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Based on staff interviews, facility document review and medical staff credential reviews the facility staff failed to ensure the performance of one newly credentialed physician was assessed after having been granted privileges to practice.

The Findings Include:

Physician #16 was granted privileges to practice at the facility on 6/23/11. The staff from the credentialing office was interviewed on 11/2/11 and provided the following information; "The Medical Staff recommends a physician for privileges and the Governing Body approves the recommendation. After a physician is approved, a focused professional practice evaluation (FPPE) is performed on 5 out of 10 of the physician's first 10 admissions and or consultations; there is no time line on when this will be done. The physician who is being evaluated is supposed to supply the Medical Staff with a list of patients so 5 can be chosen for the evaluation. If they have not provided the list within 4 months of their appointment a letter is sent to remind them they need to do this."

The credentialing office representative stated, "If there is no list after 8 months another letter is sent to remind them and at 12 months they go through the credentialing process again. We have not received a list from (name of physician #16) for the Medical Staff evaluation."

A call schedule was provided by the physician group with whom Physician #16 works with. The schedule noted in September 2011 Physician #16 was rounder (the physician covering the patients currently in the hospital) #1 or #2 on September 1, 2, 11, 19, 21 and 22. Physician #16 was on call September 10, 13 and 20. In October 2011 Physician #16 was rounder #1 or #2 on October 5, 6 and 30. Physician #16 was on call October 11, 18 and 29.

The Medical Staff Rules and Regulations; Medical Staff Management; Medical Staff Focused Professional Practice Evaluation (FPPE) with a review date of 2/10 was reviewed on 11/2/11. The Policy section of the FPPE states, "Each Medical Staff department must develop and clearly define appropriate department specific methods to assess competency for respective privileges requested with the specialty. These methods will be consistent with the requirements and standards set forth by the Medical Staff Executive Committee (MEC), the governing body and external regulatory and accrediting bodies."

The Definition section of the FPPE states, "Focused Professional Practice Evaluation (FPPE): Process to evaluate the privilege-specific competency of a practitioner who does not have documented evidence of competently performing the requested privilege at (Name of Hospital)..."

Based on patient interviews, staff interviews, clinical record review and facility document review the facility staff failed to ensure 2 patients, (Patient #1 and #2) of 23 patients were treated in a safe manner.

The Finding Include:

On 10/31/11 during the initial tour of the facility patients were randomly interviewed on various units. Patient #1 and #2 were randomly interviewed on 10/31/11.

Patient #1 was a 69 year old admitted on 10/17/11 with the diagnoses of COPD (chronic obstructive pulmonary disease) and pneumonia. During the random interview Patient #1 stated, "Things were good when I was in ICU but not always so good out here on the floor." Patient #1 stated, "Yesterday I was left on the toilet for 3 hours." "I called on the bell and they either didn't answer or said someone would be right there but no one came." "I don't have the strength in my legs yet to get around on my own."

The COMLinx-NCM report which details staff activity noted an RN entered Patient #1's room at 3:00:25 PM and no one else reentered the room until 6:10:10 PM at this time both an RN and a NA entered the room. The clinical record review noted at 15:22 (3:22 PM) Patient #1 was resting in bed, at 16:00 (4:00 PM) Patient #1's O2 SAT % was 98%, at 17:15 (5:15 PM) Patient #1 was resting in bed. The next note in the clinical record is at 19:15 (7:15 PM) indicating the hourly/comfort rounds were made and Patient #1 was resting in bed.

No staff members could recall Patient #1 sitting on the toilet/bedside commode for 3 hours.

Patient #2 was a 59 year old with the diagnosis of Multiple calculi L distal ureter. Patient #2 was randomly interviewed on 10/31/11. Patient #2 stated, "I needed help with changing my diaper yesterday (10/30/11)." Patient #2 stated, "I have a sore on my bottom and don't want it to get worse. My diaper was wet." "I kept ringing the call bell and finally about 6 PM someone came to help me." "It took them almost 2 hours." "And this morning that thing (Patient #2 pointed to the IV pump) beeped from 5 to 8 AM. I could not sleep. I called the nurses but they did not come."

