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Based on medical record review, review of facility documents, facility policy review, and interview, the facility failed to ensure the protection from abuse for one patient (#19) of thirty patients reviewed. The facility's failure to ensure protection from abuse placed patient #19 in Immediate Jeopardy.

The Director of Quality Assurance and Risk Management was informed of the Immediate Jeopardy on August 4, 2010, at 2:10 p.m., in the office of the Director of Quality Assurance and Risk Management.

The findings included:

Refer to A-145 Standard: The patient has the right to be free from all forms of abuse or harassment related to the facility's failure to report internally and to the state an abuse allegation in a timely manner; failure to investigate an allegation of abuse in a timely manner; and failure to ensure patient's protection from the alleged perpetrator of abuse prior to completion of an investigation into the allegation of abuse.

Refer to A-147 Standard: The patient has the right to confidentiality of his or her medical record. The facility failed to protect the confidentiality of the medical records of one of eleven units.

Refer to A-173 Standard: A physician's order must be obtained for the use of continued restraints beyond the time limit documented in the prior order. The facility failed to ensure restraint orders for the continued use of restaints for patient #3 and patient #7.

Based on medical record review, review of facility documents, facility policy review, and interview, the facility failed to 1.) ensure the right to be free from abuse for one patient (#19) of thirty patients reviewed; failed to 2.) ensure an incident of abuse was reported in a timely manner for one patient (#19) of thirty patients reviewed; failed to 3.) ensure a timely and thorough investigation into the allegation of abuse for one patient (#19) of thirty patients reviewed; and failed to 4.) ensure hospitalized patients' protection from abuse during an investigation into an allegation of abuse.

The findings included:

Patient #19 was admitted to the Emergency Department (ED) on July 28, 2010, at 8:16 p.m., with the Chief Complaint of Decreased Level of Consciousness for 30 minutes. Medical record review of the Pre - Hospital Patient Care Report, completed by the Emergency Medical Service (EMS) member transporting the patient to the hospital dated July 27, 2010, at 7:48 p.m., revealed "...Poss (possible) seizure. Arrived to find patient lying in the floor...Awake but disoriented...did become more alert during tx (transport)..." Medical record review revealed on arrival to the ED the patient was placed in room 22. Continued medical record review revealed, on arrival, the patient's vital signs were documented as temperature of 98 degrees, pulse of 100 beats per minute, respirations of 18 breaths per minute, blood pressure of 152/101, and oxygen saturation of 99%. Continued medical record review revealed the patient was seen by the physician on July 28, 2010, at 8:33 p.m. Continued medical record review revealed the Physician Assistant (PA #1) documented "per EMS, pt (patient) was found wandering around (named store) without shoes...unable to obtain (UTO) documented for: associated symptoms; ROS (review of symptoms); and past history. Continued review of the documentation by PA #1 revealed "...obtunded (very dulled sensorium), unequal pupils minimally reactive to light, airway intact, depressed gag reflex, and moves all extremities...Clinical Impression: Substance Abuse...Drug intoxication..." Continued medical record review of the Emergency Physician Record, no date or time noted, revealed "Progress: improved, re-examined, being combative with nursing staff, yelling, spitting, reportedly tries to grab staff and pulling at (named indwelling urinary) catheter. Pt restrained for own protection and protection of nursing staff...restraints re-evaluated. Pt more awake but still not alert. Restraints still required...2:45 a.m. Pt calming...Alert. Restraints removed. Pt non-combative..." Continued medical record review revealed the Physician's Restraint Orders, dated July 28, 2010, at 9:10 p.m., were to restrain all limbs. Medical record review of the Restraint Flow Sheet revealed Additional Notes as follows: 11:25 p.m. (July 28, 2010) - Pt spitting and yelling at (doctor #1). Tape placed on pt's mouth per (doctor #1) to prevent exposure of pt's saliva to medical staff; 11:50 p.m. - tape removed. Pt calmer; 12:20 a.m. (July 29, 2010) - pt resting quietly; 1:00 a.m. - yelling at intervals; 1:20 a.m., leg restraints released; 2:00 a.m. - arm restraints released; 2:30 a.m. - resting quietly; 3:00 a.m. - resting quietly; 3:30 a.m. - pt given D/C (discharge) inst (instructions). Pt inquiring about who to call to C/O (complain) treatment by M.D. (medical doctor). Given ED Director."

Patient #18 (spouse of patient #19) was admitted via EMS to the ED on July 28, 2010, at 8:28 p.m., with chief complaint of Decreased Mental Status. Medical record review revealed "...there is some evidence of Ultram (analgesic) abuse...Diagnosis: Substance Abuse, Unknown Drug Overdose...9:20 p.m. trying to get up and pulling off O2 (oxygen) and IV (intravenous access for installation of fluids and/or medications) and (named indwelling urinary catheter)..." Continued review revealed a Physician's Restraint Order, dated July 28, 2010, at 9:30 p.m. for two point (bilateral wrist) restraints. Continued medical record review revealed "...11:25 p.m., crying and yelling at (spouse - patient #19) in TR (trauma room) 2...11:30 p.m., yelling loudly and cursing medical staff...began kicking and grabbed (Registered Nurse - RN #1) shirt and yelling 'he hit me, he hit me'...tried to release (patient #18) hand from shirt while (RN #2) held legs (of patient #18) after (patient #18) kicked (RN#1) in the face and kicked (RN #1) glasses to the floor...(doctor #1) at bedside...Patient (#18) moved to CI #2 (close monitoring room)...11:59 p.m., went in room...(patient #18) no longer has IV...reports pulled it out...no longer in restraints..." Continued medical record review of the Emergency Department Nursing Notes, dated July 29, 2010, at 12:45 a.m., revealed "Discharged to waiting room...to await ride home..."

Review of facility's complaint documentation revealed the facility was contacted on July 30, 2010, at 2:01 p.m., by phone by the spouse of patient #19 to file a complaint alleging the facility staff had been violent towards and physically assaulted the patient, the patient's lip "was busted" when (patient #19) was hit by the staff. Continued review revealed the spouse wanted the complaint investigated.

Continued review revealed the Director of the ED was notified of the complaint on July 30, 2010, at 2:05 p.m.

Continued review revealed Registered Nurse (RN) #1, on duty in the ED July 28 - 29, 2010, 7:00 p.m. through 7:00 a.m., submitted a written account, dated August 2, 2010, at 3:25 a.m., of the events surrounding the complaint, which revealed "...I witnessed (doctor #1)...place the tape over the patient's mouth..."

Continued review revealed RN #2, on duty in the ED July 28 - 29, 2010, 7:00 p.m. through 7:00 a.m., submitted a written account, dated August 2, 2010, at 4:03 a.m., of the events surrounding the complaint, which revealed "...I witnessed (doctor #1) covering the clients mouth with surgical tape. I did not witness it, but I quickly gathered the client was spitting at the staff..."

