HospitalInspections.org

Based on record review and interview, the hospital failed to: 1) ensure a copy of a patient's power of attorney was part of the medical record for 1 of 5 patients whose medical records were reviewed for power of attorney (#1); 2) ensure patients or their representatives were given information and disclosures needed to make an informed decision about whether to consent to a procedure, intervention, or type of care that required consent by failing to ensure informed consents were signed for 4 of 4 patients (#5, #7, #12, #17); and 3) ensure two witness signatures were obtained if a patient indicated a mark as signature for 1 of 1 patients (#20) in a total sample of 20 patients. Findings:

Review of the facility's Rights policy "RTS-12 Informed Consent, Care Decisions, Conflicts, and Dilemmas" reflected "The hospital shall obtain informed consent from patients and/or the legal representative in compliance with State and Federal regulations. If a patient has a [Durable Power of Attorney] (DPOA) for Healthcarem then every effort is made y the hospital to obtain a copy of the POA to be placed on the chart" Further review of the policy reflected if a patient signature contained their mark as "x", then two witness signatures were required.

1) ensure a copy of a patient's power of attorney was part of the medical record
Review of the medical record for Patient #1 revealed he was admitted to the hospital with a diagnosis of dementia/psychosis. Further review of the medical record revealed written documentation that Patient #1's sister in law had power of attorney. Review of the entire medical record revealed no documentation the hospital had a copy of the power.

An interview was held with S1 Assistant Administrator on 11/24/2010 at 2:10 pm. After review of the medical record for Patient #1, she indicated there was no copy of the power of attorney in the medical record. She further indicated that a copy of the patient's power of attorney must be in the chart.

2) ensure patients or their representatives were given information and disclosures needed to make an informed decision.
Patient #5
Review of patient #5's medical record reflected the patient was admitted to the facility on 11/9/10. Review of the patient's informed consents revealed that the consent for family contact and emergency treatment, Acknowledgment of Notification of Rights, Advance Directive Acknowledgment, Patient Physician Authorizations and Agreements, Financial Responsibility and Insurance Billing Policy, Complaint/Grievance Process, Patient Identification Number policy, Refusal to comply with Admit Wristband/Color-Coded Alert Clasps policy and the Infectious Disease Screening Form policy consents noted in the chart were not signed to reflect the patient was made aware his rights as a patient at the facility.

Patient #7
Review of patient #7's record reflected the patient was admitted to the facility on 11/16/10. Review of the record revealed the Consent to Release Information and Refusal to Comply with Admit Wristband/Color-Coded Alert Clasps policies were not signed by the patient.

Patient #12
Review of patient #12's medical record revealed the patient was admitted to the facility on 11/10/10. Further review of the record reflected the policy concerning the patient's medicare rights had not been signed by the patient.

Patient #17
Review of the medical record for patient #17 reflected the patient was admitted to the facility on 5/24/10. Further review of the facility's policy noted in the record regarding "Refusal to Comply with Admit Wristband/Color-Coded Alert Clasps" revealed the policy had not been signed by the patient.

3) ensure two witness signatures were obtained if a patient indicated a mark as signature
Patient #20
Review of patient #20's medical record reflected the patient was admitted to the facility on 6/2/10. Further review of the patient's record reflected the patient's signature was authenticated by marking an "x" on the signature line. Review of the facility policies noted in the record, regarding the patient's rights and care while at the facility, did not reflect that two witness signatures were obtained when the patient signed the policies.

Interview with S1, Assistant Administrator on 11/23/10 at approximately 2:20 p.m. revealed that 2 witness signatures were required when a patient sign consents using an "x". S1 confirmed that there was no evidence to indicate that patient #20's consents were witnessed by 2 people.


25452

Based on observation and interview, the hospital failed to ensure patients received care in a safe setting by having plastic liners in garbage cans located in the lobby area and dining/group area, both of which were accessible to patients and could be used as a means of suffocation; long electrical cords attached to the drinking water container in the lobby and the television and DVD (digital video disc) player in the dining/group area, both of which were accessible to the patients and could be used as a means of strangulation; and an unlocked soiled utility room containing an open bag of charcoal, two large biohazard containers containing red plastic liners with biohazard waste to be discarded, and two filled needle boxes. Findings:

Observation on 11/22/10 at 11:30am, with Assistant Administrator S1 present, revealed a lobby area that was open to the nursing station and provided a pass-through for patients to enter the dining/group area and to exit the building to go to the secured outdoor area. Further observation of the lobby area revealed a large garbage can lined with a plastic liner that could be used by suicidal patients as a means of suffocation. Further observation revealed the drinking water container ' s electrical cord was long and extending from the container which could provide a means of strangulation.

Observation of the group/dining area on 11/22/10 at 11:30am, with Assistant Administrator S1 present, revealed the garbage can with a plastic liner that could be used by suicidal patients as a means of suffocation. Further observation revealed the electrical cords from the television and DVD player were hanging from the equipment and accessible to the patients. These cords could provide a means of strangulation.

Observation of the soiled utility room on 11/22/10 at 11:30am, with Assistant Administrator S1 present, revealed the door to the room was unlocked. Further observation revealed an open bag of charcoal lying inside an open plastic garbage can. Further observation revealed two red plastic biohazard containers filled with red plastic bags containing biohazard waste waiting for pick-up to be discarded. There were two filled needle boxes placed on the top of the biohazard containers. Further observation revealed no biohazard sign on the door to indicate that biohazard waste was contained inside the room.

In a face-to-face interview on 11/22/10 at 11:30am, Assistant Administrator S1 confirmed the findings. She indicated the soiled utility room should be locked at all times.

Based on record review and interview, the hospital failed to ensure the medical staff followed its bylaws in examining credentials as evidenced by failure to have at least two peer references and/or query the NPDB (National Practitioner Data Bank) and OIG (Office of the Inspector General) prior to appointment/reappointment by the governing body for 1 of 1 nurse practitioner's credentialing file reviewed (S9), 2 of 3 physicians' credentialing file reviewed (S11, S13), and 1 of 1 psychologist's credentialing file reviewed (S12). Findings:

Review of Nurse Practitioner S9's credentialing file revealed she was appointed by the governing body on 05/08/09. Further review revealed the NPDB and OIG queries were performed on 06/01/09, which was after her credentialing file had been reviewed and her appointment approved by the medical board and the governing body. Further review revealed her peer references were from a medical staff coordinator and received on 05/15/09 and a medical coordinator dated 05/14/09, which were not submitted by peer nurse practitioners and were submitted after her credentialing file had been reviewed and her appointment approved by the medical board and the governing body.

Review of Physician S11's credentialing file revealed his appointment to the medical staff was approved by the governing body on 01/04/10. Further review revealed no documented evidence that peer references were obtained and reviewed prior to appointment to the medical staff by the governing body.

Review of Physician S13's credentialing file revealed he was appointed by the governing body on 04/30/09. Further review revealed no documented evidence that peer references were obtained and reviewed prior to appointment to the medical staff by the governing body. Further review revealed the NPDB and OIG queries were performed on 06/01/09, which was after his credentialing file had been reviewed and his appointment approved by the medical board and the governing body.

Review of Psychologist S12's credentialing file revealed he was appointed by the governing body on 05/29/09. Further review revealed the NPDB and OIG queries were performed on 06/01/09, which was after his credentialing file had been reviewed and his appointment approved by the medical board and the governing body.

In a face-to-face interview on 11/23/10 at 1:55pm, Assistant Administrator S1 indicated she was responsible for the credentialing process and that she was aware the NPDB and OIG queries needed to be processed and the results obtained prior to the applicant being approved by the medical executive committee and the governing body. She further indicated she could not explain why the queries were done after Nurse Practitioner S9, Physicians S11 and S13, and Psychologist S12 had been appointed to the medical staff by the governing body. S1 further indicated she thought a Registered Health Information Administrator and a Medical Staff Coordinator could provide the peer references for the nurse practitioners, psychologists, and physicians.

Review of the "Medical Staff Bylaws", dated 07/08 and submitted by Assistant Administrator S1 as their current copy of the medical staff bylaws, revealed, in part, "...Appointments and Reappointments: Initial appointments and reappointments to the Medical Staff shall be made by the Governing Body upon a recommendation from the Medical Executive Committee, and shall be for a period not to exceed two (2) years from the month of appointment. ...Article V Allied Health Professionals Section 1 - General Allied Health Professionals (AHPs) are health care providers other than Practitioners who hold a license, certificate, or such other legal credentials as required by this State which authorizes the AHP to provide health care services. ...Section 2 - Categories of AHPs Eligible and Practice Prerogatives ... A. Licensed Independent Practitioners (LIP) 1. Clinical Psychologist are independent practitioners with all the privileges and prerogatives as any other member of the Medical Staff. ... 2. Nurse Practitioner (APRN) ... (c) Nurse practitioners are subject to the same performance improvement monitors and peer review activities as all medical staff members. ...Section 4 - Procedure For Granting Clinical Practice Privileges/Prerogatives; Termination and Corrective Action Applications for appointment, reappointment and requests for clinical Privileges/Prerogatives for AHPs shall processed in the same manner as provided in Articles VI and VII for medical Staff Membership and Clinical Privileges. ...Article VI Procedure For Appointment ...Section 4 - Submission Of Application ... The Facility shall query the National Practitioner Data Bank (NPDB), The American Medical Association, and the State licensing authority for all Practitioners/Professionals who apply for Staff membership or Clinical Privileges. Section 5 - Application Form/Information Required ... B. Specific Information Required The information shall include but not be limited to, the following: ...(l) Peer references: Three (3) written reference letters must be requested from persons other than family or affiliates by marriage who must have personal knowledge of the applicant's recent professional performance, his ethical character, current competence, and his ability to work cooperatively with others; Two of the three reference letters must be received by the Facility; ... Section 7 - Review and Recommendation Procedures ... Within thirty (30) Days of receipt of the completed Application by the Facility's Medical Staff office the Facility will verify all information and submit the completed file to the Medical Staff's Credentials Committee, a function of the Medical Executive Committee (MEC). The Credentials Committee of the MEC shall review the Application, conduct any interviews as it deems appropriate, and act within thirty (30) days following receipt of the Application. The Medical Executive Committee shall make written recommendations to the Governing Body for appointment, membership category, and approval/disapproval of Clinical privileges requested. ...C. Action by the Governing Body ...the Governing Body shall act on the matter within 30 days of receipt of the recommendation of the Medical Executive Committee. Section 11 - The Reappointment Process A. Application Within a reasonable period of time prior to the expiration of the Member's two-year appointment (but not less than one hundred twenty (120) days), the Administrator or his designated representative shall provide each Member with an approved Application for Reappointment form which must be completed and returned within thirty (30) Days to the Administrator for review on behalf of the Medical Executive Committee. ... 15. Evidence of a query sent to the National Practitioner Data Bank; and ... E. Credentialing Committee of the Medical Executive Committee At least sixty (60) days prior to the end of the appointment period, the Credentials Committee of the Medical Executive Committee shall review each Application for Reappointment and all other relevant information available on each professional being considered for reappointment. Information collected by the quality improvement program, peer review, infection control, and the member's performance evaluation will be considered when the Credential Committee determines its recommendation of the member at the Medical Executive Committee meeting. Recommendations will be made to the Governing Body for reappointment or to defer action. ... F. Medical Executive Committee The Medical Executive Committee shall forward its recommendations to the Administrator for review and submission to the Governing Body, at least sixty (60) days prior to the end of the appointment period. ... G. Final Processing and Board Action The procedure provided in Sections 7(C) "Review and Recommendation Procedures" above shall be followed ...".

