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Based on observation, interview and record review, the facility failed to provide 1 of 1 patients (#2) with comprehensive physical examinations resulting in delayed treatment of foot problems. Findings include:

Observation:

On 6/19/13 at 1:10 pm patient #2's feet were examined. Examination revealed: thick, discolored toenails extending approximately 1.0-1.5 cm. beyond the toe tops and a calloused area, approximally 2 cm. x 2 cm., growing out from the ball of the patient's left foot.

Policy Review:

Comprehensive Examinations, #200, effective 7/1/13, states:
J. "Each patient is re-assessed as necessary based on his/her plan for care and/or changes in his/her condition."

ADL (Activities of Daily Living) for Independent or Semi-independent Skill Level, 3/13, states:

Nail Care:
"Each unit will assess patient's fingernails, toenails and skin condition on a weekly basis during respective shower times."

Record Review:

On 6/19/13 from 1:30-2:30 pm patient #2's clinical record was reviewed, revealing:

1. On 3/4/13 patient #2 was treated by Podiatrist #1. The Podiatrist recommended that patient #2 return to the Podiatry Clinic in 4 weeks.
2. Patient #2 has not been treated by Podiatry since 3/4/13.
3. No documentation of the patient being offered Podiatry treatment was noted in the clinical record.
4. Patient #2's 4/11/13 Individual Plan of Service (IPOS) lists "callous of the feet" as a problem. The IPOS contained no interventions for this problem.
5. The "Personal Care Needs" section of the "Nursing Daily Charting" form did not identify patient #2's foot callous or long, thick toenails as care needs.

Interview:

1. On 6/19/13 at approximately 2 pm staff I. confirmed that patient #2's clinical record did not contain documentation of patient #2's feet being examined after the 3/4/13 Podiatry appointment.
2. On 6/19/13 at approximately 2 pm staff I. stated that patient #2's long toe nails should have been documented by nursing staff and that patient #2 "should have had Podiatry (services)."

Based on record review and interview, patient #2's Individual Plan of Service (IPOS) did not identify shower refusals as a problem resulting in lack of foot assessments and care planning to address foot problems. Findings include:

Policy Review:

Individual Plan of Services (IPOS), #261, effective 3/25/13, states:
I. The IPOS shall contain the following:
5. "Treatment problems, disabilities, and need including but not limited to educational, medial physical therapy and vocational."
6. "Diagnoses..."
8. "Planned interventions..."

ADL (Activities of Daily Living) for Independent or Semi-independent Skill Level, 3/13, states:

Bathing/Showering:
4.C. "Patient refusal to shower...will be placed on the 24-Hour Unit Report to be reported to the treatment team."
Nail Care:
"Each unit will assess patient's fingernails, toenails and skin condition on a weekly basis during respective shower times."


Record Review:

On 6/19/13 from 1:30-2:30 pm patient #2's clinical record was reviewed, revealing:

1. Patient #2's 4/11/13 Individual Plan of Service (IPOS) lists "callous of the feet" as a problem. The IPOS contained no planned interventions for this problem.
2. Patient #2's "Nursing Daily Charting" revealed documentation that patient #2 took only 1 shower from 5/19/13-6/15/13.
3.The "Personal Care Needs" section of the "Nursing Daily Charting" form did not identify patient #2's foot callous or long, thick toenails as care needs.
4. A care plan for shower refusals was not added to the IPOS.

Interview:

1. On 6/19/13 at approximately 2:10 pm Nurse I. stated that patient #2's IPOS: "should have shower refusals added as a problem."
2. On 6/19/13 at approximately 2:10 pm Nurse I. stated that patient #2 "should have had body checks with showers."
3. On 6/19/13 at approximately 2:10 pm Nurse I confirmed that there were no interventions for the problem of a foot callous noted in patient #2's 4/11/13 IPOS.

Based on observation, interview and record review, the hospital failed to maintain a system of author identification for 2 of 2 current medication orders (for patients #1 and #3) and to avoid dropping medication orders for 2 of 2 patients ( #11 and #12). Findings include:

Policy Review:

Medication Orders, #273, effective 10/25/12, states:

C. 2. "All mediation orders shall include:
(I) Name of the prescriber."
D. "The following stop order schedule for mediation has been established in order to provide for periodic review of the patient's treatment."
(Stop order time frames are listed by type of drug, ranging from 24 hours-28 days.)

Observation:

On 6/18/13 at 2:30 pm Nurse G was observed reviewing medication orders for patient's #1 and #3 in the facility's electronic medication orders. Medication orders did not include the name of the physician who had entered current medication orders. Only the name of the physician who placed the original medication order was viewable.

Interview:

On 6/18/13 at 2:30 pm Nurse G stated that the part of the medication order viewable by nurses "does not show the current doctor ordering (the medication)."

Record Review:

On 6/19/13 at 8:45 am review of facility Medication Error reports revealed:

1. Patient #11 did not receive Risperdal as ordered in April and May 2013 due in part to automatic stop orders going into effect before the physician reordered the medication. The physician did not intend to discontinue the medication.
2. On 5/21/13 at 8 am patient #12 did not receive 9 medications because the medications were dropped due to an automatic stop order going into effect. This was not the physician's intention.

Interview:

On 6/19/13 at 8:45 am staff S. stated that patients #11 and #12 did not receive medications (as noted above) "due to problems with the Medimar computer system, which automatically drops (medication) orders unless they are renewed (by physicians) within certain timeframes."