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Based on document review and interview with key personnel on October 25, 2012 and October 29, 2012, it was determined that the governing body failed to assume full legal responsibility for the ongoing conduct of the hospital.

Findings include:

1. The governing body failed to assure that the medical staff was accountable for the quality of care provided to patients. (For further information, see Tag A-0049.)

2. The facility failed to assure that the patient was free of neglect, a form of abuse. (For further information, see Tags A-0115 and A-0145.)

3. The facility failed to monitor patient safety through a program which reviewed documentation, assessed patient condition, reviewed staff following policies, and medication errors to implement a preventive action and mechanisms throughout the hospital. (For further information, see Tag A-0286.)

4. The medical staff failed to take responsibility for the quality of the medical care provided to the patients by the hospital. (For further information, see Tag A-0338).

5. The facility failed to assure that a registered nurse supervised and evaluated the nursing care for patients in accordance with hospital policies. (For further information, see Tags A-0385, A-392, A-395, and A-0405.)


The cumulative effect of these findings resulted in this Condition for Participation being out of compliance.

Based on record review and inteview with key personnel on October 25, 2012 and Ocotber 29, 2012, it was determined that the facility failed to promote and protect patient rights.

Findings include:

The hospital failed to assure that patients were free of neglect, a form of abuse. Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. (For additional information, see Tag A-0145.)

The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance.

Based on record review and interview with key personnel on October 25, 2012 and October 29, 2012, it was determined that the facility failed to assure that the medical staff was responsible for the quality of the medical care provided to the patients by the hospital.

Findings include:

1. The 'History and Physical/Post-Admission Physician Evaluation' of Patient A documented that this 90 year-old was admitted on September 28, 2012 for rehabilitation services following "a right femoral neck fracture status post hemiarthroplasty, complicated by UTI [urinary track infection] and cognitive impairment."

2. Patient A's 'Interdisciplinary Daily Documentation (IDD)' dated October 8, 2012 documented that Patient A was "Alert," had both left and right hand grasps that were "WNL [within normal limits]," and was able to move all four extremities.

3. According to the facility policy 'Emergent Medical Treatment/Transfer Policy:' "upon assessment and determination by a physician that the patient requires more specialized services, transfer to an appropriate facility will be made providing the benefits of transfer outweigh the risks."

4. The medical record of Patient A noted that the patient had fallen at 0540 on October 9, 2012. The 'Physician Acute Visit Note' dated October 9, 2012 stated: "Fall with head injury." This note was signed by Physician A.

5. Documentation in Medical Record A on October 9, 2012 at 0600 indicated that Physician A ordered that Patient A be sent for a CT (Computed Tomography) Scan of the head ASAP [as soon as possible], and ordered neurological checks every hour. However, there was no order for transfer for emergency services.

6. At 0800, Physician A conducted a visit with Patient A. The 'Physician Acute Visit Note' documented that Patient A had "a large egg-shaped swelling on left forehead," and Patient A's pupils were "irregular and minimally reactive."

7. Documentation on the 'Interdepartment Communication Board' indicated that the CT Scan appointment was for 1045 on October 9, 2012, and this was performed at 1050. Note: This was approximately five hours after the test was ordered.

8. The preliminary report from the "CT Head" dated October 9, 2012 had a fax time of "12:12pm." This report noted: "no acute intracranial abnormality." Note: This was approximately six hours after the test was ordered.

9. Nursing documentation by Nurse A regarding Patient A on the 'Daily Progress/Narrative' indicated that at 1700 on October 9, 2012: "pt [patient] reports bilateral facial twitching, which is visibly noticeable."

10. Physician B documented his observation of Patient A in the 'Progress Note' at 2115, which stated: "pupils equal" and "bil [bilateral] facial twitching - (New)." Physician B ordered a medication (Ativan), but failed to order any transfer for emergency services.

11. The Medical Record of Patient A documented that on October 10, 2012 at 0955, Physician C ordered "resume neuro checks every 1 hour." There is no documentation of a physician visit at this time and no order for transfer for emergency services is documented.