25065

Based on record reviews and interviews the Registered Nurse (RN) failed to supervise and evaluate the care of each patient as evidenced by: 1) having a Licensed Practical Nurse (LPN) completing the Admission/Continued Stay Criteria for 9 of 20 sampled patients reviewed for Admission/Continued Stay Criteria out of a total sample of 20 (#1, #2, #3, #4, #5, #6, #7, #8, #12); 2) failure to document the nursing intervention, reason for the patient's refusal, and physician notification for a patient's non-compliance with attending scheduled behavioral sessions in the hospital for 3 of 20 sampled patients reviewed for compliance with group therapy from a total sample of 20 sampled patients (#1, #2, #6); 3) failure to accurately perform a nutritional screening for 2 of 20 sampled patients reviewed for nutritional screening from a total sample of 20 patients (#2, #6); 4) failure to accurately assess the fall risk of 1 of 20 sampled patients reviewed for fall risk assessment from a total sample of 20 patients (#6); and 5) failure to accurately perform an assessment of skin integrity for 1 of 20 sampled patients reviewed for skin integrity assessment from a total sample of 20 patients (#6). Findings:

1) Having a LPN completing the Admission/Continued Stay Criteria:
Patient #1
Review of the Admission/Continued Stay Criteria form for Patient #1 revealed that S6 LPN completed, dated and timed the Admission/Continued Stay Criteria on the date of the patients admission of 11/08/10. Further review revealed this form was not signed by a RN.

Patient #2
Review of Patient #2's medical record revealed he was admitted on 11/15/10 with a diagnosis of Schizoaffective Disorder. Review of the "Continuum of Care Admission/Continued Stay Criteria" revealed Patient #2's admission criteria assessment was performed by LPN S6 with no documented evidence of a review by the RN or a physician.

Patient #3
Review of the Admission/Continued Stay Criteria form for Patient #3 dated 11/19/10 at 2030 revealed that S6 LPN completed, dated and timed the Admission/Continued Stay Criteria on the date of the patients admission of 11/19/10. Further review revealed the form was not signed by a RN.

Patient #4
Review of the Admission/Continued Stay Criteria form for Patient #4 dated 11/17/10 revealed that S6 LPN completed, dated, and timed the Admission/Continued Stay Criteria. Further review revealed the form was not signed by a RN.

Patient #5
Review of the Admission/Continued Stay Criteria form for Patient #5 dated 11/9/10 revealed that S6 LPN completed, dated and timed the Admission/Continued Stay Criteria. Further review revealed the form was not signed by a RN.

Patient #6
Review of Patient #6's medical record revealed he was admitted on 11/15/10 with a diagnosis of Alzheimer's Dementia. Review of the "Continuum of Care Admission/Continued Stay Criteria" revealed Patient #6's admission criteria assessment was performed by LPN S6 with no documented evidence of a review by the RN or a physician.

Patient #7
Review of the Admission/Continued Stay Criteria form for Patient #7 dated 11/16/10 at 1440 reflected S6 LPN completed, dated and timed the Admission/Continued Stay Criteria. Further review revealed the form was not signed by a RN.

Patient #8
Review of the Admission/Continued Stay Criteria form for Patient #8 dated 11/22/10 revealed that S6 LPN completed, dated, and timed the Admission/Continued stay criteria. Further review revealed the form was not signed by a RN.

Patient #12
Review of the Admission/Continued Stay Criteria form for Patient #12 dated 11/10/10 at 1350 reflected S6 LPN completed, dated and timed the Admission/Continued Stay Criteria. Further review revealed the form was not signed by a RN.

An interview was held with S4 RN on 11/23/2010 at 1:10 pm. After review of the Admission/Continued Stay Criteria form, she confirmed that a Registered Nurse had not completed the Admission/Continued Stay Criteria form and that the form had been completed by S6 LPN.

Review of the hospital policy titled "Admission Criteria/Continued Stay", with no documented evidence of the effective or reviewed date and submitted by Assistant Administrator S1 as their current policy for the admission criteria, revealed, in part, "...Admitting physician accepts the criteria for admission and provides necessary documentation to establish certification of medical necessity and promote safety. Medical Director/Administrator is authorized to waive any criterion for admission, with documented clinical justification. ... The admissions counselor reviews pre-admission assessment data with the physician who determines the appropriate service and level of care indicated...". Review of the entire policy revealed no documented evidence that the RN was responsible for the patient assessment to determine that admission criteria was met.

Review of the hospital policy titled "Initial Assessment and Admission Process", with no documented evidence of an effective and review date and submitted by Assistant Administrator S1 as their current policy for the admission process, revealed, in part, "...Assessment Professional/Charge Nurse ...completes pre-admission assessment to obtain the following minimum information to determine eligibility for entrance into the Facility. ...When warranted by criteria, separate specialized screening, triggers or assessment processes are identified for a more in-depth assessment... The admission's professional will contact the RN on the unit for needed medical services prior to a decision being cleared for admission, as needed. ...Physician determines if person is appropriate for admission or if a referral to a community based resource is warranted...".

Review of the Louisiana State Board of Nursing's "Delegation Decision-Making Process" revealed, in part, "...The Louisiana State Board of Nursing has the legal responsibility to regulate the practice of nursing and to provide guidance regarding the delegation of nursing interventions by the registered nurse to other competent nursing personnel. ... In Louisiana, R.S. 37:913(14)(f) provides that registered nursing includes delegating nursing interventions to qualified nursing personnel in accordance with criteria established by the Board of Nursing. LAC 46:XLVII.3703 sets the standards for implementation of the statutory mandate. The term "delegating nursing interventions" is defined and criteria are provided for all delegatory activities, for delegation to licensed practical nurses... The registered nurse who delegates nursing interventions retains the responsibility and accountability to assure that the delegated intervention is performed in accord with established standards of practice, policies and procedures. Appropriate assessment, planning, implementation and evaluation are integral activities in the fulfillment of the registered nurse's responsibility and accountability. ...".

2) Failure to document the nursing intervention, reason for the patient's refusal, and physician notification for a patient's non-compliance with attending scheduled behavioral sessions in the hospital:
Patient #1
Review of the medical record for Patient #1 revealed he did not attend the behavioral sessions on:
11/9/10 for recreation
11/11/10 for recreation and coping skills
11/12/10 for recreation and disease process
11/13/10 for recreation, diet and nutrition, or current events
11/14/10 for exercise, positive lifestyle, or current news
11/15/10 for recreation
11/16/10 for recreation
11/17/10 for recreation
11/18/10 for recreation.
11/20/10 for exercise, diet and nutrition, or current events
11/21/10 for exercise, positive lifestyle changes, or current events

Further review of the nurse's progress notes revealed no nursing interventions and no documentation the attending physician had been notified of the patient's non-compliance with attending scheduled behavioral sessions in the hospital.

An interview was held with S4 RN on 11/23/10 at 1:10 pm. After review of the medical record for Patient #1, S4 RN verified there was no documentation in the medical record of nursing interventions, the patient's reason for the refusal, or that the attending physician had been notified of the patients non-compliance with attending scheduled behavioral sessions in the hospital.

Patient #2
Review of Patient #2's medical record revealed he was admitted on 11/15/10 with a diagnosis of Schizoaffective Disorder.
Review of Patient #2's "Group Notes" revealed he did not attend recreation therapy group on 11/18/10 and on two other occasions, with no documented evidence of the date by MHT (mental health technician) S18. Further review of the entire medical record revealed no documented evidence the RN and physician had been notified of Patient #2's non-compliance with group therapy, and the care plan was not updated to reflect the non-compliance.

Patient #6
Review of Patient #6's medical record revealed he was admitted on 11/15/10 with a diagnosis of Alzheimer's Dementia.
Review of Patient #6's "Group Notes" revealed he did not attend recreational group on 11/16/10, 11/18/10, 11/19/10, 11/20/10, and one other time with no documented evidence of the date by MHT S18. Further review revealed #6 did not attend group discussion of current events on 11/20/10 and 11/21/10, group discussion of diet and nutrition on 11/20/10, and group discussion of positive lifestyle choices on 11/21/10. Further review of the entire medical record revealed no documented the RN and physician had been notified of Patient #6's non-compliance with group therapy, and the care plan was not updated to reflect the non-compliance.

In a face-to-face interview on 11/23/10 at 1:05pm, RN Charge Nurse S4 indicated the RN attempts to get patients to attend group. She further indicated the RN notifies the physician of non-compliance with group attendance and documents it on a progress note that does not become a part of the patient's medical record. She confirmed, after reviewing Patients #2's and #6's medical records, that there was no evidence the physician had been notified of their non-compliance with group therapy.

Review of the hospital Policy and Procedure titled "Right to Refuse Treatment" revealed "...the client may at any time, refuse care, treatment, and services as set in Louisiana Mental Health Code (LRS 2-14). Documentation of the refusal, and the client's reason for the refusal, must be entered into the medical record to protect the legal interest of the facility..."