On 10/31/11 Staff Member #18 was interviewed and stated, "Yes, at 7 AM when I made my rounds the IV pump alarm was going off because the IV was empty."

On 10/31/11 Staff Member #19 was interviewed. Staff Member #19 stated, "Yes, the alarm was going off at 7:30 when I made my rounds and I notified the nurse. She is not a difficult patient (Patient #2) and doesn't call for help a lot."

The COMLinx-NCM report was reviewed and noted a nurse aide enter Patient #2's room on 10/31/11 at 7:05:59, 7:14:06, 7:37:22, 7:51:51, 7:54:44, 7:54:54 and 7:55:38 AM. A nurse did not enter the room between 5:15:04 (LPN) and 8:10:10 (RN) AM.

Based on staff interviews, facility document review, clinical record review and patient/family interviews the facility staff failed to ensure the quality of care provided by 1 physician, Staff Member Physician #16.

The Findings Include:

Staff Member Physician #16 was granted privileges to practice at the facility on 6/23/11. The staff from the credentialing office was interviewed on 11/2/11 and provided the following information; "The Medical Staff recommends a physician for privileges and the Governing Body approves the recommendation. After a physician is approved a focused professional practice evaluation (FPPE) is performed on 5 out of 10 of the physician's first 10 admissions and or consultations; there is no time line on when this will be done. The physician who is being evaluated is supposed to supply the Medical Staff with a list of patients so 5 can be chosen for the evaluation. If they have not provided the list within 4 months of their appointment a letter is sent to remind them they need to do this."

The credentialing office representative stated, "If there is no list after 8 months another letter is sent to remind them and at 12 months they go through the credentialing process again. We have not received a list from (name of physician #16) for the Medical Staff evaluation."

The Chief Medical Officer (CMO) was interviewed on 11/1/11 and provided the following information. "We do not have a contract with the medical group (Name of Staff Member Physician #16 and medical group) practices with. They are a large multi-specialty group (MSG) that practices here. The group that practices here does not see patients outside of the hospital. Unassigned patients are admitted to their (MSG) service and they (MSG) will follow the patient while the patient remains in the hospital. Another physician from the MSG will cover for each other when one of the physicians is off duty."

The CMO stated, "When one of the physician's is going off duty that physician will give a report to the covering physician. I am not sure if this is done in person or not."

Patient #6 was a 76 year old admitted on 10/22/11 with the diagnoses of lower gastrointestinal bleed, dysphagia due to CVA (cerebrovascular accident (stroke)), and status post PEG tube (feeding tube surgical placed directly into stomach) placement and to remain strict NPO (nothing by mouth). Admission orders On 10/22/11 have NPO checked on the preprinted ICU Admission Orders sheet and written meds via peg tube only. Another order sheet hand written on 10/22/11 states, "All meds to be given via PEG tube, pt (Patient) NPO by mouth."

Prior to the admission on 10/22/11 Patient #6 had a modified barium swallow with speech therapy (MBSS) performed on 10/19/11. The physician who performed the test noted his impression was "Laryngeal penetration and aspiration across all consistencies, placing the patient at increased risk for aspiration pneumonia."

On 10/25/11 Patient #6 had an Endoscopy performed and the performing physician circled under diet "mechanical soft". On 10/27/11 an order from the physician who performed the Endoscopy was obtained to make Patient #6 NPO (cancel mechanical soft diet) Tube feeds as ordered.

Staff Member Physician #16 was covering the care of Patient #6 on 10/29/11 and 10/30/11. Physician #16 wrote an order on 10/29/11, "Diet: pudding consistency foods to include applesauce, milk based puddings are ok not a true milk allergy". On 10/30/11 Physician #16 wrote an order, "Please give patient pudding TID (three times per day). He does not have a true milk allergy." Also on the same physician's order sheet on 10/30/11 Physician #16 wrote, "Speech therapy eval in AM - "Patient says he's allowed to have pudding and applesauce with PEG feeds, is this ok with swallow?" See results of MBSS 10/19/11.

