff Rules and Regulations for restraints for 3 of 3 patients (# 2, 3 and 8);

2. failing to require that physicians' orders comply with the hospital requirements for completeness for 2 of 2 patients who received titrated vasoactive and/or sedation medications (Pt's #2 and 3); and

3. failing to require that the prescribing practitioner or other responsible practitioner authenticate and countersign verbal orders within 24 hours of receipt as required by hospital policy for 5 of 6 patients (Pts # 1, 2, 23, 25 and 26).

Findings include:

1. Cross Reference Tag A168 for information regarding Medical Staff Bylaws and Rules and Regulations for restraint orders, and for information regarding restraint orders contained in the medical records of (Pt's # 2, 3, and 8).

RN # 8 confirmed in an interview conducted on 12/8/11 at 1215 hours, that patient # 2's medical record contained one PRN order for restraints on 11/23/11.

RN #30 confirmed in an interview on 12/9/11 at 1100 hours, that patient # 2's medical record contained physician's orders for restraints that did not meet the requirement for renewal every 24 hours.

The "CCO" (Chief Clinical Officer) confirmed in an interview on 12/12/11, that restraint orders for patient # 2 were not renewed every 24 hours as required.

RN #30 confirmed in an interview on 12/9/11 at 1100 hours, that patient # 3's medical record contained physician's restraint orders on 11/25/11 and 11/27/11, which did not specify the type of restraint and/or the reason for the restraint as required by Medical Staff Rules and Regulations.

The CCO confirmed in an interview conducted on 12/14/11 at 1215 hours, that patient # 8's medical record contained physicians' orders for restraints which were incomplete. The orders did not include the time.

The CCO confirmed during interview conducted on 12/14/11, that Pt #32's medical record contained a physician's telephone order for PRN restraints, dated 11/13/09. She confirmed that PRN restraint orders are not permitted per hospital policy and Medical Staff Rules and Regulations.

2. Review of the Medical Staff Bylaws revealed: "...Basic responsibilities of individual staff membership...abide by the Medical Staff Bylaws and by all other lawful standards, policies and rules of the Hospital...."

Review of the hospital policy/procedure titled Medication Administration revealed: "...individuals who prepare, dispense, and administer drugs shall do so only upon the order of a practitioner who has been granted clinical privileges and is legally authorized to prescribe/order drugs...drugs shall be prepared and administered in accordance with the orders of the prescriber or practitioner responsible for the patient's care and accepted standards of practice...drug administration procedure...verify the dosage is correct...right patient...right drug...right dose...right route...right time...."

On 12/7/11 at 1630 hours, physician #2 wrote an order for Pt #2: "...Dobutamine gtt (drip) @ mcg (microgram)/min (minute)...."

On 11/20/11 at 0715 hours, an RN recorded a physician's telephone order for Pt # 3: "...start Levophed drip keep SBP (systolic blood pressure) > 100...."

On 11/23/11 at 0940 hours, an RN recorded a physician's telephone order for Pt #3: "...Propofol sedation per protocol...."

Cross reference Tag 404 for information regarding nursing administration of the Dobutamine, Levophed and Propofol to Pt's #2 and 3.

The Director of Pharmacy confirmed in an interview on 12/9/11 at 1115 hours, that the physicians' orders for Dobutamine and Levophed were incomplete. In addition, the physician's order for Propofol was incomplete, since the protocol for Propofol requires completion by the physician and Pt #3's medical record did not contain the protocol.

3 .Review of the Medical Staff Bylaws revealed: "...Basic responsibilities of individual staff membership...abide by the Medical Staff Bylaws and by all other lawful standards, policies and rules of the Hospital...."

Review of the hospital policy and procedure titled Verbal and Telephone Medication Orders revealed: "...Authentication (Verification) of Verbal Orders- orders that are not written by the prescriber (e.g., verbal orders) shall be subsequently authenticated (verified) and countersigned by the prescribing practitioner or other responsible practitioner within 24 hours of receipt...."