Continued review revealed the ED RN shift-leader on duty July 28 - 29, 2010, 7:00 p.m. through 7:00 a.m., submitted a written account, dated August 2, 2010, at 12:13 a.m., of the events surrounding the complaint, which revealed "On July 28, 2010, I was the shift leader on duty in the Emergency Department...I received a radio report that (patient #19) was being brought to the ED with a report of Seizures and possible drug overdose...The patient was placed in room 22...Shortly after (patient #19's) arrival, I received a report of an unresponsive (patient #18), reportedly the spouse of (patient #19). (patient #18) was assigned to trauma room #1...I was notified (patient #19) had decreased mental status and decreased gag reflex...I went to room 22 to assess the situation...the nurse and physician in room with (patient #19)...(patient #19) had deteriorated and the decision was made to move (patient #19) to trauma room 2 for the possibility of intubation to control the airway...Some time passed and (patient #19) became more responsive and agitated...began removing monitoring devices and attempting to remove IV (intravenous catheter for the provision of fluids) and (named indwelling catheter)...did not respond to any interventions and was placed in two point restraints...(patient #19) escalated and was placed in four point restraints...(patient #18) and (patient #19) began arguing, screaming and cursing between each other, with one in trauma room 1 and the other in trauma room 2...(patient #19) began to scream...(doctor #1) enters the room...has a wooden tongue blade in hand and tells the patient 'you need to shut the (expletive) up'...the patient begins to curse (doctor #1) and (doctor #1) uses the tongue depressor to push the patient's head back down in the bed. (doctor #1) then states 'don't you listen you need to shut the (expletive) up, this is an ED and you are creating a problem, there are kids and others in here that don't want to hear your mouth' The patient raises back up and (doctor #1) taps (patient #19) on the forehead with the tongue depressor. The patient starts screaming...and tries to raise up again. At this time the (doctor #1) places the tongue depressor under the patient's nose and pushes (patient #19) back onto the bed and takes a 2 inch silk tape and places across (patient #19's) mouth. I told (doctor #1) he should not tape the patient's mouth and suggested we utilize another method to control the situation. I informed (doctor #1) the patient still had a Head CT (computerized imaging of the brain/head) ordered and (patient #19) could not be scanned in this condition and suggested we RSI (Rapid Sequence Intubation - placement of airway and initiation of sedative medication) the patient. Went out of room to get the RSI box. Upon returning the patient's mouth had multiple strips of tape on it. I again told (doctor #1) that it was not right to tape the patient's mouth and we needed to do something else so we could properly treat the patient and obtain the CT. (doctor #1) stated 'the (expletive) piece of (expletive) doesn't need a CT, there's nothing wrong with (patient #19's) brain since (patient #19) is acting this way and I'm not wasting resources on (patient #19). Cancel the CT!'...I stepped out of the room and told (doctor #2) I needed to talk with them about the situation...Nursing staff were advised to move (patient #18) to CI 1 to help de-escalate the situation...(patient #18) escalates and staff are heard telling (patient #18) to let go and stop kicking them...(patient #18) continued to scream and (doctor #1) entered the room. (doctor #1 goes to the bin with 4X4's (4 inch by 4 inch gauze pads) and grabs a handful and walks to (patient #18) with the 4X4's and tape in hand...I step in and state 'you can't do that, it's not right'. (doctor #1) states 'what the (expletive)...I immediately go to (doctor #2) and inform them (patient #19) had been pushed in the face and head with a tongue depressor and the mouth taped shut. (doctor #2) states 'we can't do that' I stated I know, but (doctor #1) did and I need your help to get the patient taken care of and the tape off (patient #19) (doctor #2) stated they would talk to (doctor #1) and I could go get the tape off (patient #19)...I noticed (doctor #1) and (doctor #2) speaking...Upon reaching (patient #19) I noted (patient #19) appeared terrified and the tape had come loose from the right side of the mouth...I immediately took the tape completely off...(patient #19) began to get loud again...(patient #19) stated 'that (expletive) doctor just hit me while I was in restraints...punched me in the mouth" Upon looking at the tape, I noted some blood. (patient #19) asked me to look at their lips and I took a wet cloth and wiped the blood off their lips. I noted a small abrasion to the top lip and a small cut to the inside bottom lip. (patient #19) continued to ask why the doctor had hit them in the mouth. I informed (patient #19) I reported it to (doctor #2) and would report it to the ED Director...After an extended period of time, I was able to successfully calm (patient #19) down and step outside the room. I requested the House Supervisor to come to the ED and I spoke with (doctor #2). (doctor #2) told me that (doctor #1) had told them that they had 'done this before and they could justify their actions and there was not a problem' (doctor #2) stated (doctor #1) is a Senior Partner and they had done what they could to help...(patient #19) continued to calm down and was ultimately signed out AMA (against medical advice). After (patient #19) was out of all restraints (patient #18) was taken into the room to be with (patient #19) while discharge paperwork was completed..."

Interview in the ED conference room on August 3, 2010, at 7:30 a.m., with the House Supervisor (Registered Nurse on duty responsible for hospital supervision) on duty on July 28 - 29, 2010, for the 7:00 p.m. to 7:00 a.m. shift, revealed the House Supervisor did receive a notice to call the ED on July 28, 2010. Continued interview revealed the House Supervisor did return a call and was told by the ED secretary the problem was resolved. Continued interview revealed the House Supervisor was not informed of what the problem involved but the House Supervisor did not feel a need to inquire further as sometime a call is received if the staff are looking for equipment or supplies and the item is found before the House Supervisor returns the call.

Interview in the ED conference room with the ED secretary on duty on July 28 -29, 2010, for the 7:00 p.m. to 7:00 a.m. shift, revealed the ED secretary did receive a request from the RN ED shift-leader to contact the House Supervisor and have them call the ED. Continued interview revealed the RN ED shift-leader did not inform the ED secretary of the reason for needing the House Supervisor. Continued interview revealed the ED secretary thought the reason was due to the loud behavior of patients #18 and #19. Continued interview revealed the House Supervisor did return the call and was informed by the ED secretary the situation had resolved. Continued interview revealed the ED secretary did not inform the RN ED shift-leader the House Supervisor had called. Continued interview confirmed the ED secretary did not have the authority to make decisions for the RN ED shift-leader regarding when to cancel a call to the House Supervisor.

