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Based on record review and interview the facility failed to ensure the medical staff signed their physician orders within 48 hours, as required, for 3 (Patients #5, #6, and #7) out of 11 patients.

The findings include:

1. A record review on 5/31/12, for Patient #5, revealed a verbal physician order dated 2/1/12 at 2000 and remains unsigned by the physician.

2. Patient #6's record revealed 3 verbal physician orders dated 4/5/12 at 1152 and 1805 and 4/9/12 at 2008 remaining unsigned by the physician.

A physician order dated 3/30/12 at 1051 and 1447 was electronically signed by the physician on 4/26/12 at 1257, an order dated 4/6/12 at 0855 was electronically signed on 5/12/12 at 05:48 p.m.

3. Patient #7's record revealed a verbal physician order dated 2/28/12 at 2000, and three verbal physician orders dated 3/1/12 at 0930 and 2130, 3/6/12 at 1410 remaining unsigned by the physician.

Verbal physician orders dated 2/21/12 were electronically signed 3/22/12,
Three orders dated 2/27/12 were electronically signed on 4/14/12,
Two orders dated 2/28/12 were electronically signed on 3/22/12,
Order dated 2/28/12 was electronically signed on 4/11/12,
Order dated 2/29/12 was electronically signed on 4/4/12,
Order dated 3/2/12 was electronically signed on 3/27/12,
Order dated 3/3/12 was electronically signed on 3/25/12,
Order dated 3/6/12 was electronically signed on 4/11/12.

The physicians have not hand signed nor electronically signed their physician orders within the 48 hour time frame as allowed by the governing body and policy and procedure.

An interview with Employee #10 on 5/31/12, revealed she is in agreement the physician signatures are not within the 48 hour timeframe as set by hospital policy as evidenced by "they have 48 hours to sign their orders and they aren't doing it."

A Review of the By-Laws and Hospital Policies confirms the requirement of 48-hour signatures for all orders.

Please refer to A-0457 for additional information and regulations.

This Condition of Participation is not met based on clinical record reviews, interviews, and reviews of policies and procedures, it was determined the hospital failed to protect and promote patient rights. The facility failed to provide incontinent care, the facility failed to assess/investigate what appeared to be blood on the back of Patient #7's head.

This failure has the substantial probability to adversely affect all patients' physical health, safety, and well-being.

Refer to A-0144 and A-0395 for additional information.

Based on interview the facility has failed to maintain patient respect, dignity, and comfort as part of an emotionally safe environment. Facility failure to assess for wounds after observing probable blood on the back of her head for 1 (Patient #7) of 11 patients.

The findings include:

1. On 3/4/12, Patient #7 was transferred from ICU to PCU for continued care. The patient was received on the PCU unit with dried, caked feces from her heels up her back.

An interview on 5/31/12 at 6:00 p.m., with Employee #9, revealed she is the charge nurse and was informed by the Certified Nursing Assistant that Patient #7 was received on transfer from the Intensive Care Unit, to the PCU having "dried, caked feces from her feet to her back." She stated, "The aide was hysterical crying about it. She was so upset because the patient had dried feces and couldn't believe they left the patient like that. She came right away and told me. She actually cried while cleaning this woman because it was so bad. I reported it to my Director and they were going to talk to the Director of the ICU. It was really bad, the aide said it was from her feet to her back."

2. A record review on 5/31/12 of Patient #7's Electronic Medical Record (EMR) revealed a photograph, taken on 3/4/12 by Employee #8, of an area on the head of Patient#7, where there was what appeared to be blood. Further review of Patient #7's EMR as assisted by Employee #10 failed to revealed any Nursing Progress Note, Nursing Assessment or Neurological checks by Employee #8. The record failed to contain any notification to physician or family of the findings.

A record review on 5/31/12 on the facility's Incident Log & Grievance Log does not contain an entry for Patient #7 on 3/4/12. Employee #10 confirmed the finding.

An interview with Employee #10 on 5/31/12 confirmed Employee #8 did not conduct a nursing assessment as evidenced by lack of documentation of a Progress Note. She failed to notify the Physician and/or perform a Nursing Assessment as evidenced by stating, "no I don't see it either. I can't find anything. We didn't when we looked."

