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Based on review of procedure, records, and staff interview, the facility failed to develop an effective system to consistently distribute information about Patients' Rights to patients or their representatives after admission.

This deficiency was noted in nine (9) of eighteen applicable inpatient records reviewed.

Findings include:

The facility did not consistently ensure that each patient or the patient's representative was informed and signed acknowledgement of patient's rights upon admission or thereafter in a timely manner when possible.

During retrospective chart reviews and tours conducted of inpatient adult units on 5/24/10 and 5/25/10, nine of eighteen relevant inpatient adult and pediatric inpatient records did not contain documentation of the patient and/or the legal representative's written acknowledgment of patients' rights information as required by the hospital's policy and practice.

The hospital ' s policy for " Distribution of Patient Rights and Patient Record " is incomplete because it did not include a clear description of a process that ensures follow up provision of required information during inpatient hospitalization. Procedural flaws are identified in that after two unsuccessful attempts are made by a clerk to obtain acknowledgement signatures, the packet is sent with the patient record to the floor with a note indicating the reason the patient is unable to sign. There was no system developed to ensure staff accountability or follow up when the patient condition improves or when patient representatives are located.

This procedural omission did not afford patients a follow-up opportunity to receive and sign acknowledgement of patients' rights during a later point of the inpatient hospitalization, when patients might be more receptive to receive and understand this information following medical stabilization or upon location of the representative.

During instances when the completion of the acknowledgement form was not possible, there were no follow -up attempts documented by staff to obtain written acknowledgement and receipt of patients' rights information.

Examples include:
MR # 9
27 year old patient under Police custody was admitted for surgery and stabilization of self inflicted stab wounds on 5/19/10. Patient was visited on 5/24/10 at 12:35 PM by surveyors and was observed to be verbal and alert. Review of the record determined there was no documentation of written acknowledgement of patient rights information as required. Staff was notified and brought documentation of the form from another patient record. The patient ' s improved condition was not recognized as a follow-up opportunity to provide the patient rights acknowledgement.

MR#10
This 60 year old patient with diabetes was admitted on 5/18/10 for assessment and treatment of a scalp abscess. The patient was scheduled for discharge with home care referral on 5/25/10. The patient ' s record was reviewed during the morning of 5/25/10 and it was determined there was no evidence of acknowledgement of patient rights information or discharge appeals notice in the record. During interview of the patient by surveyor on 5/25/10 at 12:40 PM it was acknowledged by this patient he had just received the patients ' rights information that morning.

Refer to MR #s 8, 9, 10,11, 12, 13, 14, 15, 16.

Based on the review of medical records and other documents, the facility failed to implement its policy for pressure ulcer management in order to ensure that patients received care in a safe setting.
Specific finding is that the facility failed to implement its policy and procedure for prevention and management of pressure ulcers for high-risk patients.
This finding was noted in 7 of 30 records reviewed.

Findings include:

MR #1 is an elderly patient admitted on 11/22/09 with fever and multiple infected pressure ulcers on left heel, right foot and sacrum. The patient had contracture of upper and lower extremities and was incontinent of bowel and bladder. The medical history was significant for advanced Alzheimer ' s disease, peripheral vascular disease and osteomyelitis. The patient was aphasic, responsive to only tactile stimuli. The initial nursing assessment on 11/23/09 revealed the patient was a high risk for developing pressure ulcers evidenced by a Braden score of " 8 " and severe limitations in activities of daily living.

The nursing staff failed to fully implement the facility ' s policy and procedure on " Skin Integrity/Pressure Ulcer Management " for the patient. The nurses did not establish a written repositioning schedule and did not consistently reposition the patient every two hours as noted in the policy. Based on the review of the " Nursing Flowsheet " , the patient was repositioned every four hours on the following days: 11/23 to 12/1/09, 12/10 to 12/21 and 12/22 to 12/24.

Based on a tour of the two inpatient units (9CHC and 10 CHC) on 5/24-5/25, 2010 and the review of inpatient records, it was determined that for each patient a written repositioning schedule was not established on admission and integrated into the care plan to ensure consistent delivery of care to the patients. This finding was noted in 7 of 7 inpatient records with impaired skin integrity; MR # 2, 3, 4, 5, 6 and 7.