12. The Medical Record of Patient A documented that on October 10, 2012 at 1030, Physician C ordered "head CT [without] contrast today." There is no documentation of a physician visit at this time and no order for transfer for emergency services is documented.

13. The preliminary report from the "CT Head" dated October 10, 2012 had a fax time of "12:50pm." This report noted: "some interval reduction in the size of the left frontal scalp hematoma without underlying bony injury or acute intracranial injury." Nurse I documented that Physician C was aware of this report at 1400.

14. On October 10, 2012 at 1430, Physician D documented, "CTSC [CT Scan] for worsening status. Family very concerned" on the 'Progress Note." The documentation continued: "Marked twitching [left] side of face. [Left] upper extremity plegic." Physician D wrote orders for Patient A to by transferred to an Emergency Department for evaluation.

15. Nurse J documented on the 'Daily Progress/Narrative' that Patient A returned to the rehabilitation hospital at 1745.

16. On October 10, 2012 dictated at 1853, Patient A's 'Daily Progress Note' by Physician C documented: "Stroke: The patient is presenting with left-sided deficits and upper extremity weakness, in addition to twitching."

17. The preliminary report from a third "CT Head" dated October 11, 2012 noted: "there is a new right parietal infarct. Please correlate with any signs of left body hemineglect."

18. In spite of the documentation of four physicians of Patient A's continuing decline in the 33 hours following his/her fall, the physicians involved in Patient A's care neglected to provide transfer for emergency services until October 10, 2012 at 1430. The 'Discharge Summary' in Patient A's Medical Record dated October 15, 2012 documented that Patient A was discharged on that date with hospice care. This document stated: "given the patient's progression with [his/her] symptoms, compounded by the underlying hip fracture, and the severity of [his/her] stroke, hospice was pursued."

19. Patient A's family stated that he/she died at home on October 22, 2012.

For additional information, see Tags A-0115, A-0145, and A-0286.

The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance.

Based on record review and interview with key personnel on October 25, 2012, October 29, 2012 and November 1, 2012, the facility failed to assure nursing services were adequate to meet the needs of patients.

Findings include:

The hospital failed to assure that patients were free of neglect, a form of abuse. Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. (For additional information, see Tag A-0145.)

The facility failed to monitor patient safety through a program which reviewed documentation, assessed patient condition, reviewed staff following policies, and medication errors to implement a preventive action and mechanisms throughout the hospital. (For further information, see Tag A-0286.)

The hospital failed to provide adequate numbers of nursing staff to ensure that assessments were completed, physician orders were implemented and policies were followed. (For further information, see Tag A-0392.)

The facility failed to assure that a registered nurse supervised and evaluated the nursing care for patients in accordance with hospital policies. (For further information, see Tag A-0395.)

The facility failed to assure drugs and biological's were administered by or under supervision of nursing and in accordance with the approved medical staff policies and procedures. (For further information, see Tag A-0405.)


The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance.

Based on record review and interview with key personnel on October 25, 2012 and October 29, 2012, it was determined that the facility failed to assure that the medical staff was held accountable to the governing body for the quality of care provided to patients.

Findings include:

The medical staff failed to take responsibility for the quality of the medical care provided to the patients by the hospital. (For further information, see Tags A-0286 and A-0338).

Based on record review and interview with key personnel on October 25, 2012 and October 29, 2012, it was determined that the facility failed to assure that the patient was free of neglect, a form of abuse. Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.

Findings include:

1. The 'History and Physical/Post-Admission Physician Evaluation' of Patient A documented that this 90 year-old was admitted on September 28, 2012 for rehabilitation services following "a right femoral neck fracture status post hemiarthroplasty, complicated by UTI [urinary track infection] and cognitive impairment."

2. Patient A's 'Interdisciplinary Daily Documentation (IDD)' dated October 8, 2012 documented that Patient A was "Alert," had both left and right hand grasps that were "WNL [within normal limits]," and was able to move all four extremities. There was no documentation regarding pupils, no time of assessment and no signature on this document.

3. The medical record of Patient A noted that the patient had fallen at 0540 on October 9, 2012. The 'Physician Acute Visit Note' dated October 9, 2012 stated: "Fall with head injury." This note was signed by Physician A.

