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Based on the deficiencies cited at the following citations it is determined that the hospital failed to protect and promote each patient's rights as evidenced by:

In 3 of 24 medical records reviewed, the hospital failed to fully inform each patient of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible (A0117);

In 6 of 24 medical records reviewed, the hospital failed to ensure that each patient's informed consent was obtained regarding his or her care ( A0131);

In 5 of 24 medical records reviewed, the hospital failed to ensure that the patient was able to formulate advance directives and/or to have hospital staff and practitioners who provide care in the hospital comply with these directives ( A0132);

In 1 of 24 medical records reviewed the hospital failed to report suspected/possible patient neglect and abuse to appropriate authorities (A0145);

Based on observation and staff interview the hospital failed to ensure the confidentiality of the clinical records of 3 patients on the Saint Teresa Unit (2 South) ( A0147);

In 2 of 24 medical records reviewed, the hospital utilized restraints as a means of falls risk precautions and thus, the type or technique of restraint or seclusion was not the least restrictive intervention to effectively protect the patient from harm (A0165);

In 1 of 24 medical records reviewed the hospital failed to ensure that the use of restraint or seclusion was implemented in accordance with safe and appropriate restraint and seclusion techniques (A0167);

In 1 of 24 medical records reviewed the hospital failed to ensure that restraint was only used in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient (A0168);

In 2 of 24 medical records reviewed the hospital failed to ensure that orders for the use of restraint or seclusion were not written as a standing order or on an as needed basis (A0169); and,

In 1 of 24 medical records reviewed the hospital failed to ensure that the patient was seen face-to-face within one hour after the initiation of seclusion ( A0178).

In 3 of 24 medical records reviewed, the hospital failed to inform fully each patient of the patient's rights, in advance of furnishing or discontinuing patient care whenever possible, as evidenced by.

(1) Patient #16 was a 33 year-old male admitted to Bon Secours Hospital on 09/17/2010 with left arm swelling and diagnosis of ileus (intestinal obstruction) and constipation.
Patient #16 was not afforded an opportunity to sign consent and receipt of his consent to treatment, receipt of rights information, or rights related to advance directive decision-making. The documentation for both his receipt of rights information and his advance directives determinations indicated that the patient was unable to sign because he was handcuffed. The documentation did not evidence that patient #16 received the information in a manner that the patient could understand or that he gave any verbal consent that was witnessed.

(2) The medical record for patient #18 revealed that he did not sign the consent for treatment, including the Receipt of Notice of Privacy Practices, Patient Rights and Responsibilities, Consent for Admission and Treatment and Release of Insurance Information Agreement. The consent form ' s signature line was filled in to indicate that the patient "is blind, unable to sign." Further, the documentation did not evidence that patient #18 received the information in a manner that the patient could understand or that he gave any verbal consent that was witnessed.

(3) Patient #19 was an 82 year-old female admitted to Bon Secours Hospital on 09/09/2010 with complaint of shortness of breath, nausea and headache. Patient #19 was scheduled for the placement of dialysis catheter on 9/21/10 but her procedure was cancelled because the patient had low blood pressure. The medical record for patient #19 revealed that her general consent and receipt of patient rights information was signed by her daughter. All consents in her record except her surgical consent were signed for by family members even though there is no documentation to indicate that patient #19 did not have the capacity to sign for her own surgical consent and no evidence was found that she was certified as unable to sign her own consents. Thus, her medical record failed to demonstrate that patient #19 was fully informed of her patient rights as required.

In 6 of 24 medical records reviewed, the hospital failed to ensure that each patient's informed consent was obtained regarding his or her care as evidenced by:

(1) Patient #1 was an 84 year-old female admitted 09/01/2010 with syncope, a 3 day history of abdominal discomfort, and 24 hour history of nausea and vomiting. Patient #1's recent medical history included urinary tract infection, small bowel obstruction and leukocytosis, and she had a history of colon cancer status post hemicolectomy with primary anastomosis. Patient #1's granddaughter signed her consent for surgical removal of a loop recorder. In interview with the surveyor, the granddaughter reported that she (the granddaughter) had authorized another granddaughter to sign for this procedure. No documentation was found in the record that patient #1 was certified as unable to make her own decisions, nor that either granddaughter was authorized to make decisions for patient #1. Nonetheless, the hospital relied on family members to authorize treatment for the patient. During interview with the Surveyor, the surgeon reported that because the patient didn't object to staff getting consents from the family, he felt it was acceptable practice to rely on family for decision-making.