On 10/31/11 during the initial tour of the facility the surveyor randomly asked Patient #6's family member if they would answer a few questions regarding the care and services Patient #6 was receiving. The family member of Patient #6 stated, "The care was fine until one of the covering doctors did not read my father-in-law's chart and decided he could have something by mouth a couple of days ago." The family member stated, "He is not supposed to have anything by mouth because he gets choked and we are afraid it will get in his lungs."

The family member stated, "When his regular doctor was off the covering doctor let him have pudding by mouth. He got choked and did a lot of coughing for a couple of days but he is ok now. He knows he is not allowed to have anything by mouth."

Staff Member Physician #16 was interviewed on 11/1/11. Staff Member Physician #16 stated, "It is not my job to decide if he (Patient #6) is lying or not. He (the patient) stated he had no coughing or gagging at home. I reviewed the speech therapy report online and it stated he aspirated all liquids but was able to tolerate honey thickened liquids. The patient (Patient #6) asked for pudding, he initiated the request." Staff Member Physician #16 stated, "Dr. (Name of attending physician) said he (Patient #6) had asked him for something to eat but he never put that in his notes. I never asked the nurses and they never called me about the diet order." Staff Member Physician #16 stated, "He (Patient #6) had never been declared incompetent so he can make his own decisions."

Staff Member Physician #16 stated, "Dr. (Name of attending physician) called me because the family was upset about him (Patient #6) getting something to eat."

Staff Member Physician #22 was interviewed on 11/1/11 and stated, "He (Patient #6) was NPO because he could not swallow without choking. The nurses gave me a call about the mechanical soft diet and we canceled it. I don't think he ever received anything by mouth that time. The MBSS study recommended he not have anything by mouth due to the risk of aspiration."

Staff Member Physician #22 stated, "He had been asking me for food but I could not order it for him due to the potential consequences. However he can make his own decisions about having food even when there are risk. No one contacted me about feeding him something by mouth."

Staff Member Physician #22 stated, "When I am off I am off unless there is some information absent from the chart then I will get a call. Care of the patients is transferred to the next physician in the group and a report is given. I may not be back to care for that patient before they are discharged."

The Medical Director for the physician group Staff Member Physician #16 and #22 are members of, provided an email from Physician #22 to Physician #16 on 10/29/11 that states, "6615 AM. 76 yo male...also post CVA Dysphagia, failed swallow and NPO, only PEG feedings."

Based on a review of the clinical records and staff interviews the facility staff failed to ensure the nursing care plans identified potential problems or problems for 3 of 23 patients, Patient #2 pressure sores, Patient #23 falls as they pertain to bed alarms and random Patient #9.

Patient #2 was a 59 year old with the diagnosis of Multiple calculi L distal ureter. Patient #2 was randomly interviewed on 10/31/11. Patient #2 stated, "I needed help with changing my diaper yesterday (10/30/11)." Patient #2 stated, "I have a sore on my bottom and don't want it to get worse. My diaper was wet. I kept ringing the call bell and finally about 6 PM someone came to help me. It took them almost 2 hours. And this morning that thing (Patient #2 pointed to the IV pump) beeped from 5 to 8 AM. I could not sleep. I called the nurses but they did not come."

On 10/31/11 Staff Member #18 was interviewed and stated, "Yes, at 7 AM when I made my rounds the IV pump alarm was going off because the IV was empty."

On 10/31/11 Staff Member #19 was interviewed. Staff Member #19 stated, "Yes, the alarm was going off at 7:30 when I made my rounds and I notified the nurse. She is not a difficult patient (Patient #2) and doesn't call for help a lot."

The COMLinx-NCM report (a report which details staff activity) was reviewed and noted a nurse aide enter Patient #2's room on 10/31/11 at 7:05:59, 7:14:06, 7:37:22, 7:51:51, 7:54:44, 7:54:54 and 7:55:38 AM. A nurse did not enter the room between 5:15:04 (LPN) and 8:10:10 (RN) AM.

