HospitalInspections.org

Based on interview and record review, the facility failed to protect the rights for 2 of 46 sampled patients (Patients 8 and 46) when:

1. The hospital failed to investigate a grievance after a patient ' s (Patient 46) family formally and verbally submitted a complaint to the hospital informing them that they had concerns about Patient 46 ' s discharge medications which they believed contributed to Patient 46 ' s death. This failure violated Patient 46 ' s family rights to have their grievance/complaint investigated and/or resolved (Refer to A-0122).

2. The hospital failed to ensure they follow the grievance process for 1 of 46 sampled patients (Patient 46). This failure resulted in Patient 46's family complaint to go un-investigated and unresolved which resulted in the risk of an ineffective grievance process and substandard patient care for all patients using the facility (Refer to A-0123).

3. The hospital failed to ensure compliance with advance directive notice requirements for 1 of 46 sampled patients (Patient 8) in a universe of 574. For Patient 8, the hospital failed to protect the rights of the patient, which resulted in the missed opportunity for Patient 8 to formulate an advance directive to make decisions concerning medical care including the right to accept or refuse medical care (Refer to A-0132).

4. The hospital failed to ensure for 1 of 46 sampled patients (Patient 8), in a universe of 574, that a least restrictive intervention was attempted and determined to be ineffective prior to applying a physical restraint. This failure had the potential to compromise the safety and well-being of Patient 8 (Refer to A-0164).

The cumulative effect of these systemic failures violated the patients' rights to be informed of the resolution of their grievance, the right to be free from unnecessary restraint and the right to formulate an Advance Directive.

Based on interview and record review, the hospital failed to investigate a grievance after a patients (Patient 46) family formally and verbally submitted a complaint to the hospital. This failure violated Patient 46 ' s family rights to have their grievance/complaint investigated and/or resolved.

Findings:

A record review, on 8/8/12, indicated that Patient 46 had been hospitalized from 12/27/12 to 12/31/12 for " Increased seizure activity. " Patient 46 was treated for his seizure activity and prior to his discharge from the hospital, on 12/31/12, the physician ' s, made " Adjustments " to his seizure medications, including increasing one seizure medication (Keppra) and adding another seizure medication (Benzal).

A record review of the facility grievance log revealed that the parents of Patient 46 filed a grievance on 1/5/12, indicating that one (1) day after Patient 46 was discharged from the hospital with a change in medication, Patient 46 died. The grievance indicated that the family wanted the hospital to take responsibility for Patient 46's death.

A record review, on 8/8/12, of the "Patient Relations Worksheet" revealed that the hospital documented in the section titled, "Event Type," as "1 grievance, 1 medication errors/questions and 1 potential incident/litigation." The "significance" of the complaint was documented as "Major." On 1/5/12, Patient 46's father entered the hospital to file the complaint and he made a request for a Spanish interpreter. Patient 46's father informed the hospital that his son was in the hospital for three (3) days and was discharged with a change in his medications. Patient 46's father informed the hospital that his son took his medication the morning after he was discharged, he fell asleep and almost five (5) hours later, his son was dead. The documentation also indicated that Patient 46's father told the hospital staff that the "Mexican Consulate," sent them to the hospital to obtain assistance. The father returned to the hospital on 1/6/12 with the prescription that his son was discharged with. According to the hospital's documentation, the medication was Keppra (a medication for seizures), 1000 milligram tablets.

An interview was conducted on 8/9/12, at 11:20 AM, with the Executive Director of Compliance to discuss the investigation of the complaint made by Patient 46's father. She stated that the hospital "Patient Relations" informed the family by letter that if they wanted to file a claim, to contact "Risk Management." She also stated, "In this case, they (Patient 46's family) never called us back," and the hospital did not investigate the complaint. Additionally, she stated, "We never call complainants and ask them, do you want to file a claim?" According to the Executive Director of Compliance, she stated that a letter was sent out to the complainant.

An interview was conducted on 8/9/12, at 1 PM, with the Executive Director, Patient Safety and Reliability. She stated that she understood that the grievance process was not followed and that Risk Management did not investigate the complaint because they were waiting for the complainant to file a claim. When asked, what if the family did not want to sue and they only wanted answers regarding the medications, she replied, "Yes, you are correct, we could have done a better job of investigating."

A record review, on 8/8/12, at 4:20 PM, of the facility policy titled, "Patient Complaints or Grievances, effective July 2012," indicated the following: "...Complaints or grievances received post discharge or after termination of care shall be referred to and processed by the Patient Relations Department. The Patient Relations Specialist handling the complaint shall contact the department(s) involved to gather information and determine what action, if any, has already been taken ...After a review of the facts and circumstances regarding a grievance, the Administrative patient Representative shall be responsible for providing an appropriate, timely, written response to the patient ...All grievances received by the Patient Relations Department from a patient or the patient's representative shall receive an initial written response within seven (7) days. The follow-up response shall include: (a) Decision/resolution of the grievance process (b) name of the ... (hospital name) contact person (c) steps taken on behalf of the patient to investigate the grievance (d) date of completion ...Quality of care issues shall be referred to the Patient Safety and Reliability (PSR) Department of review and/or investigation as grievances, and findings/resolutions shall be provided to the Patient Relations Department for communication with the patient or the patient's representative ..."

Based on interview and record review, the hospital failed to ensure they followed the grievance process for 1 of 46 sampled patients (Patient 46). This failure resulted in Patient 46's family complaint to go un-investigated and unresolved which resulted in the risk of an ineffective grievance process and substandard patient care for all patients using the facility.

Findings:

A record review, on 8/8/12, indicated that Patient 46 had been hospitalized from 12/27/12 to 12/31/12 for " Increased seizure activity. " Patient 46 was treated for his seizure activity and prior to his discharge from the hospital, on 12/31/12, the physician ' s, made " Adjustments " to his seizure medications, including increasing one seizure medication (Keppra) and adding another seizure medication (Benzal).

A record review of the facility's grievance log revealed that the parents of Patient 46 filed a grievance on 1/5/12, indicating that one (1) day after Patient 46 was discharged from the hospital with a change in medication, Patient 46 died. The grievance indicated that the family wanted the hospital to take responsibility for Patient 46's death.

A record review, on 8/8/12, of the "Patient Relations Worksheet" revealed that the hospital documented in the section titled, "Event Type," as "1 grievance, 1 medication errors/questions and 1 potential incident/litigation." The "significance" of the complaint was documented as "Major." On 1/5/12, Patient 46's father entered the hospital to file the complaint and he requested for a Spanish interpreter. Patient 46's father informed the hospital that his son was in the hospital for three (3) days and was discharged with a change in his medications. Patient 46's father informed the hospital that his son took his medication the morning after he was discharged, he fell asleep and almost five (5) hours later, his son was dead. The documentation also indicated that Patient 46's father told the hospital staff that the "Mexican Consulate," sent them to the hospital to obtain assistance. The father returned to the hospital on 1/6/12 with the prescription that his son was discharged with. According to the hospital's documentation, the medication was Keppra (a medication for seizures), 1000 milligram tablets.

