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25065

Based on record reviews and interviews, the hospital failed to ensure patients' informed consents were complete by failing to include blood and/or blood components authorization, therapeutic alternatives, and/or the risks associated with the reasonable therapeutic alternatives. Findings were noted for 2 of 15 patients (#7 & #8) whose medical record was reviewed for informed consents out of a total sample of 29 patients. Findings:

Patient #7
Review of Patient #7's "Informed Consent To Medical Treatment Or Surgical Procedure (Including Blood) And Acknowledgement Of Receipt Of Medical Information" revealed it was signed by Patient #7, the witness, and her physician on 09/15/11 at 6:27 am. Further review revealed no documented evidence that the box for "yes" or "no" had been checked for the section labeled "Blood and/or Blood Components Authorized by Patient - Check box below".

Patient #8
Review of Patient #8's "Informed Consent To Medical Treatment Or Surgical Procedure (Including Blood) And Acknowledgement Of Receipt Of Medical Information" revealed it was signed by Patient #8, the witness, and his physician on 09/11/11 at 2:00pm. Further review revealed no documented evidence that therapeutic alternatives, risks associated with the alternatives, and the risks of no treatment had been discussed with the patient.

In a face-to-face interview on 09/15/11 at 10:45am, S13, Patient Care Manager of One Day Surgery (ODS), indicated the blood authorization section should be completed by the physician checking yes or no according to the patient's wishes.

In a face-to-face interview on 09/15/11 at 11:15am, Director of Nursing Resources S12 confirmed Patient #8's informed consent was incomplete, because the therapeutic alternatives, risks associated with the alternatives, and the risks of no treatment had not been written on the consent, and therefore there was no evidence the physician discussed these with Patient #8.

Review of the hospital policy titled "Informed Consent for Medical Treatment or Surgical Procedure", policy number 32 revised 01/11 and submitted by Director of Nursing Resources S12 as their current policy for informed consents, revealed, in part, "...To be informed, the patient must be capable of consenting ... and be apprised of the nature of the condition, the general nature of the proposed treatment, prospects of success, risks of failing to undergo treatment, risks of alternate treatment, and material risks of the procedure. B. With respect to those surgeries and procedures specified by Louisiana law as requiring informed consent, it is the policy of Touro that no surgery or procedure ("Surgery") shall commence unless the physician performing the Surgery (or the on-call back-up) has personally obtained the informed consent of the patient...".

Based on record review and interview, the hospital failed to ensure all departments of the hospital, to include contracted services, had evidence of Quality Assurance review and communication with the hospital's governing body regarding measuring, analyzing, and tracking quality indicators for 39 of 44 departments in the hospital and 11 of 11 contracted services for the past year (September 2010 through September 2011). Findings:

Review of a typed hospital document listing all departments of the hospital and all contracted services revealed 44 departments in the hospital and 11 Contracted Services. Review of the document revealed the last Quality Indicator Analysis and Review by Quality Assurance was April and July, 2011. Review revealed the last dates of presentation to the hospital's Governing Body was April and July, 2011. Further review revealed the departments of Lab, Radiology, and Environment had been reviewed and presented in April 2011 with Respiratory and Dietary Departments reviewed and presented in July, 2011. Review revealed no documented evidence that the hospital's Quality Assurance Department had reviewed Quality Indicators for the purpose of measuring, analyzing, and tracking quality for the other 39 departments of the hospital or the 11 Contracted Services. Further review revealed no documented evidence that the hospital's Quality Assurance Department had presented any Tracking and Trending of Quality Indicators for the other 39 departments of the hospital or the 11 Contracted Services to the Governing Body for review.

During a face to face interview on 9/19/2011 at 12:10 p.m., Quality Assurance Analyst S20 and Director of Performance Improvement S2 indicated the hospital's Quality Assurance Department had no formalized review of Quality Indicators with tracking and trending to include presentation of data to the Governing Body from September 2010 through September 2011 with the exception of Respiratory, Lab, Radiology, Environment, and Dietary. S20 indicated tracking and trending information had been available for review electronically but had never been formalized and presented at Quality Assurance meetings or to the Governing Body.

Review of the hospital's Performance Improvement Plan revealed in part, "The Performance Improvement Program is organization wide. All personnel and departments are expected to be actively involved in the program. Contract services providing direct patient care or services affecting the health and safety of patients are also included in the ongoing monitoring activities. . . The Governing Board has the ultimate responsibility for the quality of care and service provided. . . Requiring that objective measures be used to gauge the quality and safety of patient care. Ensuring that performance improvement programs are in place and working effectively to monitor and improve quality and safety. . . The Performance Improvement Department, in collaboration with Risk Management and other appropriate departments , will identify trends/patterns to determine opportunities for quality improvement and safety. On a periodic basis, the Performance Improvement Department will prepare and present summary reports to appropriate hospital committees and individual administrators. . . Hospital Quality Committee meets a minimum of 6 times per year. . . Reviews performance reports from departments within the hospital and makes appropriate recommendations for corrective action if problems are identified. . . Reviews information from internal and external data sources and identifies opportunities for improvement within the Touro Infirmary organization. Internal data is analyzed on a basis defined by and appropriate to the measurement. Most data is analyzed monthly and/or quarterly. . . Reports at least annually it's recommendations and observations to the Medical Executive Committee and Board of Governors. . ."

Based on record review and interview, the hospital failed to ensure Medical Staff Bylaws were enforced as evidenced by allowing 1 of 4 suspended physicians to schedule and perform surgery while on suspension (Physician S19). Findings:

Review of a list of suspended physicians revealed in part, Physician S19 was suspended on 8/31/2011.

Review of the hospital's surgery schedule revealed Physician S19 scheduled and performed surgery (Panendoscopy with multiple biopsies including rigid espophagoscopy and direct laryngosopy) on Patient #28 on 9/01/2011 at which time the physician (S19) was on suspension.

Surgery Booker S18 reviewed the list of Physicians on Suspension. During a face to face interview on 9/16/2011 at 10:30 a.m., Surgery Booker S18 indicated Physician S19 had scheduled and performed surgery on Patient #28 on the date of 9/01/2011 when the surgeon had been on suspension.

During a face to face interview on 9/16/2011 at 10:40 a.m., Nurse Manager S29 indicated Physician S19 had gone to Medical Records on the date of 9/01/2011 to complete her delinquent medical records in order to be removed from suspension when she (S19) had been told that she (S19) could not schedule or perform surgery on Patient #28. S29 indicated Physician S19 communicated to surgery staff that she (S19) had completed the delinquent medical records when she (S19) had not. S29 indicated the physician was allowed to proceed with surgery on Patient #28. S29 indicated there had been no written documentation from Medical Records indicating Physician S19 had been removed from suspension. S29 indicated surgery staff had taken Physician S19's word; regarding removal from suspension due to completion of delinquent medical records, when it had not been the case.

Review of a "Suspension Notification" addressed to Physician S19, dated 8/31/2011 at 11:13 a.m., revealed in part, "This notice is to confirm your suspension status as of Aug 31, 2011 at 12:00 p.m.. . . While this suspension is in effect, all admitting, consulting, and surgical privileges will be terminated. . ."