(2) Patient #3 was a 52 year-old male who was brought in by ambulance on 08/10/2010 with severe hypoglycemia (low blood sugar). Patient #3's sister signed his consent for treatment.

On 08/16 at 0520 patient #3 was downgraded from ICU to a lower acuity unit and the record indicated that on 08/22 he was "more alert" and "speaking a few words." However, later on 08/22 at 1910 the record showed that the "family states that they want a second swallow evaluation before they will give consent for PEG placement." There was no indication recorded that this was reviewed with the patient. An attending note at 0410 on 08/23 indicated that he/she was notified of the family's request and a swallow evaluation was ordered. Another untimed physician note on 08/23 stated that "talked to patient's family. Aunt agrees for GT today" and that this was discussed with another physician. A nutrition note on 08/23 at 1145 stated that "patient's family" consented to the feeding tube placement. At 1200 on 08/23 a nursing note indicated that consent was obtained, by a physician and from (the Aunt's name) who was noted as "spokesperson." However, the telephone consent incorrectly stated that the Aunt was his niece. At 1315 a physician note indicated the PEG procedure was completed. Nowhere in the record was the patient certified as unable to make his own decisions nor was any reason documented as to why so many staff members were relying on the Aunt to make decisions and sign consents, nor why the patient was excluded from involvement in the consent process related to his own care.

(3) Patient #14 was a 53 year-old male admitted to Bon Secours Hospital on 09/17/2010 with right kidney pain and blood in his urine. The record revealed that he was not afforded an opportunity to sign any of his consents except his surgical consent because he was handcuffed when he came in to the hospital.

(4) Patient #16 did not have an opportunity to sign his general consent and receipt of his rights information, or rights related to advance directive decision-making. The signature line for patient #16's receipt of rights information and his advance directive determinations both revealed that the patient was unable to sign because he was handcuffed. Again, the documentation did not evidence that patient #16 received the information in a manner that the patient could understand or that he gave any verbal consent that was witnessed.

(5) Patient #18 was a 79 year-old male admitted to Bon Secours Hospital on 09/20/2010 from a nursing home with vomiting with diarrhea. Patient #18's admission consent forms indicated that he was unable to sign because he was blind. Patient #18's right to consent to, or to refuse, treatment was not changed as a result of his eyesight.

(6) Patient #19 was an 82 year-old female admitted to Bon Secours Hospital on 09/09/2010 with complaint of shortness of breath, nausea, and headache. Patient #19 was scheduled for the placement of dialysis catheter on 09/21 but her procedure was cancelled due to low blood pressure. Patient #19 had signed all of her consents except her surgical consent, which was obtained from her daughter. No indication was found why patient #19 was not afforded the opportunity to review and sign her own consent for surgery and no evidence was found that patient #19 had authorized her daughter to make her decisions.

In 5 of 24 medical records reviewed, the hospital failed to ensure that the patient was able to formulate advance directives and/or to have hospital staff and practitioners who provide care in the hospital comply with these directives as evidenced by:

Patient #3 was a 52 year-old male who was brought in by ambulance on 08/10/2010 with severe hypoglycemia (low blood sugar). The record indicated that patient #3 had missed his last 2 appointments for dialysis when he was found unresponsive with a blood sugar of 20. On 08/10 patient #3's sister signed that he had no advance directive and that she would not want any information about advance directives. Based on his sister ' s choices, aggressive treatment began.

Patient #3 was intubated and moved to the intensive care unit. During this length of stay he also received a PEG tube for artificial feeding even though there was documentation supporting that he was trying to refuse treatment. For example, at 1515 on 08/13 a nursing note revealed that patient #3 had "eyes open and turning head when suctioned; attempting to remove ET with head thrashing; restrained." On 08/14 he was noted as opening eyes and responding to voice. On 08/14 a nurse wrote "unable to insert NG tube due to no cooperation from patient." Later on 08/14 "refuses to open mouth for PO meds ... refused NGT placement by shaking head and grabbing my arms." At 2350 still on 08/14 another nursing note revealed "tracking of eyes to name. Purposive movement. Resistive to care. NGT placed to right nare ... " Another nursing note on 08/15 indicated "continues to be resistive to care."