Interview in the ED conference room with the Director of the ED on August 2, 2010, at 3:00 p.m., confirmed was informed on July 29, 2010, at 8:15 a.m., by the RN ED shift-leader of the events of July 28 - 29, 2010, related to the allegation of abuse. Continued interview revealed the Director of the ED "...thought the tape was placed (on patient #19's mouth) by RN #1..." as the medical record documentation was not clear that doctor #1 placed the tape on patient #19's mouth. Continued interview confirmed the ED Director allowed RN #1, who was the RN suspected by the ED Director of having placed the tape on the mouth of patient #19, to work 7:00 p.m. to 7:00 a.m. on July 29 - 30, 2010, despite not having completed the investigation into the allegations. Continued interview revealed the ED Director asked RN #1 to complete a written statement on the 7:00 p.m. to 7:00 a.m. shift on July 29 - 30, 2010. Continued interview revealed an email (electronic communication) regarding the concerns of RN ED shift - leader related to the allegation of abuse by doctor #1 was sent to the Quality Assurance/Risk Management department on July 29, 2010.

Interview in the ED conference room with RN #1 on August 3, 2010, at 7:35 a.m., confirmed RN #1 did observe doctor #1 placing tape on the mouth of patient #19 on July 28, 2010, unable to recall time. Continued interview revealed RN #1 related patient #19 was yelling, cursing and spitting prior to the tape being placed. Continued interview revealed RN #1 did not observe doctor #1 shoving, pushing, hitting, or cursing patient #19. Continued interview revealed RN #1 did not feel placing tape on mouth of patient #19 was abuse as the patient was not harmed and placing tape on the mouth of a patient was not covered in the abuse training.

Interview in the ED conference room with RN #2 on August 3, 2010, at 7:45 a.m., revealed RN #2 did observe the tape on the mouth of patient #19, but had not observed when it was placed. Continued interview revealed RN #2 did not observe doctor #1 shoving, hitting, pushing, or cursing patient #19. Continued interview revealed RN #2 was unsure if the placing of tape on the mouth of patient #19 was abuse. Continued interview confirmed RN #2 understood the facility's abuse policy required immediate reporting but RN #2 did not fill out the required report as RN #2 overheard the RN ED shift-leader of the 7:00 p.m. to 7:00 a.m. shift talking about the reporting the occurrence.

Interview on August 3, 2010, at 8:00 a.m., with the RN shift-leader on duty in the ED on July 28 - 29, 2010, 7:00 p.m. through 7:00 a.m., in the ED conference room, confirmed on July 28 - 29, 2010, on the 7:00 p.m. through 7:00 a.m. shift, patient #19, and patient #19's spouse, patient #18, had been admitted to the ED via EMS for decreased mental status and suspected drug overdose. Continued interview revealed Patient #18 was placed in trauma room 1 on arrival and patient #19 was placed in room 22. Continued interview revealed patient #19 began to experience decreased level of consciousness and there was a possibility of the need for intubation necessitating moving patient #19 to trauma room 2, next door to trauma room 1 where patient #18, the spouse of patient #19, was located. Continued interview revealed patient #18 and patient #19 required the use of restraints for attempting to remove medical devices. Interview revealed patient #19 and patient #18 began experiencing increased agitation and were yelling and screaming at one another. Continued interview revealed the RN ED shift-leader witnessed doctor #1 enter trauma room; curse at patient #19; push a tongue blade into the forehead of patient #19 on two occasions and push a tongue blade into the area below the nose of patient #19 on one occasion when patient #19 attempted to rise up in the bed; and placed a strip of two inch wide silk tape across the patient's mouth to reportedly prevent the patient's spit from getting on the staff. Continued interview revealed the RN ED shift-leader was unable to say if the spit was intentional or as a result of the screaming and yelling of patient #19. Continued interview with the RN ED shift-leader revealed upon returning to trauma room 2 after retrieving the RSI box, RN ED shift-leader noted patient #19 had 2 inch wide silk tape covering an area from under the nose to under the chin and area from left ear to right ear of the cheeks. Continued interview revealed the RN ED shift-leader witnessed doctor #1 go over to trauma room 2 when patient #18 began escalating with screaming and yelling and witnessed doctor #1 gather a handful of 4X4 gauze pads and a roll of silk tape. Continued interview revealed the RN ED shift-leader stepped between patient #18 and doctor #1 to prevent doctor #1 from taping patient #18's mouth. Continued interview with the RN ED shift-leader revealed doctor #2 was advised of the situation and spoke with doctor #1. Continued interview revealed the ED secretary was asked to page the house supervisor but the house supervisor never came to the ED. Continued interview with the RN ED shift-leader revealed the RN ED shift-leaded for the 7:00 a.m. to 7:00 p.m. shift, on July 29, 2010, was given a copy of the chart and asked to give the chart of patient #19 to the ED Director related to patient's mouth being taped and for the ED Director to call upon review. Continued interview with the RN ED shift-leader confirmed the ED Director had been informed of the events of July 28 - 29, 2010, related to doctor #1's actions toward patient #19. Continued interview with the RN ED shift-leader revealed the ED Director was informed by phone of the events on July 29, 2010, around 8:00 a.m. Continued interview with the RN ED shift-leader confirmed an Occurrence Report was not completed immediately per the facility's Abuse policy and statements of staff observations were not obtained until August 2, 2010.

Interview in the ED conference room with the Medical Director of the ED on August 3, 2010, at 11:50 a.m., revealed first hearing about the taping of the mouth of patient #19 from the ED Director July 29, 2010, in the afternoon. Continued interview revealed the Medical Director of the ED spoke with doctor #1 on July 29, 2010, in the evening. Continued interview revealed doctor #1 related felt placing the tape on the mouth of the out of control patient (#19) was the best course of action. Continued interview revealed the Medical Director of the ED counseled doctor #1 on other actions which might be utilized in these situations. Continued interview revealed the Medical Director of the ED did not feel the placing of the tape on the mouth of patient #19 presented a danger. Continued interview revealed placing tape on the mouth of patient #19 may or may not be abuse, "it's a gray area" Continued interview confirmed the physicians must follow facility policies. Continued interview revealed had the additional information related to the allegations of shoving, pushing, cursing, and punching of patient #19 by doctor #1 been available to the Medical Director of the ED, doctor #1 would have been asked not to work until the investigation was completed. Continued interview confirmed doctor #1 was not informed not to work in the ED until the completion of the investigation; and doctor #1 worked in the ED on August 2, 2010, on the day shift, 7:00 a.m. to 3:00 p.m.

Interview in the ED conference room with doctor #2 on August 3, 2010, at 12:35 p.m., revealed the RN ED shift-leader for the 7:00 p.m. to 7:00 a.m. shift on July 28 - 29, 2010, had informed doctor #2 of the concerns related to doctor #1 placing the tape on the mouth of patient #19. Continued interview revealed doctor #2 spoke with doctor #1 related to the RN ED shift-leader's concerns over doctor #1 placing tape on the mouth of patient #19. Continued interview revealed doctor #2 received what was felt to be a rational reason for placing tape on the mouth of patient #19 by doctor #1. Continued interview revealed doctor #2 did not examine patient #19.

