HospitalInspections.org

Based on record review of contracts and interviews the hospital failed to ensure contracted services provided to the hospital were current as evidenced by having expired contracts which also did not contain a renewal clause, for 6 of 6 contracts out of a total sample of 20 contracts reviewed. Findings:

Review of the contract of Contract A revealed is was signed on 7/22/2002. Further review revealed there was no renewal clause in the contract.

Review of the contract of Contract B revealed is was signed on 10/01/2002. Further review revealed there was no renewal clause in the contract.

Review of the contract of Contract C revealed is was signed on 3/11/2008. Further review revealed there was no renewal clause in the contract.

Review of the contract of Contract D revealed is was signed on 2/2/2009. Further review revealed there was no renewal clause in the contract.

Review of the contract of Contract E revealed is was signed on 6/1/2009. Further review revealed there was no renewal clause in the contract.

Review of the contract of Contract F revealed is was signed on 3/10/2004. Further review revealed there was no renewal clause in the contract.

An interview was held with S9 CFO on 2/2/2011 at 3:00 PM. After review of the contracts, S9 confirmed the dates the contracts were signed and added the contracted services contracts did not contain renewal clauses to indicate the length of time these contracts would be valid with the hospital.

Based on review of the hospital's grievance process, and interviews, the hospital failed to ensure there was a clearly explained procedure for the submission of verbal grievances alleged to hospital staff members as evidenced by:
1) failing to ensure the patient understood how to submit a written grievance regarding his missing identification cards (drivers' license, ATM Card, Bank Card) by not having documented evidence the grievance process was initiated by the patient after he made five (5) verbal complaints to the hospital staff (the ED nurse on 1/21/11, S1, CNO of Unit " a " on 1/24/11, the nurse on Unit " a " on 1/27/11, the hospital ' s operator at 9:00 a.m. on 1/28/11, S19, Patient Advocate at 10:00 a.m. on 1/28/11) for 1 of 1 focused Unit " a " grievances alleged in Unit "a" for January out of a total of 1 grievance alleged in Unit "a" in January of 2011, (Patient #8); and
2) failing to have documented evidence the grievance process was initiated by the hospital staff members that the patient made 5 verbal complaints to the ED nurse on 1/21/11, S1, CNO of Unit " a " on 1/24/11, the nurse on Unit " a " on 1/27/11, the hospital ' s operator at 9:00 a.m. on 1/28/11, S19, Patient Advocate at 10:00 a.m. on 1/28/11 for 1 of 1 focused Unit " a " grievances alleged in Unit "a" for January out of a total of 1 grievance alleged in Unit "a" in January of 2011, (Patient #8);
Findings:

Review of the medical record for Patient #8 revealed he arrived at the hospital ' s ED on 1/21/11 at 0005 (12:05 a.m.) via an ambulance with the chief complaint of " fall " . The patient was found unresponsive at the casino and his ambulation was unsteady. The patient was assigned an Acuity Level of 1 Emergent in which he was brought straight to a bed in the ED. The " Patient Rights & Responsibilities " form had " Unable to Sign " handwritten in the patient ' s signature section on the form. Further review of #8 ' s medical record revealed there was no documented evidence that the patient had personal valuables in his possession upon his arrival to the ED at 12:05 a.m. on 1/21/11. Patient #8 was admitted into the hospital to Unit " a " on 1/21/11 at 0340 (3:40 a.m.). Further review revealed there was no documentation Patient #8 had personal valuables listed in his possession when he was admitted to Unit " a " at 3:40 a.m. on 1/21/11.

In an interview conducted from 1:30 p.m. to 1:50 p.m. on 2/1/11, Patient #8 indicated he reported his missing identification cards (drivers ' license, ATM Card, Bank Card) to the Emergency Department (ED) nurse on 1/21/11. The patient complained a second time to S1, Chief Nursing Officer (CNO) regarding his missing identification cards on 1/24/11. The patient verbally complained a third time to the nurse on Unit " a " regarding his missing identification cards on 1/27/11. The patient verbally complained a fourth time to the hospital ' s operator regarding his missing identification cards at 9:00 a.m. on 1/28/11. Patient #8 verbally complained a fifth time to S19, Patient Advocate regarding his missing identification cards at 10:00 a.m. on 1/28/11. The patient indicated that as of today, 2/1/11 he did not know how to submit a grievance for his five verbal complaints to the hospital staff on 1/21/11, 1/24/11, 1/27/11, 1/28/11. Patient #8 further indicated the hospital staff has yet to inform him of his missing identification cards since his arrival to the hospital's ED on 1/21/11 until present on 2/1/11.

Review of the " Patient Advocate Daily Log " for the complaints/grievances filed for Unit " a " revealed the form was blank with no documentation recorded for January of 2011. Further review revealed there was no documented evidence of Patient #8 ' s verbal complaint of his missing identification cards to the ED nurse on 1/21/11. There was no documented evidence of the patient ' s (#8's) verbal complaint of his missing identification cards (ATM Card, Bank Card) to S1, CNO on 1/24/11. Further review revealed there was no documented evidence of Patient #8 ' s verbal complaint of his missing identification cards (drivers' license, ATM Card, Bank Card) to the nurse on Unit " a " on 1/27/11. There was no documented evidence of Patient #8 ' s verbal complaint regarding his missing identification cards to the hospital ' s operator at 9:00 a.m. on 1/28/11. Further review revealed there was no documented evidence of Patient #8 ' s verbal complaint of his missing identification cards since his arrival at the hospitals' ED on 1/21/11 to 1/28/11. There was no documented evidence of Patient #8s verbal complaint regarding his missing identification cards to S19, Patient Advocate on 1/28/11.

There was no documentation the grievance process was initiated by Patient #8 after he made five verbal complaints to the hospital staff from 1/21/11 to 1/28/11. There was no documented evidence the grievance process was initiated by the hospital staff after Patient #8 made five verbal complaints to staff on 1/21/11, 1/24/11, 1/27/11, and 1/28/11 (2).

Review of S19's handwritten notes for Patient #8 revealed there was no date/time recorded on the document indicating the day that S19 spoke with the patient. Further review revealed there was no documented evidence the grievance process was initiated by S19 for Patient #8's verbal complaint his identification cards missing since his arrival at the hospital's ED on 1/21/11.