On 08/16 at 0520 patient #3 was downgraded from ICU to room 342B (a lower acuity unit). A note from an unknown discipline at 1215 on 08/22 indicated that patient #3 was "more alert" and "speaking a few words." Later on 08/22 at 1910 in the same handwriting "family states that they want a second swallow evaluation before they will give consent for PEG placement." An attending note at 0410 on 08/23 stated that he/she was notified of the family's request and a swallow evaluation was ordered. With no time a later 08/23 a physician noted stated that "talked to patient's family. Aunt agrees for GT today." A nutrition note on 08/23 at 1145 indicated that patient #3's family consented to the PEG placement. At 1200 on 08/23 a nursing note indicated that consent was obtained by a physician and from (the Aunt ' s name) who was noted as " spokesperson " . However, when obtaining consent from the Aunt staff noted she was his niece. At 1315 a physician note indicated the PEG procedure was completed. Nowhere in the record was the patient certified as unable to make his own decisions nor was any reason documented as to why so many staff members were relying on the Aunt to make decisions regarding patient #3's care.

By 08/28 the record showed that patient #3 was alert and oriented times 1 - 3, able to follow simple commands, and able to answer simple questions. Despite the documentation indicating he could manage some communication and was at times at least somewhat oriented, no effort to find out what patient #3 might have wanted regarding his own care was found documented in the record including reviewing his desires regarding code status. By 08/31 the record showed that he seemed more confused again and at 0600 on 09/01 patient #3 went into arrest and a code blue was called. CPR was initiated and patient #3 was intubated. The rapid response documentation showed that patient #3 was "in full arrest upon this RN's arrival to call patient's family in regards to code status."

(2) Patient #8 was admitted to Bon Secours Hospital on 08/25/2010. Her general consent was signed for by her nephew. No discussion was found in the record regarding what other family might have been available and/or appropriate to sign consents. No certification was found indicating that the patient would no longer be able to make her own decisions regarding informed consent. On 08/26, a nursing note indicated that patient #8 was oriented to self, more awake and interactive. Again on 08/27 a nursing note indicated she was alert and oriented times 1, and verbally responsive with clear speech. A week into her length of stay a Pulmonology note indicated that the Pulmonologist spoke with patient #7's niece and learned that she had been diagnosed in the past at another hospital, with metastatic lung cancer, the patient had decided she wanted to be a DNR, and she had determined to follow a palliative approach given her advanced age and deteriorating condition. These were important questions that the hospital had failed to ask or address for the first 7 days of her admission.

(3) Patients #14, and #16 and #18 were not afforded the opportunity to sign advance directive paperwork making their wishes known. The medical records revealed that patient #14 and 16 were not allowed to sign papers related to their advance directive wishes because they were handcuffed, and patient #18 was not able to sign because he was blind.

In 1 of 24 medical records reviewed the hospital failed to report suspected/possible patient neglect and abuse to appropriate authorities as evidenced by:

Patient #6 was a 71 year-old male who arrived at the ED on 07/02/2010 by taxi after suffering a cardiac arrest. In addition to possibly having been placed in a cab unstable, the record showed that patient #6 was cachectic (physical wasting with significant weight loss) and had numerous pressure ulcers (Stage II and III on buttocks and sacral area) on arrival, which are signs suggestive of neglect and/or abuse. He was noted to have arrived in severe respiratory acidosis, with hypothermia, bilateral lung infiltrates, urinary tract infection, and sepsis syndrome. Resuscitation efforts were necessary and he was intubated, resuscitated, and admitted to the ICU at 2150. Within 30 minutes patient #6 coded again and was pronounced at 2220. The Certificate of Death showed probable pneumonia, pulseless electrical activity, and cardiac arrest as causes of death.

On the death/organ tissue/autopsy form it was noted that staff had attempted to contact the emergency contact person but the chart contained a wrong number. The police were then contacted to attempt to contact family at an address that the hospital system showed. However, no report was made to the police or APS regarding the presentation of a cachectic, unstable patient with pressure ulcers, who had been found down in a taxi.