3) Failure to accurately perform a nutritional screening:
Patient #2
Review of Patient #2's medical record revealed he was admitted on 11/15/10 with a diagnosis of Schizoaffective Disorder. Review of the psychiatric evaluation revealed Patient #2 had diagnoses of hypertension and diabetes.
Review of Patient #2's admit orders dated 11/15/10 at 10:00am revealed a diet order of NAS (no added sugar) and NCS (no concentrated sweets) and the diabetic protocol of capillary blood glucose checks before meals and at bedtime.
Review of the nutritional screen portion of the nursing admission assessment performed by RN S7, who was also the Assistant Director of Nursing (ADON), on 11/15/10 at 11:20am, revealed no nutritional consult was needed. Further review revealed, in part, "...Nutritional Screen Critical High Risk Factors: Any risk factor triggers nutritional consultation for assessment. Inform physician nutritional consult needs to be ordered for any 1 of these conditions ... therapeutic diet... diabetes...".

In a face-to-face interview on 11/23/10 at 1:05pm, RN Charge Nurse S4, after reviewing Patient #2's chart, confirmed the nutritional assessment performed on admit was not accurate, since the patient had a therapeutic diet ordered and was diagnosed with diabetes. She indicated the registered dietitian did not review all patient records, and she only did nutritional consults when ordered after the RN's screening assessment.

Patient #6
Review of Patient #6's medical record revealed he was admitted on 11/15/10 with a diagnosis of Alzheimer's Dementia.
Review of Patient #6's physician admit orders revealed he was placed on a low fat diet.
Review of the nutritional screen portion of the nursing admission assessment performed by RN S7, who was also the ADON, on 11/18/10 at 1340 (1:40pm), revealed no nutritional consult was needed. Further review revealed, in part, "...Nutritional Screen Critical High Risk Factors: Any risk factor triggers nutritional consultation for assessment. Inform physician nutritional consult needs to be ordered for any 1 of these conditions ... therapeutic diet...".

In a face-to-face interview on 11/23/10 at 1:05pm, RN Charge Nurse S4, after reviewing Patient #6's chart, confirmed the nutritional assessment performed on admit was not accurate, since the patient had a therapeutic diet ordered.

Review of the hospital policy titled "Initial Assessment and Admission Process", with no documented evidence of an effective and review date and submitted by Assistant Administrator S1 as their current policy for the admission process, revealed, in part, "...Admitting Nurse ...reviews Initial Assessment and completes Nursing Initial Interview and Assessment. Completes all assessment triggers for evaluation of consults, precautions, and protocols.

Review of the hospital policy titled "Assessment & (and) Reassessment of Patients", with no documented evidence of the effective and review date and submitted by Assistant Administrator S1 as their current policy for the admission assessment, revealed, in part, "...At the time of admission assessment, the RN is to determine priority of patient care needs. More comprehensive assessments are performed when warranted by the patient's condition. Factors to be included when performing the admission assessment shall include, but not be limited to the following: ...9. Nutritional risk... The Assessment Process ... B. The RN analyzes the data and sets care priorities, formulating nursing diagnosis plan of care, health education and initiates referrals. ... D. On initial assessment, nurses screen patient, ... Nutritional criteria, to identify the need for specific consults for these services...".

4) Failure to accurately assess the fall risk:
Review of Patient #6's medical record revealed he was admitted on 11/15/10 with a diagnosis of Alzheimer's Dementia.
Review of the "Nursing Admit Note" documented by RN S7, who is also the ADON, on 11/15/10 at 1430 (2:30pm) revealed, in part, "...Presenting Symptoms: Patient presents with guarded affect, minimizes any problems, attempts to hide his confusion and disorientation. ...Patient is oriented to person and place. Patient was unsure of the month, stated it was the springtime, disoriented. ...Poor anger management, irritability, confusion...".
Review of the "At Risk For Falls (ARF) Score Sheet" revealed "a patient will be scored as follows: 0-5 low risk; 6-12 moderate risk (initiate fall precautions); 13-35 high risk (initiate fall precautions)". Review of the ARF assessment for Patient #6 performed by RN S7 on 11/15/10 revealed #6 was scored a "1" for being over 65 years of age and a "2" for being on hypnotic, neuroleptic, anti-anxiety or anti-depressant medications. Further review revealed RN S7 did not score Patient #6 a "5" for confused and disoriented, which would have placed Patient #6 at moderate risk for fall and would have warranted fall precautions.

In a face-to-face interview on 11/23/10 at 1:05pm, RN Charge Nurse S4, after reviewing Patient #6's chart, confirmed the fall risk assessment was inaccurate, since #6 was not scored as disoriented and confused according to his assessment by RN S7.

5) Failure to accurately perform an assessment of skin integrity:
Review of Patient #6's medical record revealed he was admitted on 11/15/10 with a diagnosis of Alzheimer's Dementia.
Review of Patient #6's "Medical History & Physical Examination" performed on 11/15/10 at 5:30pm revealed one of the medical problems to be addressed in treatment was a right wrist abrasion/skin tear.
Review of the "Skin Assessment" performed on 11/15/10 by RN S7, with no documented evidence of the time of the skin assessment, revealed "skin intact. No breakdown or impairment in skin integrity noted".

In a face-to-face interview on 11/23/10 at 1:05pm, RN Charge Nurse S4, after reviewing Patient #6's chart, confirmed the skin assessment performed by RN S7 upon admit was not accurate.

Review of the hospital policy titled "Initial Assessment and Admission Process", with no documented evidence of an effective and review date and submitted by Assistant Administrator S1 as their current policy for the admission process, revealed, in part, "...Admitting Nurse performs a complete body search. ...Admitting Nurse documents admission summary in progress notes to include: ...condition upon admission, ...summary of pertinent physical findings, ...summary of nurses' observations...".

6) Failure to supervise and evaluate the duties assigned to unlicensed personnel:
Patient #2
Review of Patient #2's medical record revealed he was admitted on 11/15/10 with a diagnosis of Schizoaffective Disorder.
Review of Patient #2's "Group Notes" revealed he did not attend recreation therapy group on 11/18/10 and on two other occasions, with no documented evidence of the date by MHT (mental health technician) S18. Further review of the entire medical record revealed no documented evidence the RN and physician had been notified of Patient #2's non-compliance with group therapy, and the care plan was not updated to reflect the non-compliance.





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25065




25452

Based on record reviews and interviews, the hospital failed to ensure the care plan: 1) was accurate for a patient with an admission diagnosis of psychosis (#1) for 1 of 20 sampled patients reviewed for accurate care plans from a total of 20 sampled patients and 2) was individualized and contained measurable goals for 2 of 20 patients' care plans reviewed for individualized care plans from a total sample of 20 medical records reviewed (#2, #6), and 3) failed to ensure the physician orders were followed for medication administration and/or ordered urinalysis and urine drug screen for 2 of 20 sampled patients reviewed for implementing physician orders from a total of 20 sampled patients (#3,#6). Findings:

1) Accurate for a patient with an admission diagnosis of psychosis:
Review of the medical record for Patient #1 revealed his admission diagnosis was dementia/psychosis. Further review of the initial problem list completed by the RN under "Problem- Altered thoughts: Psychosis" was labeled "N/A" with this entire section left blank. Review of the care plan section titled "Impaired Cognitive Functioning Related to: Dementia" was checked. Further review of the care plan revealed no documentation about the patient's psychosis.

An interview was held with S4 RN on 11/23/10 at 1:10 pm. After review of the care plan for Patient #1 she verified there was no care plan that addressed the patient's psychosis. She further indicated that diagnosis must have been over looked.

2) Individualized care plans with measurable goals:
Patient #2
Review of Patient #2's medical record revealed he was admitted on 11/15/10 with a diagnosis of Schizoaffective Disorder. Review of the psychiatric evaluation revealed Patient #2 had diagnoses of hypertension and diabetes.
Review of the problem list which was to include the patient's medical problems revealed Patient #2's problems identified were psychosis and discharge planning. There was no documented evidence that hypertension and diabetes were listed as medical problems.
Review of the "Multidisciplinary Treatment Plan" revealed the problem of psychosis was identified related to decreased functioning and impaired/disorganized thinking. The nursing short term goals included: 1) patient will establish meaningful communication with others within 5 days; 2) patient will have increased focus on reality based thoughts within 10 days; and 3) patient will respond appropriately to verbal interactions within 5 days. Further review revealed no documented evidence of the means to measure the expectations to determine if Patient #2's goals were met. Further review revealed the recreational therapist's goal was that the patient would demonstrate relaxed/socially appropriate behavior during tasks 60% (per cent) of the time. Further review revealed no documented evidence of a means of measurement to determine when Patient #2 had met the goal.
Review of the problem identified as discharge planning revealed no documented evidence of individualization of the care plan specifically for Patient #2. The long term and short term goals were pre-printed with no additions added by personnel to individualize it for Patient #2.
Review of the entire medical record revealed no documented evidence of a care plan developed and implemented for the diagnoses of hypertension and diabetes.

Patient #6
Review of Patient #6's medical record revealed he was admitted on 11/15/10 with a diagnosis of Alzheimer's Dementia.
Review of the problem list which was to include the patient's medical problems revealed Patient #6's problems identified were impaired cognitive functioning, discharge planning, and alteration in health maintenance. There was no documented evidence that alteration in skin integrity had been identified as a problem (patient was assessed by physician upon admit as having a right wrist abrasion/skin tear).
Review of the "Multidisciplinary Treatment Plan" revealed the care plan for impaired cognitive functioning related to dementia was initiated on 11/15/10. Further review revealed the long term and short term goals were pre-printed with only the number of days for the goal to be met filled in. There was no documented evidence how the staff would measure to determine if presenting signs and symptoms had decreased. Further review revealed the recreational therapist's goal was that the patient will redirect appropriately 40% of the time. There was no documented evidence what would determine appropriate redirection and how 40% would be determined.
Review of the care plan for discharge planning revealed no documented evidence of individualization of the care plan specifically for Patient #6. The long term and short term goals were pre-printed with no additions added by personnel to individualize it for Patient #6.

In a face-to-face interview on 11/23/10 at 12:30pm, LCSW (licensed clinical social worker) S5 indicated she considered Patient #2's and Patient #6's care plans individualized. She could offer no explanation when asked how the discharge planning care plan could be considered individualized when the goals were pre-printed and the same for all patients with no additions written specifically for Patient #2 and Patient #6. S5 further could offer no explanation when asked how she would measure the progress to determine if Patient #2 and Patient #6 had met their goals.