In an interview on 2/2/11 from 2:45 p.m. through 3:15 p.m., S19, Patient Advocate verified there was no documented evidence the grievance process was initiated by the hospital staff after Patient #8 complained verbally five times that his identification cards were missing since his arrival to the ED on 1/21/11 until today, 2/2/11. S19 indicated there was no documentation the grievance process was initiated after Patient #8 made five verbal complaints to the hospital staff on 1/21/11, 1/24/11, 1/27/11 and 1/28/11 (2). S19 further indicated Patient #8 did not know how to submit his five verbal complaints about his missing identification cards. S19 stated the patient (#8) was not clearly instructed on the hospital's grievance process upon admission into the hospital as per policy.

A face-to-face interview was held on 2/2/11 at 3:40 p.m. with S1, Chief Nursing Officer (CNO) of Unit " a " . S1 indicated there was no documented evidence the grievance process was initiated by the hospital staff after the patient (#8) complained verbally five times that his identification cards were missing since his arrival to the ED on 1/21/11. He verified there were no documentation the grievance process was initiated after the patient (#8) made five verbal complaints to the hospital staff on 1/21/11, 1/24/11, 1/27/11, and two (2) on 1/28/11. S1 indicated Patient #8 did not know how to submit his five verbal complaints regarding his missing identification cards from 1/21/11 to present 2/2/11. S1 stated the patient (#8) was not clearly instructed on how to submit a grievance to initiate the hospital's grievance process when the patient was admitted to Unit "a" on 1/21/11 as per policy.

Review of policy titled, " Patient Complaint-Grievance Resolution " , policy #000-000, titled Patient Grievance Policy indicate Patients receiving inpatient services in the Hospital shall be provided information on their right to file a grievance, which includes the Contact person/number within the Hospital Administration with a number provided. After hours, nights, weekends and holidays contact the charge nurse with a number provided.

Based on record reviews, and interviews, the hospital failed to ensure the policy and procedure for the patient grievance process was followed as evidenced by:
1. failure of a staff member on Unit " b " to report to S22, Director of Nursing (DON) of Unit " b " after: a) Patient #31 verbally complained that " staff did not provide socks " on 12/1/10;
b) Patient #32 filed a written complaint that " staff was rude " on 12/1/10, and
c) Patient (#32) filed a second written complaint of unknown content on 12/1/10; and
2. failure of a staff members of Unit " a " to report to the S1, Chief Nursing Officer, (CNO) after
Patient (#8) voiced verbal complaints regarding his identification cards (drivers ' license, ATM Card, Bank Card) were missing from his coat pocket on 1/21/11, 1/24/11, 1/27/11 and 1/28/11.
Findings:

Patient #31:
Review of the " Patient Complaint/Grievances " for Unit " b " filed for December of 2010 revealed Patient #31 had a verbal complaint recorded by S21, Social Worker (SW) on 12/1/10. S21 described #31 ' s verbal complaint as follows: 12/1/10 at 12:30 (12:30 p.m.) Pt. (patient) was upset that she could not get socks. She said the staff said they didn ' t (did not) have any. Pt. felt like they were telling the truth, or cared. There was no documented evidence of the date/time that S21 SW made her Response/Action to the patients ' verbal complaint on 12/1/10. Further review of the Response/Action section read, " I checked in supply room on Unit & (and) in Central Supply, and they were completely out of them. I shared this /c (with) pt. afterwards. The complaint/grievance had a check mark indicating " Resolved " under the section titled, " Result " .

Patient #32:
The " Patient Complaint/Grievances " for Unit " b " filed for December of 2010 revealed Patient #32 had written complaints documented by S21, SW on 12/1/10. Further review revealed S21 described the patient ' s written complaint as follows: 12/1/10 at 16:15 Pt. had 2 complaints that she wrote out on Pt. complaint forms. Pt. is being D/C ' d (discharged) today, but I assured her that I would make sure to pass them onto S7 (Unit " b " Program Director named) for F/U (follow up). Pt. was OK /c that. The patient ' s written complaints/grievances had a check mark indicating " Unresolved " referred to S22, DON of Unit " b " and S7 Program Director of Unit " b " . Review of Unit " b " s " Pt. (patient) C/O (complaint)/Grievance handwritten notes documented for December of 2010 by S21, SW revealed Patient #32 was discharged to home prior to S22 DON of Unit " b " or S7, Program Manager of Unit " b " following up with the patient on 12/1/10. On 1/5/11, the patient ' s written complaints/grievances " follow up documentation was not completed so pt called at home & (and) discussed issue. Pt. agreed issue resolved " .

Review of the " Patient Advocate Daily Log " for December of 2010 documented by S19, Patient Advocate for Unit " a " revealed there was no documentation recorded of the Patients (#31,#32) complaints/grievances filed for Unit " b " on 12/1/10.

In interview from 7:55 a.m. to 8:10 a.m. on 2/3/11, S7, Program Manager of Unit " b " indicated S22, DON of Unit " b " was not available for interview that he was at home sick. S7 further indicated she was the Program Manager for Unit " b " . She verified there were complaints/grievances filed by both patients (#31, #32) on 12/1/10. S7 gave the hospital ' s definition of a grievance as a complaint that cannot be resolved by the same staff immediately and required further investigation. S7 agreed both Patients (#31 ' s, #32 ' s) complaints/grievances filed /alleged on 12/1/10 required further investigation of the staff on Unit " b " . She indicated both patients (#31, #32) complaints were grievances. S7 stated the grievance process should be initiated with all complaint/grievances by the staff on Unit " b " to report the complaint/grievance to the department head, (S22, DON of Unit " b " ). S7, Program Manager of Unit " b " indicated there was no documentation the grievance process was initiated by the staff on Unit " b " to notify S22, DON of Unit " b " for both patients (#31, #32) on 12/1/10 as per policy. She reported there was no documented evidence of what Patient #32 ' s second written complaints/grievances was on 12/1/10. S7 indicated the grievance policy procedure was not followed to initiate a " Patient Grievance Resolution Form " for Patient #32 ' s second written complaint/grievance filed on 12/1/10 to a staff member of Unit " b " . S7 reported there was no documented evidence the patients (#31, #32) were notified in writing regarding their complaints/grievances for about 63 days from 12/1/10 until today, 2/3/11. She indicated the grievance policy to notify the patients in writing within 7 days was not followed for both patients (#31, #32) as of today, 2/3/11.

Patient #8:
In an interview conducted from 1:30 p.m. to 1:50 p.m. on 2/1/11, Patient #8 indicated he reported his missing identification cards (drivers ' license, ATM Card, Bank Card) to the Emergency Department (ED) nurse on 1/21/11. The patient complained a second time to S1, Chief Nursing Officer (CNO) regarding his missing identification cards on 1/24/11. The patient verbally complained a third time to the nurse on Unit " a " regarding his missing identification cards on 1/27/11. The patient verbally complained a fourth time to the hospital ' s operator regarding his missing identification cards at 9:00 a.m. on 1/28/11. Patient #8 verbally complained a fifth time to S19, Patient Advocate regarding his missing identification cards at 10:00 a.m. on 1/28/11. The patient indicated that as of today, 2/1/11 he had not received notification in writing of the nature of his complaints, who initiated his grievances, and the results of the investigations from the hospital.