Patient # 1 was admitted to the hospital on 12/4/11. Review of the medical record on 12/8/11, revealed the following verbal/telephone orders which were not authenticated:

12/4/11 at 1510, admission and admit medication order sheet;
12/4/11, precaution orders, consult request order for the Renal group, sliding scale Insulin orders, lab orders;
12/5/11, Rehabilitation admit treatment clarification orders, Occupational Therapy Services order, Physical therapy Service order, Dialysis treatment, Pharmacy consult orders to dose Aranesp, diet orders, medication orders, and Lab orders; and
12/6/11, Additional diet changes, lab orders, medication orders and Physician Wound orders.

Patient # 2 was admitted to the hospital on 11/16/11. Review of the medical record on 12/8/11, revealed the following verbal/telephone orders which were not authenticated:

12/3/11, admission order to ICU and the Natrecor drip order.

Patient #23 was admitted to the hospital on 11/30/11. Review of the medical record on 12/8/11, revealed the following verbal/telephone orders which were not authenticated:

11/30/11 at 1530, Admission Orders;
11/30/11 at 1530, Medication Reconciliation admission continuation orders;
11/30/11 at 1530, Sliding Scale Insulin Orders;
11/30/11 at 1530, Pharmacy order Clarification;
11/30/11 at 1530, medication and lab orders;
12/1/11 at 0810, suppository order;
12/1/11 at 1055, diet order, fluid restriction order, and lab order;
12/1/11 at 1935, pharmacy formulary substitution medication order;
12/1/11 at 2000, medication orders;
12/1/11 at 2000, hemodialysis order and lab order;
12/5/11 at 1640, medication order; and
12/5/11 at 1930, pharmacy consultation lab order.

Patient #25 was admitted to the hospital on 10/31/11. Review of the medical record on 12/8/11, revealed the following verbal/telephone orders which were not authenticated:

10/31/11 at 2045, Medication Reconciliation admission continuation orders;
10/31/11 at 2040, medication orders;
11/11/11 at 2030, pharmacy consultation lab order;
11/13/11 at 1740, stat lab and respiratory therapy order;
11/14/11 at 1015, Wound Orders;
11/15/11 at 1430, nutrition supplement orders;
11/16/11 at 1045, lab order;
11/21/11 at 1600, pharmacy consultation medication and lab order;
11/23/11 at 1400, pharmacy consultation lab order;
12/5/11 at 2040, Sliding Scale Insulin Orders;
12/5/11 at 2000, pharmacy formulary substitution medication order; and
12/5/11 at 2040, admit order clarification for medication and lab orders.

Patient #26 was admitted to the hospital on 11/29/11. Review of the medical record on 12/8/11, revealed the following verbal/telephone orders which were not authenticated:

11/29/11 at 1230, Medication Reconciliation admission continuation orders;
11/29/11 at 1230, medication orders;
11/29/11 at 2130, Potassium & Magnesium Replacement Orders;
11/29/11 at 1200, wound care orders;
11/29/11 at 1215, pharmacy consult orders for lab orders;
11/29/11 at 1505, diet order, lab order;
11/29/11 at 2000, admit order clarification (medication orders);
11/30/11 at 1315, pharmacy consult lab orders;
12/1/11 at 1110, nutrition/diet orders; and
12/1/11 at 1140, Wound Care Orders.

The Chief Clinical Officer confirmed during an interview conducted on 12/12/11 at 1315 hours, that orders in the medical records of Pts #1 and 2 were not authenticated according to hospital policy

The day shift Nursing Supervisor confirmed during an interview conducted on 12/8/11, that the orders in the medical records of Pts #23, 25, and 26 were not authenticated according to hospital policy.

Based on review of hospital policy/procedure, medical record, and interview, it was determined that the hospital failed to require that an RN supervise and evaluate the nursing care for each patient as evidenced by failing to require daily reassessment for factors that put the patient at risk for falls, and failing to require reassessment of the patient's physical condition after a fall and initiate a Potential for Injury plan of care as required by hospital policy for 1 of 1 patient who sustained a fall during his hospitalization (Pt # 23).

Findings include:

Review of hospital policy/procedure titled 24 Hour Patient Care Documentation revealed: "...Information within the 24 Hour Care Record includes but is not limited to the following:...Fall Risk/Safety evaluation, as performed a minimum of every 12 hours, includes level of risk and checkmark...of pertinent interventions preformed (sic) based on the risk level...."