Interview by phone with the facility Chief of Staff on August 4, 2010, at 12:20 p.m., revealed, on August 2, 2010, around 12:00 p.m., the Chief of Staff became aware doctor #1 had placed tape on the mouth of patient #19. Continued interview revealed the Chief of Staff did not feel doctor #1's placing of tape on the mouth of patient #19 was so egregious that any action needed to be taken related to having doctor #1 not work in the ED until a complete investigation had occurred as there was no threat to the patient. Continued interview revealed the Chief of Staff was not aware of the allegations of doctor #1 cursing, pushing, shoving and hitting patient #19. Continued interview revealed if all the information regarding the allegations against doctor #1 had been available, doctor #1 would have been removed from the ED work schedule until the investigation was completed.

Interview in the ED conference room with doctor #1 on August 2, 2010, beginning at 2:25 p.m., confirmed doctor #1 admitted cursed patient #19; had no recall of using a tongue blade to push patient #19 down in the bed "...it broke before I could get over there I was so mad..."; did tape the mouth of patient #19 "...to keep spit off the staff...wasn't harmful to the patient...trained in the use of tape to keep people from spitting...last used in the past five years...can't remember if it has been used here (facility) or not...in past used an O2 mask taped to the face..." and did not feel like the use of tape was abuse. Continued interview confirmed doctor #1 first heard about the facility's concerns related to the taping of patient #19's mouth on July 31, 2010, unsure of the time, by the Director of the ED.

Review of an email (electronic mail communication) from the Director of the ED to the Quality Assurance/ Risk Management department, dated July 29, 2010, at 8:36 a.m., revealed "FYI (for your information) we had a patient in the ED last night and (their) mouth was taped shut due to spitting. (RN ED shift-director) says (doctor #1) did it but when you look at the chart it looks like (RN #1) did it...It is charted that the mouth was taped shut. Tape was on the mouth about 30 minutes."

Review of the computer calendar page, dated July 29, 2010, at 12:30 p.m., of the Director of Quality Assurance/ Risk Management revealed "Mtg (meeting) regarding employee suspension related to (patient #19) in (Vice President of Patient Care's) office.

Review of an email from the Director of the ED to the Vice President of Patient Care, dated July 29, 2010, at 4:22 p.m., revealed (doctor #1) said he "...did put tape on (patient #19's) mouth and that (the RN ED shift-leader) got the situation started by putting the husband and wife in the same (area) which started a shouting match and (patient #19) began spitting and cursing and he (doctor #1) had as much as he can stand so he put tape on (patient #19's) mouth. (doctor #1) said the RN ED shift-leader tried to get (doctor #1) to paralyze and Intubate (patient #19)."

Review of an email from the Quality Assurance/Risk Management Department to the facility's Administrator, dated July 30, 2010, at 2:08 p.m., revealed "FYI - official complaint made by the (spouse) of patient whose mouth was taped shut.

Review of an email from the Director of Quality Assurance/Risk Management to the Facility Administrator, dated July 30, 2010, at 3:36 p.m., revealed "I wanted to send you an email following our conversation yesterday about the patient (#19) whose mouth was taped shut by (doctor #1). The patient's (spouse) has formally filed a complaint and based on our knowledge of events, we will be required to report this to TN (Tennessee) Department of Health. I wanted you to know because I feel pretty certain (doctor #1's) part of this will be further investigated under the licensing board, I have spoken with (the ED Director) who is working on retrieving written statements from employees. I would also suggest that you have (doctor #1) provide us a written response of his account as well. I will be reporting this first thing Monday after I have all written statements in hand..."

Review of the facility "Abuse Policy", issued July 13, 2010, revealed "...each patient has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, misappropriation of his/her property and to be treated with respect and dignity at all times. Each patient has the right to considerate, respectful, protective, supportive care for his/her physical, psychological social, emotional concerns and respect for his/her personal values and beliefs in an environment that preserves dignity and contributes to positive self-image...each patient has the right to freedom from all forms of abuse/harassment, neglect and exploitation by spouse, family, friends, staff member, visitor, healthcare provider, and other patients...any inpatient or outpatient facility employee with first hand account of a suspected occurrence of patient abuse...will complete an Occurrence Report...forwarded to Risk Management as soon as possible...The occurrence will be analyzed and should the review substantiate the likelihood of patient abuse by staff, Risk Management will issue a report to the appropriate state and/or regulatory agency...an employee who is under investigation for alleged abuse will be suspended pending investigation..."

Interview in the Medical Office Building conference room with the Vice President of Patient Care Services on August 4, 2010, at 8:15 a.m., confirmed the policy had not been followed for the reporting of abuse; and the investigation had not been completed timely before allowing the alleged perpetrator of abuse to return to caring for patients.

Interview in the Medical Office Building conference room with the Director of Quality Assurance and Risk Management on August 4, 2010, at 10:35 a.m., confirmed the facility policy had not been followed for the reporting of abuse; the occurrence had not been reported to the state agency at that time; the investigation had not been completed timely before allowing the alleged perpetrator of abuse to return to caring for patients, and the statements from the staff involved had not been obtained until August 2, 2010.



C/O 26507

Based on observation and interview, the facility failed to ensure patient records were secured and not accessible to unauthorized individuals for one (3 East) of eleven inpatient units observed.

The findings included:

Observations and interviews with the Clinical Leader and Clinical Educator of 3 East on August 3, 2010, from 11:20 a.m., until 11:40 a.m., on the 3 East unit, confirmed the unit was a twelve bed unit and had eight patients on August 3, 2010. Further observations and interviews confirmed the patients' medical records were stored in a chart holder on the outside wall of each patient room, beside the door. Further observations and interviews confirmed the unit had open visiting hours and families and visitors were allowed on the unit at any time and without having to check with facility staff. Further observations and interviews confirmed the only staff member in the hall between 11:20 a.m., and 11:40 a.m., was a case manager who was talking on the phone, documenting in a patient record, and was not watching activities in the hallway.

Observation and interview with the Clinical Educator of 3 East on August 3, 2010, at 11:40 a.m., on the 3 East hallway, confirmed the patient records were accessible to anyone walking down the hall and were not secured from unauthorized individuals.

Based on medical record review, observation, and interview, the facility failed to ensure physician's orders for restraints were complete for one patient (#3); and failed to renew the order within 24 hours for restraint for one patient (#7) of five patients with restraints reviewed.


The findings included:

Patient #3 was admitted to the facility on July 13, 2010, with a diagnosis of Upper GI (gastrointestinal) Bleed.

Medical record review of the physician's orders dated July 16 through August 2, 2010, revealed the patient had orders for physical restraints signed daily. Medical record review of the physician's orders for restraints dated July 28 and 29, 2010, revealed the physician did not time the orders or indicate a time period the restraints were to be implemented.