Review of the " Patient Advocate Daily Log " for the complaints/grievances filed for Unit " a " revealed the form was blank with no documentation recorded for January of 2011. Further review revealed there was no documented evidence of Patient #8 ' s verbal complaints/grievances alleged to the ED nurse on 1/21/11 recorded on the daily form completed by S19, Patient Advocate. There was no documented evidence of the patient ' s verbal complaint alleged to S1, CNO on 1/24/11 recorded on the daily form. Further review revealed there was no documented evidence of Patient #8 ' s verbal complaints/grievances alleged to the nurse on Unit " a " on 1/27/11 recorded on the daily form. There was no documented evidence of Patient #8 ' s verbal complaints/grievances alleged to the hospital ' s operator at 9:00 a.m. on 1/28/11 recorded on the daily form. Further review revealed there was no documented evidence of Patient #8 ' s verbal complaints/grievances alleged to S19, Patient Advocate on 1/28/11 recorded on her daily form.

Review of the handwritten notes documented by S19, Patient Advocate for Patient #8 with no date/time recorded on the document read as follows,
" Casino-
Ambulance called
-he told amb (ambulance) - his ID (identification) in his pocket.
-They (ED) cut his clothes off
- they (ED) found NO ID
-gets a VA & SS
-ATM Card for both VA & SS
He cannot get his money.
Ambulance people claim he had NO ID-
-Amb people did not find keys did not find money
he (Amb) does not have any clothes now
-blue jeans
-green turtleneck
-sweatshirt blue
-red jacket -from gift shop at Casino
Needs-
VA Card
SS Card
Dr (driver) License " .

There was no documentation on S19 ' s handwritten notes that S1, Chief Nursing Officer (CNO) of Unit " a " was notified of Patient #8 ' s missing identification cards (drivers ' license, ATM Card, Bank Card) on 1/28/11.

Review of the medical record for Patient #8 revealed he arrived at the hospital ' s ED on 1/21/11 at 0005 (12:05 a.m.) via an ambulance with the chief complaint of " fall " . The patient was found unresponsive at the casino and his ambulation was unsteady. The patient was assigned an Acuity Level of 1 Emergent in which he was brought straight to a bed in the ED. The " Authorization For Emergency Treatment " form, " Condition of Admission to the Hospital " form, and " Patient Rights & Responsibilities " forms had " Unable to Sign " handwritten in the patient ' s signature section on the forms. Further review of #8 ' s medical record revealed there was no documented evidence that the patient had personal valuables in his possession upon his arrival to the ED at 12:05 a.m. on 1/21/11. Patient #8 was admitted into the hospital to Unit " a " on 1/21/11 at 0340 (3:40 a.m.). Further review revealed there was no documentation Patient #8 had personal valuables listed in his possession when he was admitted to Unit " a " at 3:40 a.m. on 1/21/11.

An interview was held on 2/2/11 from 2:45 p.m. through 3:15 p.m. with S19, Patient Advocate. She verified the " Patient Advocate Log " for the complaints/grievances for January of 2011 was a blank form. She confirmed Patient #8 was not documented on the January 2011 " Patient Advocate Log " for all complaints/grievances alleged by patients at the hospital. S19 indicated she was in the process of updating the " Patient Advocate Log " for the January complaints/grievances alleged by the patients on Unit " a " , today, 2/2/11. She reviewed her handwritten notes for Patient #8. She verified her handwritten notes did not have a date/time that the she documented the information for Patient #8. She recalled visiting the patient that Friday morning at about 10:00 a.m. on 1/28/11. She indicated she was performing her daily routine patient rounds on Unit " a " that morning when she entered the patient ' s room at about 10:00 am. She did not recall the hospital operator contacting her regarding the patient ' s missing identification cards at 9:00 a.m. that same morning. She reviewed her handwritten notes for the patient. She then indicated the patient was missing his identification cards (drivers ' license, ATM Bank Cards for his VA and Social Security). She recalled the patient indicating that he needed his identification cards to withdraw his monthly VA and SS payments. She stated the patient told me his identification cards were missing since his arrival to the ED on 1/21/11. She confirmed the patient had cash money that was missing upon his arrival to the ED on 1/21/11. She indicated the patient ' s money was found by the ambulance people and returned to the patient that same night. She denied knowledge that the patient ' s cash money was returned to him while he was still in the ED that same night. She stated that she does not do the complaint/grievance investigations that S1, CNO does. She indicated S1, CNO investigates all hospital complaints/grievances alleged on Unit " a " . She denied informing the patient that she would get back to him before 4:00 pm in regards to his missing identification cards. She recalled verbally instructing S1, CNO of the patient ' s missing ID (identification), but did not recall what specific information that she told him (S1) regarding the patient ' s missing identification cards. She recalled reporting to S1, CNO that the patient was missing his identification cards (drivers ' license, ATM Bank Cards for VA and SS). She verified there was no documented evidence of what information was reported to S1, CNO for the patient on 1/28/11. She denied knowledge that S1, CNO was not aware that the patient was missing his ATM Bank Cards for VA and SS monthly withdrawals. She further denied whether or not she reported to S1 that the patient ' s identification cards had been missing for about 7 days since his arrival to the ED on 1/21/11. She confirmed there was no documented evidence of the date/time that she notified S1, CNO regarding the patient ' s missing identification cards. She verified there was no documented evidence of what information that she reported to S1 of the patient ' s missing identification cards. She stated there was no documented evidence in her daily " Patient Advocate Log " for January and/or handwritten notes of the patient ' s first verbal complaint/grievance alleged in the ED on 1/21/11. She further stated there was no documentation of the patient ' s second verbal complaint/grievance alleged to the nurse on Unit " a " on 1/27/11. She did not recall the nurse on Unit " a " notifying her regarding the patient ' s second verbal complaint/grievance regarding his missing identification cards since his arrival at the hospital ' s ED on 1/21/11. She indicated there was no documented evidence of the patient ' s third verbal complaint/grievance alleged to the hospital ' s operator on 1/28/11. She stated there was no documented evidence the grievance process was initiated by the ED nurse to notify the department head of the ED of the patient ' s missing identification cards on 1/21/11 as per policy. She verified there was no documented evidence the grievance process was initiated by the nurse on Unit " a " to notify the department head of the unit (S1, CNO) regarding the patient ' s missing identification cards on 1/27/11 as per policy. She indicated there was no documented evidence the grievance process was initiated by the hospital ' s operator to notify the department head of the hospital (S1, CNO) regarding the patient ' s missing identification cards on 1/28/11 as per policy. S19, Patient Advocate indicated there was no documented evidence Patient #8 was notified in writing of his complaints/grievances for 12 days from 1/21/11 through 2/2/11. S19 further indicated the hospital ' s grievance policy was not followed to notify the patient in writing within 7 days. She indicated Unit " b " complaints/grievances are completed by S22, Director of Nursing for Unit " b " . She further indicated she did not have any documentation regarding Patient #31 and/or Patient #32 ' s complaints/grievances alleged/filed on 12/1/10 as recorded on the " RAG Committee Meeting Minutes " dated 1/20/11.