An interview was conducted on 8/9/12, at 11:20 AM, with the Executive Director of Compliance to discuss the investigation of the complaint made by Patient 46's father. She stated that the hospital "Patient Relations" informed the family by letter that if they wanted to file a claim, to contact "Risk Management." She also stated, "In this case, they (Patient 46's family) never called us back," and the hospital did not investigate the complaint. Additionally, she stated, "We never call complainants and ask them, do you want to file a claim?" According to the Executive Director of Compliance, she stated that a letter was sent out to the complainant.

A record review, on 8/9/12, at 12 PM, of a letter mailed to the complainant by the hospital Patient Relations Coordinator, revealed that the letter was written in English and expressed the hospital's condolences for their loss. The letter also instructed the complainant to "..Please write with specific details to Risk Management, c/o Clinical Risk Manager ..."

An interview was conducted on 8/9/12, at 12:50 PM, with the Patient Relations Coordinator who wrote the letter to the complainant expressing condolences. He stated that he was aware that the complainant required a Spanish translator when the complaint was submitted. When asked if the hospital sent the complainant a follow up letter to determine if the patient's family understood the letter that was previously sent to them and written in English or if they were satisfied with the investigative results, he stated, "No."

An interview was conducted on 8/9/12, at 1 PM, with the Executive Director, Patient Safety and Reliability. She stated that she understood that the grievance process was not followed and that Risk Management did not investigate the complaint because they were waiting for the complainant to file a claim. When asked, what if the family did not want to sue and they only wanted answers regarding the medications, she replied, "Yes, you are correct, we could have done a better job of investigating."

A record review, on 8/8/12, at 4:20 PM, of the facility policy titled, "Patient Complaints or Grievances, effective July 2012, " indicated the following: "...Complaints or grievances received post discharge or after termination of care shall be referred to and processed by the Patient Relations Department. The Patient Relations Specialist handling the complaint shall contact the department(s) involved to gather information and determine what action, if any, has already been taken ...After a review of the facts and circumstances regarding a grievance, the Administrative patient Representative shall be responsible for providing an appropriate, timely, written response to the patient ...All grievances received by the Patient Relations Department from a patient or the patient's representative shall receive an initial written response within seven (7) days. The follow-up response shall include: (a) Decision/resolution of the grievance process (b) name of the ... (hospital name) contact person (c) steps taken on behalf of the patient to investigate the grievance (d) date of completion ...Quality of care issues shall be referred to the Patient Safety and Reliability (PSR) Department of review and/or investigation as grievances, and findings/resolutions shall be provided to the Patient Relations Department for communication with the patient or the patient's representative ..."

Based on interview and record review, the facility failed to ensure compliance with the advance directive notice requirements for 1 of 46 sampled patients (Patient 8) in a universe of 574.

For Patient 8, the hospital failed to protect the rights of the patient, which resulted in the missed opportunity for Patient 8 to formulate an advance directive to make decisions concerning medical care including the right to accept or refuse medical care.

Findings:

A record review, on 8/8/12, at 9:30 AM, of Patient 8 indicated that the patient was admitted on 2/8/12 with lethargy (lack of energy), decreased intake and a diagnosis which included altered level of consciousness. Patient 8 had a nasogastric tube (NGT - a tube inserted in thru the nose and down into the stomach and used to provide feedings, administer medications, and could be used to remove stomach contents). Patient 8 also had an intravenous line (IV used to administer medications and provide fluids) and a foley catheter (FC - a tube inserted into the bladder and used to drain urine).

A record review, on 8/8/12, at 9:30 AM, of Patient 8, revealed that there was no advance directive in the medical record to indicate that the hospital informed the patient or the responsible party of their right to formulate an advance directive.

During an interview, on 8/8/12, at 9:30 AM, Quality Coordinator 1, stated that she was unable to locate an advance directive in Patient 8's medical record.

A record review on 8/2/12, at 1 PM, of the hospital policy titled, "Patients' Rights Regarding Advance Directives and Acceptance/Refusal of Medical Care, effective July 2012," revealed the following:

1. "...(name of hospital) shall recognize that the patient has the right to:

1.1 Make decisions about medical care as defined in Policy P-1, Patients' Rights and Responsibilities.

1.2 Formulate an advance directive in accordance with federal and state statutes, regulations, and court decisions ..."

2. "For all adult and emancipated minor inpatients, (name of hospital) shall:

2.1 "Provide written information at the time of admission/registration concerning an individual's right to make decisions regarding his or her medical care, including the right to accept or refuse treatment and the right to formulate advance directives.

2.3 Comply with California and federal law regarding advance directives."

3."(hospital name) staff shall:

3.1 Provide the patient with an advance directive form if the patient indicates the desire to execute an advance directive.

3.2 Make reasonable attempt to obtain a copy of the advance directive if the patient's family or agent indicates that one has been executed.

3.5 Document in a prominent part of the patient's medical record whether or not he or she has executed an advance directive ..."

Based on interview and record review, the facility failed to ensure for 1 of 46 sampled patients (Patient 8), in a universe of 574, that a least restrictive intervention was attempted and determined to be ineffective prior to applying a physical restraint. This failure had the potential to compromise the safety and well-being of Patient 8.

Findings:

A record review, on 8/8/12, at 9:30 AM, of Patient 8 indicated that the patient was admitted on 2/8/12 with lethargy (lack of energy), decreased intake and a diagnosis which included altered level of consciousness. Patient 8 had a nasogastric tube (NGT - a tube inserted in thru the nose and down into the stomach and used to provide feedings, administer medications, and could be used to remove stomach contents). Patient 8 also had an intravenous line (IV used to administer medications and provide fluids) and a foley catheter (FC - a tube inserted into the bladder and used to drain urine).

A record review, on 8/8/12, at 9:30 AM, of Patient 8 revealed a "Restraint Order," dated 2/9/12 at 5:18 PM. The order indicated to apply bilateral (both) wrist restraints to Patient 8. There was no documented evidence that prior to the application of the restraints, that least restrictive measures were attempted and determined to be ineffective.

An interview was conducted on 8/8/12, at 10:25 AM with Quality Coordinator 1. She stated that she was unable to locate documentation that indicated a least restrictive measure was attempted prior to the application of the wrist restraints.

A record review, on 8/8/12, at 1:30 PM, of a hospital policy titled, "Restraints and Safety Devices, effective August 2010," indicated the following: "...6. Restraints shall be used only if less restrictive alternatives have been determined to be contraindicated, ineffective, or insufficient to protect the patient or others from injury...8. Documentation shall include: 8.1 Medical necessity/clinical justification, including demonstrated behavior leading to need for restraints 8.2 Ineffectiveness of less restrictive measures..."