Review of the hospital policy titled, "Delinquent Medical Records, #23, last revised 5/11" presented by the hospital as current policy revealed in part, " Medical records available for completion but remaining incomplete after 30 days post discharge shall necessitate the following actions: Medical Record/ Health Information Management personnel will update the electronic, on-line Suspension List. Notification to the physicians that they have been placed on medical staff suspension; copies of such notification shall be forwarded to the physician's Credential files. Notification of suspension to appropriate clinical departments, medical Staff of this action.. . "

Review of the hospital's "Medical Staff Rules and Regulations" presented as current revealed in part, "Based on availability, records remaining incomplete 30 days of discharge will necessitate the suspension of all clinical privileges. . ."

20638


Based on record reviews and interviews, the registered nurse failed to ensure the supervision and evaluation of care provided to 6 of 20 patients whose medical record was reviewed for the provision of nursing care out of a total sample of 29 patients. This was evidenced by:

1. Failing to ensure nutritional supplements were administered as ordered to a patient (Patient #15) who was noted to have a 22 pound weight loss in 10 days. Findings:

Patient #15:
Review of the medical record revealed Patient #15 was admitted to the hospital on 08/31/11 at 6:00 pm with the diagnosis of CVA (cerebrovascular accident), /c (with) dysphagia, decreased mentation, HTN (hypertension), HLD (hyperlipidemia), gout and other diagnosis. Further review revealed a physician's order dated 09/03/11 at 10:15 a.m. for shakes with each meal. Documentation revealed Patient #15's weights were assessed at 178 pounds on 08/31/11 (day of admission), 167 pounds on 09/03/11 (resulting in an 11 pound weight loss in 3 days), and 156 pounds on 09/10/11 (resulting in a 22 pound weight loss in 10 days). Review of the "Graphics" and "Medication Administration Record" revealed a total of 17 missed shake supplement administrations for Patient #15 from 09/05/11 through 09/15/11. There was no documentation to indicate that Patient #15 was administered a shake with the breakfast meal on 09/05/11, lunch meal on 09/06/11, dinner meal on 09/06/11, breakfast meal on 09/07/11, dinner meal on 09/07/11, lunch meal on 09/08/11, dinner meal on 09/08/11, dinner meal on 09/09/11, dinner meal on 09/11/11, breakfast meal on 09/12/11, dinner meal on 09/12/11, dinner meal on 09/13/11, breakfast meal on 09/14/11, dinner meal on 09/14/11, breakfast meal on 09/15/11, lunch meal on 09/15/11 and/or dinner meal on 09/15/11.
In interviews conducted on 09/16/11 at 9:20 a.m. and at 10:40 a.m., S30 (PCM M6 Unit) and S31 (PCM M9 Unit) both verified the physician ordered shakes with each meal on 09/03/11 for Patient #15. S30 and S31 confirmed there were 17 missed shake administrations documented for Patient #15 from 09/05/11 through 09/15/11. S30 and S31 indicated Patient #15 should have been administered a shake with each meal as ordered by the physician. S30 and S31 denied knowledge of why the nursing staff failed to follow the orders relating to the administration of shakes with each meal. S30 and S31 verified Patient #15 lost eleven (11) pounds in 3 days and then lost another 11 pounds in seven (7) days resulting in a twenty-two (22) pound weight loss in ten (10) days. S30 and S31 indicated the registered nurse is responsible to assess and evaluate the patient's care every shift. Further S30 and S31 stated there was no documented evidence Patient #15's weight loss was evaluated and assessed on an ongoing basis by the registered nurse. S30 and S31 denied knowledge of why the nursing staff failed to evaluate and re-assess Patient #15's weight loss on an ongoing basis. S30 and S31 indicated the registered nurse is to notify the physician of any changes in the patient's condition, immediately as per policy. S30 and S31 both stated the registered nurse failed to notify the physician of Patient #15's weight loss.
During interviews held on 09/16/11 at 9:20 a.m., at 9:35 a.m., and at 10:40 a.m., S3CNO confirmed there was no documentation Patient #15 was administered a shake with each meal from 09/05/11 to 09/15/11 as ordered by the physician. S3 verified Patient #15 had a total of 17 missed shake administrations from 09/05/11 through 09/15/11.
Review of the policy titled, "Nursing Assessment/Reassessment of Admitted Patients", Policy #: 300.9, Effective date of 11/08, Revision date of 6/11, with no reviewed date, presented as the hospital's current "Nursing Assessment" policy on 09/15/11 at 3:30 p.m., read in part, "...Purpose:...Systemically collect relevant data about the patient as the initial step of the nursing care process...Continually collect and review patient specific data throughout the patient's hospitalization...Accurately document assessment findings in the Medical Record...Policy:...1. Admitted patients receive nursing care based on a documented systematic assessment of their needs, strengths, and treatment expectations...Procedure:...2. Assess each patient...continuously throughout the patient's hospitalization as warranted by changes in the patient's needs through the systematic collection of data...Shift assessments should be completed, at the minimum of every 12 hours...3. Identify and document nursing diagnosis/problem statements and formulate the plan of care based on findings...".

2. Failing to ensure accuchecks were performed as ordered by the practitioner for Patient #14 & Patient #9. Findings

Patient #14:
Medical record review revealed that Patient #14 was admitted to the hospital on 9/01/2011 with diagnoses that included Acute Cholecystitis and Diabetes Mellitus. Review of Patient #14's physician orders dated 9/01/2011 (no documented time) revealed in part, "Check BG (blood glucose) every 4 hr (hours) in fasting pts (patients)". Review of the medical record revealed accuchecks were performed on 9/02/2011 at 10:30 p.m. followed by 9/03/2011 at 6:04 a.m. (time span of 7 hours and 34 minutes). Further review revealed an accucheck was performed on 9/03/2011 at 9:56 p.m. followed by 9/04/2011 at 7:15 a.m. (time span of 9 hours and 19 minutes).

These findings were confirmed in an interview with S14 (Director of Maternal/Child and Surgery) on 9/15/2011 at 4:00 p.m. S14 indicated she was not able to find any therapeutic reason for nursing staff not to follow the orders for accuchecks on Patient #14. S14 indicated Patient #14 had been fasting and had a NG (Nasogastric) tube in place. S14 indicated Patient #14 should have had accuchecks performed every four hours as ordered.

Patient #9:
Review of the medical record for Patient #9 revealed a "Physician Order" dated/timed 09/01/11 at 5:00 p.m. for accu checks ac/hs (before meals and at bedtime). No order was found to clarify the need for continued accu checks or to discontinue the accu checks. The "Medication Administration Record" for Patient #9 revealed there were a total of 46 missed accu checks from 09/02/11 through 09/14/11. Further review revealed there were three (3) missed accu checks on 09/02/11 and 09/03/11. There were four (4) missed accu checks on 09/05/11, 09/06/11, 09/07/11, 09/08/11, 09/09/11, 09/10/11, 09/11/11, 09/12/11, 09/13/11, and 09/14/11.