In a face-to-face interview on 11/24/10 at 8:35am, Certified Therapeutic Recreational Specialist S14 indicated he performed all recreational assessments and formulated the treatment plans. He further indicated he did not personally conduct groups; they were conducted by the MHTs (mental health technicians). After reviewing Patient #2's and Patient #6's care plans, S14 indicated it was his opinion that they were individualized and the short term goals were measurable. He further indicated he did not write long term goals, because the hospital was a short term facility. S14 confirmed that since he did not conduct group personally, he would not be able to determine if the patients' goals were met.

Review of the hospital policy titled "Multidisciplinary Treatment Planning", with no documented evidence of an effective and review date and submitted by Assistant Administrator S1 as their current policy for the multidisciplinary treatment plan, revealed, in part, "...A multidisciplinary treatment plan will be completed on all patients within ninety-six (96) hours of admission. Nursing must initiate the treatment plan at the time of admit by the admitting RN. Treatment plans must be individualized, active, and both short and long term goals and objectives behavioral, observable and measurable. All modalities will be scribed by the primary person, by identifying their name and credentials, who will be primarily responsible to carry out the intervention. Treatment Planning updates will occur every seven (7) days or sooner if needed. ...Documentation to support the patient's progress, or lack of progress will be addressed and the plan will be updated accordingly. ... Procedure: ...All care plan will include short and long term goals, expected outcomes and each discipline's intervention for reaching these goals. All medical problems must be addressed an the problem list/care plan. The nurse must cross reference the History and Physical, MD (medical doctor) orders, and MD progress notes to properly identify and address any medical and/or psychiatric problems arising throughout the course of the patients' stay...".

3) Ensure the physician orders were followed for medication administration and ordered urinalysis and urine drug screen:
Review of Patient #6's medical record revealed he was admitted on 11/15/10 with a diagnosis of Alzheimer's Dementia.
Review of Patient #6's physician admit orders revealed an order for a urinalysis with culture and sensitivity and a urine drug screen. Further review revealed a physician's order on 11/18/10 at 9:00am for Ativan 1 mg (milligram) TID (three times a day).
Review of the entire medical record revealed no documented evidence that the urine sample had been obtained and sent for the urinalysis with culture and sensitivity and the urine drug screen. Further review revealed Ativan was first administered on 11/18/10 at 8:00pm. There was no documented evidence of the reason Ativan was not administered on 11/18/10 at 2:00pm, which was the next scheduled time for medication administration after having received the order at 9:00am on 11/18/10.

In a face-to-face interview on 11/23/10 at 1:05pm, RN Charge Nurse S4 confirmed there was no documentation of a result of a urinalysis with culture and sensitivity and a urine drug screen for Patient #6. After checking lab requests, she indicated the record showed that the tests were requested. She further checked a "daily jot sheet of notes" that the nursing staff left for one another with notes of anything that was pending regarding lab tests, and S4 indicated there was no documentation on the jot sheet that anything was pending for Patient #6. S4 indicated the night nurse usually checked for lab reports as part of the 24 hour chart check, but they have no system in place for tracking that ordered tests were completed and the resulting report had been obtained. S4 indicated there was no documentation why the Ativan was not given at 2:00pm on 11/18/10, and she indicated it should have been administered at 2:00pm which was the scheduled time for a medication ordered TID.

Patient #3
Review of the medical record for patient #3 revealed the patient was admitted to the facility on 11/19/10. Review of the patient's admission orders reflected "Medications: See Med. List". Review of the Physician's Orders dated 11/19/10 reflected Ambien CR 12.5 mg (hypnotic) was not continued. Further review of the orders reflected Ambien 10 mg by mouth every night was ordered. Review of the November, 2010 Medication Administration Record (MAR) reflected the patient was ordered Ambien 12.5 mg by mouth every night.

Review of patient #3's narcotic medication record reflected the patient refused Ambien 12.5 mg on 11/19/10. Further review of the medication record reflected that on 11/20/10 and 11/21/10 "n/a" (not applicable) was noted in the initial blanks. Documentation on the November, 2010 MAR revealed the patient received Ambien (hypnotic) 2 (5 mg) tablets on 11/22/10 for the first time since the patient's admit date of 11/19/10.

Interview with S6, LPN on 11/23/10 at 8:30 a.m. confirmed that patient #3's medication order was written for Ambien 10 mg every night. S6, LPN further confirmed that chart checks had been done by both RN's and LPN's; however, the medication transcription error was not discovered until 11/22/10 at 9:00 p.m. (2100).

Based on record review and interview, the hospital failed to ensure medications were administered as ordered by the physician for 1 of 20 sampled patients reviewed for medication administration from a total of 20 sampled patients (#6). Findings:

Review of Patient #6's medical record revealed he was admitted on 11/15/10 with a diagnosis of Alzheimer's Dementia.
Review of Patient #6's physician orders revealed order on 11/18/10 at 9:00am for Ativan 1 mg (milligram) TID (three times a day).
Review of the MAR (medication administration record) revealed Ativan was first administered on 11/18/10 at 8:00pm. There was no documented evidence of the reason Ativan was not administered on 11/18/10 at 2:00pm, which was the next scheduled time for medication administration after having received the order at 9:00am on 11/18/10.

In a face-to-face interview on 11/23/10 at 1:05pm, RN Charge Nurse S4 confirmed there was no documentation why the Ativan was not given at 2:00pm on 11/18/10, and she indicated it should have been administered at 2:00pm which was the scheduled time for a medication ordered TID.

Based on observation, record review, and interviews, the hospital failed to ensure: 1) medical records were protected from fire and water damage by having medical records stored on open shelving in the locked medical record room with no means of protection from fire and water and 2) patient medical records were completed within 30 days of discharge by having 2 of 11 closed medical records from a total sample of 20 medical records without a completed discharge summary within 30 days of discharge (#15, #17) and 15 of 15 random patient records without a completed discharge summary within 30 days of discharge (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15). Findings:

1) Medical records protected from fire and water:
Observation of the medical record storage area on 11/23/10 at 2:55pm revealed a locked room that contained open shelving where the patient medical records were stored. Further observation revealed no means of protecting the records from fire or water damage.

In a face-to-face interview on 11/23/10 at 2:55pm Medical records Coordinator S2 confirmed there was no covering to protect the medical records from fire or water damage.

2) Patient medical records completed within 30 days of discharge:
Patient #15
Review of the closed medical record for Patient #15 revealed a discharge date of 05/06/10. Review of Patient #15's discharge summary revealed the dictation date was 09/19/10, which was 136 days after discharge.

In interview on 11/24/10 at 10:15 a.m., S1, Assistant Administrator, confirmed the discharge summary was not completed within 30 days after discharge. S1 further indicated the dictation tapes had malfunctioned leading to discharge summaries not being completed on time.

Patient #17
Review of Patient #17's "Physician Discharge Summary" revealed the patient was discharged on 6/02/10. Further review revealed the discharge summary was not dictated until 9/18/10.


Patient R1
Review of Patient R1's "Physician Discharge Summary" revealed he was discharged on 10/04/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated. As of 11/24/10 the discharge summary had not been authenticated by RN S25, and R1's medical record was not completed within 30 days of discharge.

Patient R2
Review of Patient R2's "Physician Discharge Summary" revealed she was discharged on 10/06/10. Further review revealed her discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated. As of 11/24/10 the discharge summary had not been authenticated by RN S25, and R2's medical record was not completed within 30 days of discharge.

Patient R3
Review of Patient R3's "Physician Discharge Summary" revealed she was discharged on 10/07/10. Further review revealed her discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated. As of 11/24/10 the discharge summary had not been authenticated by RN S25, and R3's medical record was not completed within 30 days of discharge.

Patient R4
Review of Patient R4's "Physician Discharge Summary" revealed she was discharged on 10/04/10. Further review revealed her discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated. As of 11/24/10 the discharge summary had not been authenticated by RN S25, and R4's medical record was not completed within 30 days of discharge.

Patient R5
Review of Patient R5's "Physician Discharge Summary" revealed he was discharged on 10/11/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated. As of 11/24/10 the discharge summary had not been authenticated by RN S25, and R5's medical record was not completed within 30 days of discharge.
Review of a second "Physician Discharge Summary" for Patient R5 revealed he was discharged on 10/21/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated. As of 11/24/10 the discharge summary had not been authenticated by RN S25, and R5's medical record was not completed within 30 days of discharge.

Patient R6
Review of Patient R6's "Physician Discharge Summary" revealed he was discharged on 10/14/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated. As of 11/24/10 the discharge summary had not been authenticated by RN S25, and R6's medical record was not completed within 30 days of discharge.

Patient R7
Review of Patient R7's "Physician Discharge Summary" revealed he was discharged on 10/19/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated. As of 11/24/10 the discharge summary had not been authenticated by RN S25, and R7's medical record was not completed within 30 days of discharge.

Patient R8
Review of Patient R8's "Physician Discharge Summary" revealed he was discharged on 10/13/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated. As of 11/24/10 the discharge summary had not been authenticated by RN S25, and R8's medical record was not completed within 30 days of discharge.

Patient R9
Review of Patient R9's "Physician Discharge Summary" revealed he was discharged on 10/21/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated. As of 11/24/10 the discharge summary had not been authenticated by RN S25, and R9's medical record was not completed within 30 days of discharge.

Patient R10
Review of Patient R10's "Physician Discharge Summary" revealed he was discharged on 10/11/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated. As of 11/24/10 the discharge summary had not been authenticated by RN S25, and R10's medical record was not completed within 30 days of discharge.

Patient R11
Review of Patient R11's "Physician Discharge Summary" revealed he was discharged on 10/04/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated. As of 11/24/10 the discharge summary had not been authenticated by RN S25, and R11's medical record was not completed within 30 days of discharge.

Patient R12
Review of Patient R12's "Physician Discharge Summary" revealed he was discharged on 10/05/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated. As of 11/24/10 the discharge summary had not been authenticated by RN S25, and R12's medical record was not completed within 30 days of discharge.

Patient R13
Review of Patient R13's "Physician Discharge Summary" revealed he was discharged on 09/29/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated. As of 11/24/10 the discharge summary had not been authenticated by RN S25, and R13's medical record was not completed within 30 days of discharge.

Patient R14
Review of Patient R14's "Physician Discharge Summary" revealed he was discharged on 10/01/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated. As of 11/24/10 the discharge summary had not been authenticated by RN S25, and R14's medical record was not completed within 30 days of discharge.