Based on interview and record review, the hospital failed to ensure that the medical staff adopted and enforced their bylaws by failing to identify:
(1) that Surgeon 1 continued to perform surgeries while his privilege was suspended.
(2) that the hospital did not have an effective system in place to track the activities of all physicians/surgeons on suspension in the hospital.

These failures had the potential to result in negative patient outcomes based on care being provided by physicians/surgeons that were on suspensions.

Findings:

On 8/8/12, after reviewing the "Medical Records Suspension Report", dated January through July 2012, a request was made to review the surgery schedule from 5/16/12 to 7/31/12, during the suspension period for Surgeon 1.

An interview was conducted on 8/8/12, at approximately 4:00 PM with the Interim Chief Nursing Officer (CNO). The Interim CNO stated that on 8/8/12, while obtaining and reviewing the surgery schedule, it was noted that Surgeon 1, continued to perform surgeries at Hospital # 2, during his suspension. A review of the surgery schedule noted that 12 surgeries were performed by Surgeon 1 during his suspension period. The Interim CNO stated that the Director of Hospital #2 where the surgeries were scheduled and performed did not receive the fax notification that Surgeon 1 was on suspension.

A review of the hospital policy titled "Medical Staff Bylaws", adopted by the Medical Staff on 6/14/11, included the following: "8.3 Automatic Suspension (d) Medical Records - For failure to complete medical records in the manner and within the time limits established by Medical Staff Rules and regulations and Medical center policies, a practitioner's clinical privileges (except with respect to his/her patients already in the Medical Center) and his/her rights to admit patients and to provide any other professional services, shall be automatically suspended until all delinquent records are completed .... "

A review of "Medical Staff Rules & regulations (O) Medical Records" adopted by the medical Staff on 6/12/12, noted, "All delinquent records must be completed and a fine paid before privileges will be reinstated .... "

An interview was conducted on 8/9/12, at approximately 9:10 AM, with the Director Medical Staff Administration. She stated that Surgeon 1's office was notified of the suspension and that the suspension notification was faxed to all parties on hospital distribution list. The director stated that she was in communication with Surgeon 1's office and that the Surgeon was aware that he was suspended until the fine was paid.

An interview was conducted on 8/9/12, at approximately 9:30 AM, with the Vice President of Medical Staff. He stated that it was a communication 'glitch' (fax problem) between Nursing Administration and Medical Staff Administration. He stated that Surgeon 1 only performed 1 surgery on 5/18/12 while he was on suspension. He stated that Surgeon 1 completed his medical records on 5/23/12. (According to records reviewed, Surgeon 1 had completed 3 surgeries prior to completion of his delinquent medical records on 5/25/12).

A review of the "Suspensions/Medical records Suspensions/F-Med Rec Suspension Tracking" was conducted on 8/9/12 with the Director of Medical Staff Administration. It noted that Surgeon 1's office was notified of his suspension on 5/16/12 at 10:00 AM. On 5/25/12 at 11:00 AM, the Health Information Management (HIM) notified medical staff administration that Surgeon 1 had completed his medical records. On 7/31/12, Surgeon 1 paid his fine and was taken off suspension.

An interview was conducted on 8/9/12, at approximately 10:07 AM with the Surgery Scheduler at Hospital # 2 where the surgeries were scheduled and performed. She stated that she was not notified that Surgeon 1 was on suspension and therefore she continued to schedule his surgeries.

2. On 8/8/12, during a review of the "Medical Records Suspension Record", several other Surgeons/Physicians were selected for review of their schedule during suspension. The Hospital did not provide documented evidence documenting whether or not Physician 1 had practiced in the hospital during his suspension from 4/10/12 to 5/2/12.

An interview was conducted on 8/9/12, at approximately 9:31 AM, with the Interim CNO. The Interim CNO stated that the hospital did not have a schedule for Physician 1 and did not know if Physician 1 had practiced in the hospital during his suspension period. The Interim CNO stated that Physician 1 office was called to see if they had a schedule for his activities in the hospital during his suspension.

Based on interview and record review, the hospital failed to:

1. Identify a pressure ulcer for 1 of 46 sampled patients (Patient 41), before it became unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough which is necrotic or dead tissue that can be yellow, tan, gray, green or brown) and/or with eschar (scab formed in the colors of tan, brown or black in the wound bed). This failure resulted in Patient 41 developing an unstageable pressure ulcer to the mid lower back, 9 days after admission.

2. Ensure that an RN supervised and evaluated the nursing care for two patients (Unsampled Patient B and C) while the primary RN was on a meal break. This failure had the potential for patients to not have their nursing care needs met.

Findings:

1. A review of Patient 41's medical record was conducted on 8/7/12. It noted that the patient was admitted on 6/17/12 through the emergency department and was later transferred to the medical intensive care unit (MICU is a specialized section of a hospital that provides comprehensive and continuous care for persons who are critically ill). The diagnoses included altered mental status (decreased alertness) characterized by confusion, acute respiratory distress (difficulty breathing) and end stage renal disease (ESRD, the kidneys are no longer able to work at a level needed for day-to-day life) on dialysis (a process of filtering the blood, the way kidneys normally do, using a machine). Other diagnoses included diabetes mellitus (high glucose levels in the blood) and hypertension (high blood pressure).

A review of the entity reported incident noted that on 6/26/12, Patient 41 was identified with an unstageable pressure ulcer to the lower back. This was 9 days after admission.

A review of Patient 41's medical record was conducted on 8/7/12 at approximately 10:30 AM with the Quality Resource Nurse 1. The Nursing Adult Assessment completed on 6/17/12 at 1:20 PM, noted the following:

The patient received a Braden Score (an assessment tool to determine if the patient was high risk for skin breakdown) of 13. A score of 18 or below is often the prediction of pressure ulcer risk. Subsequent Braden Score results conducted between 6/17/12 and 6/26/12, noted a fluctuation in the scores between 8 and 13. For patient 41, the Braden Score represented: Sensory perception - ranged from no impairment on admission, to very limited to complete limited from 6/18/12 through 6/28/12. The patient was bedfast (stayed in bed) and completely immobile (required staff assistance for movement). Nutrition assessment ranged from probably inadequate, adequate to very poor. Friction/Shear to the skin fluctuated between a skin problem and potential skin problem.