In an interview conducted on 09/14/11 at 2:20 p.m., S31 (PCM M9 Unit) and S3 (CNO) verified Patient #9 had a total of 46 missed accu checks from 09/02/11 through 09/14/11. S31 and S3 indicated the registered nurse failed to ensure the physicians orders for accu checks were followed as per policy. S31 and S3 denied a reason why the nursing staff failed to follow the physician's orders for Patient #9's accu checks to be performed ac & hs from 09/02/11 to 09/14/11.

Review of the hospital policy titled, "Blood Glucose Determination, #102" presented by the hospital as current revealed in part, "Testing is performed when ordered by the patient's health care provider."


3. Failing to clarify orders for frequency of measurements, parameters, and interventions regarding Tube Feeding Residuals for Patient #23. Findings:

Patient #23:
Medical record review revealed Patient #23 was admitted to the hospital on 9/09/2011 with medical diagnoses that included Draining Wound Right Upper Chest. Review of Patient #23's Enteral Nutrition Orders dated 9/10/2011 at 8:10 p.m. revealed in part, "Gastric Residual Volume Check, Standard Protocol, Other". Review of the medical record revealed no documented check mark to indicate if the physician wished to have the standard protocol followed or chose a different intervention for handling Tube Feeding Residuals. Review of Patient #23's Medical Record revealed Patient #23 had a Residual Tube Feeding measurement of 200 milliliters on 9/15/2011 at 7:30 a.m. when the patient was receiving tube feedings at 70 milliliters per hour with no documented intervention in the section titled, "Comment". Further review revealed the next residual measurement was not taken until 9/15/2011 at 12:00 p.m. when the measurement was 150 milliliters.

During a face to face interview on 9/19/2011 at 8:10 a.m., S14 (Nurse Manager) indicated the nursing staff providing care to Patient #23 should have clarified physician's orders for frequency of measurements, parameters, and interventions regarding Tube Feeding Residuals for Patient #23.


4. Failing to assess and/or reassess the blood pressure and/or pulse rate prior to the administration of cardiac medications for Patient #10. Findings:

Patient #10:
Review of the medical record for the patient (#10) revealed orders dated/timed 09/09/11 at 1:35 p.m. for Carvedilol (Coreg) 12.5mg (milligrams) po (oral) q12 (every 12 hours) and Lisinopril 5mg po daily. Further review revealed Coreg CR 6.25mg BID (two times a day) was ordered by the physician on 09/09/11 at 7:26 p.m. There was an order dated/timed 09/10/11 at 5:00 p.m. to, "...hold Lisinopril for systolic BP (blood pressure) < (less than) 100...". There was an order dated/timed 09/14/11 at 11:00 a.m. to, "...hold coreg for pulse < 60 or systolic BP < 100...". There was no documented evidence of blood pressure parameters from 09/09/11 through 09/14/11.

Review of the "Graphics and/or Vital Signs" Sheets for Patient #10 revealed blood pressure readings of 88/44 millimeters of mercury at 8:00 p.m. on 09/09/11; 92/53 millimeters of mercury at 6:03 a.m. on 09/11/11; 90/48 millimeters of mercury at 8:00 p.m. on 09/13/11; and 98/62 millimeters of mercury at 6:17 a.m. on 09/14/11. Further review revealed no documented evidence the registered nurse notified the physician of Patient #10's low blood pressure readings as per protocol.

The "Medication Administration Record" revealed Lisinopril was administered on 09/11/11 at 8:00 a.m. after Patient #10's blood pressure was assessed to be 92/53 at 06:03 a.m. on 09/11/11. There was no documented evidence to indicate Patient #10's blood pressure was assessed immediately prior to the administration of Lisinopril medication on 09/11/11 as per protocol. Further review revealed Coreg medication was administered to Patient #10 on 09/14/11 at 8:00 a.m. after Patient #10's blood pressure was assessed to be 98/62 at 6:17 a.m. on 09/14/11. There was no documentation to indicate Patient #10's blood pressure was assessed immediately prior to the administration of Coreg medication as per protocol.

In face-to-face interviews on 09/14/11 at 3:50 p.m., S32 (M6/W6 Units) and S3 (CNO) verified Patient #10 had low blood pressure readings of 88/44 on 09/09/11, 92/53 on 09/11/11, 90/48 on 09/13/11, and 98/62 on 09/14/11. S32 indicated a systolic blood pressure reading of less than 100 millimeters of mercury and/or a diastolic blood pressure reading of less than 60 millimeters of mercury requires the nursing staff to notify the physician immediately (within one hour) as per protocol. S32 and S3 had no reason why the nursing staff failed to notify the physician of Patient #10's low blood pressure readings of 88/44 on 09/09/11, of 92/53 on 09/11/11, of 90/48 on 09/13/11, or of 98/62 on 09/14/11.

During an interview on 09/15/11 at 9:50 a.m., S30 (PCM M6 Unit) confirmed there was no documented evidence Patient #10's blood pressure was assessed on 09/11/11 at 8:00 a.m. prior to the administration of Lisinopril as per protocol. S30 verified Patient #10's blood pressure at 6:03 a.m. was 92/53 that required a re-assessment of the blood pressure prior to administering the Lisinopril medication at 8:00 a.m. S30 confirmed Patient #10 was administered Coreg medication at 8:00 a.m. on 09/14/11. S30 verified there was no documented evidence Patient #10's blood pressure was re-assessed prior to administering the Coreg medication on 09/14/11. S30 indicated Patient #10's blood pressure should have been re-assessed by the nursing staff prior to administering the Coreg medication.


5. Failing to accurately input handwritten orders for laboratory testing into the electronic medical record system for Patient #1. This data entry error resulted in the omission of 2 sets of cardiac enzymes ordered for Patient #1. Findings:

Patient #1:
Medical record review revealed Patient #1 was admitted to the hospital on 9/11/2011 with medical diagnoses that included Sepsis and Pulmonary Fibrosis. Review of the record revealed handwritten physician orders dated 9/12/11 at 9:21 p.m. for cardiac enzymes to be obtained now and every 8 hours X 3. Review of the medical record revealed only 2 sets of cardiac enzymes were obtained on Patient #1 (not 4 sets as ordered). Review of the medical record revealed results for cardiac enzymes were obtained on 9/12/2011 at 10:15 p.m. and on 9/13/2011 at 4:30 a.m. There was no documentation to indicate the cardiac enzymes were obtained every 8 hours times 3 as ordered.

In an interview on 9/14/2011 at 2:00 p.m., S5 (RN Manager of the 8th floor intermediate unit) reviewed the medical record of Patient #1 and confirmed the cardiac enzymes were not obtained on Patient #1 as ordered. S5 indicated the cardiac enzymes were incorrectly entered into the electronic medical record system by the registered nurse and reported this data entry error led to the missed laboratory tests for Patient #1.