Patient R15
Review of Patient R15's "Physician Discharge Summary" revealed he was discharged on 10/18/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated. As of 11/24/10 the discharge summary had not been authenticated by RN S25, and R15's medical record was not completed within 30 days of discharge.

In a face-to-face interview on 11/23/10 at 2:55pm, Medical Records Coordinator S2 indicated the discharge summaries for Patients R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, and R15 had been dictated by RN S25 who is a RN who works for Physician S11. She further indicated RN S25 was not a hospital employee. S2 indicated RN S25 had dictated the discharge summaries, Physician S11 had signed them, and RN S25 had not returned to authenticate the discharge summaries.

In a face-to-face interview on 11/25/10 at 9:55 am, Medical Records Coordinator S2 indicated she had not counted the random patients' medical records as incomplete and delinquent, because she was told that once the discharge summary was printed, she could mark the record as completed in the computer system.

In a face-to-face interview on 11/24/10 at 11:15 am, Assistant Administrator S1 indicated she was responsible for Medical Records Coordinator S2 documenting the completion of patient medical records incorrectly. She indicated that she gave S2 the direction to mark it as completed once the discharge summary was printed.

Review of the "Medical Staff Rules and Regulations", revised 08/12/10 and approved by the governing body on 09/10/10 and submitted by Assistant Administrator S1 as their current rules and regulations, revealed, in part, "...7. Discharge Summary. A discharge summary shall be written or dictated on all medical records of patients hospitalized at the time of discharge but no later than 15 days following the patient's discharge. If this is not possible due to the absence of laboratory or other crucial and essential reports, a final progress note shall be written by the attending physician and shall include the final diagnosis. ... The discharge summary shall be dated, timed and authenticated by the 30th day after discharge. ...10. Delinquent Medical Records. A medical record is determined to be delinquent 30 days after a patient's discharge if all components of the medical record are not completed, dated, timed, and authenticated by the attending physician...".




25452




25892

Based on record reviews and interviews, the hospital failed to ensure all medical record entries were labeled, dated, timed, and authenticated by the person responsible for providing or evaluating the service provided for 5 of 5 medical records reviewed for time, date, patient identification, and authentication from a total sample of 20 charts ( #1, #4, #8, #9, #16 ). Findings:

Review of the medical record for Patient #1 revealed the 24 Hour Daily Nursing Assessment was not timed by the RN. Further review of the medical record revealed the three sections on the Group Notes from 11/09/10 through 11/21/10 were not timed.

Review of the medical record for Patient #4 revealed the Group Notes from 11/18/10 through 11/21/10 were not timed when completed. Further review of the Psychosocial Assessment (Social Worker/Therapist) form dated 11/17/10 revealed no time documented when completed.

Review of the medical record for Patient #8 revealed the following forms were not labeled with the patient's identification: Initial problem list, Social/Leisure Activity History and Assessment, Psychosocial Assessement (Social Worker/Therapist), and the Treatment Planning Data Form.

Review of the medical record for Patient #9 revealed the Physician Progress Notes on 11/17/10, 11/19/10, and 11/22/10 were not timed by the physician. Further review of the medical record revealed the three sections on the Group Notes from 11/19/10 through 11/21/10 were not timed. Review of a page in the section on the Group Notes revealed there was no date or time on the entire page to indicated when these activities occurred.

Review of the medical record for Patient #16 revealed the discharge summary was not dated or timed by the nurse that dictated the discharge summary or by the practitioner to verify that the content was accurate.

In interview on 11/23/10 at 2:00 p.m. S1, Assistant Administrator, indicated that all medical record entries should be labeled, dated, timed, and authenticated by the person responsible for providing or evaluating the service provided.

Review of the hospital Policy and Procedure titled "Documentation Guidelines" revealed "...All entries must be dated, timed, and signed with including credentials, as applicable..."







25892

25065

Based on record review and interview the hospital failed to ensure: 1) discharge summaries were dated and timed when authenticated by the registered nurse (RN) who was dictating discharge summaries for 3 of 11 closed medical records reviewed out of a total sample of 20 medical records (#15, #16, #19); 2) discharge summaries were dated and timed by the physician when co-authenticating discharge summaries to verify its content for 4 of 11 closed medical records reviewed out of a total sample of 20 medical records (#15, #16, #17, #19) and 15 of 15 random patient medical records (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15); and 3) the completion of discharge summaries were delegated to qualified health practitioners who had been credentialed/privileged to coordinate and dictate the discharge summaries for 3 of 3 closed medical records reviewed out of a total sample of 20 medical records (#15, #17, #19) and 15 of 15 random patient medical records (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15). Findings:

1) Discharge summaries dated and timed when authenticated by the RN who dictated the discharge summary:
Patient #15
Review of the discharge summary for Patient #15 revealed it was not dated and timed when authenticated by the registered nurse who was dictating the discharge summary for the attending physician.

Patient #16
Review of the discharge summary for Patient #16 revealed it was not dated and timed when authenticated by the registered nurse who was dictating the discharge summary for the attending physician.

Patient #19
Review of the discharge summary for Patient #19 revealed it was not dated and timed when authenticated by the registered nurse who was dictating the discharge summary for the attending physician.

2) Discharge summaries dated and timed by the physician when authenticating the discharge summary:
Patient #15
Review of the discharge summary for Patient #15 revealed it was not dated and timed by the physician when co-authenticating discharge summaries to verify the content .

Patient #16
Review of the discharge summary for Patient #16 revealed it was not dated and timed by the physician when co-authenticating discharge summaries to verify the content .

Patient #17
Review of the discharge summary for Patient #17 revealed it was not dated and timed by the physician when authenticating the discharge summary to verify the content.

Patient #19
Review of the discharge summary for Patient #19 revealed it was not dated and timed by the physician when co-authenticating discharge summaries to verify the content.

Patient R1
Review of Patient R1's "Physician Discharge Summary" revealed he was discharged on 10/04/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated.

Patient R2
Review of Patient R2's "Physician Discharge Summary" revealed she was discharged on 10/06/10. Further review revealed her discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated.

Patient R3
Review of Patient R3's "Physician Discharge Summary" revealed she was discharged on 10/07/10. Further review revealed her discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated.

Patient R4
Review of Patient R4's "Physician Discharge Summary" revealed she was discharged on 10/04/10. Further review revealed her discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated.

Patient R5
Review of Patient R5's "Physician Discharge Summary" revealed he was discharged on 10/11/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated.
Review of a second "Physician Discharge Summary" for Patient R5 revealed he was discharged on 10/21/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated.

Patient R6
Review of Patient R6's "Physician Discharge Summary" revealed he was discharged on 10/14/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated.

Patient R7
Review of Patient R7's "Physician Discharge Summary" revealed he was discharged on 10/19/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated.

Patient R8
Review of Patient R8's "Physician Discharge Summary" revealed he was discharged on 10/13/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated.

Patient R9
Review of Patient R9's "Physician Discharge Summary" revealed he was discharged on 10/21/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated.

Patient R10
Review of Patient R10's "Physician Discharge Summary" revealed he was discharged on 10/11/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated.

Patient R11
Review of Patient R11's "Physician Discharge Summary" revealed he was discharged on 10/04/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated.

Patient R12
Review of Patient R12's "Physician Discharge Summary" revealed he was discharged on 10/05/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated.

Patient R13
Review of Patient R13's "Physician Discharge Summary" revealed he was discharged on 09/29/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated.

Patient R14
Review of Patient R14's "Physician Discharge Summary" revealed he was discharged on 10/01/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated.

Patient R15
Review of Patient R15's "Physician Discharge Summary" revealed he was discharged on 10/18/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated. The discharge summary was signed by Physician S11 with no documented evidence of the date and time the summary was authenticated.

In interview on 11/23/10 at 2:00 p.m. S1, Assistant Administrator, indicated that discharge summaries should be timed and dated at the time of authentication by the registered nurse or the physician co-authenticating the discharge summary.

Review of the "Medical Staff Rules and Regulations", revised 08/12/10 and approved by the governing body on 09/10/10 and submitted by Assistant Administrator S1 as their current rules and regulations, revealed, in part, "...All clinical entries and summaries shall be accurately dated, timed, and authenticated...".

3) Completion of discharge summaries were delegated to qualified health practitioners who had been credentialed/privileged to coordinate and dictate the discharge summaries:
Review of the discharge summary for Patient #15 revealed a dictation date of 09/19/10. Further review revealed the discharge summary was dictated by S1, Assistant Administrator.

Review of the discharge summary for Patient #17 revealed a dictation date of 9/18/10. Further review revealed the discharge summary was dictated by S1 Assistant Administrator.

Review of the discharge summary for Patient #19 revealed a dictation date of 06/10/10. Further review revealed the discharge summary was dictated by S25, RN.

Patient R1
Review of Patient R1's "Physician Discharge Summary" revealed he was discharged on 10/04/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated.

Patient R2
Review of Patient R2's "Physician Discharge Summary" revealed she was discharged on 10/06/10. Further review revealed her discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated.

Patient R3
Review of Patient R3's "Physician Discharge Summary" revealed she was discharged on 10/07/10. Further review revealed her discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated.

Patient R4
Review of Patient R4's "Physician Discharge Summary" revealed she was discharged on 10/04/10. Further review revealed her discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated.

Patient R5
Review of Patient R5's "Physician Discharge Summary" revealed he was discharged on 10/11/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated.
Review of a second "Physician Discharge Summary" for Patient R5 revealed he was discharged on 10/21/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated.

Patient R6
Review of Patient R6's "Physician Discharge Summary" revealed he was discharged on 10/14/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated.

Patient R7
Review of Patient R7's "Physician Discharge Summary" revealed he was discharged on 10/19/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated.

Patient R8
Review of Patient R8's "Physician Discharge Summary" revealed he was discharged on 10/13/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated.

Patient R9
Review of Patient R9's "Physician Discharge Summary" revealed he was discharged on 10/21/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated.

Patient R10
Review of Patient R10's "Physician Discharge Summary" revealed he was discharged on 10/11/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated.

Patient R11
Review of Patient R11's "Physician Discharge Summary" revealed he was discharged on 10/04/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated.

Patient R12
Review of Patient R12's "Physician Discharge Summary" revealed he was discharged on 10/05/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated.