Patient #23 was a 52 year old admitted on 1/4/11 with the diagnoses of Acute and subacute necrosis of the liver, Viral hepatitis C, Acute kidney failure, diabetes mellitus type II, HIV and Metabolic encephalopathy. Patient #23 was described through out the clinical record as being generally confused. Patient #23 was placed on fall precautions on 1/4/11. The clinical records notes Fall Prevention as a part of the plan of care. The Fall Prevention was noted frequently through out the clinical record "fall prevention = adeq. lighting, bed low, brakes locked, call light close, provide assistance, room uncluttered, safe environment". It does not note the use of a bed alarm.

The Chief Nursing Officer was interviewed on 11/1 and 2/11 and stated, "The fall precautions includes adequate lighting, bed low, brakes locked, call light close, provide assistance, room uncluttered, safe environment and bed alarm on."

Patient #23 fell on 1/18/11. The post fall assessment notes the bed alarm was activated at the time of the fall. Patient #23 fell again on 1/22/11, the post fall assessment does not note the use of a bed alarm at the time of the fall. After Patient #23's second fall it was noted he was moved closer to the nurses' station.

During the initial tour of the facility on 10/31/11 random patients and or families were interviewed. Patient #9's wife was interviewed regarding the care and services Patient #9 had received since his admission. Patient #9's wife stated, "Some floors are better than others. When I came to see my husband on 10/30/11 his gown was wet and bloody. He wanted it changed and had asked to have the gown changed. He sat with the wet bloody gown on for over an hour before anyone would come to change it."

Based on a review of the clinical records and staff interviews the facility staff failed to ensure the nursing care plans identified potential problems or problems for 3 of 23 patients, Patient #2 pressure sores, Patient #6 difficulty swallowing and Patient #23 falls as they pertain to bed alarms.

The Findings included:

Patient #2 was a 59 year old with the diagnosis of Multiple calculi L distal ureter. Patient #2 was randomly interviewed on 10/31/11. Patient #2's initial nursing assessment identified Patient #2 had an old healed pressure sore on her sacrum. Patient #2 was noted to be chairfast. On 10/28/11 at 8:00 AM Patient #2 is noted to have a stage II pressure sore on her sacrum. The plan of care was not updated to include the return of the pressure sore. Patient #2 stated, "I needed help with changing my diaper yesterday (10/30/11). I have a sore on my bottom and don't want it to get worse. My diaper was wet. I kept ringing the call bell and finally about 6 PM someone came to help me. It took them almost 2 hours."

Patient #6 was a 76 year old admitted on 10/22/11 with the diagnoses of lower gastrointestinal bleed, dysphagia due to CVA (cerebrovascular accident (stroke)), and status post PEG tube (feeding tube surgical placed directly into stomach) placement and to remain strict NPO (nothing by mouth). Patient #6's plan of care does not address the risk if Patient #6 is given something by mouth. Admission orders On 10/22/11 have NPO checked on the preprinted ICU Admission Orders sheet and written meds via peg tube only. Another order sheet hand written on 10/22/11 states, "All meds to be given via PEG tube, pt (Patient) NPO by mouth."

Prior to the admission on 10/22/11 Patient #6 had a modified barium swallow with speech therapy (MBSS) performed on 10/19/11. The physician who performed the test noted his impression was "Laryngeal penetration and aspiration across all consistencies, placing the patient at increased risk for aspiration pneumonia."

Patient #23 was a 52 year old admitted on 1/4/11 with the diagnoses of Acute and subacute necrosis of the liver, Viral hepatitis C, Acute kidney failure, diabetes mellitus type II, HIV and Metabolic encephalopathy. Patient #23 was described through out the clinical record as being generally confused. Patient #23 was placed on fall precautions on 1/4/11. The clinical records notes Fall Prevention as a part of the plan of care. The Fall Prevention was noted frequently through out the clinical record "fall prevention = adeq. lighting, bed low, brakes locked, call light close, provide assistance, room uncluttered, safe environment". It does not note the use of a bed alarm.

The Chief Nursing Officer was interviewed on 11/1 and 2/11 and stated, "The fall precautions includes adequate lighting, bed low, brakes locked, call light close, provide assistance, room uncluttered, safe environment and bed alarm on."