25059

Based on record reviews and staff interviews, the registered nurse failed to ensure the nursing care plan was developed, revised and kept current for 4 of 20 patients (#9, #10, #11 & #15) whose medical record was reviewed for the provision of nursing care out of a total sample of 29 patients. Findings:

Patient #9:
Review of the medical record for Patient #9 revealed a 19 year old male admitted to the hospital on 09/01/11 with C3/C4 Sublaxian; C2/C3, C3/C4 Jump Facet fracture; C3 Transverse Foraminal fracture; Right Nasal Bone Fracture; Right Vertebral Artery Occlusion, Acute Respiratory Failure, and Bipolar Disorder. Record review revealed orders dated 09/01/11 at 5:00 p.m. for accuchecks AC (before meals) & HS (at bedtime); Incentive Spirometry TID (three times a day) orders and C-Collar at all times orders were written on 09/01/11 at 1:45 p.m.; and orders for Duonebs tid (three times a day) dated 09/03/11 at 9:45 a.m. The "Initial Interdisciplinary Plan of Care" including plan of care updates were reviewed. There was no documented evidence in the plan of care addressing interventions for the accuchecks performed AC & HS; no documented evidence in the plan of care addressing interventions developed for incentive spirometer treatments and/or duoneb treatments; and no documented evidence in the plan of care addressing interventions developed for the C-Collar worn by Patient #9.

In an interview on 09/16/11 at 11:25 a.m., S31 (PCM M9) and S3 (CNO) both verified there was no documented evidence in the plan of care addressing interventions for the accuchecks performed AC & HS; no documented evidence in the plan of care addressing interventions developed for incentive spirometer treatments and/or duoneb treatments; and no documented evidence in the plan of care addressing interventions developed for the C-Collar worn by Patient #9.


Patient #10:
Review of the medical record for Patient #10 revealed a 66 year old male admitted to the hospital on 09/09/11 with the diagnosis of Anoxic Brain injury secondary to cardiac arrest, dysphagia, Coronary Artery Disease, and Hypertension. Further review revealed orders for Carvedilol (Coreg) 12.5mg (milligrams) po (oral) q12 (every 12 hours) and Lisinopril 5mg po daily written on 09/09/11 at 1:35 p.m. The "Graphics and/or Vital Signs" Sheets for Patient #10 were reviewed and revealed blood pressure readings of 88/44 at 8:00 p.m. on 09/09/11, 92/53 at 6:03 a.m. on 09/11/11, 90/48 at 8:00 p.m. on 09/13/11, and 98/62 at 6:17 a.m. on 09/14/11. Review of the "Initial Interdisciplinary Plan of Care" developed 09/02/11 revealed no documentation addressing Patient #10's low blood pressure readings throughout his hospitalization.

During an interview on 09/14/11 at 10:40 a.m., S30 (PCM M6 Unit) and S31 (PCM M9 Unit) verified there was no documented evidence to indicate the care plan addressed Patient #10's low blood pressure readings. S30 and S31 indicated Patient #10's low pressure readings should have been included in the plan of care.


Patient #11:
Review of the medical record for Patient #11 revealed a 71 year old male admitted to the hospital on 09/13/11 with the diagnosis of Congestive Heart Failure and AS (Atrial Stenosis). Further review revealed orders for Insulin Sliding Scale accuchecks ac (before meals) & hs (at bedtime) was written on 09/13/11 at 2:37 p.m. Review of the "History and Physical" dated 09/13/11 (not timed) read in part, "...extremities ...edema...cellulitis...". Review of a "Consultant Report" dated 09/13/11 at 3:46 p.m. read in part, " ...Dx: (diagnosis) Mult. (multiple) bilateral leg...blisters...Chronic lymphademia /c (with) Cellulitis...". Review of the "Initial Interdisciplinary Plan of Care" for Patient #11, initiated 09/14/11, revealed there was no documented evidence the plan of care addressed the chronic cellulitis to the bilateral extremities and/or insulin sliding scale.

In a face to face interview on 09/15/11 at 2:15 p.m., S5 (PCM M8 Unit) verified there was no documentation to indicate the plan of care addressed Patient #11's cellulitis and/or insulin sliding scale. S5 indicated Patient #11's care plan should have included interventions for cellulitis and insulin sliding scale.


Patient #15:
Review of the medical record for Patient #15 revealed a 91 year old female admitted to the hospital on 08/31/11 with the diagnosis of CVA (cerebrovascular accident) /c (with) dysphagia, decreased mentation, hypertension, hyperlipidemia, and gout. Further review of the "History and Physical" read in part, "...History of Present Illness:...blindness...dysphagia...". There was a physician's order written on 09/03/11 at 10:15 a.m. for shakes with each meal. Documentation in the medical record revealed that Patient #15 had a 22 pound weight loss within a 10 day time frame during their hospitalization. Review of the "Initial Interdisciplinary Plan of Care" revealed no documented evidence to indicate the plan of care addressed the patient's blindness and/or nutritional status.

In interviews conducted on 09/16/11 at 9:20 a.m. and at 10:40 a.m., S30 (PCM M6 Unit) and S31 (PCM M9 Unit) verified there was no documentation in the plan of care addressing Patient #15's blindness and/or nutritional status. S30 and S31 indicated there should be interventions for Patient #15's blindness and nutritional status.

Review of the policy titled, "Care Plan", Policy #253, Effective date of 1/10, Revision date of 9/11, submitted as the hospital's current "Care Plan" policy read in part, "...Patients receive care and treatment on an assessment of their needs and the severity of their disease, condition, impairment, or disability. The data obtained from the assessment is used to determine and prioritize the patient's plan of care. The development, implementation, and maintenance of an individualized patient's plan of care is an interdisciplinary process. All disciplines involved in the care of a patient collaborate to develop the patient's plan of care. Each healthcare team member provides input into the plan of care ...The plan of care identifies needs, including education; collaborates and prioritizes care plan goals;...and records progress towards...goals...The patient's progress will be evaluated...and the plan of care will be revised daily and/or as indicated...".

20638

Based on record reviews and interviews, the registered nurse failed to ensure medications were administered in accordance with the orders of the practitioner and failed to ensure the ordering practitioner was notified of medication administration errors. Findings were noted for 3 of 15 patients (#14, #24, #29) whose medical record was reviewed for medication administration out of a total sample of 29 patients. Findings:

Patient #14:
Review of Patient #14's medical record revealed the patient was admitted to the hospital on 9/01/2011 with diagnoses that included Acute Cholecystitis and Diabetes Mellitus. Further review revealed a physician's order dated 9/02/2011 at 8:40 a.m. for "Vitamin K 10 mgm (milligrams) IM (Intramuscular) now and q4h (every four hours) x 2 doses." Review of the Medication Administration Record revealed no documented evidence that Patient #14 received the 9:30 a.m. and 1:30 p.m. dosage of Vitamin K on 9/02/2011. Review of Patient #14's electronic "Charting Reason and Effect" documentation revealed in part, "Phytonadione (Vitamin K) 9/02 (2011) 0930 (9:30 a.m.) Reason: not available from pharmacy. Phytonadione 9/02 1330 (1:30 p.m.) Reason: not available from pharmacy."