Patient R13
Review of Patient R13's "Physician Discharge Summary" revealed he was discharged on 09/29/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated.

Patient R14
Review of Patient R14's "Physician Discharge Summary" revealed he was discharged on 10/01/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated.

Patient R15
Review of Patient R15's "Physician Discharge Summary" revealed he was discharged on 10/18/10. Further review revealed his discharge summary was dictated on 11/07/10 by RN S25 with no documented evidence of the time it was dictated.

The hospital list of employees was reviewed which revealed that S25, RN, was not an employee of the hospital. Review of the hospital's contracts revealed that S25, RN, had not been contracted by the hospital.

In a face-to-face interview on 11/23/10 at 2:55pm, Medical Records Coordinator S2 indicated the discharge summaries for Patients R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, and R15 had been dictated by RN S25 who is a RN who works for Physician S11. She further indicated RN S25 was not a hospital employee.

In interview on 11/24/10 at 2:00 p.m., S1, Assistant Administrator, indicated that S25, RN, was not an employee or contractor for the hospital. S1 further indicated that S25, RN, worked for S11, MD, and was responsible for dictating discharge summaries for this physician. S1 further confirmed that one of her duties (S1's) is to dictate discharge summaries for the physicians at the hospital. Review of the personnel file for S1, Assistant Administrator, revealed no documented evidence of credentialing by the medical staff to dictate discharge summaries.

Review of the hospital policy/procedure manual and medical staff by-laws revealed the hospital failed to develop a policy/procedure that addressed delegating dictation of discharge summaries to other qualified health care personnel.
















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Based on record review and interview, the hospital failed to ensure medication orders were accurate by having medication orders without the route of administration and the site for ointment application for 1 of 20 sampled patient records reviewed for accurate medication orders from a total of 20 sampled patients (#6). Findings:

Review of Patient #6's medical record revealed he was admitted on 11/15/10 with a diagnosis of Alzheimer's Dementia.

Review of Patient #6's physician orders revealed an order on 11/15/10, with no documented evidence of the time the order was written, to "apply triple Abx (antibiotic) ointment BID & PRN" (twice a day and as needed). Further review revealed no documented evidence of the site to which the ointment was to be applied. Further review revealed an order on 11/18/10 at 9:00am for Ativan 1 mg (milligram) TID (three times a day). Further review revealed no documented evidence of the route of administration.

In a face-to-face interview on 11/23/10 at 1:05pm, RN Charge Nurse S4 confirmed the orders for the antibiotic ointment and Ativan should have been clarified to include the site of application and the route of administration, respectively.

Based on interview, the hospital failed to ensure the radiologist contracted to interpret radiological testing had been credentialed and approved by the medical staff and governing body. Findings:

In a face-to-face interview on 11/23/10 at 1:55pm, Assistant Administrator S1 indicated the medical staff and governing body had not credentialed and privileged the contracted radiologist who was responsible for interpreting radiological tests for the hospital.

Based on record review and interview the hospital failed to ensure the infection control officer was qualified through education, training, experience, or certification to direct the hospital's infection control program.
Findings:

Review of the personnel file for S24, Director of Nursing, revealed she was designated as the hospital's infection control officer on 07/01/08. Review S24's entire personnel file revealed no documented evidence of training in infection control from a nationally recognized organization or certification in infection control. Further there was no documented evidence that S24, DON, had prior experience as an infection control officer. S24, DON, was unavailable for interview during the survey.

In interview on 11/24/10 at 10:00a.m., S1, Assistant Administrator, confirmed that S24, DON, was the hospital's designated infection control officer. S1 further confirmed that there was no documented evidence of infection control training and experience in S24, DON's personnel file. S1 further indicated that S24, DON, had worked under and received training from a certified infection control officer at a previous employer. S1 could provide no documented evidence of the specific infection control training that was provided to S24, DON, from her previous employer.

Based on observation, record review, and interviews, the hospital failed to ensure the infection control officer: 1) maintained a sanitary physical environment regarding food sanitation by having unlabeled and undated food containers in the patient nourishment refrigerator and freezer and 2) implemented and monitored the hospital policy for employee screening for TB (tuberculosis) which resulted in 9 of 12 MHTs' (mental health technicians) personnel files reviewed for TB screening being out of compliance (S15, S16, S17, S18, S19, S20, S21, S22, S23) and 1 of 1 psychologist's credentialing file reviewed with no documented evidence of TB screening (S12). Findings:

1) Sanitary physical environment regarding food sanitation:
Observation of the patient nourishment refrigerator/freezer on 11/22/10 at 11:40am, with Assistant Administrator S1 present, revealed: 1) an unlabeled and undated Styrofoam cup containing butter with a plastic spoon placed in the butter with a paper towel placed over the top of the cup in the refrigerator; 2) an unlabeled and undated partially-filled bottle of drinking water that had colored flavoring added to it in the refrigerator; 3) a container of chocolate pudding with the foil lid partially loosened that provided visibility of the pudding by the surveyor in the refrigerator; 4) an unlabeled and undated plastic container with cooked beans and meat placed in a plastic grocery bag in the refrigerator; and 5) an unlabeled and undated container containing partially-eaten ice cream cake in the freezer.

In a face-to-face interview on 11/22/10 at 11:45am, Assistant Administrator S1 confirmed the above findings. She indicated the nursing home was responsible for the dietary contents in the patient nourishment refrigerator/freezer.

Review of the hospital policy titled "Refrigerator, Freezers and Ice Machines", effective 05/01/06 and submitted by Assistant Administrator S1 as their current policy for maintaining the patient nourishment refrigerator/freezer, revealed, in part, "...Refrigerators freezers and ice machines will be maintained for patient safety and for general cleanliness. All patient and employee items placed in their designated refrigerators must be labeled with either patient and or staff name and dated. After 3 days of original date, all items must be discarded. ... Nourishment Refrigerators: Nursing responsibility daily recording of temperature. Use only for patient nourishment provided by FANS (food and nutritional services). ...FANS Responsibility when restocking nourishment refrigerator, FANS staff will remove expired items and discard all food which was not placed in refrigerator by dietary....Dietary Refrigerators: are strictly monitored per department protocol ... ".

2) B screening for employees and psychologist:
Review of MHT S15's "Annual Tuberculosis Screening Documentation" revealed she received a PPD (purified protein derivative) skin test on 01/05/10, and it was read on 01/08/10. Further review revealed no documented evidence of the times of administration and the reading of results to ensure the test was read no sooner than 48 hours of administration and no more than 72 hours after it was administered.

Review of MHT S16's "PPD Skin Testing" revealed the test was administered on 01/20/10 and read on 01/22/10. Further review revealed no documented evidence of the times of administration and the reading of results to ensure the test was read no sooner than 48 hours of administration and no more than 72 hours after it was administered.

Review of MHT S17's "Annual Tuberculosis Screening Documentation" revealed the test was administered on 12/21/09 and read on 12/25/09, which was greater than 72 hours after administration.

Review of MHT S18's "Annual Tuberculosis Screening Documentation" revealed the PPD skin test was administered on 01/05/10, and it was read on 01/08/10. Further review revealed no documented evidence of the times of administration and the reading of results to ensure the test was read no sooner than 48 hours of administration and no more than 72 hours after it was administered.

Review of MHT S19's employee health file revealed no documented evidence that he had been tested for TB since 05/16/09.

Review of MHT S20's "Tuberculosis Screening Documentation" revealed he was tested for TB on 08/17/10 at 11:35am. Further review revealed the test was read on 08/20/10 at 12:00pm, which was greater than 72 hours after the test was administered.

Review of MHT S21's "Tuberculosis Screening Tool" revealed the test was administered on 02/05/10 and read on 02/08/10. Further review revealed no documented evidence of the times of administration and the reading of results to ensure the test was read no sooner than 48 hours of administration and no more than 72 hours after it was administered.

Review of MHT S22's employee health file revealed no documented evidence S22 had been tested for TB since 09/25/09.

Review of MHT S23's employee health file revealed no documented evidence S23 had been tested for TB since 12/18/08.

Review of Psychologist S12's credentialing file revealed no documented evidence that S12 had been tested for TB.

In a face-to-face interview on 11/24/10 at 11:00am, Assistant Administrator S1 indicated she had no documented evidence to provide that Psychologist S12 had been tested for TB. She further indicated one of the quality indicators for infection control monthly was to check for updated health information of the employees. She further indicated MHT/Human Resource Coordinator S23 was responsible for printing the list of employee health information a month in advance to give to DON (director of nursing) S24 who was the Infection Control Officer for the hospital. S1 could offer no explanation for the lack of documented times of administration and reading, the expired TB results, and the TB tests that were read greater than 72 hours after administration.

Review of the hospital policy titled "Employee Health Program", submitted by Assistant Administrator S1 as their current policy for TB testing, revealed, in part, "...An assessment will be conducted by Infection Control/Employee Health staff before personnel begin duty, when they are given a different work assignment with new tasks, and annually. ...Procedure: ... 3. Conduct routine screening for TB using intradermal (Mantoux (5 tuberculin units) PPD test on all employees, unless history positive. ...If history positive, a chest x-ray is done. ...The annual assessment will include: 1. Routine screening for TB using intradermal Mantoux, (5 tuberculin units) PPD test on all employees, unless history positive. Chest x-rays are done only if employee is symptomatic for TB e.g. (that is), lasting more than three weeks, unexplained weight loss, or night sweats. Positive PPD converters will have a chest x-ray. If the chest x-ray is normal, no work restriction is required ...".

Based on record review and interviews, the hospital failed to ensure each patient had an individualized comprehensive treatment plan by having treatment plans that were pre-printed and used for all patients with the same diagnosis for 2 of 20 patients reviewed for individualized comprehensive treatment plans from a total of 20 sampled patients (#2, #6). Findings:

Patient #2
Review of Patient #2's medical record revealed he was admitted on 11/15/10 with a diagnosis of Schizoaffective Disorder. Review of the psychiatric evaluation revealed Patient #2 had diagnoses of hypertension and diabetes.

Review of the problem list which was to include the patient's medical problems revealed Patient #2's problems identified were psychosis and discharge planning. There was no documented evidence that hypertension and diabetes were listed as medical problems.