4. Documentation in Medical Record A on October 9, 2012 at 0600 indicated that Physician A ordered that Patient A be sent for a CT (Computed Tomography) Scan of the head ASAP [as soon as possible], and ordered neurological checks every hour. However, there was no order for transfer for emergency services.

5. Documentation on the 'Neurological Monitoring Form' dated October 9, 2012 demonstrated that at 0545, 0600 and 0700, Patient A's pupils were PERL [Pupils Equal and Reactive to Light], he/she was "Alert," and that his/her right hand grasp was stronger than his/her left hand grasp. The documentation for 0545 and 0600 was initialed by Nurse D. The documentation for 0700 was not initialed.

6. At 0800, the 'Neurological Monitoring Form' first documented that Patient A's pupillary response was "sluggish." This was initialed by Nurse C.

7. At 0800, Physician A conducted a visit with Patient A. The 'Physician Acute Visit Note' documented that Patient A had "a large egg-shaped swelling on left forehead," and Patient A's pupils were "irregular and minimally reactive."

8. Documentation on the 'Interdepartment Communication Board' indicated that the CT Scan appointment was for 1045 on October 9, 2012, and this was performed at 1050.

9. The preliminary report from the "CT Head" dated October 9, 2012 had a fax time of "12:12pm." This report noted: "no acute intracranial abnormality."

10. The 'Interdisciplinary Daily Documentation (IDD)' on October 9, 2012 at 1445 written by Nurse C noted that Patient A was "Alert," had both left and right hand grasps that were "Weak" and was able to move all four extremities. In spite of the documented changes from Patient A's baseline, Nurse C wrote in the 'Daily Progress/Narrative' at 1445 that "neuro [checks] WNL."

11. Nursing documentation by Nurse A regarding Patient A on the 'Daily Progress/Narrative' indicated that at 1700 on October 9, 2012: "pt [patient] reports bilateral facial twitching, which is visibly noticeable."

12. In spite of documentation on the 'Neurological Monitoring Form' which noted Patient A to have "sluggish" pupils at 1700 on October 9, 2012 and the documentation of the facial twitching, the 'Daily Progress/Narrative' for the same date and time, also written by Nurse A, noted "Neuro checks within normal limits."

13. Physician B documented his observation of Patient A in the 'Progress Note' at 2115 on October 9, 2012, which stated: "pupils equal" and "bil [bilateral] facial twitching - (New)." Physician B ordered a medication (Ativan), but failed to order any transfer for emergency services.

14. Despite the clinical changes noted by the nurses and physicians, there was little documentation of further assessment. The 'Neurological Monitoring Form' dated October 9, 2012 contained no further documentation of neurological assessments. And on the 'Daily Progress/Narrative' for October 9, 2012, Nurse B documented at 2130 that "Neuro checks have been within normal limits."

15. In spite of the physician's order for hourly neurological checks, there was no nursing documentation in Medical Record A from 2130 on October 9, 2012 until 1000 on October 10, 2012 to indicate that neurological assessments were completed.

16. The Medical Record of Patient A documented that on October 10, 2012 at 0955, Physician C ordered "resume neuro checks every 1 hour." There is no documentation of a physician visit at this time and no order for transfer for emergency services was documented.

17. On the 'Neurological Monitoring Form' dated October 10, 2012 at 1000, Nurse I documented that Patient A's pupils were "= [equal] sl [sluggish?] reactive bilateral," he/she was "Drowsy," and that his/her right hand grasp was stronger than his/her left hand grasp.

18. On the 'Neurological Monitoring Form' dated October 10, 2012 at 1100, Nurse G documented that Patient A was "Sleepy."

19. The Medical Record of Patient A documented that on October 10, 2012 at 1030, Physician C ordered "head CT [without] contrast today." There is no documentation of a physician visit at this time and no order for transfer for emergency services was documented.

20. Documentation on the 'Interdepartment Communication Board' indicated that the CT Scan appointment was for 1145 on October 10, 2012, and this was performed at 1148.