An interview on 5/31/12 with Employee #6 revealed when asked if Employee #8 had ever mentioned to her as her superior, of any head injury to a patient or noticed any bleeding from the scalp of Patient #7 and/or if she had been shown the picture Employee #8 took on 3/4/12, she replied "no. (in response to all questions)."

An interview on 5/30/12 with Employee #4 revealed, "I have seen this picture. I saw it about a week ago. Employee #8 is the nurse who took it. She didn't have much to say to me. I asked her if she can recall if anything happened with this lady, an injury, and a fall anything of that nature ...she said no. She said as part of her assessment she took the picture. What she told me is that she saw a little blood on the pillow and then assessed her and then took the picture." She was asked where the assessment was and she replied "I don't know."

An interview on 5/31/12 with Employee #8 revealed the following:
She was the author of the picture of the back of the head of Patient #7's whose name is on the photo. When asked what prompted you to take the picture and she replied, "There was blood on the back of her head. I wasn't told that in report and I didn't see anything about it in her chart." When asked if she could recall what she did next she stated, "no I don't." She was asked if she called the doctor she answered "I do remember I saw bloody hair, but I couldn't find anything." She was asked if she could explain what "I couldn't find anything" means and she stated, "I couldn't find a wound, so no, I didn't call anybody." She was asked if she knew where the blood was coming from she said "I don't know off hand." When asked about writing a progress note, she said "I'm not sure if I did." When asked is she alerted the charge nurse so she might be able to see where the bleeding was coming from she responded "I don't remember if I did or not." She was asked if she remembers if she helped the patient get out of bed she replied "no, I don't believe I did." When asked if she remembers an incidence of her falling she responded "if she had fallen I would have filled out an incident sheet." Employee #8 was asked if she told anybody about what she found, another nurse maybe she responded "I don't recall." She was then asked "is it possible during turning her or positioning her she hit her head" she stated, "No, it happened early in the shift, there was blood on the pillow." When asked if the family was there she said, "The family came in not long after." "Did you tell the family", she responded "I am not sure if I told them or if they noticed the blood in her hair."

Based on clinical record reviews, interviews, and reviews of policies and procedures, it was determined the hospital does not have an effective organized nursing service that provides 24-hour services to maintain the health, safety and well-being of the patients it serves. The facility failed to ensure (1) nursing staff assess Patient #7 after discovering what appeared to be blood on the back of her head; (2) failed to notify physician and family of possible injury; (3) nursing services failed to deliver care for Patient #7 when she became incontinent and prior to transferring to another unit.

This failure has the substantial probability to adversely affect all patients' physical health, safety, and well-being.

Refer to A-0395 for additional information.

Based on record review and interview the facility failed to provide nursing care by not appropriately assessing patient care needs for 1 (Patient #7) out of 11 patients.

The findings include:

1. On 3/4/12, Patient #7 was transferred from ICU to PCU for continued care. The patient was received on the PCU unit with dried, caked feces from her heels up her back.
An interview on 5/31/12 at 6:00 p.m., with Employee #9, revealed she is the charge nurse and was informed by the Certified Nursing Assistant that Patient #7 was received on transfer from the Intensive Care Unit, to the PCU having "dried, caked feces from her feet to her back." She stated, "The aide was hysterical crying about it. She was so upset because the patient had dried feces and couldn't believe they left the patient like that. She came right away and told me. She actually cried while cleaning this woman because it was so bad. I reported it to my Director and they were going to talk to the Director of the ICU. It was really bad, the aide said it was from her feet to her back."

2. A record review on 5/31/12 of Patient #7's Electronic Medical Record (EMR) revealed a photograph taken on 3/4/12 by Employee #8 of an area on the head of Patient#7 where there was what appeared to be blood. Further review of Patient #7's EMR as assisted by Employee #10 failed to revealed any Nursing Progress Note, Nursing Assessment or Neurological checks by Employee #8. The record failed to contain any notification to physician or family of the findings.

A record review on 5/31/12 on the facility's Incident Log & Grievance Log does not contain an entry for Patient #7 on 3/4/12. Employee #10 confirmed the finding.