Based on information obtained from observations, staff interviews, and review of medical records, the clinical records of 3 patients (1 in the preoperative area and 2 on the Saint Teresa Unit) were not maintained securely as evidenced by:

(1) The Surveyor observed and noted via interview with the charge nurse in the pre-operative holding area that the medical records are left at the bedside. The pre-operative area has 13 total beds. This area has cubicles that have between 2-4 beds in each cubicle separated by curtains. On the morning of 09/21/2010 the Surveyor noted that one patient had a sitter at his bedside and another patient from the correctional department had an officer at his bedside. With the patient's medical record left unsecured at the bedside, others who have no need to know have free access to the patient's information, including other patients, sitters, family members, and correctional officers.

(2) The nursing station on the Saint Teresa Unit is boxed shaped with a counter that encloses the station and has two entrances/exits at the end of the counter. In the middle of the nurse's station is a table with chairs and several booths on one wall for staff to complete documentation. There is also a chart room within the nurse's station. While reviewing medical records at the nursing station and interviewing staff, the Surveyor observed that medical records were left open on the counter at the nurse's station. Although there is a chart room, on 09/21/10 in the morning, the Surveyor observed a physician (who appeared to be orienting a student) review the medical record for patient #20. Patient #20 was a 61 year-old male admitted to Bon Secours Hospital on 09/16/10 status-post femopopliteal bypass and transmetatarsal amputation. The Surveyor observed that the physician left the medical record open on the counter and walked back to the patient's room with the student. The Surveyor observed that the chart remained open on the counter for 4 minutes where any one passing through the hallway or the nurse's station could view the information. After 4 minutes, a case manager closed the record as she walked by.

(3) The Surveyor observed a second occurrence where another medical record was left open and unattended at the same nursing station counter. In this observation, the Unit Secretary was transcribing physician orders into records at a work area at the end of the station counter. While transcribing the orders, the unit secretary left the medical record for patient #21 open and unsecured on the desk while she retrieved the medication/treatment Cardex. Again, this practice allows anyone walking up to the counter or walking through the nurse's station to view the unsecured records.

In 2 of 24 medical records reviewed, the hospital utilized restraints as a means of fall-risk precautions and thus, the type or technique of restraint or seclusion was not the least restrictive intervention to effectively protect the patient from harm as evidenced by:

(1) Patient #7 was a 66 year-old female admitted to Bon Secours Hospital on 06/23/2010 with seizure, altered mental status and urinary tract infection.

(a) On 06/28 at 1500 a nursing note indicated that "upon arrival patient in restraints and trying to get out of bed, restraints removed and patient rolled to right side with minimal assist; supine to sitting with minimal assist ... " Patient was ambulated with assist and complained of dizziness that decreased with rest. "Patient returned to supine and placed in restraints; continue per patient plan."

(b) The record showed that at 0700 on 07/01, patient #7 was again placed into restraint (roll belt) as a falls precaution measure. Both nursing and medical staff signed off on the order to use restraint as a falls precaution measure.

(2) Patient #10 was admitted through the ED on 07/14/2010 after a fall with injury. He had been showing some improvement but on 07/21 the records showed that patient #10's blood pressure dropped from 106/63 at 0700 to 79/47 at 1500. He received a bolus of normal saline and recheck at 1700 showed his blood pressure still very low at 92/54. A medicine note at 1915 indicated patient #10 had received the normal saline and vital signs were "OK" but vital sign data showed at 2000 his blood pressure was still very low at 97/51.

At 2150 a nursing note indicated that a nurse tech saw patient #10 fell onto the floor. Blood pressure was again down to 79/43, which may have been contributory to his dizziness and fall, but his decreasing blood pressure was not addressed. Instead he was briefly assessed and placed into restraints (roll belt) as a falls precaution measure. At 2243 the record showed that patient #10 was in full code and CPR had been started. Patient #10 expired at 0137 am on 07/22.

In 1 of 24 medical records reviewed the hospital failed to ensure that the use of restraint or seclusion was implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law as evidenced by:

Patient #2 was a 26 year-old female admitted on 06/22/2010 with a diagnosis/history of schizophrenia. On 2 different occasions patient #2 was inappropriately restrained without an order, in order to force her to take IM medications that she tried to refuse.

(1) A 1630 nursing note on 06/28 stated that patient #2 was guarded, responding to internal stimuli, and exhibited pressured speech. This note indicated that patient #2 denied and Suicidal Ideation/Homicidal Ideation and also denied visual or auditory hallucinations. Without sufficient justification documented in the medical record, patient #2 "received Haldol 10 mg IM with Ativan 2 mg IM with Benadryl 50 mg IM as ordered for agitation/psychosis. Patient resisted ... 6 staff present to assist ...patient refused dinner, thought processes delusional and disorganized, paranoid and suspicious ... " The record also revealed that the order did not actually specify any indication for the use of these medications; the nursing note failed to demonstrate justification for restraining the patient in order to force these IM medications on her; and no order was obtained for the restraint associated with the administration.