During a face to face interview on 9/16/2011 at 8:20 a.m., Director of Maternal Child and Surgery S14 indicated she had researched into the hospital's failure to administer Vitamin K to Patient #14 after the surveyor had discovered the documentation. S14 indicated Vitamin K had not been administered to Patient #14 due to the dose being reviewed by pharmacy and determined as too high. S14 indicated there had been no documented evidence in Patient #14's medical record of the pharmacist and/or the registered nurse's conversation with the ordering physician regarding changes in the order. S14 indicated there should have been clear documentation as to the patient's physician's orders in response to pharmacy's concern that the Vitamin K dosage was too high.

Patient #24:
Review of Patient #24's medical record revealed the patient was admitted to the hospital on 9/14/2011 with diagnoses that included Diabetic Ketoacidosis. Further review revealed a physician's order for Insulin Infusion Protocol Orders dated 9/14/2011 at 1925 (7:25 p.m.) which included in part, "Start insulin infusion: 100 units Novolog insulin in 100 ml (milliliters) NS (normal saline). 100 units insulin in 100 ml. NS = 1 unit insulin per 1 ml NS or 1:1 concentration. Calculate initial infusion rate using the formula below: (Blood glucose - 60) x 0/03 = units of insulin per hour (Note 0/03 = starting coefficient). Target blood glucose range in mg (milligrams)/dl (deciliter): Low target 120, High target 160. Calculate new insulin infusion rate every hour using the most recent blood glucose value and adjust coefficient in insulin infusion rate formula as follows: If blood glucose is greater than high target increase previous coefficient by 0.01. Within target no change in coefficient (but recalculate infusion rate). Less than Low target decrease previous coefficient by 0.01."

Review of Patient #24's Insulin Infusion Flowsheet revealed the following (in part):
9/15/2011 at 10:00 a.m., CBG (Capillary Blood Glucose) 226, Coefficient on Insulin Drip 0.08
9/15/2011 at 11:00 a.m., CBG 177, Coefficient on Insulin Drip 0.08 (according to physician orders, if blood glucose is greater than high target (160) increase previous coefficient by 0.01)
9/15/2011 at 12:00 p.m., CBG 125, Coefficient on Insulin Drip 0.07 (according to physician orders, if blood glucose is within target no change in coefficient). . . .
9/15/2011 1600 (4:00 p.m.), CBG 97, Coefficient on Insulin Drip 0.07
9/15/2011 at 1700 (5:00 p.m.), CBG 106, Coefficient on Insulin Drip 0.07 (according to physician orders, if blood glucose is less than Low target decrease previous coefficient by 0.01.)
9/15/2011 at 1800 (6:00 p.m.), CBG 249, Coefficient on Insulin Drip 0.08
9/15/2011 at 1900 (7:00 p.m.), CBG 254, Coefficient on Insulin Drip 0.08 (according to physician orders, if blood glucose is greater than high target (160) increase previous coefficient by 0.01)

During a face to face interview on 9/16/2011 at 1440 (2:40 p.m.), Patient Care Manager S5 confirmed the above findings. S5 further indicated nursing staff should have followed physician's orders for adjusting Patient #24's Insulin Drip. S5 further indicated that any nurse that may have had a concern about a change in the Insulin Drip rate for Patient #24 should have called the patient's physician for an order change.

Patient #29:
Review of Patient #29's medical record revealed the patient was admitted to the hospital on 9/14/2011 with medical diagnoses that included "diffuse rash-inflamed". Review of the record revealed a physician's order dated 9/14/2011 at 2:28 p.m. for "Diflucan 200mg IV daily". Review of the Medication Administration Record revealed no documented evidence to indicate the IV Diflucan was administered to Patient #29 on 9/14/2011 as ordered. Documentation revealed the first dose of IV Diflucan was not administered to Patient #29 until 9:00 a.m. on 9/15/2011. This resulted in a delay in the initiation of IV Diflucan treatment. Review of the record revealed a physician's order dated 9/14/2011 at 6:30 p.m. for Zinc Oxide paste to be applied to the groin area. Review of the Medication Administration Record revealed no documented evidence to indicate the Zinc Oxide paste was applied to Patient #29's groin area on 9/14/2011 as ordered. This record review revealed a total of two medication errors for Patient #29. There was no documentation to indicate the ordering practitioner was notified of the medication errors that occurred during the provision of care to Patient #29.

Review of the hospital policy titled, "Medication Variances, #130, last revised 7/10" presented by the hospital as current revealed in part, "Notification: Medication variances shall be reported immediately upon discovery to the nurse assigned to the patient, who immediately notifies the patient's physician and immediate nursing supervisor, and provides for close observation and monitoring of the patient. In the absence of a clinical pharmacist, dispensing errors should be reported to a pharmacist in the central inpatient pharmacy. Reporting: The medication Variance Report shall be completed. . . A medication variance occurs whenever an error is detected in the prescribing, dispensing, administration, documentation, or monitoring of a drug. . ."

Review of the hospital policy titled, "Pharmacy Essentials of Patient Information for Medication Dispensing and Administration, #136" presented by the hospital as current revealed in part, "A pharmacist shall clarify medication orders, whenever he/she believes that administration of the medication may result in adverse effects, a medication order is incomplete, a non-formulary medication is ordered, dangerous abbreviation or if any pertinent information is missing or unclear."

Based on record reviews and interviews, the hospital failed to ensure: 1) medical records were complete within 30 days of patient's discharge and 2) medical records were protected from water should the sprinkler be activated. Findings:

1. Review of the hospital's "Delinquent Charts Status Report" dated 9/19/2011 revealed 31 physicians with delinquent medical records 60 days or greater. Of the 60 delinquent medical records greater than 60 days, 5 were greater than 100 days delinquent. Review of the hospital's Physician Suspension List revealed none of the 31 physicians were on suspension.

During a face to face interview on 9/19/2011 at 10:30 a.m., S21 (Health Information Manager) confirmed the above findings. S21 indicated she (S21) had been following hospital policy which allowed physicians an extra 30 days in the event that a chart was not available when they attempted to complete delinquent medical records. S21 indicated it had been difficult for the Medical Records Department to ensure Medical Records were available for physicians to complete when patients were often seen by multiple physicians during their hospital stay. S21 indicated unavailable medical records had contributed to the hospital exceeding 30 days in completing medical records once patients were discharged. S21 indicated the Medical Records were often unavailable because they were sitting in another physician's mailbox for completion due to more than one physician having delinquencies for the same patient.

During a face to face interview on 9/19/2011 at 12:00 p.m, S22 (Medical Director) indicated he (S22) had not been aware that completion of delinquent Medical Records had exceeded 60 days post discharge. S22 further indicated having delinquencies that exceeded 60 days meant the hospital needed to revisit their policies and procedures for completing medical records.