An interview with Employee #10 on 5/31/12 confirmed Employee #8 did not conduct a nursing assessment as evidenced by lack of documentation of a Progress Note. She failed to notify the Physician and/or perform a Nursing Assessment as evidenced by stating, "no I don't see it either. I can't find anything. We didn't when we looked."

An interview on 5/31/12 with Employee #6 revealed when asked if Employee #8 had ever mentioned to her as her superior, of any head injury to a patient or noticed any bleeding from the scalp of Patient #7 and/or if she had been shown the picture Employee #8 took on 3/4/12, she replied "no. (in response to all questions)."

An interview on 5/30/12 with Employee #4 revealed, "I have seen this picture. I saw it about a week ago. Employee #8 is the nurse who took it. She didn't have much to say to me. I asked her if she can recall if anything happened with this lady, an injury, and a fall anything of that nature ...she said no. She said as part of her assessment she took the picture. What she told me is that she saw a little blood on the pillow and then assessed her and then took the picture." She was asked where the assessment was and she replied "I don't know."

An interview on 5/31/12 with Employee #8 revealed the following:

She was the author of the picture of the back of the head of Patient #7's whose name is on the photo. When asked what prompted you to take the picture and she replied, "There was blood on the back of her head. I wasn't told that in report and I didn't see anything about it in her chart." When asked if she could recall what she did next she stated, "no I don't." She was asked if she called the doctor she answered "I do remember I saw bloody hair, but I couldn't find anything." She was asked if she could explain what "I couldn't find anything"means and she stated, "I couldn't find a wound, so no, I didn't call anybody." She was asked if she knew where the blood was coming from she said "I don't know off hand." When asked about writing a progress note, she said "I'm not sure if I did." When asked is she alerted the charge nurse so she might be able to see where the bleeding was coming from she responded "I don't remember if I did or not." She was asked if she remembers if she helped the patient get out of bed she replied "no, I don't believe I did." When asked if she remembers an incidence of her falling she responded "if she had fallen I would have filled out an incident sheet." Employee #8 was asked if she told anybody about what she found, another nurse maybe she responded "I don't recall." She was then asked "is it possible during turning her or positioning her she hit her head" she stated, "No, it happened early in the shift, there was blood on the pillow." When asked if the family was there she said, "The family came in not long after." "Did you tell the family", she responded "I am not sure if I told them or if they noticed the blood in her hair."

Based on record review and interview the facility failed to ensure the medical staff signed the physician verbal orders for 3 (Patients #5, #6 and #7) out of 11 patients.

The findings include:

1. A record review on 5/31/12, for Patient #5, revealed a verbal physician order dated 2/1/12 at 2000 and remains unsigned by the physician.

2. Patient #6's record revealed 3 verbal physician orders dated 4/5/12 at 1152 and 1805 and 4/9/12 at 2008 reamining unsigned by the physician.

A physician order dated 3/30/12 at 1051 and 1447 was electronically signed by the physician on 4/26/12 at 1257, an order dated 4/6/12 at 0855 was electronically signed on 5/12/12 at 05:48 p.m.

3. Patient #7's record revealed a verbal physician order dated 2/28/12 at 2000, and three verbal physician orders dated 3/1/12 at 0930 and 2130, 3/6/12 at 1410 reamining unsigned by the physician.
Verbal physician orders dated 2/21/12 were electronically signed 3/22/12,
Three orders dated 2/27/12 were electronically signed on 4/14/12,
Two orders dated 2/28/12 were electronically signed on 3/22/12,
Order dated 2/28/12 was electronically signed on 4/11/12,
Order dated 2/29/12 was electronically signed on 4/4/12,
Order dated 3/2/12 was electronically signed on 3/27/12,
Order dated 3/3/12 was electronically signed on 3/25/12,
Order dated 3/6/12 was electronically signed on 4/11/12.

The physicians have not hand signed nor electronically signed their physician orders within the 48 hour time frame as allowed by the governing body and policy and procedure.

An interview with Employee #10 on 5/31/12, revealed she is in agreement the physician signatures are not within the 48 hour timeframe as set by hospital policy as evidenced by "they have 48 hours to sign their orders and they aren't doing it."

A Review of the By-Laws and Hospital Policies confirms the requirement of 48-hour signatures for all orders.