21. The preliminary report from the "CT Head" dated October 10, 2012 had a fax time of "12:50pm." This report noted: "some interval reduction in the size of the left frontal scalp hematoma without underlying bony injury or acute intracranial injury." Nurse I documented that Physician C was aware of this report at 1400.

22. The 'Neurological Monitoring Form' dated October 10, 2012 at 1300 documented that Patient A's pupils were "= [equal] sl [sluggish?] react," and he/she was "Drowsy." There were no initials for this documentation.

23. On the 'Neurological Monitoring Form' dated October 10, 2012 at 1400, Nurse G documented that Patient A's right hand grasp was stronger than his/her left hand grasp.

24. On October 10, 2012 at 1430, Physician D documented, "CTSC [CT Scan] for worsening status. Family very concerned" on the 'Progress Note." The documentation continued: "Marked twitching [left] side of face. [Left] upper extremity plegic." Physician D wrote orders for Patient A to by transferred to an Emergency Department for evaluation.

25. Nurse J documented on the 'Daily Progress/Narrative' that Patient A returned to the rehabilitation hospital at 1745.

26. On October 10, 2012 dictated at 1853, Patient A's 'Daily Progress Note' by Physician C documented: "Stroke: The patient is presenting with left-sided deficits and upper extremity weakness, in addition to twitching."

27. The 'Neurological Monitoring Form' dated October 10, 2012 at 1800 documented that Patient A's pupils were "= [equal] sluggish," he/she was "Sleepy," and that his/her right hand grasp was stronger than his/her left hand grasp. There were no further neurological assessments documented on this form.

28. Nurse J documented on the 'Interdisciplinary Daily Documentation (IDD)' on October 10, 2012 at 1930. This document noted that Patient A was "Lethargic," had an "Absent" left grasp and a "Weak" right hand grasp, and was able to move his/her right extremities.

29. The preliminary report from a third "CT Head" dated October 11, 2012 had a fax time of "12:49pm." This report noted: "there is a new right parietal infarct. Please correlate with any signs of left body hemineglect."

30. In spite of the documentation of seven nurses and four physicians of Patient A's continuing decline in the 33 hours following his/her fall, the physicians and nurses involved in Patient A's care neglected to provide transfer for emergency services until October 10, 2012 at 1430. The 'Discharge Summary' in Patient A's Medical Record dated October 15, 2012 documented that Patient A was discharged on that date with hospice care. This document stated: "given the patient's progression with [his/her] symptoms, compounded by the underlying hip fracture, and the severity of [his/her] stroke, hospice was pursued."

31. Patient A's family stated that he/she died at home on October 22, 2012.

Based on record review and interview with key personnel on October 25, 2012 and November 1, 2012, it was determined that the facility failed to monitor patient safety through a program which reviewed documentation, reviewed assessments of patient condition, reviewed policy implementation, and medication errors to implement a preventive action and mechanisms throughout the hospital.

Findings include:

Failure to Complete Neurological Assessments

1. On October 9, 2012 at 0600, Physician A had ordered that Patient A have neurological checks every hour. Additionally, the Medical Record of Patient A documented that on October 10, 2012 at 0955, Physician C ordered "resume neuro checks every 1 hour." There were no orders in Patient A's Medical Record instructing nursing to discontinue neurological checks.

2. The 'Neurological Monitoring Form' dated October 9, 2012 documented neurological checks at only 0545, 0600, 0700, 0800 and 1700. The 'Neurological Monitoring Form' dated October 10, 2012 documented neurological checks at only 1000 and 1100, and partial neurological checks at 1300, 1400 and 1800. The 'Interdisciplinary Daily Documentation (IDD)' forms for October 9, 2012 at 1445 and October 10, 2012 at 1930 also contained some nursing documentation of neurological assessments. This represents 12 neurological assessments during 42 hours.

Medication Error

3. The policy entitled "Administration of Fluids and Medications via Intravenous Therapy" stated under 'General Procedures for all IV Therapy Administration', "A physician's order is obtained for routine discontinuation of IV Therapy."