(2) A nursing note on 07/01 at 2150 indicated that patient #2 stated " I don ' t have to take that medication; that is not what the Doctor said. " Later the same note indicated that patient #2 ' s " mood escalated to verbally aggressive, paranoid disorganized, and delusional thinking. Patient eventually took the Seroquel (medication by mouth) but continued to yell and act aggressively verbally towards staff ... medicated with IM meds as ordered for agitation. " The note continued at 2215 " patient escorted to room and told to lay down for IM meds. Haldol, Ativan, and Benadryl, were all given IM while staff held patient to prevent injury. Being verbally aggressive, paranoid, or delusional is insufficient justification to hold a patient down and force them to receive an IM medication against their will. The documentation did not indicate any specific behavior that might have justified the actions taken; and no order was obtained for the restraint associated with the administration.

In 1 of 24 medical records reviewed the hospital failed to ensure that restraint was only used in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient as evidenced by:

Patient #2 was a 26 year-old female admitted to Bon Secours Hospital in Baltimore Maryland on 06/22/2010 with a diagnosis/history of schizophrenia. On 2 different occasions, patient #2 inappropriately restrained without an order to force her to take IM medications that she tried to refuse.

(1) A 1630 nursing note on 06/28 stated that patient #2 was guarded, responding to internal stimuli, and exhibited pressured speech. This note indicated that patient #2 denied and Suicidal Ideation/Homicidal Ideation and also denied visual or auditory hallucinations. Without sufficient justification documented in the medical record, patient #2 "received Haldol 10 mg IM with Ativan 2 mg IM with Benadryl 50 mg IM as ordered for agitation/psychosis. Patient resisted ... 6 staff present to assist ...patient refused dinner, thought processes delusional and disorganized, paranoid and suspicious ... " The record also revealed that the order did not specify any indication for the use of these medications; the nursing note failed to demonstrate justification for restraining the patient in order to force these IM medications on her; and no order was obtained for the restraint associated with the administration.

(2) A nursing note on 07/01 at 2150 indicated that patient #2 stated "I don't have to take that medication; that is not what the Doctor said." Later the same note indicated that patient #2's "mood escalated to verbally aggressive, paranoid disorganized, and delusional thinking. Patient eventually took the Seroquel (medication by mouth) but continued to yell and act aggressively verbally towards staff ... medicated with IM meds as ordered for agitation." The note continued at 2215 "patient escorted to room and told to lay down for IM meds.' Haldol, Ativan, and Benadryl, were all given IM while staff held patient to prevent injury. Being verbally aggressive, paranoid, or delusional is insufficient justification to hold a patient down and force them to receive an IM medication against their will. The documentation did not indicate any specific behavior that might have justified the actions taken; and no order was obtained for the restraint associated with the administration.

In 2 of 24 medical records reviewed the hospital failed to ensure that orders for the use of restraint or seclusion were not written as a standing order or on an as needed basis as evidenced by:

(1) Patient #3 was a 52 year-old male who was brought in to the Bon Secours Hospital Emergency Department by ambulance on 08/10/2010 with severe hypoglycemia (low blood sugar). The record indicated that patient #3 had missed his last 2 appointments for dialysis when he was found unresponsive with a blood sugar of 20. At 0800 on 08/16 a PRN (as needed) order for restraint was entered in the record for patient #3. The order showed the patient name and was signed off by the nurse and physician but all other parameters of the authorization for restraint usage were left blank and therefore left open for staff to decide how, if, and when to implement the order.

(2) Patient #9 was a 53 year-old patient admitted on 08/23 with low-grade fever, productive cough, and anorexia. She was thought to possibly be septic and was therefore admitted. At 0600 on 08/26 a verbal order set for medications appeared in the record and immediately following that order set an untimed PRN restraint order was found in the record. The physician signed this order and it was checked off as a restraint order on the
restraint/seclusion order form. The type of restraint, the time, the date, the time period of authorization, the reason, and the discussion with patient were all left blank for staff to complete as needed.