Review of the handwritten notes documented by S1, CNO for Patient #8 read, 1/2411 at 1355 (1:55 p.m.) the patient states cut his clothes off. States he did not find ID or DL (drivers ' license). Found money. States his DL was in pants. States could not tell anyone due to slurred speech. -Ask if I would talk to police & medics (EMS) to ask if they know anything (about his ID card). -Now states has a jacket in his car at Casino and the DL may be in the pocket (in his car) " .

Review of the " Patient Complaint-Grievance Resolution Form " revealed the incident date was 1/21/11 - (at) 0005 (12:05 a.m.) (in the ) ER (emergency room) for Patient #8. S1, Chief Nursing Officer (CNO) called the patient on 1/24/11 at 13:55 (1:55 p.m.) and investigated the incident on 1/24/11 at 1430 (2:30 p.m.) that same day. Further review revealed S1 spoke with the Assistant Chief of Police at the nearby Casino that reviewed the report of response by Police and Medics. States that there was no ID (identification) on the patient and in fact they had to run his car license plate to identify the patient. The ambulance (EMS) assumed control of the patient upon arrival and transported him to the hospital. They too denied finding an ID Cards. I spoke with staff (ED) on duty on 1/21/11 and they also stated that no ID was found. The ER staff did cut his clothes off to assess him due to the fact that without know mechanism of injury. Further review of the section titled, " Findings " read, " Based on interview with staff, medics, and policy, we can ' t prove that pt (patient) had any ID on him. Review of the section titled, " Response to complaint " read, " Patient state, " I have a jacket in my car and the license may be in the pocket. I will get someone to go see " . There was no documented evidence of the dates/times of the " Findings " and/or " Response to Complaint " sections were completed by S1, CNO recorded on the form.

In a face-to-face interview on 2/2/11 at 3:40 p.m., S1 CNO of Unit " a " indicated there was no documented evidence in Patient #8 ' s medical record that he had personal valuables at the time of his arrival to the ED on 1/21/11. He confirmed there was no documented evidence in the patient ' s medical record that he had personal valuables in his possession during his admission to Unit " b " on 1/21/11 until today, 2/2/11. He stated the patient indicated during my interview with him on 1/24/11 that he was missing his ID (drivers ' license) and cash money. He stated the patient ' s cash money was found in his coat pocket on the floor in the ED. The ED staff had to cut the patient ' s clothing off of him in order to assess him. The patient arrived to the hospital ' s ED that night unresponsive, unable to speak and no ID. The patient instructed the ED nurse later that night when his speech returned that he had an ID and cash money in his coat pocket. At this time, the ED staff searched the patient ' s clothes on the floor and found his money. The ED nurse then returned the patient his cash money before he was admitted to Unit " a " . S1, CNO indicated there was no documentation the grievance process was initiated by the ED nurse of Patient #8 ' s missing identification card (drivers ' license). S1 did not know the patient was missing his ATM cards to access his monthly payments from VA and SS. He stated the ER nurse did not follow the policy to initiate the grievance process for Patient #8 ' s missing identification cards (drivers ' license, ATM Card, Bank Card) on 1/21/11. He reported the ED staff did not initiate the grievance process to notify the department head of the ED for about 12 days from 1/21/11 until today, 2/2/11. He indicated the nurse on Unit " a " did not initiate the grievance process to notify the department head (S1) of Patient #8 ' s missing identification cards (ATM, Bank) on 1/27/11 as per policy. He further indicated the hospital ' s operator did not follow the policy to notify the department head, (S1) to initiate the grievance process for Patient #8 ' s missing identification cards on 1/28/11 as per policy. S1 stated S19, Patient Advocate did not initiate the hospital ' s grievance policy for Patient #8 to notify the department head (S1) of the patients ' missing identification cards (ATM Card, Bank Card) on 1/28/11. S1, CNO of Unit " a " indicated there was no documented evidence Patient #8 was notified in writing within 7 days of his verbal complaints/grievances alleged to the hospital staff on 1/21/11, 1/27/11 or 1/28/11 as per policy.

Review of policy titled, " Patient Complaint-Grievance Resolution " , policy #000-000, titled Patient Grievance Procedure indicated all complaints that cannot be immediately and effectively identified, investigated and resolved by an individual staff member will be directed up the chain of command to the level required for the most compete resolution possible. All complaints are documented using the " Patient Complaint-Grievance Resolution Form " . When the individual staff member receives a complaint, he/she takes immediate action on the complaint notifying the appropriate personnel responsible for the area in which the problem occurred. The complaint resolution forms are initiated and sent to the appropriate department. The responsible department manager should contact the patient with 24 - 72 hours to discuss the problem. Once the investigation process is complete, the department manager will complete the Patient Complaint-Grievance Resolution form. The department manager will be notified of any grievance as defined above. The grievance form will be initiated and sent to the appropriate department manager and Administration. The department manager will investigate the grievance and contact the patient within 24 - 72 hours of receipt. The Grievance will be reviewed by the Grievance Committee to assure thoroughness of the investigation, to assure resolution and to formulate the appropriate response to the complainant. The patient/complainant will receive written notice within seven (7) days regarding the grievance resolution which will include:
a. Name of the contact person
b. Steps taken to investigate the grievance
c. Resolution of the grievance
d. Date of completion.

If the grievance will not be resolved, or if the investigation is not or will not be completed within seven days, the hospital will inform the patient in writing that the hospital is addressing the grievance and will follow up with a written response within 30 days. A report of the Grievances and their resolution will be reported from the Grievance Committee to the Quality Improvement Committee for trending and pattern identification, and then to the Governing Board.