A review of the skin assessment noted an Ulcer/Non-Blanchable/Erythema (redness to intact skin), Stage II (partial thickness dermis loss) to the left elbow. Ulcer/Non-Blanchable Erythema to the right heel, suspected deep tissue injury (an injury to a patients underlying tissue below the skin ' s surface that results from prolonged pressure in an area of the body). Vascular ulcer to the right lateral hip and erythema/redness to the posterior coccyx/sacrum (lower buttock). Erosion (ulceration) to the posterior coccyx/sacrum. There was no documented evidence of any new skin breakdown or pressure areas identified from admission until 6/26/12.

A review of the " Interdisciplinary Care Plan Current Interventions Adult Skin Assessment " completed on 6/17/12, included the following:

W1 (wound 1), Stage III (full thickness tissue loss) to left elbow. the intervention was to off load pressure (keep pressure off of the area).
W2, Non-Blanchable (erythema or redness to intact skin) to right heel. The intervention - "not visible" (could not determine the meaning).
W4, Stage II (partial thickness loss of dermis) deep tissue injury & erythema to coccyx (small bone at the base of the sacrum) and sacrum (the bottom of the spine). The intervention was to apply barrier cream (a special cream is rubbed on the skin to protect the skin from contact with harmful substances) and to off load pressure.
W5, erosion (ulceration) to scrotum (the external sac of skin that encloses the testicles). the intervention was to keep the area clean and apply barrier cream.
W6, Unstageable to left lateral (outside area) hip. The intervention was to apply Telfa dressing (an absorbent and choice of dressing for partial thickness wounds).

A review of the "Wound Care Team", assessment completed on 6/19/12, included the following:

#1 Assessment: Ulcer/Non Blanchable Erythema to left elbow. length 2.5 cm x width 0.8 cm x depth 0.1 cm. Stage III pressure was present on admission. 95 % yellow/tan necrotic (dead or dying tissue) area with scant serosanguineous (consisting of both blood and serous fluid) drainage.

Recommendation:
a. Cleanse wound with wound cleanser.
b. Cover wound with Hydrocolloid (a therapeutic or protective material applied to a wound) every 3 days.
c. Strict turning schedule, low air loss bed (a mattress that provides a flow of air to assist in managing the heat and humidity of the skin), keep pressure off wound.
d. Float heels (keep pressure off the heels); heel lift boots.

#4. Assessment: Ulcer/Non -Blanchable Erythema to coccyx/sacrum. 1 cm x 0.2 cm x 0 cm. Stage II pressure ulcer present on admission with scant serosanguineous.

Recommendation:
a. Cleanse with wound cleanser.
b. Cover with Mepilex (is a soft and highly conformable foam dressing that absorbs exudate and maintains a moist wound environment) sacral border, change every 3 days.
c. Strict turning schedule, low air loss bed, keep pressure off wound.
d. Float heels, heel lift boots.

#6 Assessments: Ulcer/Non-Blanchable Erythema unstageable pressure ulcer to left hip, present on admission; 4 cm x 3 cm x 0 cm; no drainage.

Recommendation:
a. Cleanse with wound cleanser.
b. Cover with Hydrocolloid, change every 3 days.
c. Strict turning schedule, low air loss bed, keeps pressure off wound.
d. Float heels, heel lift boots.
e. Nutritional and physical mobility evaluation.

Further review of the medical record noted that on 6/23/12 at 7:00 PM, Patient 41 was on the Low Air Loss Bed. The Wound Care Consultant had recommended a Low Air Loss Bed on 6/19/12. A review of the physician order dated 6/23/12 at 9:25 AM, confirmed an order for a specialty bed for wound.

A review of the "Interdisciplinary Care Plan Current Interventions Adult Skin Assessment" noted, Unstageable deep tissue injury to lower back. There was no measurement or description of the wound. Intervention was to cleanse the wound with soap and water; apply Mepilex; (6/26/12) Low Air Loss Bed.

A review of the "Wound Care Team" assessment completed on 6/27/12, noted the following:

Wound # 7, Ulcer/Non-Blanchable Erythema to lower back. Proximal end of wound is open and unstageable. Medial part of the wound is blood filled blister and distal part of the wound is deep tissue injury. There is Unblanchable Erythema that connects the three areas of the wound. The wound was unstageable and measured 12 cm (4 ? inches) x 3 cm x 0 cm with scant serosanguineous drainage. The wound was not present on admission. The treatment was for wet to moist dressing changes.

An interview was conducted on 8/7/12, at approximately 10:35 AM, with the Quality Resource Nurse 1, during the review of Patient 41's medical record. There was no documented evidence in the medical record of any new skin break down or pressure area to Patient 41's lower back/spine from admission until 6/26/12; when the area was identified as unstageable. The Resource Nurse 1 stated that it was possible that the patient was admitted with the pressure area to the lower back and that the nurses were documenting the wrong location in the medical record. A later comparison of the wound photographs taken on 6/17/12 noted a stage 11 pressure area to the patient's coccyx/sacrum and the photograph taken 6/26/12 noted the new wound to the middle lower back/spine area.

An interview was conducted on 8/7/12, at approximately 11:00 AM, with Registered Nurse (RN) Educator 1. RN Educator 1 stated that she was familiar with Patient 41's medical condition and the care that was provided. RN Educator 1 confirmed that wound #7 was not present on admission. She stated that the patient was very sick and that there were times when the patient coded (heart stopped and had to resuscitated) and that the patient was not able to be turned due to his medical condition. She also stated that the patient had diarrhea since admission and during his entire hospital stay which increased his risk for skin breakdown. RN Educator 1 stated that a head to toe skin assessment was completed on Patient 41 whenever he received baths, and linen changes. RN Educator 1 responded that she was not sure why the area to the lower back was not identified prior to it becoming unstageable on 6/26/12.

A review of patient 41's "Flow-sheet: Pressure Ulcer Review", from 6/17/12 to 6/26/12 noted the following:

On 6/17/12, there were multiple entries noting normal skin color, skin warm with moist mucus membrane and no problem with skin turgor (a reflection of the skin elasticity).

On 6/17/12, 9:05 AM, it was noted that the patient diaper and linen were changed. There was no documentation of any new skin break down or pressure areas.

On 6/18/12 at 7:30 AM, it was noted that the patient skin temperature was cold with fragile skin turgor.

On 6/18/12, at 8:45 AM the patient chux (an absorbant pad) and linen was changed. Barrier cream was applied.

On 6/18/12, at 3:00 PM, a bath was provided and barrier cream applied. The chux and linen were changed. There was no documentation of any new skin break down or pressure areas. Also, there was no documentation of skin protective/comfort devices being used.

On 6/19/12, at 1:00 PM, a bath was provided, barrier cream applied and the linen was changed.

On 6/19/12, at 7:00, partial linen change took place.

On 6/19/12, at 9:00 PM, bath, chux and linen changes were provided. There was no documentation of any new pressure areas or skin breakdown. Also, there was no documentation of skin protective/comfort devices being used.