In 1 of 24 medical records reviewed the hospital failed to ensure that the patient was seen face-to-face within one hour after the initiation of seclusion used for the management of violent or self-destructive behavior as evidenced by:

On 06/24/2010 patient #2 went into seclusion due to verbal and physical aggressiveness. The order was not signed by the writer and then was not signed off by the physician for more than four days (it was signed off on 06/28 at 1645). No face-to-face evaluation was found documented in the record for this instance of the use of seclusion

In 1 of 24 medical records reviewed the hospital failed to ensure that a medical history and physical was completed and documented in the medical record no more than 30 days before or 24 hours after admission as evidenced by:

Patient #5 was a 43 year-old male admitted to Bon Secours Hospital on 06/24/2010 with depression. His length of stay continued through 07/01/2010 but the record did not contain the required History and Physical.

In 2 of 24 medical records reviewed, the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for each patient including assessing the patient's care needs, the patient ' s health status/conditioning, and patient's response to intervention(s) as evidenced by.

(1) Patient #1 was an 84 year-old female admitted to Bon Secours Hospital on 09/01/2010 with nausea, vomiting and abdominal pain for one week. The patient had a history of syncopal episodes, which led to the prior surgical placement of a loop recorder. On admission, the loop recorder was infected requiring removal. Patient #1 was seen by the cardiologist who cleared the patient for surgery. The patient medical history also included urinary tract infection, small bowel obstruction and leukocytosis.

Patient #1 exhibited elevated blood pressure and blood sugar for most of her hospital stay. On 09/03/10 the patient had elevated blood pressure and pulse on the medical-surgical unit. Her blood pressure dropped from 172/87 at 0400 to 124/65 at 0800, and her heart rate had fallen from 68 at 0400 to 50 at 0800. Review of the medical record revealed a progress note by cardiology regarding her drop in blood pressure and heart rate. However, there was no documentation by the nurse of the change in patient #1's vital signs and there was no reassessment documented in the record after the 0800 change until 1100 when the patient was seen by anesthesiology. Although the OR called the floor and received a verbal report, there was no documentation showing that that the preoperative nurse, the surgeon, or the anesthesiologist, were informed of the change in the patient's condition. Based on interviews, there is no report given between the floor nurse and the preoperative nurse when a patient is transferred. There is only a requirement that a checklist be sent with the patient.

Patient #1 went to the OR and the loop recorder was removed. Immediately after removal, the anesthesiologist noted that her heart rate fell to 40 as she was being transferred to the stretcher and she coded. The patient was resuscitated but suffered anoxic brain damage and was later transferred to ICU where she expired at 0801 on 09/05/2010.

In summary, based on staff interviews and review of the medical record, it was determined that on the morning of her surgery, patient #1 had a significant change in her condition when she had a drop in both her blood pressure and heart rate. Review of the medical record revealed that:

1. The patient had a persistent high blood pressure and elevated blood sugar for two days prior to the surgery;
2. Although vital sign data obtained at 0800 revealed a significant change in blood pressure and heart rate, there was no nursing assessment related to the change documented in the record;
3. No documented reassessment of vital signs after 0800 and before her surgical procedure was documented in the medical record. The first note of recheck of vital signs was noted by the anesthesiologist at approximately 1100 when he/she saw the patient was seen in the pre-operative area;
4. No documented communication regarding the vital signs changes was documented in the medical record between the floor nurse or cardiologist to the pre-operative nurse, surgeon or anesthesiologist; and,
5. No pre-operative nursing note was documented on the medical record as required by hospital policy.

(2) Patient #10 was admitted through the ED on 07/14/2010 after a fall with injury. He had been showing some improvement but on 07/21 the records showed that patient #10's blood pressure dropped from 106/63 at 0700, to 79/47 at 1500. He received a bolus of normal saline; and recheck 2 hours later at 1700, showed his blood pressure still very low at 92/54. A medicine note at 1915 indicated patient #10 had received the normal saline and vital signs were "OK" but vital sign data showed at blood pressure 1700 at 92/54 and then at 2000 his blood pressure was still very low at 97/51.