There was no documentation the Unit " b " staff followed the " Patient Grievance " Procedure Policy to notify the department head of Unit " b " (S22, DON of Unit " b " ) when Patient #31 verbally complained that " staff could not provide socks " on 12/1/10.

There was no documentation the Unit " b " staff followed the Patient Grievance Procedure Policy to notify the DON of Unit " b " when Patient #32 filed a written complaint that " staff was rude " on 12/1/10. There was no documented evidence the Unit " b " staff followed the Patient Grievance Procedure Policy to notify the DON of Unit " b " when Patient #32 filed a second written complaint. There was no documentation the Unit " b " staff followed the Patient Grievance Procedure Policy to initiate the Patient Complaint-Grievance Resolution form for all complaints.

There was no documented evidence the ED nurse followed the " Patient Grievance " Procedure Policy to notify the department head of the ED when Patient #8 verbally voiced his identification cards (drivers ' license, ATM Card, Bank Card) were missing from his coat pocket on 1/21/11. There was no documented evidence S1, CNO followed the " Patient Grievance " Procedure to notify the department head, (Administrator) when Patient #8 verbally voiced his identification cards were missing on 1/24/11. There was no documentation the nurse on Unit " a " followed the " Patient Grievance " Procedure Policy to notify the department head, (S1, CNO on Unit " a " ) when Patient #8 verbally complained that his identification cards were missing on 1/27/11. There was no documented evidence the hospital ' s operator followed the " Patient Grievance " Procedure to notify the department head, (S1, CNO of Unit " a " ) when Patient #8 verbally complained that his identification cards were missing at 9:00 a.m. on 1/28/11. There was no documentation S19, Patient Advocate followed the " Patient Grievance " Procedure Policy to notify the department head, (S1, CNO of Unit " a " ) when Patient #8 verbally complained that his identification cards were missing on 1/28/11.

Based on record reviews and interviews, the hospital failed to follow their policy of notification of the results of the investigation of the grievances as evidenced by having 2 of 2 focused grievances for Unit " b " for December of 2010 out of a total of 4 grievances for December, (Patient #31, #32) and 1 of 1 focused grievance for Unit " a " for January of 2011 out of a total of 1 grievance for January, (Patient #1) with no written confirmation/notification of the results of the investigations shared with the complainants.
Findings:

Patients (#31, #32):
Review of the " Patient Complaint/Grievances " for Unit " b " for December of 2010 revealed there were complaints/grievances filed by both Patients (#31, #32) on 12/1/10. Further review of the December Grievance reports revealed no documented evidence from 12/1/10 until today, 2/3/11 the patients (#31, #32) were notified in writing of the nature of the complaints, who initiated the grievances, and the results of the investigations for about 63 days.

In an interview on 2/3/11 from 7:55 a.m. to 8:10 a.m., S7, Program Manager of Unit " b " stated if a patient complains verbally and/or in writing, the complaint/grievance is initiated by the staff member on Unit " b " by completing the written report, ( " Patient Complaint/Grievance Resolution Form " ). The staff member then submits the grievance form to S22, Director of Nursing (DON) of Unit " b " . S22 then investigates the grievance. After the investigation was complete, S22 verbally notifies the complainants of the results of the investigations. S7 indicated both patients (#31, #32) had grievances filed on 12/1/10. She confirmed there were no written confirmations/notifications to the complainants (#31, #32) about the results of the investigations conducted by S22, DON of Unit " b " since 12/1/10 until today, 2/3/11. S7 indicated the " Grievance " policy was not followed for all grievances to be notified in writing within 7 days of the nature of the complaints, who initiated the grievances, and the results of the investigations. S7, Program Manager further indicated both Patients (#31, #32) were not notified of the grievance results in writing within 7 days as per the " Grievance " policy.

Patient #8:
In an interview conducted from 1:30 p.m. to 1:50 p.m. on 2/1/11, Patient #8 indicated he reported his missing identification cards (drivers ' license, ATM Card, Bank Card) to the Emergency Department (ED) nurse on 1/21/11. The patient complained a second time to S1, Chief Nursing Officer (CNO) on 1/24/11. The patient verbally complained a third time to the nurse on Unit " a " regarding his missing identification cards on 1/27/11. The patient verbally complained a fourth time to the hospital ' s operator regarding his missing identification cards at 9:00 a.m. on 1/28/11. Patient #8 verbally complained a fifth time to S19, Patient Advocate regarding his missing identification cards at 10:00 a.m. on 1/28/11. The patient indicated that as of today, 2/1/11 he had not received notification in writing of the nature of his complaints, who initiated his grievances, and the results of the investigations from the hospital.

Review of the " Patient Advocate Daily Log " for January of 2011 recorded by S19, Patient Advocated for Unit " a " complaints/grievances revealed it was a blank form. Further review of the " Patient Advocate Daily Log " for January revealed no documented evidence from 1/21/11 until today, 2/3/11 the patient (#8) was notified in writing of the nature of his complaints, who initiated his grievances, and the results of the investigations for about 12 days.

An interview was held on 2/2/11 from 2:45 p.m. through 3:15 p.m. with S19, Patient Advocate. S19 stated if a patient complains verbally and/or in writing, the complaint/grievance is initiated by the staff member on Unit " a " by contacting her by telephone. S19 then completes the " Patient Advocate Daily Log " documenting the written grievance from the patient. She reports the grievance verbally to S1, Chief Nursing Officer of Unit " a " . S1 investigates the grievance. After the investigation is completed by S1, he verbally notifies the complainants (#8) on Unit " a " of the results of his investigations. S19 indicated there were no written confirmations/notifications for the complainant (#8) of the nature of his complaints, who initiated his grievances, and/or the results of the investigations from the hospital as of today, 2/2/11. She reported the " Grievance " policy for all grievances to be notified in writing within 7 days of the nature of the complaints, who initiated the grievances, and the results of the investigations was not followed by S1CNO or S19 Patient Advocate. S19, Patient Advocated indicated Patient #8 was not notified of the grievance results in writing within 7 days as per the " Grievance " policy.

Review of policy titled, " Patient Complaint-Grievance Resolution " , policy #000-000, titled Procedure indicated the patient/complainant will receive written notice within seven (7) days regarding the grievance resolution which will include:
a. Name of the contact person
b. Steps taken to investigate the grievance
c. Resolution of the grievance
d. Date of completion.

If the grievance will not be resolved, or if the investigation is not or will not be completed within seven days, the hospital will inform the patient in writing that the hospital is addressing the grievance and will follow up with a written response within 30 days.