On 6/20/12, at 3:00 PM, the chux was changed and barrier cream was applied. There was no documentation of any new pressure areas or skin breakdown. Also, there was no documentation of skin protective/comfort devices being used.

On 6/21/12, at 1:00 AM and 11:00 PM, baths were provided. The chux and linen were changed. There was no documentation of any new skin breakdown or pressure areas.

On 6/21/12, at 5:00 PM and 9:00 PM, the chux and linen were changed. There was no documentation of any new skin breakdown or new pressure areas.

On 6/22/12, there was no notation of bath, chux or linen change. There was no documentation of any new skin breakdown or new pressure areas.

On 6/23/12 at 7:00 PM the linen was changed. There was no documentation of any new skin breakdown or pressure areas.

On 6/24/12 at 1:00 PM the linen was changed. There was no documentation of any new skin breakdown or pressure area.

On 6/25/12, there was no documentation of bath, chux or linen change. There was no documentation of any new skin breakdown or pressure area.

On 6/26/12 at 2:00 AM and 9:00 PM, baths were provided and barrier cream applied. The chux and linen were changed. There was no documentation of any new pressure areas or skin breakdown.

A review of the hospital policy titled, "Assessment and Reassessment", effective 7/12, included the following: "Reassessment - The patient is reassessed (a) a minimum of each shift for all inpatients .... "

An interview was conducted on 8/8/12, at approximately 12:35 PM, with the Wound Care Consultant who verified that Patient 41's unstageable pressure ulcer was not present to the lower back on 6/19/12, when she completed the first wound assessment of the patient. The Wound Care Consultant stated that the patient was in poor health and that she had speculated that the patient developed the deep tissue injury to the spine when he went to CT (computed tomography) Scan (a machine that takes detailed pictures inside the body from different angles) a couple of days before. (Patient 41 completed the CT Scan on 6/20/12; the unstageable area was not identified until 6/26/12). The Wound Care Consultant stated, "The patient was in renal failure, poor health with the bones protruding from his spine; the same areas that developed the unstageable pressure ulcer. The patient was very thin and debilitated and was prone to skin breakdown". The Wound Care Consultant responded when asked why the pressure area was not identified earlier before it became unstageable, "It is usually not evident at the time the injury occurred, it shows up later".

A review of the document titled, " Mosby ' s Skills- pressure Ulcer: Risk Assessment (Adult and Pediatric) " received on 8/8/12, (guidelines for nurses to follow when assessing and treating patients with pressure ulcers or at risk for pressure ulcers) included the following for Pressure Ulcer Risk Assessment and prevention:

" 1. Perform a risk assessment using the Braden Scale for the adult population .... at least once a shift. Adult patients with a Braden scale score of 18 or less are noted at increased risk for skin breakdown. "

" 2. Assess patient ' s skin general condition, temperature, color and turgor, including general condition of mucous membranes at least once a shift.

" 4 ...Assess and treat incontinence: clean and dry skin after each incontinence episode using a PH-balance cleanser. Use incontinence skin barriers as needed to protect and maintain skin integrity .... "

" 5. Initiate and modify as appropriate the patient care plan for those patients identified at increased risk for skin breakdown. "

The following was noted under Assessment and preparation:

" ...6. Assess condition of patient ' s skin over region of pressure:
a. Inspect skin for discoloration (redness in light-tone skin; purplish or bluish in darkly pigmented skin), inspect tissue consistency (firm or boggy feel) and/or palpate for abnormal sensations ... .... "
b. Palpate discolored area for blanching. "
d. Inspect for absence of superficial skin layers " .
Procedure: " When repositioning a patient, observe for skin discoloration in the area that was under pressure .... "



26500

2. On 8/1/12 at 2:30 PM, an interview was conducted with Registered Nurse (RN) 4 (Charge Nurse [CN]on Unit 1100). A review of unit 1100's patient care assignment was conducted with RN 4. There were five (included the CN) RN's on duty. When asked how the facility assigned and covered the RN's meal breaks, RN 4 stated that he covered all RN meal breaks on unit 1100. A review of the unit's "Meal Break Schedule and Waiver" document, revealed that the RN's name that was assigned to Patients B and C in room 1102 was not on the document. RN 4 stated that when Patient B and C had their rehabilitation services (physical, speech, and/or occupational therapy) the RN would have taken her meal break at that time.

On 8/1/12 at 2:45 PM, an observation of the room 1102 revealed that Patients B and C were in their beds. There was a Patient Care Assistant in the patients' room. When asked to speak with the RN assigned to supervise and evaluate the nursing care for Patients B and C, RN 4 stated that the RN assigned to those patients was a on a meal break.

RN 4 stated that he was not knowledgeable as to when the RN assigned to supervise and evaluate nursing care for Patients B and C went on her meal break. He stated that the RN should have informed him that she was going on a meal break. RN 4 stated that there was no RN assigned to supervise and evaluate the nursing care for Patients B and C while the RN was on a meal break and that there should have been.

On 8/1/12 at 3 PM, an interview was conducted with RN 5 (Unit 1100's Nurse Manager). RN 5 stated that the RN assigned to supervise and evaluate the nursing care for Patients B and C should have "handed off" (given report on) her patients to the Charge Nurse prior to going on her meal break.

On 8/2/12 at 8:25 AM, an interview was conducted with the East Campus Nursing Director. She confirmed that on 8/1/12, during the assigned RN's meal break, Patients B and C's nursing care was not supervised and evaluated by a RN and that it should have been.

Based on interview and record review, the hospital failed to ensure that for 1 of 46 sampled patients, (Patient 4) in a universe of 574, a Registered Nurse (RN) failed to obtain a physician's order prior to writing an order for heparin flushes (an anti-clotting medication which can contribute to bleeding and is used to insert into a central line {an intravenous line inserted thru a large vein and used to administer medications and fluids or to withdraw blood} to keep the line from clogging). This failure had the potential to affect the safety and well-being of Patient 4.

Findings:

A record review of Patient 4 and a concurrent interview were conducted with RN 1, on 8/2/12, at 11:11 AM. Patient 4 was admitted on 7/23/12 with the diagnosis of sickle cell crisis (a hereditary blood disorder that can cause severe pain and lead to anemia {a reduction in red blood cells}).

A record review and a concurrent interview were conducted with RN 1, on 8/2/12, at 11:11 AM. Patient 4's medical record revealed a hospital document dated 7/23/12 and titled, "Adult Heparin/Saline Flushes for Peripheral & Central Vascular Access & Hemodynamic Monitoring Devices Per Patient Care Practice." The document revealed an order to administer five (5) milliliters of heparin flushes into Patient 4's central line. The document was signed by a Registered Nurse and did not contain a physician's signature to indicate that a physician ordered the heparin flushes. RN 1 stated that the heparin flush order was written by a RN and did not contain a physician signature.