Interview and medical record review with the Associate Clinical Leader of 4 West on August 3, 2010, at 8:55 a.m., at the 4 West nursing station, confirmed the patient was in a vest restraint on July 28 and 29, 2010; the facility required all physical restraint renewal orders to be completed every 24 hours with the time indicated on the order; and the physician's orders for the restraints dated July 28 and 29, 2010, did not have a time indicated.




21161


Patient #7 was admitted to the facility on July 27, 2010, with diagnoses including Subarachnoid Hemorrhage.

Observation of patient #7 on August 3, 2010, at 1:55 p.m., revealed the patient lying in bed without restraints.

Medical record review of the physician's orders dated July 27, 2010, and timed 7:49 p.m., revealed patient #7 was restrained with a vest restraint for safety and to protect "tubes and lines from being removed".

Medical record review of the physician's orders and nurses' notes dated July 27-August 1, 2010, revealed the patient remained restrained as the physician ordered.

Medical record review of the Physician's renewal order dated July 29, 2010, revealed the order for the vest restraint was timed 7:30 p.m..
Medical record review of the Physician's renewal order dated July 30, 2010, revealed the order for the vest restraint was timed 11:22 p.m.
Medical record review of the nurses' notes dated July 30, 2010, revealed the resident was restrained from 7:30 p.m. to 11:22 p.m..

Interview with the Interim Clinical Leader on August 3, 2010, at 2:08 p.m., confirmed patient #7 was restrained from 7:30p.m. to 11:22p.m. on July 30, 2010, without an order from the physician.

Based on review of credentialing files, review of Medical Staff Bylaws, and interview, the facility failed to ensure Medical Staff bylaws were followed for credentialing of one physician (doctor #1) of six physicians reviewed.

The findings included:

Review of a credentialing file for doctor #1 revealed the following Reappointment Letter recommendations:
1) August 29, 2003: reappointed to Active staff; did not attend at least one Department of Medicine or Department of Surgery meeting in 2001 and 2002; required to attend (1) of both Department of Medicine and Quarterly Staff meetings each year; was deficient in 6 hours of CMEs (Continuing Medical Education credits); physician had 6 months to correct the deficiencies or would be changed to Associate staff.
2) August 22, 2005: reappointed to Active staff; was deficient in 13.75 CMEs; physician had 6 months to correct deficiencies or would be changed to Associate staff.
3) June 26, 2007: reappointed to Active staff; was deficient in 28.25 CMEs; had not renewed CPR (cardiopulmonary resuscitation) in last 5 years; physician had 6 months to correct deficiencies or be changed to Associate staff.
4) June 8, 2009: reappointed to Active staff; was deficient in 50 CMEs; physician had 6 months to correct deficiencies or be changed to Associate staff.
5) February 16, 2010 - February 16, 2012 appointment period: reappointed to Active staff; was deficient in 19 CMEs; physician had 6 months to correct deficiencies or be changed to Associate staff.

Review of the Medical Staff bylaws adopted June 26, 2001, and amended June 15, 2010, revealed "Each member of the Active Staff shall...Satisfies CME requirement of 50 hours of Category I credits every two years..."

Review of doctor #1's CMEs dated December 17, 1999, through May 1, 2009, revealed the physician obtained 44 hours between July 31, 2002, and August 6, 2003, for a deficiency of 6 hours (as noted in the reappointment letter). Continued review revealed the physician obtained 20.25 hours on August 6, 2003, with 6 hours used to meet the 50 hour requirement, and the additional 14.25 hours applied to the next two year appointment period. Continued review revealed the physician obtained 21.75 hours on August 7, 2005, for a total of 36 hours, a 14 hour deficiency (reappointment letter indicated 13.75 hour deficiency). Continued review revealed, in the 6 month period allowed to correct the deficiency, the physician obtained only 2 hours on November 1, 2005, which did not meet the 50 hour requirement. Continued review revealed the physician had 23.5 CME hours between the November 1, 2005, credit and November 14, 2006; with no hours obtained in 2007 (reappointment letter indicated a 28.25 CME deficiency). Continued review revealed the physician did not obtain any CMEs until May 25, 2008, not correcting the deficient CMEs in the 6 month period allowed. Continued review revealed the physician received 31 hours between May 25, 2008, and May 1, 2009, for a deficiency of 19 hours.

Interview with the Director of Credentialing on August 4, 2010, at 3:30 p.m., and 4:00 p.m., in the 3 West MOB (Medical Office Building) Conference Room, confirmed the file did not contain any follow up information regarding whether the physician had met the requirements in the 6 month periods allowed, as indicated in the reappointment letters. Further interview confirmed the physician had not met the requirement of 50 CMEs every two years as dictated by the Medical Staff bylaws, and no action had been taken to change the physician to Associate staff as was indicated in the reappointment letters. Continued interview confirmed the Medical Staff bylaws had not been followed.

Based on review of credentialing files, review of Medical Staff Bylaws, and interview, the facility failed to ensure Medical Staff bylaws were enforced for one physician (doctor #1) of six physicians reviewed.

The findings included:

Review of a credentialing file for doctor #1 revealed the following Reappointment Letter recommendations:
1) August 29, 2003: reappointed to Active staff; did not attend at least one Department of Medicine or Department of Surgery meeting in 2001 and 2002; required to attend (1) of both Department of Medicine and Quarterly Staff meetings each year; was deficient in 6 hours of CMEs (Continuing Medical Education credits); physician had 6 months to correct the deficiencies or would be changed to Associate staff.
2) August 22, 2005: reappointed to Active staff; was deficient in 13.75 CMEs; physician had 6 months to correct deficiencies or would be changed to Associate staff.
3) June 26, 2007: reappointed to Active staff; was deficient in 28.25 CMEs; had not renewed CPR (cardiopulmonary resuscitation) in last 5 years; physician had 6 months to correct deficiencies or be changed to Associate staff.
4) June 8, 2009: reappointed to Active staff; was deficient in 50 CMEs; physician had 6 months to correct deficiencies or be changed to Associate staff.
5) February 16, 2010 - February 16, 2012 appointment period: reappointed to Active staff; was deficient in 19 CMEs; physician had 6 months to correct deficiencies or be changed to Associate staff.

Review of the Medical Staff bylaws adopted June 26, 2001, and amended June 15, 2010, revealed "Each member of the Active Staff shall...Satisfies CME requirement of 50 hours of Category I credits every two years..."