26313

Based on observations, interviews, and record reviews, the facility failed to:
1.Ensure Medical Staff Review Functions were accurately tracked, trended, and analyzed as evidenced by the failure to ensure entries in the medical records were legible, signed, dated, timed, and authenticated in a prompt manner.
2. Have a system in place to accurately track, trend, and analyze infections in the hospital.
3. Accurately monitor the process of how 24 hour chart checks (which is a clinical indicator) are completed as evidenced by the lack of a policy to ensure 24 hour chart checks are consistently reviewed.
4. Have Patient Grievances was a quality indicator

Findings:
1. In an interview with S13, Health Information Manager (HIM) on 2/2/11 at 2:30 p.m., she stated she checks the medical records to ensure the verbal and telephone orders were authenticated by the physicians within the 10 day time frame as outlined in the Hospital Documentation policy. S13 confirmed quality indicators for Medical Staff Functions included the percentage of use of verbal orders, the percentage use of read back telephone orders, percentage of entries dated, timed, legible, and authenticated.

A record review of the 2010 Hospital Quality Improvement Report Card revealed the percentage of use of Read Back Verbal Orders on Unit A ranged from 4% in September, 5% in October, 3% in November, and 1% in December. There was missing documentation on the Quality Improvement Report Card of the percentage of use of Read Back Verbal Orders for Unit B.

The percentage use of Read Back Telephone Orders for Unit A ranged from 29% in May, 18% in June, 21% in July, 18% in August, 40% in September, 19% in October, 30% in November, and 24% in December. The percentage of Read Back Telephone Orders for Unit B ranged from 27% in July, 25% in August, 40% in September, 32% in October, 32% in November, and 29% in December.

The percentage of Physician's Orders entries dated on Unit A ranged from 99% to 100%; timed ranged from 98% to 100%; legible ranged from 99% to 100%; and authenticated (within 10 day time frame) ranged from 94% to 100%.

The percentage of Physician's Orders entries dated on Unit B ranged from 99% to 100%; timed ranged from 98% to 100%; and authenticated (within 10 day time frame) ranged from 67% to 100%. There was no data collected to reflect the percentage of legible Physician's Orders entries on Unit B.

S13, HIM confirmed this data was based on the percentage of use of verbal orders from a randomly selected sample of medical records. She also confirmed this data was based on the percentage of use of read back telephone orders from randomly selected medical records from Unit A and Unit B. S13 explained this data reflects individual entries in the Physician's
orders.

2. Review of the Infection Control Data presented by S11 LPN/Infection Control Coordinator revealed no documentation of a system for identifying, reporting, tracking, trending and investigating infections and communicable diseases of patients on Unit A and Unit B. There was no documentation to indicate tracking and trending of infections present upon admission, antibiotic use, location of infections within the facility, different types of infections such as respiratory, gastrointestinal, genitourinary, and integumentary, or active surveillance of isolation techniques used by staff.

Review of the Infection Control Rounds documentation dated October - December, 2010 reflected S11 LPN/Infection Control Coordinator made rounds to observe infection control issues/techniques utilized by hospital staff on both units only one time per month.

Interview with S11 LPN/Infection Control Coordinator on 2/3/11 at 7:45 a.m. revealed she was responsible for obtaining and analyzing infection control data for Units A&B of the hospital. She stated she observed different areas in the hospital and staff only once monthly to determine if proper infection control techniques were being utilized. She indicated she had no system for being notified when or why patients were placed on antibiotics and tracking/trending the locations of various types of infection throughout the facility. Further interview reflected she had only been tracking hospital acquired urinary infections and reporting them to the QA committee.

Record review of the 2010 Hospital QI Report Card revealed one hospital acquired infection (HAI) reported in August, one in September on Unit A, and one HAI in October on Unit B. The number of communicable diseases reported were: one in the month of March, one in the month of May, one in the month of November, and one in the month of December. The number of community acquired antibiotic resistant infections were reported as: Four in the month of January, Four in the month of March, Seven in the month of April, Two in the month of May, Eight in the month of June, One in the month of July, Six in the month of August, Four in the month of September, Five in the month of October, Two in the month of November, and Four in the month of December.

There was no documentation on the 2010 Hospital QI Report Card which indicated which organism was present in the urinary tract infections and whether the organism was an antibiotic resistant infection.

Interview with S1 RN/CNO on 2/3/11 at 8:30 a.m. confirmed the above findings obtained from S11 LPN/Infection Control Coordinator. He further indicated the facility was not obtaining, documenting, and analyzing infection control data according to hospital policy and procedure.

3. Record review of the 2010 Hospital QI Report Card revealed one of the quality indicators was the percentage of compliance with 24 hour chart checks completed. The QI Report Card revealed this indicator met 100% compliance for the year.

On 2/2/10 at 4:00 p.m. in an interview with S1, CNO, he stated the facility did not have a policy regarding what needs to be checked during a 24 hour chart check. S1 confirmed the lack of consistency of how the charts were being checked by the nursing staff.

On 2/3/10 at 8:30 a.m. in an interview with S10, RN, QA Coordinator, she acknowledged she was not aware the facility did not have a policy on what needs to be checked during a 24 hour chart check. She confirmed the results of this quality indicator was inaccurate because of the lack of consistency in how the charts are checked by the nursing staff.

4. Record review of the 2010 Hospital QI Report Card revealed Patient Grievances was a quality indicator. The QI Report revealed grievances were 100% resolved for the 2010 according to policy.

On 2/3/10 at 8:30 a.m. in an interview with S10, RN, QA Coordinator, she confirmed the percentage of responses to grievances according to policy was incorrect because 3 grievances had not been investigated and not resolved in 2010.

Based on record review and interview, the facility failed to ensure that all patient medical record entries were complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures for 4 of 4 records reviewed (#11, #13, #7, #8) in a total sample of 32. Findings:

1. Review of the physician's Progress Notes dated 1/12/11 for patient #11 revealed there was no time documented for the entry.

Review of the facility's Hospital Wide Documentation policy and procedure reflected every entry in the medical record must contain a time.

Interview with S1 RN/CNO on 2/2/11 at 12:18 p.m. revealed each chart entry should contain a time the entry was made.

2. Review of the Nutritional Assessment for patient #13 revealed no documentation of a date, time or signature to indicate who made the entry.

Review of the facility's Hospital Wide Documentation policy and procedure reflected every entry in the medical record must contain a date, time, and signature.

Interview with S1 RN/CNO on 2/2/11 at 12:18 p.m. revealed each chart entry should be complete with a date, time and signature of the person who made the entry.