Review of the hospital policy titled, "Delinquent Medical Records, #23, last revised 5/11" presented by the hospital as current policy revealed in part, " Medical records available for completion but remaining incomplete after 30 days post discharge shall necessitate the following actions: Medical Record/ Health Information Management personnel will update the electronic, on-line Suspension List. Notification to the physicians that they have been placed on medical staff suspension; copies of such notification shall be forwarded to the physician's Credential files. Notification of suspension to appropriate clinical departments, medical Staff of this action.. . "

Review of the hospital's "Medical Staff Rules and Regulations" presented as current revealed in part, "Based on availability, records remaining incomplete 30 days of discharge will necessitate the suspension of all clinical privileges. . ."

2. Observations on 9/19/2011 at 10:30 a.m. revealed 2 wooden containers with 3 open shelves on each container located in the center floor area of the Medical Records department. Each open container had Medical Records stored on all three shelves. Further observations revealed open metal shelves located in the Physician's area of Medical Records (where records are placed while awaiting physician's completion post discharge). Each shelf contained medical records.

During a face to face interview on 9/19/2011 at 10:30 a.m., Registered Health Information Administrator S21 confirmed the above findings. S21 indicated there was approximately 100 medical records per each wooden container located in the center floor of Medical Records for a total of 200 Medical Records. S21 indicated there were approximately 170 Medical Records located on open shelves in the Physician Room of the Medical Records Department. S21 confirmed the medical records located in the Physician's Room and the Center Floor area of the Department were not protected from water should the sprinkler system be triggered. S21 further indicated the Medical Records in both locations (Center Floor Area and Physician's Area) contained Medical Records for an extended number of days while awaiting filing and/or completion by physicians.

Based on observations and interviews, the hospital failed to ensure the facilities, supplies, and/or equipment were maintained in a manner to ensure an acceptable level of safety and quality. Findings:

Observations in the kitchen on 9/15/11 at 10:10 a.m. revealed the following:
-a section (approximately 3 square foot) of lint/dust buildup was noted to be hanging from the ceiling above one of the food preparation areas. This lint/dust buildup included the air-conditioning intake grills and several drop ceiling panels immediately around the intake grills.
-sections of peeling/flaking paint were noted on several ceiling tiles in the kitchen.
-sections of surface rust were noted on several areas of the metal frames that hold the ceiling tiles in place including sections above the food preparation area. In an interview at the time of this observation, S2 confirmed the above findings. S2 confirmed that the ceilings were in disrepair and in need of cleaning.

Observations in the biohazardous waste storage room on 9/15/11 at 10:50 a.m. revealed the following:
-Several areas of the flooring were noted to have sections of cracked, shattered, and/or missing floor tile. In addition, the flooring was noted to have a dirt/grime buildup and discarded trash including, but not limited to, cardboard and cigarette butts on the floor. In an interview at the time of this observation, S2 confirmed the above findings. S2 confirmed that the floors were in disrepair and in need of cleaning.

20638

Based on observation, record review, and interview, the hospital's Infection Control Officer failed to ensure the consistent implementation of an effective infection control program within the hospital as evidenced by:

1. Failing to ensure patient care equipment and patient care areas were properly cleaned and disinfected to ensure a sanitary environment. Findings:

Observations on 9/14/2011 at 2:15 p.m. of Patient Room C (Patient Room reported to be clean and ready for a newly admitted patient) revealed multiple stains on the shower curtain in the bathroom and a red droplet measuring approximately 3 inches in length on the side of the red biohazardous container in this room. The stains on the shower curtain and the red droplet was easily removed with a damp washcloth indicating the areas were not cleaned and disinfected prior to reporting the room as clean and ready for a new patient.

In an interview at the time of this observation, S6 (RN Manager) confirmed the room was not properly cleaned and disinfected. S6 reported the shower curtain and the biohazardous container were missed during the cleaning and disinfection process. S6 reported the room would need to be redone prior to admitting a new patient.

Observations on 9/16/2011 at 9:30 a.m. revealed Housekeeper S16 cleaning a patient room (Room A) in the One Day Stay Surgical Unit of the hospital. These observations revealed the housekeeper using a disinfectant soaked cloth to clean the bed, furniture, equipment, and room. Observations revealed S16 cleaning the top of the stretcher's mattress. Further observations revealed S16 failed to cleanse the bottom of the mattress. Observations revealed S16 cleaning the top of the stretcher's handrails. Further observations revealed S16 failed to cleanse the underside of the side rails. Observations revealed S16 cleansing the top of the phone. Further observations revealed S16 failed to cleanse the ear and mouth piece of the phone.

During a face to face interview on 9/16/2011 at 9:40 a.m., House Keeping Supervisor S28 confirmed the above findings. S28 further indicated Housekeeper S16 should have thoroughly cleaned all of the room/equipment/stretcher to include the bottom of the mattress, underside of the handrails, and mouth/earpiece of the phone.

Review of the hospital policy titled, "Patient Room Checkout Procedures, Policy #03, last reviewed 7/11" presented by the hospital as current policy revealed in part, "Cleaning Check Outs, Wash beds and furniture with disinfectant solution."

2. Failing to ensure the separation of clean and dirty by failing the have separate areas designated for clean and dirty equipment and/or supplies in the one day surgery area, by failing to have a designated area for soiled linen and/or soiled items in the wound care center and by failing to ensure that soiled lab coats were not held in the hospital's main clean linen holding room. Findings:

Observation on 09/15/11 at 9:50am, with Director of Nursing Resources S12 and Patient Care Manager of One Day Surgery S13 present, revealed Room B was used as a storage area for clean equipment. Further observation revealed an intravenous/PCA (patient controlled analgesia) pump attached to the pole with no evidence of a plastic bag wrapped around the pump.

In a face-to-face interview on 09/15/11 at 9:50 a.m., Patient Care Manager of One Day Surgery S13 indicated the absence of a plastic bag around the pump meant that the pump had not been cleaned, and the pump should not be stored in this clean equipment room. S13 further indicated the process was that equipment should be wiped down after patient use, and a plastic bag should be placed over it.

Review of the hospital policy titled "Cleaning and Storage of Patient Care Equipment", policy number 500.1 effective 01/09 and submitted by Director of Nursing Resources S12 as their current policy for cleaning equipment, revealed, in part, "... 1. The following types of small moveable equipment will be returned to Medical Equipment Distribution after each patient use: ... IV (intravenous) pumps ... PCA pumps... 2. All equipment will be returned through the decontamination area. ... 4. Wipe all surfaces of the equipment, including cords and hoses with a hospital-approved germicidal solution. 5. Rinse well and dry. ... 8. Place a plastic bag on each piece of equipment after cleaning. Place covered equipment in the clean equipment storage area...".

Observation on 09/16/11 at 9:50am, with Director of Nursing Resources S12 and Manager of the Comprehensive Wound Healing Center S27 present, revealed no evidence of a soiled utility room.