Review of the "Multidisciplinary Treatment Plan" revealed the problem of psychosis was identified related to decreased functioning and impaired/disorganized thinking. The nursing long term goal was : patient will demonstrate absence of hallucinations and/or delusions. Further review revealed short term goals included: 1) patient will establish meaningful communication with others within 5 days; 2) patient will have increased focus on reality based thoughts within 10 days; and 3) patient will respond appropriately to verbal interactions within 5 days. Further review revealed no documented evidence of additions to the pre-printed goals that individualized the plan specifically for Patient #2.

Review of the problem identified as discharge planning revealed no documented evidence of individualization of the care plan specifically for Patient #2. The long term was that he/she will be in agreement with discharge plans. The short term goals included: he/she will participate in discharge planning and 2) he/she will identify preferences for post-hospital care. The goals were pre-printed with no additions added by personnel to individualize it for Patient #2.
Review of the entire medical record revealed no documented evidence of a care plan developed and implemented to address Patient #2's diagnoses of hypertension and diabetes.

Patient #6
Review of Patient #6's medical record revealed he was admitted on 11/15/10 with a diagnosis of Alzheimer's Dementia.

Review of the problem list which was to include the patient's medical problems revealed Patient #6's problems identified were impaired cognitive functioning, discharge planning, and alteration in health maintenance. There was no documented evidence that alteration in skin integrity had been identified as a problem (patient was assessed by physician upon admit as having a right wrist abrasion/skin tear).

Review of the "Multidisciplinary Treatment Plan" revealed the care plan for impaired cognitive functioning related to dementia was initiated on 11/15/10. Further review revealed the long term goal included that he/she will experience therapeutic response from medications structure and close supervision prior to discharge. Further review revealed the short term goals included: 1) he/she will be 100% (per cent) compliant with medication regime times 12 days; 2) he/she presenting signs and symptoms will be decreased times 7 consecutive days; 3) he/she will comply with verbal re-direction within 5 days. Further review revealed the goals were pre-printed with no additions made by the staff to individualize the care plan specifically for Patient #6.
Review of the care plan for discharge planning revealed no documented evidence of individualization of the care plan specifically for Patient #6. The long term and short term goals were pre-printed and the same as those implemented for Patient #2 with no additions added by personnel to individualize it for Patient #6.

In a face-to-face interview on 11/23/10 at 12:30pm, LCSW (licensed clinical social worker) S5 indicated she considered Patient #2's and Patient #6's care plans individualized. She could offer no explanation when asked how the discharge planning care plan could be considered individualized when the goals were pre-printed and the same for both patients with no additions written specifically for Patient #2 and Patient #6.

In a face-to-face interview on 11/24/10 at 8:35am, Certified Therapeutic Recreational Specialist S14 indicated he performed all recreational assessments and formulated the treatment plans. He further indicated he did not write long term goals, because the hospital was a short term facility.

Review of the hospital policy titled "Multidisciplinary Treatment Planning", with no documented evidence of an effective and review date and submitted by Assistant Administrator S1 as their current policy for the multidisciplinary treatment plan, revealed, in part, "...A multidisciplinary treatment plan will be completed on all patients within ninety-six (96) hours of admission. Nursing must initiate the treatment plan at the time of admit by the admitting RN. Treatment plans must be individualized, active, and both short and long term goals and objectives behavioral, observable and measurable. ...Procedure: ...All care plan will include short and long term goals, expected outcomes and each discipline's intervention for reaching these goals. All medical problems must be addressed an the problem list/care plan. The nurse must cross reference the History and Physical, MD (medical doctor) orders, and MD progress notes to properly identify and address any medical and/or psychiatric problems arising throughout the course of the patients' stay...".

Based on record review and interviews, the hospital failed to provide treatment plans that identified specific patient-related short-term and long-term goals stated in observable, measurable, and behavioral terms for 2 of 20 patients reviewed for patient-specific treatment plans from a total of 20 sampled patients (#2, #6). The goals were generic and not specific to the patient's needs for recovery. This hindered the treatment team's ability to measure treatment changes and could contribute to failure to modify plans in response to patient needs. Findings:

Patient #2
Review of Patient #2's medical record revealed he was admitted on 11/15/10 with a diagnosis of Schizoaffective Disorder. Review of the psychiatric evaluation revealed Patient #2 had diagnoses of hypertension and diabetes.

Review of the problem list which included the patient's medical problems revealed Patient #2's problems identified were psychosis and discharge planning. There was no documented evidence that hypertension and diabetes were listed as medical problems.

Review of the "Multidisciplinary Treatment Plan" revealed the problem of psychosis was identified related to decreased functioning and impaired/disorganized thinking. The nursing long term goal was that the patient will demonstrate absence of hallucinations and/or delusions. Further review revealed short term goals included: 1) patient will establish meaningful communication with others within 5 days; 2) patient will have increased focus on reality based thoughts within 10 days; and 3) patient will respond appropriately to verbal interactions within 5 days. Further review revealed no documented evidence of how these goals would be measured to determine if the goal was met or if the treatment plan required modification. Further review revealed the recreational therapist's goal was that the patient would demonstrate relaxed/socially appropriate behavior during tasks 60% (per cent) of the time. Further review revealed no documented evidence of a means of measurement to determine when Patient #2 had met the goal.

Review of the problem identified as discharge planning revealed no documented evidence of individualization of the care plan specifically for Patient #2. The long term goal was that he/she will be in agreement with discharge plans. The short term goals included: he/she will participate in discharge planning and 2) he/she will identify preferences for post-hospital care. There was no documented evidence of the means of measurement to determine when the goals were met or if the treatment plan required modification.
Review of the entire medical record revealed no documented evidence of a care plan with short-term and long-term goals developed and implemented to address Patient #2's diagnoses of hypertension and diabetes.

Patient #6
Review of Patient #6's medical record revealed he was admitted on 11/15/10 with a diagnosis of Alzheimer's Dementia.

Review of the problem list which was to include the patient's medical problems revealed Patient #6's problems identified were impaired cognitive functioning, discharge planning, and alteration in health maintenance. There was no documented evidence that alteration in skin integrity had been identified as a problem (patient was assessed by physician upon admit as having a right wrist abrasion/skin tear).

Review of the "Multidisciplinary Treatment Plan" revealed the care plan for impaired cognitive functioning related to dementia was initiated on 11/15/10. Further review revealed the long term goal included that he/she will experience therapeutic response from medications structure and close supervision prior to discharge. Further review revealed the short term goals included: 1) he/she will be 100% (per cent) compliant with medication regime times 12 days; 2) he/she presenting signs and symptoms will be decreased times 7 consecutive days; 3) he/she will comply with verbal re-direction within 5 days. Further review revealed the goals were pre-printed with no additions made by the staff to individualize the care plan specifically for Patient #6. Further review revealed the recreational therapist's goal was that the patient will redirect appropriately 40% of the time. There was no documented evidence what would determine appropriate redirection and how 40% would be determined.

Review of the care plan for discharge planning revealed no documented evidence of individualization of the care plan specifically for Patient #6. The long term and short term goals were pre-printed and the same as those implemented for Patient #2 with no additions added by personnel to individualize it for Patient #6.

In a face-to-face interview on 11/23/10 at 12:30pm, LCSW (licensed clinical social worker) S5 indicated she considered Patient #2's and Patient #6's care plans individualized. She could offer no explanation when asked how the discharge planning care plan could be considered individualized when the goals were pre-printed and the same for both patients with no additions written specifically for Patient #2 and Patient #6.

In a face-to-face interview on 11/24/10 at 8:35am, Certified Therapeutic Recreational Specialist S14 indicated he performed all recreational assessments and formulated the treatment plans. He further indicated he did not personally conduct groups; they were conducted by the MHTs (mental health technicians). After reviewing Patient #2's and Patient #6's care plans, S14 indicated it was his opinion that they were individualized and the short term goals were measurable. He further indicated he did not write long term goals, because the hospital was a short term facility. S14 confirmed that since he did not conduct group personally, he would not be able to determine if the patients' goals were met.

Review of the hospital policy titled "Multidisciplinary Treatment Planning", with no documented evidence of an effective and review date and submitted by Assistant Administrator S1 as their current policy for the multidisciplinary treatment plan, revealed, in part, "...A multidisciplinary treatment plan will be completed on all patients within ninety-six (96) hours of admission. Nursing must initiate the treatment plan at the time of admit by the admitting RN. Treatment plans must be individualized, active, and both short and long term goals and objectives behavioral, observable and measurable. ...Procedure: ...All care plan will include short and long term goals, expected outcomes and each discipline's intervention for reaching these goals. All medical problems must be addressed an the problem list/care plan. The nurse must cross reference the History and Physical, MD (medical doctor) orders, and MD progress notes to properly identify and address any medical and/or psychiatric problems arising throughout the course of the patients' stay...".

Based on record review and interviews, the hospital failed to develop treatment interventions based on the individual needs of the patients for 2 of 20 sampled patients reviewed for treatment plan interventions from a total sample of 20 patients (#2, #6). The interventions listed were generic, routine duties of hospital personnel rather than focused on the specific needs of the patients. Findings:

Patient #2
Review of Patient #2's medical record revealed he was admitted on 11/15/10 with a diagnosis of Schizoaffective Disorder. Review of the psychiatric evaluation revealed Patient #2 had diagnoses of hypertension and diabetes.

Review of Patient #2's treatment plan for psychosis related to decreased functioning and impaired/disorganized thinking revealed the following clinical interventions:
Physician will direct treatment plan and team on admit, prescribe and evaluate effectiveness of medication as needed and meet with the patient one-on-one three times a week to assess psychiatric status, offer support and opportunity to express feelings;
Nursing will: educate on disease process/symptom management with nursing group for 30 minutes per day three times a week; institute relaxing, quieting activities before bedtime; assess frequency and intensity of hallucinations, behavior, appetite, mood and cognitive ability every day and opportunities to interact and disclose feelings with peers and staff daily; monitor, evaluate, and educate on the importance of compliance with anti-psychotic medications, effectiveness and side effects and treatment one-on-one with patient as per initial assessment, with each new medication change, and via medication education groups 30 minutes three times a week; reinforce reality orientation as needed for duration of treatment; and redirect patient as necessary;
Social Services will: gather history and assess level of functioning during first 72 hours; gain the patient's cooperation to facilitate active participation in the formulation of their treatment plan within 96 hours; assist the patient to increase insight into his or her mental illness by reviewing reality-based evidence and his/her misinterpretation of reality via groups and or individual sessions; demonstrate acceptance through calm, nurturing manner, good eye contact, and active listening; reinforce socially and emotionally appropriate responses to others; encourage patient to remain medication-compliant; assist patient in reducing threat in the environment; and provide group process therapy 40 minutes five days per week to reinforce reality based and cognitive based thoughts; and
Therapeutic Recreational staff will provide a safe environment.
Further review revealed all interventions were pre-printed as the same to be used for all patients with no additions made to Patient #2's to individualize it to meet his needs.