Review of physician #1's CMEs dated December 17, 1999, through May 1, 2009, revealed the physician obtained 44 hours between July 31, 2002, and August 6, 2003, for a deficiency of 6 hours (as noted in the reappointment letter). Continued review revealed the physician obtained 20.25 hours on August 6, 2003, with 6 hours used to meet the 50 hour requirement, and the additional 14.25 hours applied to the next two year appointment period. Continued review revealed the physician obtained 21.75 hours on August 7, 2005, for a total of 36 hours, a 14 hour deficiency (reappointment letter indicated 13.75 hour deficiency). Continued review revealed, in the 6 month period allowed to correct the deficiency, the physician obtained only 2 hours on November 1, 2005, which did not meet the 50 hour requirement. Continued review revealed the physician had 23.5 CME hours between the November 1, 2005, credit and November 14, 2006; with no hours obtained in 2007 (reappointment letter indicated a 28.25 CME deficiency). Continued review revealed the physician did not obtain any CMEs until May 25, 2008, not correcting the deficient CMEs in the 6 month period allowed. Continued review revealed the physician received 31 hours between May 25, 2008, and May 1, 2009, for a deficiency of 19 hours.

Interview with the Director of Credentialing on August 4, 2010, at 3:30 p.m., and 4:00 p.m., in the 3 West MOB Conference Room confirmed the file did not contain any follow up information regarding whether the physician had met the requirements in the 6 month periods allowed as indicated in the reappointment letters. Further interview confirmed the physician had not met the requirement of 50 CMEs every two years as dictated by the Medical Staff bylaws, and no action had been taken to change the physician to Associate staff as was indicated in the reappointment letters. Further interview confirmed the Medical Staff bylaws had not been followed or enforced.

Based on medical record review, observation, facility policy review, and interview, the facility failed to monitor patient status during administration of conscious sedation during a Transesophageal Echocardiogram (TEE) for two (#13, #29) of four patients with a TEE performed at bedside reviewed; and the facility failed to prevent the development of a pressure ulcer and failed to implement the treatment for a stage II pressure ulcer per protocol for one (#10) of twenty-two inpatient records reviewed.


The findings included:

Medical record review revealed patient #13 was admitted to the facility on July 28, 2010, with diagnoses including Cerebral Edema.

Observation of patient #13 on August 2, 2010, at 1:40 p.m., revealed the patient in the Cardiovascular Intensive Care Unit (CVICU) with external cardiac pacer in use to maintain adequate heart rate.

Medical record review of the Physician's order dated July 29, 2010, revealed an order for a TEE (an invasive procedure guiding an endoscope with ultrasound transducer down the patient's throat to evaluate heart status while the patient is awake but is under conscious sedation).

Medical record review revealed the TEE was performed on July 30, 2010.

Medical record review of the Physician's orders dated July 30, 2010, revealed an order for Fentanyl 100 micrograms, Demerol 100 milligrams, and Versed 5 milligrams "at bedside for procedure" (medications used for conscious sedation) .
Review of the medication dispensing system revealed the medications were removed from the system as ordered for patient #13, and were administered.

Review of the medical record for patient #13 revealed no documentation of the monitoring of the patient's status (ability to move extremities, respiratory or circulatory functioning, blood pressure, heart rate, consciousness, and oxygen saturation) during the procedure.

Medical record review of the medical record revealed patient #29 was admitted to the facility on May 21, 2010, with diagnoses including Cellulitis.
Medical record review of the Physician's order dated May 25, 2010, revealed an order for a TEE.
Medical record review revealed the TEE was performed on May 25, 2010.
Review of the medical record revealed no documentation of the monitoring of the patient's status during the procedure.
Review of the policy titled, Sedation (Moderate or Deep) Administration by Non-Anesthesia Personnel, revealed, " ...Since the patient receiving moderate or deep sedation may progress unintentionally into a state of deep sedation or general anesthesia, respectively, the patient's oxygen saturation, respiratory rate and blood pressure will be evaluated and documented at frequent intervals (See attached Sedation Assessment Form)..."

Interview in CVICU at the nurses' station with the ICU Educator on August 2, 2010, at 2:00 p.m., revealed the Sedation Assessment form is to be used for documentation during the procedures including TEE performed at bedside.

Interview in the conference room with the Clinical Leader of the Intermediate Care Unit (IMU, the unit on which the TEE was performed for patients #13 and #29) and the Educator for the intensive care units on August 3, 2010, at 12:20 p.m., verified the conscious sedation was administered by Registered Nurses (non- Anesthesia personnel), and confirmed the facility failed to assure the patients' status was monitored during administration of conscious sedation.

Medical record review revealed patient #10 was admitted to the facility on July 29, 2010, with diagnoses including Squamous Cell Carcinoma.
Medical record review of the Skin Risk Screen in the nursing Flowsheet dated July 29, 2010, revealed patient #10 was assessed as "no risk" level and the skin assessment was "within normal limits."

Review of the medical record revealed patient #10 had surgical intervention on July 29, 2010, for a Permanent Ostomy placement. (An ostomy is a surgically created opening of the colon and a portion of the colon or the rectum is removed and the remaining colon is brought to the abdominal wall).

Medical record review of the Skin Risk Screen in the nursing Flowsheet dated July 29, 2010,(after the surgery) revealed patient #10 was assessed as "no risk" level, which was no different than prior surgery.

Medical record review of the Physician's Orders dated August 2, 2010, revealed an order to consult Wound Care Nurse.

Medical record review of the evaluation by the Wound Care Nurse (WCRN #1) dated August 2, 2010, revealed patient "also has pressure ulcer X 2 in gluteal fold; is approx (approximately) 4 cm (centimeters) X 1 cm; skin with purple discoloration and epidermis rolled away, deep tissue injury and (L) Left Buttock stage II, approx 1.5 cm X 1.5 cm..."

Review of the facility policy titled, Wound and Skin Care revealed, "...Upon assessment and identification of a pressure area or skin breakdown, the nurse will initiate the treatment intervention as per protocol...)
Review of the Wound and Skin Care protocol for the treatment for a stage II pressure ulcer include "Dress with (named re-hydrating gel)..."

Interview in the conference room on August 3, 2010, at 7:50 a.m., with WCRN #1, revealed the record had been reviewed and the pressure ulcers were visualized this morning. Continued interview revealed, "when I saw (patient #10) this morning at 7AM...the pressure ulcers were not covered with a dressing."
Continued interview revealed the WCRN #1 assisted the patient to the bathroom, and..."required a lot of assistance...used a walker...not very independent ..."
Continued interview with the WCRN #1 verified the skin risk assessment for patient #10 after surgery was not performed accurately.
Continued interview with the WCRN #1 in the conference room revealed the pressure ulcers were "nosocomial" (developed while in the hospital); and confirmed the facility failed to implement the protocol to treat the pressure ulcers.

Based on medical record review, observation, facility policy, and interview, the facility failed to assure telemetry alarms remain activated for one (#9) of twenty-two inpatient records reviewed.

