HospitalInspections.org

Based on a review of documentation and an interview with staff, the govening body did not appoint a chief executive officer who was responsible for management of the hospital.

Findings were:

Facility policy titled "Fall Risk" states, in part, "If a fall occurs:
1) Notify the physician regarding the fall and obtain orders if needed.
2) Notify the Nursing Supervisor regarding the fall.
3) Notify the patient's family, as appropriate.
4) Enter the event into SafERS.
5) Enter a nursing note in Wizard, Print a copy of the note and attach to the Fall Follow-up Report.
6) Print the Interdisciplinary Care Plan after the identified fall risk level is entered and attach to the Fall Follow-up Form.
7) Turn into the Nursing Supervisor: Fall Follow-up Form and all printed documentation including a copy of the Fall Risk Re-assessment."

Based on a review of documentation and an interview with RN #27, there was no documentation to indicate that the physician was notified, the patient's family was notified, a nursing note was completed, the Fall Follow-up Report was completed or that any paperwork was turned into the Nursing Supervisor following patient #1's fall at approximately 11:30 am on 10-25-13.

Facility policy titled "Vital Signs and Weights" states, in part, "Temperature, pulse, respirations, blood pressure and pain are assessed BID (0600 - 1800) unless ordered otherwise by physician."

A review of clinical records revealed that 4 of 20 patients (patients #1, #4, #9 and #10) did not have their vital signs assessed twice daily throughout their stay although it was ordered by their physician.

Facility policy titled "Medical Record Delinquency Notification" states, in part, "If the record remains incomplete for thirty days after discharge, the record is considered 'delinquent'."

A review of clinical records revealed that 2 of 20 records (patients #3 and #7) were still delinquent 30 days after the patient's discharge.

The above was confirmed in a meeting with the Supervisor of Therapy Staff, Quality Manager, RN Educator, Director, Vice President and Nurse Manager on the afternoon of 3-19-14 in the DePaul Center conference room.

Based on a review of documentation, the facility failed to protect the patient's right to participate in the development and implementation of his or her care plan.

Findings were:

A review of the clinical records for 20 patients revealed that 4 of the 20 patients (patients #1, #4, #10 and #11) did not participate in the development and implementation of their care plan. No documentation was found to indicate the reason for the patient's lack of participation.

Facility policy titled "Interdisciplinary Plan of Care" states, in part, "Procedure: 1. Initiating the Care Plan C. 4. The Case Manager should print the Care Plan and hold primary responsibility for ensuring that all parties including the patient, case manager, nurse and psychiatrist sign the form."

The above was confirmed in a meeting with the Supervisor of Therapy Staff, Quality Manager, RN Educator, Director, Vice President and Nurse Manager on the afternoon of 3-19-14 in the DePaul Center conference room.

Based on a review of documentation and an interview with staff, the facility did not require appropriate staff to have education, training and demonstrated knowledge in the use of cardiopulmonary resuscitation, including required periodic recertification.

Review of employee personnel files revealed 1 of 27 registered nurses (RN #23) did not have current Cardiopulmonary Resuscitation (CPR).

In an interview on 03/19/2014 at 2:41 pm with RN #27, RN #27 revealed that RN #23 had been suspended and removed from the work schedule until her CPR card was renewed.

The above was confirmed in a meeting with the Supervisor of Therapy Staff, Quality Manager, RN Educator, Director, Vice President and Nurse Manager on the afternoon of 3-19-14 in the DePaul Center conference room.

Based on a review of documentation and an interview with staff, a registered nurse did not adequately supervise and evaluate the nursing care for each patient.

Findings were:

Based on a review of documentation and an interview with RN #27, there was no documentation to indicate that the patient was assessed, the physician was notified, the patient's family was notified, a nursing note was completed, the Fall Follow-up Report was completed or that any paperwork was turned into the Nursing Supervisor following patient #1's fall at approximately 11:30 am on 10-25-13.

A review of clinical records revealed that 4 of 20 patients (patients #1, #4, #9 and #10) did not have their vital signs assessed twice daily throughout their stay although it was ordered by their physician.

The above was confirmed in a meeting with the Supervisor of Therapy Staff, Quality Manager, RN Educator, Director, Vice President and Nurse Manager on the afternoon of 3-19-14 in the DePaul Center conference room.