In a face-to-face interview on 09/16/11 at 9:50 a.m., Manager of the Comprehensive Wound Healing Center S27 confirmed the center did not have a soiled utility room. S27 indicated soiled bed linens were placed in plastic bag-lined hampers in the patient rooms. She further indicated these bags of soiled linen were picked up by housekeeping at the end of shift. S27 confirmed the soiled linen in the linen hampers remained in the patient rooms used by multiple patients throughout the day. S27 indicated if bed linens were visibly soiled with wound drainage, blood, or body fluids, the soiled linen would be placed in a linen hamper and stored in a multi-use patient bathroom (bathroom used by more than one patient) until housekeeping gathered the soiled linen at the end of the shift.

Observation of the main clean linen holding room on 9/15/2011 at 11:00 a.m. revealed a hamper of soiled lab coats in this room that was designated for clean linen. In an interview at the time of this observation, S2 (Director of Performance Improvement) confirmed that the hamper of soiled lab coats was in the room designated for clean linen. S2 indicated that the soiled lab coats should not be in the clean linen room.

3. Failing to ensure therapy mats in the outpatient therapy gym were free of tears and failure to have a clean (washed and not previously used) ace wrap for individual patient use in the outpatient gym. Findings:

Observation on 09/15/11 at 1:35 p.m. of the outpatient gym, with Director of Nursing Resources S12 and Director of Outpatient and Acute Therapy S24 present, revealed two (2) mat tables with multiple torn edges and a one (1) inch tear to one of the mats present. Further observation revealed an unwrapped ace wrap lying on the top of the weight rack.

In a face-to-face interview on 09/15/11 at 1:35 p.m., Director of Outpatient and Acute Therapy S24 confirmed that the tear and torn edges of the mats would present an infection control issue by allowing patient drainage to possibly seep into the mat and not be able to be cleaned.

In a face-to-face interview on 09/15/11 at 1:40 p.m., Occupational Therapist S25 indicated the ace wrap was used to assist patients to hold onto equipment handles. S25 confirmed the same wrap was used for multiple patients without being sent to be cleaned between patient use. During the same interview Director of Outpatient and Acute Therapy S24 indicated the ace wrap should not be used for multiple patients without cleaning between each patient's use.


4. Failing to develop a system to ensure all physicians and/or practitioners were free of tuberculosis (TB) upon appointment and annually thereafter for 5 of 5 physicians and/or practitioners (S18, S35, S36, S37, S38) whose files were reviewed for TB screening. Findings:

Review of the credentialing files for S18, S35, S36, S37 and S38 revealed no documented evidence of TB screening.

In an interview on 9/19/11 at 10:35 a.m., S22 (Medical Director) indicated the hospital did not have evidence to show the physicians and/or practitioners have had TB screenings.

Review of Centers for Disease Control Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 revealed in part, "...HCWs (Health Care Workers) refer to all paid and unpaid persons working in health-care settings who have the potential for exposure to M. tuberculosis through air space shared with persons with infectious TB disease. Part time, temporary, contract, and full-time HCWs should be included in TB screening programs. All HCWs who have duties that involve face to-face contact with patients with suspected or confirmed TB disease (including transport staff) should be included in a TB screening program. The following are HCWs who should be included in a TB screening program: ... Dental staff ... Physicians (assistant, attending, fellow, resident, or intern), including anesthesiologists, pathologists, psychiatrists, psychologists...".


5. Failing to ensure the correct concentration mixture of sanitizing solution was maintained in the three compartment sink to ensure the sanitization of cookware and utensils in the hospital's kitchen. Findings:

Observations in the kitchen on 9/15/11 at 10:00 a.m. revealed a food services worker (S8) cleaning pans, dishes, and utensils in the 3 compartment sink. When asked the method for verifying the concentration of the sanitizing solution in the 3 compartment sink, S8 indicated that he did not know the correct method used to verify the concentration of sanitizing solution in the 3 compartment sink. S8 explained that he does not usually work with the 3 compartment sink and reported that he was just pulled to the area (that includes the 3 compartment sink) because of an employee call in. S8 reported he has not received any training relating to the 3 compartment sink and was unable to determine the correct concentration mixture for the sanitizing solution used in the 3 compartment sink. Review of the Sanitizing Log used to determine the concentration of the sanitizing solution revealed the concentration should be maintained at a level of at least 200 PPM (parts per million) for adequate sanitation to occur. The initials of S8 were documented on the Sanitizing Log for the date of 9/15/11 with documentation indicating the solution concentration was 200 PPM. When asked who completed the Sanitizing Log for 9/15/11, S8 reported he completed the log. When asked how he was able to determine the concentration of the sanitizing solution in the 3 compartment sink, S8 indicated that he did not check the concentration of the sanitizing solution. When asked who did, S8 indicated that he did not know if anyone had checked.




25065

Based on record review and interview, the hospital failed to ensure the physical therapy policy provided for services to be furnished based on the patient's assessed needs and would not be adjusted according to staffing needs. Findings:

Review of the hospital policy titled "Patient Referrals and Assessment", policy number 300.1 revised 09/11 and submitted by Director of Outpatient and Acute Therapy S24 as the current policy for scope of service, revealed, in part, "... A. Priority of Care: In case of extensive demands for PT (physical therapy) services, there are several adjustments, which can be made: (These are not in order of implementation.) ...2. decrease length of treatment time ... 7. place patients on a waiting list 8. reduce frequency In all cases, patients will be assessed on an individual basis regarding: 1. Will a decrease, loss or delay of treatment cause regression in the patient's condition or undue loss of progress? 2. Will this loss of progression be difficulty to regain? 3. Can supportive personnel assist in the PT program? The decision to make any of the above adjustments will be made by the Rehab Director...".

In a face-to-face interview on 09/19/11 at 12:50pm, Director of Outpatient and Acute Therapy S24 confirmed the referral and assessment policy allowed PT services to be adjusted based on staffing needs rather than patient need.

Based on record review and interviews, the hospital failed to implement its policies for referrals, assessments, and/or discharge as evidenced by failure to discharge a patient when he was admitted to an acute setting (#18), failure to obtain an order for therapy services upon return from an acute admission (#18), and/or failure to perform therapy services at the frequency ordered by the physician (#17, #18) for 2 of 3 outpatient therapy patients reviewed from a total of 29 sampled patients. Findings:

Patient #17
Review of Patient #17's medical record revealed an order on 06/28/11 for PT (physical therapy) and OT (occupational therapy) to evaluate and treat secondary to multiple sclerosis. Review of the OT evaluation performed on 08/16/11 revealed a frequency of one time a week. Review of the PT evaluation performed 08/26/11 revealed a frequency of 2 times a week.

Review of a prescription signed by Patient #17's physician on 08/30/11 and shown as faxed to Touro on 08/30/11 at 8:12am revealed PT and OT were to be performed 2-3 times a week for 8 weeks.

Review of Patient #17's PT notes revealed she received PT on 09/02/11 and 09/09/11, which was one time a week rather than 3 times a week as ordered on 08/30/11. Review of Patient #17's OT notes revealed she received OT services 08/30/11, 09/06/11, and 09/13/11, one time a week rather than 3 times a week as ordered.