The findings included:

Medical record review revealed patient #9 was admitted to the facility on July 19, 2010, with diagnoses including Confusion, Nausea and Vomiting.
Medical record review of the physician's orders dated July 19, 2010, revealed an order for cardiac telemetry (continuous monitoring of heart rate and rhythm).

Observation of the screens of telemetry monitors located at the 2 West nurses' station revealed patient #9 had an irregular rhythm with a heart rate 70-80.
Observation and interview with the Interim Clinical Leader of the telemetry screensverified the "irregular rhythm" alarm was turned off for patient #9 on August 3, 2010, at 11:50 a.m.

Interview on August 3, 2010, at 11:50 a.m., with the Interim Clinical Leader at the nurses' station, revealed the telemetry screens were observed continuously at the remote site on the third floor. Interview by telephone with the Monitor Technician (MT #1) on August 3, 2010, at 11:51 a.m., revealed the alarm had been turned off "Due to the audible alarm going off."

Review of the facility policy titled, 'Cardiac Monitoring Protocol' included, "1. Monitor alarms are to be kept in the "On" position at all times at sufficiently audible levels ..."

Interview with the Interim Clinical Leader at the nurses' station on August 3, 2010, at 11:53 a.m., confirmed the nursing staff failed to monitor the cardiac telemetry to assure the alarms remain in the 'on' position.

Based on observation and interview the facility failed to ensure outdated and unusable medications were not available for patient use in one of one Post Anesthesia Care Units and one of two operating rooms observed.

The findings included:

Observation of the Post Anesthesia Care Unit (PACU) on August 2, 2010, at 3:40 p.m., revealed a multi-drawer rolling cart stocked with patient supplies and medications. Continued observation of the drawers revealed the following items: One container of Mylanta, Ultimate Strength 70 tablets, ½ full, with an expiration date of February, 2010; Isopropyl Rubbing Alcohol, 4 ounces, 1/3 full, with an expiration date of December, 2006; Rolaids 100 tablets 1/3 full; Ibuprofen 100 tablets 1/3 full; Xylocaine 1% 30 ml (milliliters), unopened, with a patient label indicating dispense date of April 9, 2008; Sterile Water 20 ml, with an expiration date of November 1, 2009; Bacteriostatic 0.9% Sodium Chloride 30 ml, 2 vials, with an expiration date of January 1, 2010; and Sterile Water 30 ml, with an expiration date of March 1, 2010.

Interview with the PACU Clinical Leader on August 2, 2010, at 3:50 p.m., in PACU, confirmed the Mylanta, Rolaids, and Ibuprofen were "probably staff" medications. Continued interview confirmed the cart contained expired medications and one medication charged to a patient and not credited back to the patient, but available for use on other patients.

Observation of OR #1 (operating room) on August 2, 2010, at 4:20 p.m., revealed the anesthesia cart contained the following expired medications: Propranolol 1mg/ml (milligram per milliliter) expired April 10, 2010; Lasix 40 mg/4 ml, expired March, 2010; and Norepinephrine 4 mg/ml, expired April, 2010.

Interview with the Director of Anesthesia on August 2, 2010, at 4:20 p.m., in OR #1, confirmed the medications had expired and were available for use on patients.

Based on observation and interview, the facility failed to ensure dietary services were provided in a sanitary manner for one of one deli cooler in the dietary department and one of one refrigerator in the endoscopy unit.

The finding included:

Observation of the dietary department on August 2, 2010, at 11:30 a.m., revealed one reach in deli cooler contained two ham sandwiches, two bowls of potato salad, and one bowl of cottage cheese, uncovered, with the dietary tickets setting directly on top of and touching the food items.

Interview with the Dietary Manager on August 2, 2010, at 11:30 a.m., in the dietary department, confirmed the food items were not covered and were not stored in a sanitary manner.

Observation of the endoscopy unit on August 2, 2010, at 3:15 p.m., revealed one patient nutrition refrigerator contained drinks and items for patients to consume following anesthesia. Continued observation revealed the refrigerator contained two 20 ounce Styrofoam cups of fluid, one with a lid and straw and one uncovered; one 16.9 ounce plastic bottle of water, ½ full; and a 20 ounce plastic soft drink bottle, ½ full.

Interview with the Clinical Leader on August 2, 2010, at 3:15 p.m., in the endoscopy unit, confirmed the drinks were staff drinks stored with patient nutrition items and staff drinks were not to be stored with patient nutrition.

Based on observation, review of facility policy, Center for Disease Control (CDC) Guidelines, and interview, the facility failed to ensure disinfection and sterilization practices were followed in one of one endoscopy unit; failed to separate clean and dirty items in one of one soiled utility in the Preoperative unit; failed to ensure patient care items were not available for use beyond the expiration date for two of two phlebotomy boxes and one of one clean utility in the Preoperative Unit, and for one of two rooms in Interventional Radiology; failed to ensure patient care items were stored in a sanitary manner for one of one medication room on 4 West; failed to ensure separation of clean and soiled items at the nursing station of the Emergency Department; and failed to follow isolation precautions for one (#13) of thirty patients reviewed.

The findings included:

Observation of the clean utility in the endoscopy unit on August 2, 2010, at 3:15 p.m., revealed a closet with clean endoscopy scopes hanging and ready for patient use. Continued observation revealed approximately six inches of the end of one scope was hanging outside of the closet and draped across the floor.

Interview with the Endoscopy Clinical Leader on August 2, 2010, at 3:15 p.m., in the clean utility, confirmed the scope had been disinfected, was not stored in a sanitary manner, and could not be used for a patient procedure.

Observation of the Preoperative unit on August 2, 2010, at 2:45 p.m., revealed a soiled utility room with clean toilet seat covers for use in the patient bathrooms, in a cabinet, stored with dirty items.

Interview with the Clinical Leader of the Preoperative unit on August 2, 2010, at 2:45 p.m., in the soiled utility room, confirmed the clean toilet seat covers were for use in the patient bathrooms and were not to be stored in the soiled utility.

Observation of the Preoperative unit on August 2, 2010, at 2:45 p.m., revealed a phlebotomy box in the clean utility with three green top vaccutainers (for blood collection) with an expiration date of July, 2010; one tray, 1/2 full, of green top vaccutainers with an expiration date of July, 2010; and one phlebotomy box at the nursing station with a green top vaccutainer with an expiration of July, 2010.

Interview with the Preoperative Clinical Leader on August 2, 2010, at 2:45 p.m., confirmed the vaccutainers had expired and were available for patient use.

Observation of Special Procedures Room #1 on August 4, 2010, at 8:05 a.m., revealed a drawer containing five 1 milliliter syringes with an expiration date of April, 2009. Continued observation of a second drawer revealed one blue top vaccutainer with an expiration date of April, 2009; two blue top vaccutainers with an expiration date of July, 2010; one yellow top vaccutainer with an expiration date of May, 2009; and two green top vaccutainers with an expiration date of February, 2009.