An interview, on 8/2/12, at 12:10 PM, was conducted with RN 2 who stated, "It's a nursing standard protocol. There is no physician order, they (referring to physicians) just tell us we can access the central lines and then we as nurses initiate the heparin flush."

An interview, on 8/2/12, at 12:15 PM, was conducted with the Director of Pharmacy who stated that the heparin flush can't be initiated without a physician's order.

Based on observation and interview the facility failed to safeguard and secure patients' confidential information and failed to ensure that access of patients' information was limited only to authorized individuals when:

(1) the facility left patients' confidential medical records unsecured and unattended and

(2) the facility failed to secure discharged medical records at Hospital # 3.

These deficient practices allowed for possible unauthorized access and/ or unauthorized removal of clients' confidential information without the facility's knowledge resulting in unauthorized use or identity theft.

Findings:

1. On 8/1/12 at 11:15 AM, during the environment tour with the Department Manager of Pediatric Hematology, it was observed that there was a three (3) tiered roller cart full of patients' medical records left unattended in the middle of the busy unit. The family members and patients freely moved around the unit.

A concurrent interview with the Manager was conducted concerning the patients' clinical records (medical records) that were exposed and readily accessible to unauthorized individuals such as visitors, family members, vendors and repair men entering the facility. The Manager stated that the records were, "usually kept locked in the medicine room. They will be brought back to the medicine room where they used to be."

She further stated that for security reasons, housekeeping personnel's access to the medicine room to clean this area, could only be done with an authorized staff person present during clinic hours.





28068

2. On 8/3/12, at approximately 9:05 AM an interview was conducted with the Unit Secretary at Hospital # 3 regarding the storing of discharged medical records. She stated that the discharge records were rubber band and stored in the employee locker room until they were picked up at 8:00 AM.

On 8/3/12, observation was made of the employee locker room which was away from the nurses' station. There was no lock on the entrance door of the locker room. A patient discharge medical record was observed bundled with rubber band on the top of a desk that was inside of the entrance to the locker room.

An interview was conducted on 8/3/12, at approximately 9:07 AM, with the Unit Secretary who confirmed that the locker room entrance door did not have a locking device and that the discharged medical records were stored in the locker room until pick up.

A review of the hospital policy titled, "Medical records: Composition, management, and Access", effective 7/12, included the following:

"B. Management of Medical Records (3) Medical records shall be maintained in a safe and secure area. Safeguards to prevent loss, destruction and tampering will be maintained as appropriate .... "

Based on interview and record review, the facility failed to ensure that all entries for 1 of 46 sampled patients (Patient 5) in a universe of 574, were completed and legible. For Patient 5, the hospital failed to ensure that a surgical consent was legible and complete. This failure had the potential to be misread or misinterpreted and the potential to contribute to adverse patient events.

Findings:

A record review of Patient 5, on 8/3/12, at 9:20 AM, indicated that Patient 5 was admitted on 7/5/12 with a diagnosis which included testicular tumor with metastasis to the pelvis, brain and spine (a tumor that had spread to the pelvis, brain and spine).

A record review of Patient 5's consent dated 8/1/12, was not legible and was incomplete. The section which identified the admitting physician was left blank, the surgeons name was not legible, the name of the procedure and the common risks and side-effects were not legible.

On 8/3/12, at 9:20 AM, a record review and a concurrent interview were conducted with the primary Register Nurse (RN 3) for Patient 5. RN 3 stated that Patient 5's consent was not legible but RN 3 knew that Patient 5 was having a ventriculoperitoneal shunt (a surgery to relieve increased pressure inside the skull). RN 3 also stated that she was unable to read the name of the surgeon and the risks and side-effects that were hand written on the informed consent form by the physician. RN 3 stated that there was no name listed in the section titled, "Your admitting physician is ____, MD."

A record review on 8/3/12, at 9:50 AM, of the hospital policy titled, "Patient Consent, effective February 2011," indicated that the "Medical Center personnel shall: verify that informed consent form has been completed and documented in the medial record..."

Based on observation, interview and record review, the facility failed to:

(1) implement the hospital's policy and the manufacturer's recommendation for the use of Sterile Water Irrigation,

(2) maintain an accurate record of sample medication dispensed,

(3) maintain an accurate record of dispensed sample medication for 1 of 46 sampled patients (Patient 39). This had the potential for medication discrepancy to occur increasing the risk of harm to the patients due to the use of medication/treatments that was not intended by the physician.

Findings:

1. During an observation of the medication storage area at the Pediatric Teaching Clinic on 7/31/12 at 11:30 AM with the Licensed Vocational Nurse (LVN) and the Administrative Staff, the facility was found to store an opened one (1) liter container of Sterile Water for Irrigation. The date written on the label indicated it was opened on 8/5/12.

During a concurrent interview with the LVN, she stated that the Sterile Water was used for ear irrigation (the flushing out of the ear canal). The LVN verified that the date written on the container's label was the date that the container was first opened. The LVN believed that the Sterile Water was good for 28 days from the day that the container was opened.

On 8/1/12 at 11:30 AM, an interview with Executive Director of Pharmacy was conducted to determine the hospital' s policy for storing Sterile Water Irrigation from the time it was opened.

The Executive Director of Pharmacy and Supply Chain Management presented an operating policy for Pharmaceuticals:

The policy was reviewed and read in part: " Single dose vials shall be used whenever possible and discard immediately after use (within one hour). "

In addition he presented an insert from the package of the Sterile Water for Irrigation with INDICATIONS AND USAGE:

"Sterile Water for Irrigation is indicated for use as an irrigating fluid or pharmaceutic aid.

WARNINGS:

After opening the container, its contents should be used promptly to minimize the possibility of bacterial growth or pyrogenic formation (pyrogenic- causing heat or fever as a result of bacterial growth/infection).

Discard unused portion of irrigating solution since it contains no preservative."

The finding was confirmed on 8/1/12, during the review of the hospital policy for pharmaceuticals with Executive Director of Pharmacy.



28068

2. On 8/6/12, an inspection was conducted of the three (3) sample medication cabinets located in clinic # 1. The tracking log for sampled Aquadeks (a multivitamin) was compared to the quantity of sample Aquadeks in the sample medication. The log listed one (1) patient was dispensed one (1) bottle on 5/10/12. Another patient was dispensed two (2) bottles on 7/18/12. On 7/31/12, an update noted that two (2) bottles were left. There was no documentation on 7/31/12 indicating if a bottle of Aquadeks was dispensed to a patient or why one (1) bottle was not accounted for.

During an interview, conducted on 8/6/12 at approximately 11:07 AM, the Nurse Manager, confirmed that there was no documentation regarding the discrepancy between the Aquadeks dispensed and the amount that was present and accounted for.