4. Physician's orders for initiating an IV of NS at 50 cc/hr (normal saline at 50 cubic centimeters per hour) were written on October 10, 2012 at 1420. Although the nurse obtained venous access, the nurse did not start the NS, and the patient was transferred for CT Scan. After Patient A returned, the IV solution was still not initiated. There was no documentation of an order to discontinue this IV solution.

Failure to Follow Documentation Policy

5. The policy entitled 'Documentation of the Rehabilitation Nursing Process' stated: "General Guidelines for Documentation: a. All documentation must be dated, times (military time), and signed with full signature and clinical designation. B. Documentation will occur in real time whenever feasible. ac. Documentation will be legible and follow Nursing Standard 3.1: Abbreviations. d. Late entries will be documented on the Patient Progress note. The current date and time will be used with the notation text "Late entry for ____" indicating that the information is in addition to previously entered documentation."

6. Documentation on Patient A's 'Progress Note' indicated that on October 10, 2012, a nurse wrote documentation which was timed 0955 and noted to be a late entry. The same nurse wrote another note timed 1030 and also documented as a late entry. This nurse continued to write notes timed at 1330, 1415 and 1500 without any indication that any of these were late entries. Note: These entries followed a physician note which was timed 1430 on October 10, 2012.

Quality Assurance and Performance Improvement

7. The 'Quality Metrics Report' documented that the hospital tracks and trends indicators including "fall rate," "falls with injury," "medication errors," "decline in patient condition," and "acute care transfers physician review." While the 'Post Fall Huddle Tool' was completed for Patient A, there was no documentation that the failure to complete neurological assessments, the medication error involving the IV fluids, and the documentation errors were reviewed. Additionally, there was no documentation that Patient A's record had been referred for physician review at the time of survey.

8. During an interview on November 1, 2012, the Director of Quality Improvement stated based on this survey, the hospital would review the issues identified.

For additional information, see Tags A-0043, A-0049, A-0115, A-0145, A-0338, A-0385, A-0392, A-0395, and A-0405.

Based on record review and interview with key personnel on October 25, 2012 and November 1, 2012, it was determined that the hospital failed to provide adequate numbers of nursing staff to ensure that assessments were completed, physician orders were implemented and policies were followed.

Findings include:

Failure to Complete Neurological Assessments

1. Physician A had ordered that Patient A have neurological checks every hour at 0600 on October 9, 2012. Additionally, the Medical Record of Patient A documented that on October 10, 2012 at 0955, Physician C ordered "resume neuro checks every 1 hour." In addition, there were no orders in Patient A's Medical Record instructing nursing to discontinue neurological checks.

2. The 'Neurological Monitoring Form' dated October 9, 2012 documented neurological checks at only 0545, 0600, 0700, 0800 and 1700. The 'Neurological Monitoring Form' dated October 10, 2012 documented neurological checks at only 1000 and 1100, and partial neurological checks at 1300, 1400 and 1800. The 'Interdisciplinary Daily Documentation (IDD)' forms for October 9, 2012 at 1445 and October 10, 2012 at 1930 also contained some nursing documentation of neurological assessments. This represents 12 neurological assessments during 42 hours.

Medication Error

3. The policy entitled "Administration of Fluids and Medications via Intravenous Therapy" stated under 'General Procedures for all IV Therapy Administration', "A physician's order is obtained for routine discontinuation of IV Therapy."

4. Physician's orders for initiating an IV of NS at 50 cc/hr (normal saline at 50 cubic centimeters per hour) were written on October 10, 2012 at 1420. Although the nurse obtained venous access; the nurse did not start the NS, and the patient was transferred for CT Scan. After Patient A returned, the IV solution was still not initiated. There was no documentation of an order to discontinue this NS.

For additional information, see Tags A-0115, A-0145, A-0395, and A-0405.

Based on record review, policy review and interview with key personnel on October 25, 2012 and October 29, 2012, the facility failed to assure that a registered nurse supervised and evaluated the nursing care for patients in accordance with hospital policies.

Findings include:

Failure to Complete Neurological Assessments

1. Physician A had ordered that Patient A have neurological checks every hour at 0600 on October 9, 2012. Additionally, the Medical Record of Patient A documented that on October 10, 2012 at 0955, Physician C ordered "resume neuro checks every 1 hour." In addition, there were no orders in Patient A's Medical Record instructing nursing to discontinue neurological checks.