At 2150 a nursing note indicated that a nurse tech saw patient #10 fall onto the floor. The record indicated his blood pressure by then was down to 79/43, which clinically would contribute to dizziness. But still, patient #10 ' s decreasing blood pressure was not clinically addressed. With a critically low and falling blood pressure, the record showed that there was a delay in assessing or recognizing the seriousness of the falling blood pressure which was down to 79/43 by 2150. Furthermore, he was placed into restraints (roll belt) as a falls precaution measure at this time. By 2243 the record showed that patient #10 was in full code and CPR had been started. Patient #10 expired at 0137 am on 07/22.

In 4 of 24 medical records reviewed (patients #4, 7, 9, and 11), entries were not legible, complete, dated, timed, and/or authenticated as evidenced by:

(1) An illegible order appeared in the record for patient #4 at 0950 on 08/31.

(2) Patient #7 was a 66 year-old female admitted to Bon Secours Hospital on 06/23/2010 with seizure, altered mental status, and urinary tract infection.

(a) An order set entered on 06/25 for patient #7 was partly illegible and included two sections that were inappropriately scratched over.

(b) Another order for patient #7 entered at 0220 on 06/26 was noted as both verbal and telephone and when signed off by the physician was neither dated, nor timed.

(c) On 06/26 at 0220, an order for a sitter was obtained for patient #7 due to fall risk, confusion, and pulling at lines. When signed off by the physician the order signature was neither dated nor timed.

(3) Patient #9 was a 53 year-old patient admitted on 08/23 with low-grade fever, productive cough, and anorexia. She was thought to possibly be septic and was therefore admitted. The 08/26 Intensive Care Unit admission orders for patient #9 were illegible.

(4) Patient #11 was an 86 year-old male admitted to Bon Secours Hospital on 08/30/2010. On 08/30 at 2000 an order was entered into the record that included illegible portions and scratch-outs. On 09/02 at 1821 a telephone order was entered for patient #11, to change Novolin NPH insulin to 25 units in AM. The order did not specify if it was a one time change or permanent change and did not specify if the change should be made in the morning or if the morning administration should be changed. When signed off by the physician the signature was neither dated nor timed.

In 2 of 24 medical records reviewed, orders were not dated, timed, and/or authenticated promptly. For example:

(1) On 06/24/2010 patient #2 went into seclusion due to verbal and physical aggressiveness. The order was not signed by the writer and then was not signed off by the physician for more than four days. It was signed off on 06/28 at 1645.

(2) Patient #3 was a 52 year-old male who was brought in to the Bon Secours Hospital Emergency Department by ambulance on 08/10/2010 with severe hypoglycemia (low blood sugar).

(a) At 0800 on 08/11 patient #3 went into bilateral wrist restraint to keep him from pulling at lines. The time the nurse signed off and the time the physician signed the order was filled in by same individual at the same time and in the same handwriting, rather than each practitioner signing and dating their respective signatures.

(b) At 0800 on 08/12 a new order for bilateral wrist restraints was entered to keep patient #3 from pulling at lines. The physician did not date or time his or her signature.

(c) At 0800 on 08/13 a new order for bilateral wrist restraints was entered to keep him from pulling at lines. The physician did not date or time his or her signature.

(d) At 0800 on 08/15 a new order for restraints was entered. This order form was left mostly blank with no time specification, no reason, and no date or time entered with the physician signature.

(e) At 0130 on 08/31 a telephone order for restraint was entered in the record for patient #3. This order was never signed off by a physician.

In 5 of 24 medical records reviewed (patients #2, 3, 4, 7, and 9), verbal orders were not authenticated within 48 hours as evidenced by:

(1) At 1300 on 06/25, the medical record for patient #2 revealed a telephone order for Benadryl 50 mg IM stat, Haldol 10 mg IM stat, and Ativan 2 mg IM stat. The order was not signed off for more than 3 days (it was signed off on 06/28 at 1645).

Another telephone order for Benadryl 50 mg IM up to every 6 hours as needed, Haldol 10 mg IM up to every 6 hours as needed, and Ativan 2 mg IM up to every 6 hours as needed, was entered into the record for patient #2 at 1600 on 06/25. This telephone order was also not signed off for more than 3 days.

(3) The medical record for patient #3 reveled the following:

At 0000 on 08/12 a verbal order set was entered into the record but when it was signed off the signature was not signed and was not dated.

At 2305 on 08/13 a verbal order set was entered into the record but when it was signed off the signature was not signed and was not dated.

At 2300 on 08/14 a telephone order was entered into the record but when it was signed off the signature was not signed and was not dated.