A review of the hospital policy titled, "use and storage of Sample Medications in Hospital-Based Clinics", effective 10/11, included the following:

" 6. All patient samples shall be signed out on the sample medication log.
6.2 The inventory shall be adjusted on the sample drug inventory record".

3. On 8/6/12, Patient 39's record was obtained from the sample medication record in outpatient Clinic #1. It was noted that Patient 39 received 2 bottles of Aquadeks (liquid vitamins) from the sample medications.

On 8/7/12, Patient 39's medical record was reviewed on the computer for the visit on 7/12/12 in Clinic#1. Patient 39 was seen in the clinic for eczema (a noncontiguous inflammation of the skin, characterized chiefly by redness, itching, and the outbreak of lesions that may discharge fluid matter and become encrusted and scaly) poor weight gain and a cough.

A review of the clinician note included the following, "Parental/Client Concerns - ran out of medications- aquadek -will not provide the pharmacy- gave enough for 4 months... "

There was no documented evidence of a written prescription for dispensing the Aquadeks in the medical record on 7/12/12.

A review of the hospital policy titled, "Use and storage of Sample medications in Hospital - Based Clinics", effective 10/11 included:

"12. The physician or nurse practitioner shall document the following in the patient's medical record:

"12.1 Name of medication
12.2 Dose
12.3 Frequency
12.4 Quantity "

An interview was conducted on 8/7/12 at approximately 1:25 PM, with the Director of Pharmacy. He confirmed that the medical record dated 7/12/12, did not have the dose, frequency and quantity of the Aquadeks per the hospital policy.

An entity reported incident regarding a wrong medication which was dispensed to a patient (Patient 45) was reported to the Department by the hospital. The entity reported incident was investigated during the survey.

Based on record review and interview the hospital failed to ensure that medications prescribed to patients were being monitored to assure that medication therapy was appropriate and minimized the occurrence of possible adverse events for 1 of 46 sampled patients (Patient 45) in a universe of 574. This deficient finding resulted in Patient 45 receiving the wrong medication.

Findings:

On 8/9/12, at 9 AM, a record review was conducted and revealed that Patient 45 was taken to the hospital emergency department (ED) by ambulance on 6/19/12 as a result of a seizure. The patient was seen, treated and given a prescription for Keppra 300 milligrams by mouth twice a day (a medication for seizures). Patient 45 was discharged home the same day.

On 8/9/12, at 9 AM, a record review revealed that Patient 45 returned to the hospital on 6/20/12. According to Patient 45's physician's history and physical of Patient 45, the patient presented to the ED with "...excessive drowsiness since yesterday when he had a seizure. Seen here for the seizure and was started on Keppra. After first dose the patient has appeared to be somnolent (drowsy) and difficult to arouse. Called 911, paramedics arrived and patient had some reaction to stimulation ...Patient has continued to have altered level of consciousness per mother. There have been no other new medications ...As patient with new onset seizures and with newly started Keppra, patient to be admitted for further evaluation of seizures and appropriate medication ..."

On 8/9/12, at 9 AM, a record review of Patient 45 physician's discharge summary, revealed the following, "...(the name of the patient) ... presented with 1 day history of new onset seizure activity, consisting of fluttering eyes, tongue deviation to the left, and weird facial expressions that would last 3 minutes... was initially seen at the (name of hospital) ED and pediatric neurology was contacted. They recommended starting Keppra and he was discharged. At home, mom administered 1 dose of Keppra and 15 minutes later, he fell asleep and remained unarousable for 5 hours. Upon admission, patient was continued on Keppra and routine EEG (electroencephalogram - monitors the electrical activity of the brain) was obtained. No abnormalities were seen on EEG, but patient continued to remain very sleepy and was only able to stay awake for 2 hours out of the day. Video EEG was then obtained due to a concern for ongoing seizure activity; however none of the event alarms correlated with electrographic seizure activity. Throughout the hospitalization, no seizures occurred and (patient) remained on Keppra. His somnolence continued to improve ...and resolved by the time of discharge ..." According to the physician's discharge summary, "The mother called the hospital after she returned home with (patient's name) and informed us that she had picked up his regular medications a day prior to his admission and had been mistakenly given Labetalol (used to treat high blood pressure and can contribute to drowsiness) 10 milligrams per milliliter solution prescribed for another child ..."

On 8/9/12, at 10:15 AM, an interview was conducted with the Director of Pharmacy. He stated, "...a technician (at an outpatient pharmacy), picked up the wrong prescription (Labetalol) for another patient without following procedure to check medications before giving it to the patient. The physician was notified who reviewed the medical record ..." He also stated that it was their fault (referring to the hospital) and the technician was given a written warning.

A record review and a concurrent interview with the Director of Pharmacy, on 8/9/12 at 10:45 AM were conducted. He stated that they did not have a formal policy however they did have a process for verifying medications prior to providing them to patients. A hospital document titled "Pharmacy Training - Phase 1," instructed staff to "Check profile for proper patient (date of birth, last name: first 3 - 4 letters) ..."

Based on observation and interview, the hospital failed to ensure that the overall condition of the hospital's environment was maintained in a manner to ensure the safety and well-being of all patients. This failure had the potential to contribute to an increased risk of patient accidents and affect the well-being for a universe of 574 patients.

1. On 8/7/12, at 9:35 AM, a tour was conducted with the assistance of a hospital escort (Escort 1), of an outpatient rehabilitation building. Escort 1 attempted to open a door to a room that had been used as a pediatric therapeutic gym, it was observed that the door was difficult to open. Upon entering the room, an observation of the carpet revealed that it had buckled and lifted from the floor. The door was difficult to open because as the door was opened, it caught and dragged on the loose carpet. Escort 1 stated that she needed to put in a "work order."

On 8/7/12, at 10 AM, an interview was conducted with a Senior Occupational Therapist. She was asked if she noticed the buckling of the carpet, she stated that she had used the room in the past and noticed the carpet but did not take much notice to it because she focused on the patients. She also stated that she believed that the technicians told the Team Leader (Rehab Technician Team Leader 1) and she put in a requisition to have it repaired.

On 8/7/12, at 10:15 AM, an interview was conducted with the Rehab Technician Team Leader 1 who stated that she submitted a requisition "today."

2. On 8/7/12, at 9:35 AM, a tour was conducted with the assistance of Escort 1, as well as the Chief of Patient Care, Director, of the hospital's outpatient rehabilitation building. The escort opened the door to a storage room. The room contained multiple items which included, patient equipment (not labeled to indicate if they were clean or dirty), office supplies, Christmas supplies, walkers, tables, toys, televisions, tables (used as storage space), chairs, baskets, a non-working telephone, a ladder and various other items. The items were stored from the floor to about 1 foot away from the ceiling and half of the room was not accessible due to the amount of supplies and equipment that filled the room. When the escort was asked how they identify what is clean and dirty, she stated that "The items are dirty and they get cleaned as they are taken out." She also stated, "We only have one (1) storage area."