Review of Patient #2's treatment plan for discharge planning revealed the following clinical interventions to be performed by Social Services: assist patient in exploring discharge options that are realistic and viable; assist patient to obtain information regarding alternate living situations; make appropriate referrals and provide necessary information for continuity of care; re-assess patient's capacity for self-care, ability to return to pre-hospital setting and family support on an ongoing basis in treatment team meetings or sooner if needed; provide a one-to-one discharge session to educate him/her, family/caregiver(s) about post hospital care plans; and re-assess his/her feelings regarding preparation for discharge within 48 to 72 hours prior to discharge. Further review revealed all interventions were pre-printed as the same to be used for all patients with no additions made to Patient #2's to individualize it to meet his needs.

Patient #6
Review of Patient #6's medical record revealed he was admitted on 11/15/10 with a diagnosis of Alzheimer's Dementia.

Review of the treatment plan for impaired cognitive functioning related to dementia revealed the following clinical interventions:
Physician will prescribe, adjust, and monitor his/her psychotropic medications twice weekly;
Nursing will: provide safety and structure with clues for 24 hour reality orientation; implement every 15 minute close observations per physician orders; assess cognitive impairment upon admission; monitor and record his/her mental status and behavior daily; give simple step by step instructions; be alert to underlying fears and needs in his/her verbal statements; approach him/her in calm, slow manner, using his/her name for reality orientation; reinforce positive responses and behaviors, assist or provide him/her ADL's (activities of daily living) daily; monitor his/her nutritional status via meal consumption 3 times daily and weekly weights;
Social Work will provide opportunities for reminiscing in group therapy for 45 minutes daily or individual therapy as needed; and Therapeutic Recreational Therapy staff will provide a safe environment.

Review of the treatment plan for discharge planning revealed the same clinical interventions listed above for Patient #2. Further review revealed all interventions were pre-printed as the same to be used for all patients with no additions made to Patient #6's to individualize it to meet his needs.

Review of the care plan for alteration in health maintenance related to medical treatment and comfort alteration revealed the following clinical interventions:
Physician will assess physical needs and address per consultations and provide orders for treatment and medications;
Nursing will assess vital signs and assess physical status at least twice daily and notify physician of any abnormal findings; educate on signs and symptoms of disease process 30 minutes per day three times a week; educate on importance of diet and exercise to promote physical health in symptoms management group or individually 30 minutes per day three days per week; provide medications and treatments as ordered; and monitor his/her daily medication responses including any medication side effects and report to the physician. Further review revealed all clinical interventions were generic-pre-printed interventions with only the number of minutes and days per week individualized for Patient #6.

In a face-to-face interview on 11/23/10 at 12:30pm, LCSW (licensed clinical social worker) S5 indicated she considered Patient #2's and Patient #6's care plans individualized. She could offer no explanation when asked how the clinical interventions on the discharge planning care plan could be considered individualized when the goals were pre-printed and the same for all patients with no additions written specifically for Patient #2 and Patient #6.
In a face-to-face interview on 11/24/10 at 8:35am, Certified Therapeutic Recreational Specialist S14 indicated he performed all recreational assessments and formulated the treatment plans. He further indicated he did not personally conduct groups; they were conducted by the MHTs (mental health technicians). After reviewing Patient #2's and Patient #6's care plans, S14 indicated it was his opinion that they were individualized. He could offer no explanation as to what interventions would be implemented by the MHTs while providing a safe environment.

Review of the hospital policy titled "Multidisciplinary Treatment Planning", with no documented evidence of an effective and review date and submitted by Assistant Administrator S1 as their current policy for the multidisciplinary treatment plan, revealed, in part, "...A multidisciplinary treatment plan will be completed on all patients within ninety-six (96) hours of admission. Nursing must initiate the treatment plan at the time of admit by the admitting RN. Treatment plans must be individualized, active, and both short and long term goals and objectives behavioral, observable and measurable. All modalities will be scribed by the primary person, by identifying their name and credentials, who will be primarily responsible to carry out the intervention. Treatment Planning updates will occur every seven (7) days or sooner if needed. ...Documentation to support the patient's progress, or lack of progress will be addressed and the plan will be updated accordingly. ... Procedure: ...All care plan will include short and long term goals, expected outcomes and each discipline's intervention for reaching these goals. All medical problems must be addressed an the problem list/care plan. The nurse must cross reference the History and Physical, MD (medical doctor) orders, and MD progress notes to properly identify and address any medical and/or psychiatric problems arising throughout the course of the patients' stay...".

Based on record review and interview, the hospital failed to provide consistent, individualized therapeutic activities by having all recreational therapy groups conducted by mental health technicians (MHTs) (whose competency had not been assessed) rather than the certified therapeutic recreational specialist for 2 of 20 sampled patients reviewed for therapeutic recreational activities from a total of 20 sampled patients (#2, #6). Findings:

Patient #2
Review of Patient #2's medical record revealed he was admitted on 11/15/10 with a diagnosis of Schizoaffective Disorder. Review of the psychiatric evaluation revealed Patient #2 had diagnoses of hypertension and diabetes.

Review of the medical record revealed the "Social/Leisure Activity History and Assessment" was performed by CRTS (certified therapeutic recreational therapist) S14 on 11/15/10 at 5:30pm. Further review revealed the goal was for Patient #2 to exhibit a decrease in paranoid behavior. Review of the "Multidisciplinary Treatment Plan" revealed CRTS S14's goal for Patient #2 was that he would demonstrate relaxed/socially appropriate behaviors during tasks 60% (per cent) of the time, and the clinical intervention was that the therapeutic recreational staff would provide a safe environment.

Review of Patient #2's "Group Notes" revealed all recreational therapy groups were conducted by MHTs. Further review revealed Patient #2 did not attend recreation therapy group on 11/18/10 and on two other occasions, with no documented evidence of the date by MHT (mental health technician) S18. Further review of the entire medical record revealed no documented evidence the RN and physician had been notified of Patient #2's non-compliance with group therapy, and the care plan was not updated to reflect the non-compliance. There was no documented evidence of alternative clinical interventions attempted by the therapeutic recreational staff.

Patient #6
Review of Patient #6's medical record revealed he was admitted on 11/15/10 with a diagnosis of Alzheimer's Dementia.

Review of the medical record revealed the "Social/Leisure Activity History and Assessment" was performed by CRTS S14 on 11/15/10 with no documented evidence of the time the assessment was performed. Further review revealed S14's goal for Patient #6 was that he would demonstrate increased reality functioning prior to discharge.

Review of Patient #6's "Multidisciplinary Treatment Plan" revealed the CRTS goal for Patient #6 was that he would re-direct appropriately 40% of time, and the clinical intervention was to provide a safe environment.

Review of Patient #6's "Group Notes" revealed he did not attend recreational group on 11/16/10, 11/18/10, 11/19/10, 11/20/10, and one other time with no documented evidence of the date by MHT S18. Further review of the entire medical record revealed no documented evidence the RN and physician had been notified of Patient #6's non-compliance with group therapy, and the care plan was not updated to reflect the non-compliance. There was no documented evidence of alternative clinical interventions attempted by the therapeutic recreational staff.

In a face-to-face interview on 11/24/10 at 8:35am, Certified Therapeutic Recreational Specialist S14 indicated he performed all recreational assessments and formulated the treatment plans. He further indicated he did not personally conduct groups; they were conducted by the MHTs. After reviewing Patient #2's and Patient #6's care plans, S14 indicated he did not write long term goals, because the hospital was a short term facility. S14 confirmed that since he did not conduct group personally, he would not be able to determine if the patients' goals were met. Regarding the training of MHTs to conduct group therapy, S14 indicated he in-serviced MHTs on coping skills which included anger management, assertiveness training, and stress management. He further indicated he educated on leisure activities such as participating in arts and crafts, board activities, exercises, and listening to music. S14 indicated the last in-service he provided was about one year ago. He further indicated he did not attend treatment team meetings and confirmed there was no interaction between him and the physician regarding patients' progress towards goals or the lack of progress. S14 indicated he educated MHTs but had never performed an assessment of the competency of any MHT for their duties regarding recreational therapy activities.

Review of the job description signed by CRTS S14 on 05/29/09 revealed the following essential job functions: "provides direct therapeutic recreation therapy services in accordance with accepted standards of therapeutic recreation practice ... plans and conducts individual and group therapy as assigned by Administrator or physician's order ... participates as an active member of the treatment team by A. attending/assigning treatment team meetings when indicated and reporting on assigned patients and their progress toward treatment goals ...".

Review of MHT S18's personnel file, the MHT who conducted group therapy for Patients #2 and #6, revealed her job description did not include the duties of conducting recreational therapy groups. Further review revealed S18 attended an in-service on 05/29/09 presented by CTRS S14 on "Facilitating Groups/Documentation/Recreational Therapy" and an in-service on 06/05/09 presented by CTRS S14 on "Supervision of Groups/Documentation/Recreational Therapy". Review of MHT S18's "Activity Therapy Competency Checklist" revealed her competency was assessed by a nurse on 12/30/09. There was no documented evidence of an assessment by a CTRS.

Review of the hospital policy titled "Multidisciplinary Treatment Planning", with no documented evidence of an effective and review date and submitted by Assistant Administrator S1 as their current policy for the multidisciplinary treatment plan, revealed, in part, "...A multidisciplinary treatment plan will be completed on all patients within ninety-six (96) hours of admission. Treatment plans must be individualized, active, and both short and long term goals and objectives behavioral, observable and measurable. All modalities will be scribed by the primary person, by identifying their name and credentials, who will be primarily responsible to carry out the intervention. Treatment Planning updates will occur every seven (7) days or sooner if needed. ...Documentation to support the patient's progress, or lack of progress will be addressed and the plan will be updated accordingly. ... Procedure: ...All care plan will include short and long term goals, expected outcomes and each discipline's intervention for reaching these goals. All medical problems must be addressed on the problem list/care plan...".