Review of hospital policy/procedure titled Fall Prevention Program revealed: "...Policy:...All patients will be assessed upon admission for factors that put them at risk for falls and reassessed daily and/or whenever there is a change in the patient's condition/status. The patient's fall risk status shall be noted on each shift...6. Any time a patient may fall the following actions are to be taken: a. Assess the patient's physical condition...e. Initiate a 'Potential for Injury' plan of care...."

Pt #23 was admitted to the facility on 11/30/11 as a transfer from an acute hospital. He had a right below-knee amputation due to a complex right foot diabetic nonhealing necrotic wound with a wound infection causing osteomyelitis. He was admitted for continuing wound care and comprehensive physical and occupational therapy. The physician's admission assessment included end-stage liver disease, end-stage renal disease, severe debility, hypertension, and anemia. The patient was on contact isolation precautions at the time of the survey on 12/8/11.

On 11/30/11, an RN documented assessment of the patient's fall risk as "12" (with Moderate Risk 5-12 and High Risk 13-27). The section on the 24 hour care record for fall safety assessment was blank for 12/1/11. An RN documented on 12/1/11 at 1245: "...Aide reported pt is on his knee @ bedside. pt found knee on the floor and stooling. pt helped to bed. Stump drsg (dressing) redone. Call light within reach. The medical record did not contain an RN assessment of the patient's physical condition post fall. The section on the 24 hour care record for fall safety assessment was blank on 12/2/11 and 12/5/11. His fall risk was rated "13" (High) on 12/3/11.

On 12/8/11, RN #27 confirmed that Pt #23's medical record did not contain documentation of his fall risk assessment on 12/1/11, 12/2/11, or 12/5/11. RN #27 also confirmed that the patient's plan of care had not been updated as required by policy/procedure.

On 12/14/11, the COO confirmed that an RN did not complete and document, in the medical record, an assessment of the patient's physical condition post fall.

Based on review of hospital policies/procedures, medical records and interviews, it was determined that the hospital failed to ensure that the nursing staff develop and keep current a nursing care plan for 4 of 5 patients (Pts # 2, 3, 23 and 25).

Findings include:

Review of hospital policy/procedure titled Interdisciplinary Treatment Planning revealed: "...Planned patient care shall be performed in a coordinated interdisciplinary manner...Planning of patient care shall begin upon admission post assessment of the patient and shall continue throughout the patient's hospitalization as the patient's needs or changes in current planned care are identified...Plans of care are reviewed or revised a minimum of weekly before and/or during team conference and as change in patient condition warrants...."

Pt #2 was admitted on 11/16/11 to the LTAC hospital as a transfer from an acute hospital. Review of her medical record on 12/8/11, revealed that she had Diabetes mellitus; chronic renal failure with hypernatremia, currently with a foley catheter; difficulty swallowing, with a percutaneous endoscopic gastrostomy (PEG) feeding tube in place; history of ventilator dependent respiratory failure, currently with bi-level positive airway pressure (BiPAP) at night and as needed; history of coronary artery disease, and chronic obstructive pulmonary disease. The patient had a central arterial line in place.

Review of patient #2's Interdisciplinary Plan of Care during survey, on 12/9/11, revealed: "...Problem...Impaired Gas exchange r/t (related to) Altered oxygen supply...Involved Discipline...MD/DO...Nursing...Resp...." The date 11/17/11, was entered in the "Goal Met" column. The space for "Initiated" was blank. The space for documentation of review dates contained only the date 12/8/11. The problem "Alteration in comfort r/t:" was blank, however the space for "Involved Discipline" contained check marks for "...MD/DO...Nursing...PT (Physical Therapy)...OT (Occupational Therapy)...Pharm (Pharmacy)...." The space for goals contained: "...Indicate pain level minimized to comfort level of 3-4...." The date 11/17/11, was entered in the "Goal Met" column and the "Initiated" column. The space for documentation of review dates contained only the date 12/8/11. The problem "Ineffective Breathing r/t" contained check marks by "...Decreased function of lung tissue...and...Decreased ability to cough and deep breathe...." The space for "Involved Discipline" contained check marks for "...MD/DO...Nursing...Resp (Respiratory)...and IC (Infection Control)...." The section for documentation of goals was blank. Several check marks were entered next to selected interventions. The space for "Initiated" was blank. The space for documentation of review dates contained the date 12/8/11. The problem "Altered Fluid & Electrolyte Balance r/t" contained check marks by: "...Intake greater than output...and...Electrolytes altered...." "Involved Discipline" contained check marks for "...MD/DO...Nursing...Goals:...Maintain fluid and electrolyte balance...Recognize signs and symptoms of fluid balance...." The date 11/18/11, was entered in the "Goal Met" column.