At 0655 on 08/15 a telephone order was entered into the record but when it was signed off the signature was not signed and was not dated.

Additional telephone or verbal orders that were noted as received but were not signed, dated, and/or timed were received at 0105 on 08/30, and at 2215 on 08/30.

(4) The medical record for patient #4 revealed a verbal order entered on 09/02 at 2100 that was never signed off.

(5) The medical record for patient #7 revealed two telephone orders that were entered into the record on 06/27. The first was entered at 0500 and was never signed off by the physician and the second was entered at 0650 but it could not be determined when the physician sign this order because he/she recorded no date or time when the telephone order was signed.

(6) A telephone order for restraint for patient #9 was never signed.

The hospital failed to ensure that surgical services are provided in accordance with acceptable standards of practice as evidenced by:

As detailed under Tag A951, the hospital failed to institute a safe and effective hand-off procedure between medical surgical floors and the preoperative area for surgical services. This contributed to a communications failure where patient #1 went to surgery without adequate consideration for changes in her vitals signs where both her blood pressure and heart rate had dropped significantly at 0800 on the morning of a scheduled surgical procedure. Without any discussion of her clinical change found documented in the record, patient #1 went to the operating room for a short procedure. Unfortunately, patient #1's heart rate fell again and she coded at the conclusion of the surgical procedure while still in the operating room. Patient #1 suffered anoxic brain damage and was transferred to the ICU where she later expired. The system that allowed for the transfer of patients from medical surgical floors to the preoperative area without safe and effective reporting of clinical data to the receiving nurses, increased the likelihood for communications failures of this type.

Based on review of the patient medical records and policies and procedures it was determined that the hospital failed to ensure that surgical services are consistent with the needs and resources and that policies governing surgical care are designed to assure the achievement and maintenance of high standards of medical practice and patient care as evidenced by:

Patient #1 was an 84 year-old female admitted to Bon Secours Hospital on 9/1/10 with nausea, vomiting, and abdominal pain for one week. The patient had syncopal episodes, and a related history of placement of a loop recorder. The patient exhibited elevated blood pressure and blood sugar for most of her hospital stay. When she presented, the loop recorder was infected and it was surgically removed during this length of stay.

During this admission a Cardiologist saw patient #1 and cleared her for the surgical removal of the loop recorder. On the date of the scheduled procedure (09/03) patient #1 had an elevated blood pressure and heart rate while on the medical-surgical unit. At 0800, recorded vital signs showed that her blood pressure dropped from 172/87 (at 0400) to 124/65 and her heart rate had fallen from 68 (at 0400) to 50. When he/she saw patient #1, the Cardiologist noted the patient's vital sign changes. However, there was no nursing documentation regarding the change, there were no vital signs obtained to reassess the patient, nor was there documentation that the surgeon or the anesthesiologist were informed of the change in the patient's condition.

The OR called the floor and received verbal report, but when interviewed, the surgeon reported he had no recollection of any change in vital signs that were reported to him prior to surgery. The patient was sent to the pre-operative holding area but there was no report provided to the pre-op nurse. Based on interviews with staff the hospital has no formal process for hand-offs between the floor and the pre-op area. Critical information did not flow from the floor to the preoperative area and then to the operating room. Immediately after a short procedure to remove the loop recorder, patient #1'

In 1 of 22 records reviewed, the hospital failed to ensure that a properly executed informed consent form for a surgical procedure was in the patient's chart before surgery, as evidenced by:

Patient #1 was an 84 year-old female admitted 09/01/2010 with syncope, a 3 day history of abdominal discomfort, and 24 hour history of nausea and vomiting. Patient #1 ' s recent medical history included urinary tract infection, small bowel obstruction and leukocytosis, and she had a history of colon cancer status post hemicolectomy with primary anastomosis. Patient #1's granddaughter signed her consent for the surgical removal of an infected loop recorder. In interview with the surveyor, the granddaughter reported that she (the granddaughter) had authorized another granddaughter to sign for this procedure. No documentation was found in the record that patient #1 was certified as unable to make her own decisions, nor that either granddaughter was authorized to make decisions for patient #1. Nonetheless, the hospital relied on family members to authorize surgical treatment for the patient. During interview with the Surveyor, the surgeon reported that because the patient didn't object to staff getting consents from family, he felt it was acceptable practice to rely on family for decision-making.