3. Review of the Physician's Orders for patient #7 revealed the physician's signature was not dated and timed to indicate when the physician authenticated the order on the following days: 4 physician's order entries on 1/25/11; 1 physician order entry on 1/26/11; 2 physician order entries on 1/27/11; 2 physician order entries on 1/28/11; 1 physician order entry on 1/30/11; and 1 physician order entry on 1/31/11.

Interview with S1 RN/CNO on 2/2/11 at 12:18 p.m. revealed each chart entry should contain a time the entry was made.

4. Review of the Physician's Orders for patient #8 revealed the physician's signature was not dated and timed to indicate when the physician authenticated the order on the following days: 1 physician order entry on 1/26/11; 4 physician order entries on 1/27/11; 2 physician order entries on 1/30/11; 1 physician order entry on 1/31/11; 1 physician order entry on 2/1/11.

Record review of policy number 000-000 titled "Hospital Wide Documentation" (pg 1 of 1), under Policy, contains the following: "Medical records shall be documented legibly, dated, timed, and authenticated."

Record review of the Rules and Regulations of the Medical Staff Section III.- Medical Records 5. reads "All clinical entries in the patient's medical record shall be complete, legible, accurately dated, timed and signed by the responsible physician."




25059




26313

26313

Based on observation, interview, and policy review, the facility failed to 1. ensure the medical staff were authenticating verbal orders/telephone orders promptly as evidenced by 2 of 32 sampled patient records having no dates and times of when the verbal/telephone orders were authenticated (#7,#8); and 2. ensure physician verbal and telephone orders were minimally used. Findings:

1. Patient #7: Review of the Physician's Orders for patient #7 revealed the physician's signature was not dated and timed to indicate when the physician authenticated the order on the following days: 4 physician's order entries on 1/25/11; 1 physician order entry on 1/26/11; 2 physician order entries on 1/27/11; 2 physician order entries on 1/28/11; 1 physician order entry on 1/30/11; and 1 physician order entry on 1/31/11.

Interview with S1 RN/CNO on 2/2/11 at 12:18 p.m. revealed each chart entry should contain a time the entry was made.

Patient #8: Review of the Physician's Orders for patient #8 revealed the physician's signature was not dated and timed to indicate when the physician authenticated the order on the following days: 1 physician order entry on 1/26/11; 4 physician order entries on 1/27/11; 2 physician order entries on 1/30/11; 1 physician order entry on 1/31/11; 1 physician order entry on 2/1/11.

Record review of policy number 000-000 titled "Hospital Wide Documentation" (pg 1 of 1), under Policy, contains the following: "Medical records shall be documented legibly, dated, timed, and authenticated."

Record review of the Rules and Regulations of the Medical Staff Section III.- Medical Records 5. reads "All clinical entries in the patient's medical record shall be complete, legible, accurately dated, timed and signed by the responsible physician."

2. In an interview with the S13, Health Information Manager on 2/2/11 at 2:50 p.m., she stated that verbal read back orders were to be authenticated by the attending physician within 10 days.

Record review of the facility's policy number 000-000 titled "Verbal and Telephone Physician's Orders" (pg 1 of 2) under Policy, contains the following: "Physician verbal and telephone orders shall be utilized only in situations where the ordering doctor is not available to write the order and delay will result in a compromise in patient care. Every effort will be made to minimize the use of verbal orders."

On pg 2 of the policy titled "Verbal and Telephone Physician's Orders" under Policy, contains the following: 6) Verbal and telephone orders shall be signed or initialed by the prescribing practitioner as soon as possible, but not later than ten (10) days after being given."

Based on observations, record reviews and interviews, the facility failed to: 1. ensure outdated, unusable drugs and biologicals were not available for patient use in 2 of 3 areas in the facility (Unit B) where drugs and biologicals were housed and 2. follow their policy of having a system in place that ensures expired (outdated) drugs and devices are not available for patient use as evidenced by having: a. expired drugs in pharmacy stock and floor stock (Unit A medication room), and b. expired IV solution in the crash cart (Unit A). Findings:

1. Observation of the medication room on the Unit B on 2/1/11 at 12:00 p.m. with S7 Program Director revealed there was a vial of Lantus Insulin in the refrigerator that was opened on 12/7/10 and available for patient use.

Interview with S8 LPN at that time reflected the insulin should be discarded and not used after 28 days from the time it was opened.

Review of the Lantus Insulin package insert revealed vials must be discarded 28 days after being opened.

Review of the facility's Expiration Dates: Monitoring policy and procedure reflected the pharmacy shall have a system that ensures expired/outdated drugs were not available for patient use. Further review revealed all expired stock shall be removed and quarantined by the pharmacy.

2. a. An observation tour of the pharmacy on 2/1/11 at 10:50 a.m. made with S20, Pharmacist revealed one blister package of Children's Chewable Tablets with 22 tablets that had an expiration date on the compartment bin of 1/2011.

In an interview with S20, Pharmacist, he stated he pulls the medication from the pharmacy stock when the medication expires at the end of the month. S20, Pharmacist confirmed the expiration date on the Children's Chewable Tablets and the blister package had not been pulled from the compartment.
Policy number 11-12 titled "Expiration Dates: Monitoring" (pg 1 of 1) contained the following: "If an expiration date is expressed only as a month and year, the date of expiration shall be the conclusion of the last day of the stated month."
An observation tour of the medication room on Unit A on 2/2/11 at 2:00 p.m. revealed one box of Tetanus Toxoid vials (2 remaining in the box) with an expiration date of 1/8/11 on the outside of the box. S20, Pharmacist confirmed the box of Tetanus Toxoid had expired on 1/8/11.
Policy number 11-12 titled "Expiration Dates: Monitoring" (pg 1 of 1) contained the following: "If an expiration date is expressed as a month, day, and year, the date of expiration shall be at the conclusion of the stated day."
b. An observation of the Unit A Adult Crash Cart revealed one 500 milliliter bag of Normal Saline solution which expired on 1/11. This observation was confirmed by S10, RN and S20, Pharmacist on 2/1/11 at 11:00 a.m.
Policy number 11-11 titled "Expiration Dates: Assignment" (pg 1 of 1) contained the following: "Expiration dates shall be assigned to all prepackaged products."