On 12/9/11, the RN shift supervisor confirmed that Pt # 2's plan of care did not contain documentation that it was not initiated or reviewed by nursing as required by hospital policy/procedure.

Pt #3 was admitted to the LTAC hospital on 10/28/11, as a transfer from an acute hospital. He was post total colectomy. He was in the Intensive Care Unit (ICU) at the time of the survey, 12/8/11. Review of his medical record on 12/9/11, revealed that he was ventilator dependent and had undergone insertion of a tracheostomy tube and PEG feeding tube on 12/9/11. The patient had a "pelvic abscess" and decubiti on his sacrum and buttocks. He was assessed as having fluid overload. His wife was described as distressed and having difficulty coping with his illness.

Review of Pt #3's plan of care revealed: "...Problem...Safety r/t...History of falls...Fall risk score 17...Impaired judgment...Visual Deficits...Weakness of BLE (Bilateral Lower Extremities)...Risk r/t removing medical devices...." The space for "Involved Discipline" contained check marks for "...Nursing...PT...OT...and Resp...." The plan of care related to the problem "Safety" contained several goals and interventions and documentation that it was initiated by an RN on 10/28/11. However, it did not contain documentation that it had been reviewed since its initiation. The section of the plan of care designated to identify a problem with Ineffective Breathing was blank. The problem "Impaired Gas exchange r/t" contained check marks by "...Altered oxygen supply...and...Altered oxygen carrying capacity of blood...." The space for "Involved Discipline" contained check marks by "MD/DO...Nursing...and Resp...." The plan of care related to the problem "Impaired Gas exchange" contained a goal and interventions and documentation that it had been initiated by an RN on 10/28/11. However, it did not contain documentation that it had been reviewed since its initiation. The sections of the plan of care related to "Altered Skin Integrity," "Alteration in Communication," "Altered Bowel Elimination,"and "Ineffective Coping," were all blank.

On 12/9/11, the RN shift supervisor confirmed that Pt # 3's plan of care did not contain documentation that it was not initiated or reviewed by nursing as required by hospital policy/procedure.

Pt #23 was admitted to the facility on 11/30/11, as a transfer from an acute hospital. He had a right below-knee amputation (RBKA) due to a complex right foot diabetic nonhealing necrotic wound with a wound infection causing osteomyelitis. He was admitted for continuing wound care and comprehensive physical and occupational therapy. The physician's admission assessment included end-stage liver disease, end-stage renal disease, severe debility, hypertension, and anemia. The patient was on contact isolation precautions at the time of the survey on 12/8/11.

Pt #23's plan of care contained documentation that a nurse initiated the problem "Safety" on 11/30/11. However on 12/8/11, during survey, the plan of care did not contain documentation that this problem with goals and interventions had been reviewed. On 12/8/11, the section of the plan of care related to Infection was blank. Pt #23's plan of care contained documentation that a nurse initiated the problem "Alteration in comfort r/t" "Chronic pain r/t RBKA" and "Chronic pain r/t neuropathy" on 11/30/11. However, on 12/8/11, during survey, the plan of care did not contain documentation that this problem with goals and interventions had been reviewed.

On 12/8/11, RN #27 confirmed that Pt #23's plan of care did not contain documentation that it was initiated and/or reviewed by nursing as required by hospital policy/procedure. She stated that the team conference had been conducted on 12/7/11, and that the plan of care should have been reviewed prior to or during the team conference. In addition, she identified the following sections of the plan of care as requiring review: "Altered Fluid & Electrolyte Balance...Alteration in Cognition...Ineffective Coping...."