3. On 8/7/12, at 9:45 AM, a tour was conducted with the assistance of Escort 1, as well as the Chief of Patient Care, Director, of the hospital's outpatient rehabilitation building. The escort opened the "Soiled Linen" room, an observation revealed 2 bags filled with soiled laying on the floor and 2 blue carts which overflowed with bags filled with soiled linen. The escort stated "The soiled linen gets picked up only on Thursdays."

4. On 8/7/12, at 9:50 AM, a tour was conducted with the assistance of Escort 1, as well as the Chief of Patient Care, Director, of the hospital's outpatient rehabilitation building. The escort opened a "Whirlpool room" which contained a clean linen cart covered with sheets near an infectious waste bin. Patient equipment such as wheel chairs and walkers, among other equipment were also stored in the whirlpool room. The equipment was not labeled to indicate if they were clean or dirty.

On 8/7/12, at 10:15 AM, an interview was conducted with Rehab Technician Team Leader 1. She was asked about the hospital's storage space and the clean and soiled linen rooms. She stated, "We used to have a way to separate the clean from the dirty but they took away our storage rooms and turned them into exam rooms. I come in the morning and think, how am I going to store the clean linen but the best that I could do is place a sheet to cover up the clean linen carts that are stored in the whirlpool room. I know it's wrong but what else can I do, we have no storage. Clean and dirty are being stored together. We try our best."

On 8/7/12, at 11 AM, a record review of the hospital policies titled "Linen Management, effective August 2012" and "Storage of Equipment and Furniture, effective July 2012," was conducted. The policy for "Linen Management" indicated, "Clean lines are delivered to ...(name of hospital) completely covered and delivered to a designated clean area..." The policy titled, "Storage of Equipment and Furniture " indicated that "Each department/designee is responsible for identifying furniture, equipment, and supplies in excess of department operations needs...Excess items are picked up by the Materials Supply and Distribution Department (MSD) for storage, along with authorized requisition..."

Based on observation and interview, Hospital # 2, failed to have a thorough infection control surveillance system that monitored the conditions and practices of the dietary services staff. This deficient practice of preparation and distribution of foods under unsafe and unsanitary conditions had the potential for such continuation in the absence of identification and remediation which could result in cross contamination of food and the spread of food borne illness.

Findings:

On 8/2/12, Dietary Cook 1 at Hospital #2, was observed preparing scallops for lunch. Cook 1 used 3 different food trays while preparing the scallops. Tray 1 contained flour. Tray 2 contained a liquid egg batter. Tray 3 contained bread crumbs. Cook 1 rolled the scallop into the flour mixture, then into the egg mixture and then into the bread crumbs. Cook 1 white lab coat left sleeve was long and was observed into all three (3) mixtures while he was preparing the scallops.

After observing this practice, an interview was conducted on 8/2/12, at approximately 11:02 AM with the Registered Dietitian Manager, who was also observing Dietary Cook 1. The Dietary Manager confirmed that that Dietary Cook 1's coat sleeve was getting into the food as he went back and forth between the three (3) containers. The Dietary Manager pointed this out to Cook 1 who continued to prepare the food without adjusting his coat sleeve.

A review of the hospital policy titled, "Nutritional Services, Infection Control Responsibilities" included:

"33. Attends scheduled in-service education and completes competencies on sanitation and safe food handling and hand hygiene practices..."

Based on observation and interview, the hospital failed to ensure that the Urgent Care Clinic at Hospital # 2 clearly advised the public of the differences between urgent care services provided at the clinic and emergency services. This failure had the potential to delay emergency services/treatment for patients with life threatening conditions.

Findings:

On 8/2/12, an observation was made of a sign that read, "URGENT CARE". This sign was located in the corner of the parking lot, close to the street in front of the facility. On the outside of the entrance into the lobby of the Urgent Care Clinic, adjacent to the entrance door a sign read: "Urgent Care; Open 9:00 AM until 8:00 PM". Inside the lobby and on the outside of the entrance to the registration area, the sign read: "Urgent Care", Hours of Operation Sunday through Saturday; 9:00 AM to 8:00 PM. After hours - in case of emergency go to any emergency department."

An interview was conducted on 8/2/12, at approximately 11:45 AM with the Director of Quality at Hospital #2. He confirmed that the "Urgent Care" signage did not instruct the community regarding care provided at the urgent care clinic, versus those provided at an emergency department.

A review of the urgent care department scope of service, revised 4/11, noted, "Urgent Care (UC) is an 11 bed out-patient clinic that provides evaluation and treatment of non-life threatening conditions as well as episodes illnesses for pediatric through later adult patient populations. "

Based on interview and record review, the facility failed to ensure that all Physical Therapy services were provided as ordered by the physician for 1 of 46 sampled patients (Patient 25). This failure had the potential for all patients that received rehabilitation services in the facility to not reach their maximum rehabilitation potential due to services that were not provided as ordered.

Findings:

On 7/30/12, Patient 25's medical record was reviewed.

A review of the face sheet showed that the patient was admitted on 7/23/12 with a diagnosis of an incarcerated inguinal hernia (a condition where abdominal organs become stuck in the groin).

A review of the "Rehabilitation Therapy Physician Orders," dated 7/25/12, showed an order for Physical Therapy (PT) twice a day, seven days per week.

A review of the "Rehabilitation Therapy Physician Orders," dated 7/28/12, showed an order for Physical Therapy (PT) twice a day, seven days per week.

A review of the "Acute Physical Therapy Daily Progress Note," dated 7/25/12 through 7/30/12, revealed PT services were provided once per day as follows:

7/26/12 at 10:15 AM

7/27/12 at 2:30 PM

7/29/12 at 11:30 AM

On 7/30/12 at 3:30 PM, an interview and record review was conducted with Registered Nurse (RN) 6. RN 6 confirmed that the physician orders (PO), dated 7/25/12 and 7/28/12, indicated that the PT services were to be provided twice a day (7 days a week). She acknowledged that the patient received PT services once a day on 7/26/12, 7/27/12 and 7/29/12. RN 6 was unable to provide documentation to show that the PO for PT services was changed to once per day. She stated that the services should have been provided according to the PO.

On 8/3/12 at 11:40 AM, an interview was conducted with the Director of Rehabilitation Services (DRS). She confirmed that Patient 25 did not receive PT services as ordered (twice a day, seven days per week). The DRS confirmed that all rehabilitation services that the therapist recommend need to be ordered by the patients' physician prior to the services being implemented.

A review of the policy titled, "Physical Therapy, Patient Care," documentation, dated 3/12, showed that the therapist was responsible for the evaluation. After the evaluation, "b. Update order with duration, frequency shall be completed if different from original order."