2. The 'Neurological Monitoring Form' dated October 9, 2012 documented neurological checks at only 0545, 0600, 0700, 0800 and 1700. The 'Neurological Monitoring Form' dated October 10, 2012 documented neurological checks at only 1000 and 1100, and partial neurological checks at 1300, 1400 and 1800. The 'Interdisciplinary Daily Documentation (IDD)' forms for October 9, 2012 at 1445 and October 10, 2012 at 1930 also contained some nursing documentation of neurological assessments. This represents 12 neurological assessments during 42 hours.

Medication Error

3. The policy entitled "Administration of Fluids and Medications via Intravenous Therapy" stated under 'General Procedures for all IV Therapy Administration', "A physician's order is obtained for routine discontinuation of IV Therapy."

4. Physician's orders for initiating an IV of NS at 50 cc/hr (normal saline at 50 cubic centimeters per hour) were written on October 10, 2012 at 1420. Although the nurse obtained venous access; the nurse did not start the NS, and the patient was transferred for CT Scan. After Patient A returned, the IV solution was still not initiated. There was no documentation of an order to discontinue this NS.

Failure to Follow Documentation Policy

5. The policy entitled 'Documentation of the Rehabilitation Nursing Process' stated: "General Guidelines for Documentation: a. All documentation must be dated, times (military time), and signed with full signature and clinical designation. B. Documentation will occur in real time whenever feasible. ac. Documentation will be legible and follow Nursing Standard 3.1: Abbreviations. d. Late entries will be documented on the Patient Progress note. The current date and time will be used with the notation text "Late entry for ____" indicating that the information is in addition to previously entered documentation."

6. Documentation on Patient A's 'Progress Note' indicated that on October 10, 2012, a nurse wrote documentation which was timed 0955 and noted to be a late entry. The same nurse wrote another note timed 1030 and also documented as a late entry. This nurse continued to write notes timed at 1330, 1415 and 1500 without any indication that any of these were late entries. Note: These entries followed a physician note which was timed 1430 on October 10, 2012.

Failure to Follow Emergent Medical Treatment/Transfer Policy

7. According to the facility policy 'Emergent Medical Treatment/Transfer Policy:' "upon assessment and determination by a physician that the patient requires more specialized services, transfer to an appropriate facility will be made providing the benefits of transfer outweigh the risks. In the event the physician is not physically present, a licensed nurse will notify the physician of the patient's condition and obtain an order for the emergency transfer."

8. In spite of the documentation of seven nurses of Patient A's continuing decline in the 33 hours following his/her fall, the nurses involved in Patient A's care neglected to obtain an order for transfer for emergency services until October 10, 2012 at 1430. For additional information, see Tags A-0115, A-0145, A-0392 and A-0405.

Based on record review, facility policy and interviews with key personnel, on October 29, 2012, the facility failed to assure drugs and biological's were administered by or under supervision of nursing and in accordance with the approved medical staff policies and procedures.

Findings include:

1. The policy entitled "Administration of Fluids and Medications via Intravenous Therapy" stated under 'General Procedures for all IV Therapy Administration', "A physician's order is obtained for routine discontinuation of IV Therapy."

2. Physician's orders for Patient A, dated October 10, 2012 at 1430, directed staff to start an IV of NS @50 cc/hr (intravenous of normal saline at 50 cubic centimeters per hour). A second order for an IV was dated October 12, 2012 at 1030 which directed staff to start NS @ 70 cc/hr x 1 L (for one liter).

3. Review of the Medication Administration Record's for this patient indicated no IV was started from October 10, 2012 until October 12, 2012 at 1600. The initial IV order from October 10, 2012 was not transcribed onto Patient A's 'Medication Administration Record.' In addition, there were no orders to discontinue the initial IV order.

4. In an interview with the Chief Nursing Officer on October 29, 2012, she confirmed that there was no order to discontinue the IV after the patient returned and stated "the Charge Nurse said she had not seen or was not told about the IV order."

For further information, see Tags A-0145 and A-286.