Interview with the Charge Nurse of Interventional Radiology on August 4, 2010, at 8:05 a.m., in Special Procedures Room #1, confirmed the syringes and vaccutainers were available for patient use beyond the expiration dates.

Observation of the medication room on 4 West on August 3, 2010, at 8:00 a.m., revealed a box of 10 milliliter syringes, 1/2 full, stored underneath the sink.

Interview with the Clinical Leader of 4 West on August 3, 2010, at 8:00 a.m., in the clean utility room of 4 West, confirmed the syringes were for patient use and were not to be stored under the sink.



21160

Observation of the soiled utility room in the Emergency Department (ED) on August 2, 2010, at 4:00 p.m., revealed a drawer containing 2 Intravenous (IV) start kits, and 3 syringes stored with a computer part, three pads of paper, a Manuel for equipment, and a roll of carpenters tape.

Interview with the Quality Assurance and Risk Management staff in the soiled utility room on August 2, 2010, at 4:00 p.m., confirmed the patient items were not to be stored in the soiled utility room.

Observation of the ED nursing station on August 2, 2010, between 4:00 p.m. and 5:00 p.m., revealed the following patient care item stored in drawers and cabinets at the nursing station which contained various staff belongings and unclean items: 2 hemostats; 2 pick up instrument; 1 scissor; 2 IV start kits; 1 scapulae blade; 1 operating room towel; 2 five milliliter (ml) syringes; 1 ten ml syringe; 1 eye tray; bandaids; and alcohol wipes.

Interview with the Quality Assurance and Risk Management staff in the ED on August 2, 2010, between 4:00 p.m. and 5:00 p.m., confirmed patient supplies are not to be stored in areas where staff items or unclean items are stored.

Interview with Registered Nurse (RN) ED shift leader for 7:00 a.m. to 7:00 p.m. and Licensed Practical Nurse #1, at the ED nursing station on August 3, 2010, at 9:40 a.m., and interview with RN #3 in the newborn nursery, on August 4, 2010, at 2:10 p.m., revealed all staff members reported the glucometer (equipment to measure blood glucose) was cleaned after each patient use with alcohol prep pads.

Review of facility policy Guidelines for Cleaning/Disinfecting and Storing of Common (Noncritical) Patient Care Equipment) revealed "...shared patient care equipment is clean...Patient Care Equipment that is used on multiple patients...glucometer...items MUST be cleaned and disinfected with approved cleaner/disinfectant between patient use..."

Review of CDC Guidelines revealed "...Recommended Infection-Control...Practices to Prevent Patient-to-Patient Transmission of Bloodborn Pathogens...If a glucometer that has been used for one patient must be reused for another patient, the device must be cleaned and disinfected...to prevent the spread of blood-borne-pathogens...recommend highlevel disinfection...with an EPA (Environmenta Protection Agency) Registered disinfectant...hypochlorite (boleach solution) (diluted 1:10 with water)..."

Interview in the Medical Office Building conference room with the Infection Control Nurse on August 4, 2010, at 12:30 p.m., confirmed the use of alcohol preps to clean the glucometer did not meet Center for Disease Control guidelines (guidelines establised by the CDC to prevent the spread of infection).


21161

Medical record review revealed patient #13 was admitted to the facility on July 28, 2010, with diagnoses including Cerebral Edema. Review of the Registration Form dated July 28, 2010; revealed patient #13 was a "C2".

Interview in the CVICU with the ICU Educator on August 2, 2010, at 1:50 p.m., revealed 'C2' indicated the patient had a history of "VRE" (vancomycin-resistant enterococci, which is a hospital acquired infection resistant to antibiotics.)

Medical record review revealed patient #13 was placed in isolation until July 31, 2010. Medical record review revealed a Physician's order dated July 31, 2010, to discontinue isolation.

Medical record review of the laboratory studies revealed no documentation of stool examination or evidence of negative stool cultures since admission for patient #13.

Observation of patient #13 on August 2, 2010, at 1:40 p.m., revealed the patient in the Cardiovascular Intensive Care Unit (CVICU) with external cardiac pacer in use to maintain adequate heart rate. Continued observation revealed patient #13 was not in isolation.

Interview in the conference room with the Infection Preventionist on August 4, 2010, at 12:35 p.m., and review of the Infection Control policy for isolation of patients, revealed the facility must obtain two negative stool cultures or rectal swabs before a patient with a history of VRE can be removed from isolation. Further interview confirmed the facility failed to follow guidelines regarding isolation of communicable diseases.

Based on medical record review and interview, the facility failed to ensure the Physical Therapy evaluation was complete for one (#8), and failed to ensure the Therapy service was provided as ordered for two (#7, #3) of thirty patients reviewed.

The findings included:

Medical record review revealed patient #8 was admitted to the facility on July 28, 2010, with diagnoses including Bronchitis with possible Rib Fractures.

Medical record review of the Physician's orders dated July 28, 2010, revealed an order including a Physical Therapy consultation.
Medical record review of the Physical Therapy (PT) Initial Assessment Record revealed the evaluation was performed on July 29, 2010.

Medical record review of the evaluation dated July 29, 2010, revealed no documentation of the frequency or duration for the treatment plan.
Interview with Physical Therapist #1 at the nurses' station on the 2nd floor, confirmed the therapist failed to complete the evaluation.

Medical record review revealed patient #7 was admitted to the facility on July 27, 2010, with diagnoses including Subarachnoid Hemorrhage.
Medical record review of the Physician's orders dated July 29, 2010, revealed an order including a Physical Therapy consultation.
Medical record review of the Physical Therapy (PT) Initial Assessment Record revealed the evaluation was performed on July 29, 2010.
Review of the PT evaluation dated July 29, 2010, revealed the treatment plan included gait training and therapeutic exercises to be performed on a daily basis.

Medical record review of the PT Flow sheet revealed the patient received therapy on July 30, 31, and August 2, 2010.

Interview with Physical Therapist #1 at the nurses' station on the 2nd floor, verified an order for "daily" means "once every day."
Continued interview with the therapist confirmed the PT department failed to treat patient #7 as ordered.


21689

Patient #3 was admitted to the facility on July 13, 2010, with a diagnosis of Upper GI (gastrointestinal) Bleed.

Medical record review of the Physical Therapy Initial Assessment Record dated July 15, 2010, revealed the patient was to receive gait training, therapeutic exercise, functional mobility training, balance training and patient/family education daily.

Medical record review of the Physical Therapy Flow Sheet revealed no documentation of therapy provided for August 2, 2010.

Interview with the Nurse Manager of 4 West on August 3, 2010, at 10:30 a.m., at the 4 West nursing station, confirmed the patient did not receive the daily physical therapy on August 2, 2010.