Pt #25 was admitted to the LTAC hospital on 10/31/11, as a transfer from an acute hospital. She had a complex sacrococcygeal wound and pseudomonas urosepsis at that time. The patient has had a total colectomy with an ileostomy placement and right hemiparesis from an old "CVA." An RN initiated Pt #25's plan of care on 10/31/11 for the problem "Safety" and on 11/1/11, for the following problems: "Infection," "Alteration in comfort," "Altered circulation," "Altered Bowel Elimination," "Altered Urinary Elimination." On 12/8/11, during survey, review of the plan of care revealed that it did not contain documentation that these problems with goals and interventions had been reviewed.

On 12/8/11, RN #27 confirmed that Pt #25's plan of care did not contain documentation that it had been reviewed by nursing as required by hospital policy/procedure.

Based on review of hospital policy/procedure, medical records and staff interview, it was determined that the hospital failed to require that drugs and biologicals be distributed in accordance with applicable standards of practice consistent with federal and state law for 2 of 2 patients who received intravenous titrated vasoactive and/or sedation medications (Pts # 2 & 3).

Findings include:

Cross reference Tag A404 for information regarding policy and procedure titled Medication Administration, and information regarding medication orders for Pts # 2 & 3.

The Pharmacy manager confirmed in an interview on 12/9/11 at 1115 hours, that the Dobutamine, Levophed and Propofol drips were dispensed without Pharmacy clarifying the physicians' orders for route, dosage and rate of the drips.

Based on policy and procedure, review of medical records and interview with staff, it was determined the hospital failed to require that drugs were administered in accordance with the orders of a practitioner responsible for the patient's care and accepted standards of practice, as evidenced by failure of the RN to clarify an incomplete physician's order for intravenous titration of a vasoactive and/or sedation medication prior to administration of the medication for 2 of 2 patients (# 2 & 3).

Findings include:

Review of Arizona Administrative Code, Title 4., Chapter 19, Board of Nursing R4-19-402. Standards Related to Registered Nurse Scope of Practice C. 4. revealed: "... Provide nursing care within the RN scope of practice in which the nurse: a. Administers prescribed aspects of care including treatments, therapies, and medications; b. Clarifies health care provider orders when needed...."

Cross reference Tag 0353 #2 for information regarding hospital policy titled Medication Administration, and incomplete physician orders for titrated medications for patients # 2 and 3.

Pt # 2's medical record contained documentation that an RN started a Dobutamine drip on 12/7/11 at 1630 hours, without clarification of the order for dosage, route and rate.

The Pharmacy Manager confirmed in an interview on 12/9/11 at 1115 hours, that the RN started the Dobutamine drip without clarifying the order for dosage, rate and route.

RN # 8 confirmed in an interview on 12/9/11 at 1145 hours, that the RN started the Dobutamine drip without clarification for dosage and rate.

Pt # 3's medical record contained documentation that an RN started a Levophed drip at 22.5 "mcg" (micrograms)/hr on 11/20/11 at 0700 hours, and continued with that dosage until 1700 hours when the drip was decreased to 15 mcg/hr.

Pt # 3's medical record contained documentation that the nurse started a Propofol drip
at 3.8 mcg/min on 11/23/11 at 1000 hours. The medication was decreased to 1.9 mcg at 1100 hours and then increased to 3.8 mcg at 1200 hours. The dose continued at that rate until 1900 hours. The dose was then decreased to 2.7 mcg/min, and continued at that rate until 2300 hours. At 2300 hours the rate was increased to 4.7 mcg/min and continued at that rate until 0600 on 11/24/11.

The Pharmacy Manager confirmed, during an interviews conducted on 12/9/11 at 1115 hours, that the Levophed and Propofol drips were dispensed without the nurse clarifying the physicians' orders for route, dosage and rate of the drips. The Pharmacist stated that there is a specific order form for ordering Propofol titled, Physician Orders For Propofol (Diprivan) For IV Sedation In Mechanically Ventilated Patients. The pharmacist confirmed that the medical record did not contain the Propofol order form.