Patient #18
Review of Patient #18's medical record revealed the following orders:
Prescription dated 01/25/11 for outpatient ST (speech therapy)/OT/PT "3 times a week for 4 weeks then please reassess and re-eval (re-evaluate);
"Plan of Treatment For Outpatient Rehabilitation" signed by the physician on 02/11/11 for OT certification for 60 - 90 days (no documented evidence of the from and through dates) with the frequency and duration of 3 times a week times 12 weeks;
"Plan of Treatment For Outpatient Rehabilitation" for ST certification from 02/11/11 through 03/12/11, with a frequency and duration of 2 times a week times 4 weeks, signed by the physician on 03/02/11, 19 days after the start of the certification period;
Prescription from the physician signed 03/25/11 for ST/PT/OT with a frequency and duration of 2-3 times a week for 8 weeks;
"Plan of Treatment For Outpatient Rehabilitation" for PT certification from 02/15/11 through 03/15/11, with a frequency and duration of 2-3 times a week for 8 weeks (duration is longer than the certification period), signed by the physician on 04/18/11, more than 2 months after the beginning of the certification period;
"Updated Plan of Progress For Outpatient Rehabilitation" for PT certification from 03/16/11 through 06/08/11, with a frequency and duration of 2-3 times a week times 3 months, signed by the physician on 04/18/11, more than one month after the start of the certification period;
Prescription signed by the physician on 05/02/11 for PT/OT services with no documented evidence of a frequency and duration of services being ordered;

Review of the entire medical record revealed no documented evidence Patient #18 was discharged from rehab services on 04/12/11 when he was scheduled to have an acute admission for a cranioplasty. Further review revealed Patient #18 had PT services initiated on 05/03/11 with no documented evidence of an evaluation. Further review revealed OT performed an evaluation on 05/03/11 and ST performed an evaluation on 05/06/11. There was no documented evidence a physician's order/referral was received PT/OT/ST services after discharge from acute care post cranioplasty.

Review of Patient #18's medical record revealed he was "placed on hold until medically stable" on 07/08/11 after having been transferred to the emergency room on 07/01/11. Further review of the PT note of 08/16/11 revealed, in part, "...Pt (patient) is resuming PT after 1 mo. (month) (secondary to) reported kidney failure. Pt now presents (with) c/o (complaints of) L (left) shoulder pain rated 5-7/10...". Further review revealed no documented evidence a PT evaluation was performed with the start of care. Further review revealed OT resumed care on 08/09/11 with no documented evidence of an evaluation. Further review revealed no documented evidence of a physician's order/referral to initiate PT/OT/ST care after discharge from the acute setting.

Review of Patient #18's PT, OT, and ST treatment notes revealed no documented evidence any of the services were provided 3 times a week as ordered by the physician. The initial OT evaluation performed on 02/07/11 revealed a frequency of 2-3 times a week for 12 weeks, the initial PT evaluation performed on 02/15/11 revealed a frequency of 2-3 times a week for 8 weeks, and the ST evaluation performed revealed a frequency of 2-3 times a week with no documented evidence of a duration. Review of the PT/OT/ST progress notes revealed no documented evidence treatments were provided at a frequency of 3 times a week as ordered and as recommended by the therapists per their patient evaluation.

In a face-to-face interview on 09/15/11 at 2:50pm, Licensed Rehab Counselor S26 indicated he was the supervisor for the outpatient rehab center. S26 indicated Patient #18 should have been discharged when he was admitted to an acute care hospital and not placed on hold. He further indicated a complete evaluation should have been performed by PT, OT, and ST upon his return from the acute hospital admissions. S26 indicated frequency ranges were used, because patients can't always get to their appointments due to transportation issues. S26 confirmed that the higher frequency was what was recommended by the therapist.

In a face-to-face interview on 09/16/11 at 10:15am, Director of Outpatient and Acute Therapy S24 confirmed Patient #18 should have been discharged when he was admitted to an acute care setting. She further indicated a new order should have been obtained, and a new evaluation should have been performed by the therapist. S24 confirmed the frequency of visits for Patients #17 and #18 were not performed as ordered by the physician.

Review of the hospital policy titled "Patient Referrals and Assessment", policy number 300.1 revised 09/11 and submitted by Director of Outpatient and Acute Therapy S24 as the current policy for scope of service, revealed, in part, "... Referrals are made by any licensed physician in written form and brought by the patient, faxed or mailed directly to the program. Phone or oral referrals will be taken as necessary but must be followed up by a written referral. ... Reassessments should be done ... monthly for outpatients or as frequently as needed based on duration of treatment recommended, changes in patient's response to treatment, medical status, physician's orders, regulations and/or treatment plan...".

Review of the hospital policy titled "Discharge Protocol", revised 04/06 and submitted by Director of Outpatient and Acute Therapy S24 as their current policy for discharge, revealed, in part, "...Typically, the following guidelines can be used to determine a client's appropriateness for discharge from the program: ... 4. There are medical or psychiatric complications, which necessitate transfer to acute care or to another setting...".

Review of the hospital policy titled "Documentation Guidelines", policy number 1000.1 revised 09/11 and submitted by Director of Outpatient and Acute Therapy S24 as their current policy for documenting discharges, revealed, in part, "...10. Discharge/discontinuation of services to include: summary of assessment and treatment provided; include a concise summary of total PT intervention and functional outcomes; home programs; follow-up plans; recommendations; referrals to other services".

Based on record review and interviews, the respiratory therapist failed to ensure respiratory services were delivered in accordance with medical staff directives by failing to administer 8 duoneb treatments as ordered by the physician for 1 of 10 patients (Patient #12) whose medical record was reviewed for respiratory services out of a total sample of 29 patients. Findings:

Patient #12:
Review of the medical record for Patient #12 revealed a "Physician's Order" dated 09/10/11 at 3:25 p.m. for duonebs every six hours and prn (as needed).

Review of the "Respiratory Medication Administration Record" for Patient #12 revealed there were a total of eight (8) missed duoneb treatments from 09/10/11 thru 09/12/11. "Treatment not provided" was documented for the duoneb treatment as follows:
09/10/11 at 10:00 p.m.; 09/11/11 at 4:00 a.m., at 10:00 a.m., at 4:00 p.m. and at 10:00 p.m.;
09/12/11 at 5:30 a.m., at 11:30 a.m., and at 5:30 p.m.

In an interview on 09/15/11 at 3:35 p.m., S33 (PCM T7 Unit) and S34 (Respiratory Care Mgr) verified Patient #12 was not administered 8 duoneb treatments from 09/10/11 thru 09/12/11 as ordered by the physician. S33 and S34 did not have an explanation as to why the duoneb treatments were not administered as ordered.

The policy titled, "Charting Policy", Policy # 1000.1, Effective date of 1/94; last reviewed date of 9/11, indicated the Respiratory Therapist will utilize the hospital information system, both manual and electronic, to obtain physician orders and document services delivered.

Review of the policy titled, "Pharmacy", Policy #159; Effective date of 12/88; Last Revision date of 9/11; indicated it was policy to ensure that all medication orders were administered to the patient.