26313

Based on observation and interview, the facility failed to ensure the condition of the physical plant and overall hospital environment was maintained in such a manner that the safety and well-being of patients was assured in 1 of 2 units (Unit B) in the hospital. Findings:

The following environmental issues were observed in the Unit B along with S7 Program Director on 2/1/11 from 11:05 - 11:47 a.m.:

(a) Room 200 - One large ceiling tile was falling down, and one baseboard was off and laying on the floor in the bathroom.
(b) Room 205 - There was chipped paint on the wall, and a baseboard was missing.
(c) Room 206 - A night stand had peeling and chipping wood on it.
(d) Room 209 - The velcro pieces used to hold the shower curtain in place in the bathroom were mildewed, and a nightstand had peeling and chipping wood on it.
(e) Room 214 - The foot board at the end of the bed was missing, causing sharp edges to be exposed.
(f) Antee Room - There were holes in the sheetrock wall.
(g) Observation Room - The bottom of the bedside table was rusted.
(h) The double gray doors leading to the outside sitting/smoking area on the male end of the hall were rusted on the inside. One of the latches on top of the doors was broken, and the other was missing a connecting piece.
(i) There were 2 floor tiles missing in front of the above mentioned gray doors.

Interview with S7 Program Director on 2/1/11 at 12:00 p.m. confirmed the above environmental findings observed in the Recovery Unit.

Based on observation, record review and interview, the facility and Infection Control Coordinator failed to (1) follow their Infection Control Plan policy and procedure (2) develop a system for identifying, reporting, tracking, trending and investigating infections and communicable diseases of patients for 2 of 2 units in the hospital (3) ensure bed mattresses and pillows for patient use on 1 of 2 units (Unit B) in the hospital were not torn/cracked, and (4) ensure all physicians had annual Tuberculosis (TB) testing for 3 of 6 credentialing files reviewed. Findings:

1. Review of the Infection Control Plan policy and procedure revealed the facility should have an ongoing review and evaluation of all aseptic, isolation and sanitation techniques, including hand hygiene, within the facility. Further review reflected identification of contagious diseases or infections; an ongoing system for reporting, evaluation and maintaining records of infections and/or risk factors among patients and employees; ongoing surveillance activities to monitor the effectiveness of intervention strategies to assure appropriate care and precautions that would not compromise the quality of care to patients; and opportunities to improve the quality of patient care should be carried out to restrict and/or minimize the spread of existing diseases or infections.

2. Review of the Infection Control Data presented by S11 LPN/Infection Control Coordinator revealed no documentation of a system for identifying, reporting, tracking, trending and investigating infections and communicable diseases of patients on Units A and B. There was no documentation to indicate tracking and trending of infections present upon admission, antibiotic use, location of infections within the facility, different types of infections such as respiratory, gastrointestinal, genitourinary, and integumentary, or active surveillance of isolation techniques used by staff.

Review of the Infection Control Rounds documentation dated October - December, 2010 reflected S11 LPN/Infection Control Coordinator made rounds to observe infection control issues/techniques utilized by hospital staff on both units only one time per month.

Interview with S11 LPN/Infection Control Coordinator on 2/3/11 at 7:45 a.m. revealed she was responsible for obtaining and analyzing infection control data for Units A&B of the hospital. She stated she observed different areas in the hospital and staff only once monthly to determine if proper infection control techniques were being utilized. She indicated she had no system for being notified when or why patients were placed on antibiotics and tracking/trending the locations of various types of infection throughout the facility. Further interview reflected she had only been tracking hospital acquired urinary infections and reporting them to the QA committee.

Interview with S1 RN/CNO on 2/3/11 at 8:30 a.m. confirmed the above findings obtained from S11 LPN/Infection Control Coordinator. He further indicated that the facility was not obtaining, documenting and analyzing infection control data according to hospital policy and procedure.

3. Observation of the Unit B on 2/1/11 from 11:20 - 11:39 a.m. revealed the following infection control issues:
a. Room 207 - 1 bed mattress had multiple holes in it, and 2 pillows were cracked and torn.
b. Room 212 - 1 bed mattress had a 12 inch tear on the seam.

Interview with S7 Program Director on 2/1/11 at 12:00 p.m. confirmed the above environmental/infection control issues found in Unit B.

4. Review of the credentialing files for S16MD, S17MD, and S18MD revealed no documentation of TB testing.

An interview was held with S19 Credentialing on 2/2/2011 at 2:05 PM. After review of the credentialing files for for S16MD, S17MD, and S18MD, she indicated there was no documentation that the physicians had annual TB testing.

An interview was held with S11LPN, Infection Control on 2/3/2011 at 7:00 am. She indicated there was no documentation that S16MD, S17MD, and S18MD had annual TB testing.

Review of the hospital policy titled PPD Testing revealed that it was the policy of the hospital "...that all employees working in direct patient care will have a PPD test done at the time of hire and there after or provide proof of current test..."


25452

Based on interview and record review, the facility to follow the Hospital Wide DNR policy as evidenced by 1 of 2 deceased patient records out of a total of 32 sampled patients did not have a DNR Declaration form signed by the family members in the clinical record (#9).Findings:

Review of the medical record of Patient #9 revealed the patient was admitted to Unit A on 10/27/10 with a principal diagnosis of Urosepsis. Secondary diagnoses included: Dysphagia (inability to swallow), Congestive Heart Failure (CHF), Severe Osteoporosis, and Coumadin Toxicity. The admission sheet revealed the patient had no written Advanced Directives. On 10/30/10, patient #9 was discharged from Unit A and transferred to Unit C status because her condition continued to deteriorate.

A record review of the physician's orders dated 10/30/10 and timed at 1:40 p.m. reflected order #8 as "DNR" and order #9 as "Have ER MD assess for DNR activation."

The record review revealed no DNR Declaration Form in patient #9's closed medical record.

In an interview with S1, CNO on 2/2/11 at 11:30 a.m., he confirmed the signed DNR Declaration signed by the family members was not in patient #9's closed medical record. He added when patients transfer from Unit A to Unit C, the charts are thinned.

In a second interview with S1, CNO on 2/2/11 at 12:15 p.m., S1, CNO brought the acute care clinical record of patient #9, which had been thinned. S1, CNO confirmed the two physician signatures, but could not locate the signed DNR Declaration Form in the acute care clinical record.

The review of policy number 000-000 titled "DNR" (pg 8 of 9), under Procedure, contains the following: Nurse: 2. Place a copy of the patient's Advanced Directive in the medical record."

Based on interview and policy review, the facility failed to have a policy to obtain routine and 24-hr emergency dental care as evidenced by no documented policy for Unit C, which addresses dental services for patients who were Unit C status. Findings:
On 2/3/11 at 8:00 a.m. in an interview with S11, LPN, Director of Unit C, she stated that the Unit C Policy and Procedure Manual did not contain a policies regarding how the facility would assist patients in obtaining routine and 24-hour emergency dental care, which Medicare patients may be charged an additional amount for routine and emergency dental services, or which Medicaid patients must promptly be referred to a dentist if they have lost or damaged dentures.