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Based on record review and interview the hospital failed to have a system in place to ensure all grievances mailed to the hospital were identified, investigated and a response sent to the patient or the patient's representative for 1 out 1 (Patient #7) sample patients reviewed for not receiving a response to a mailed grievance.
Findings:

Review of the medical record for Patient #7 revealed he was admitted to the hospital on 5/25/12. He was a 41 year old male with the following diagnoses: Stage 4 non-Hodgkin's lymphoma, Squamous cell carcinoma at base of tongue, severe pain, neoplasm related, acute respiratory failure, dyspnea, history of hypertension, Do not resuscitate, and comfort care only.

Continued review of his medical record revealed S27 Wife to Patient #7 had notarized papers in his medical record revealing she was the Manadary/Representative for Patient #7.

A phone interview was conducted with S27 Wife to Patient # 7 on 9/13/12 at 3 p.m. She reported she had sent a letter certified mail to the hospital's administration to address her grievance related to her husband's fall on 5/26/12. She further reported she had heard nothing from the hospital about the grievance even though she received a receipt from the certified letter that the hospital had received the letter. She also reported her mother-in-law had sent a letter to the hospital in early July, through regular mail, addressed to administration. The letter was a grievance about her son's fall on 5/26/12. She also had not received a response to her grievance either.

A review of the receipt from the certified letter revealed the letter was addressed to the hospital 's administration and the letter was received by the hospital on 6/28/12 and was signed for by " MH " .

An interview was conducted with S10 Division Director of Admission Service on 9/18/12 at 9:45 a.m. She reported she was the person responsible that handled the grievance process in the hospital. She further reported the process was whoever received the grievance would enter the grievance into the hospital's tracking software. She reported all leaders with direct clinical care had been trained to use the tracking system. The hospital staff reports grievances through their chain of command. Each patient is given a patient handbook and the handbook directs them on how to file a grievance. The hospital responds to a grievance by service recovery, entering the grievance into the tracking system, documenting and sending a letter to the patient. If a family member files a grievance, they would send a letter to the patient. If the patient cannot communicate, the letter would be sent to the next of kin. The hospital does keep a record of the letters sent to the patients and the goal is to close the grievance within 7 days of receiving the grievance. When questioned if a letter is addressed to administration, where does the grievance letter get sent? S10 reported the letter would go to the administrator's secretary and she would route the letter to the appropriate person. The manager of the department is responsible for investigating the grievance and writing the letter to the patient and S10 reported she reviewed the letter to the patient prior to the letter being mailed to the patient. When questioned if the hospital had received a grievance from Patient #7, she stated no.

A phone interview was conducted with 29 Director of Supply Chain Services on 9/17/12 at 12 p.m. He reported he was over the mail room at the hospital. When questioned about the delivery of the mail to the hospital, he reported the mail carrier came to the hospital between 2 p.m. and 3 p.m. and the mail carrier would hand the mail to a receiving clerk (S12 Stock Clerk II, S13 Supply/Receiving Clerk, S14 Stock Clerk III, and S15 Shipping/Receiving Clerk). The receiving clerk would then take the mail to S16 Stock Clerk II in the mail room and she would open the mail and route the mail to the correct department in the hospital. When questioned about certified mail, he stated a log was kept in the mail room of all certified mail the hospital received.

An interview was conducted with S12 Stock Clerk II, S13 Supply/Receiving Clerk, S14 Stock Clerk III, S15Shipping/Receiving Clerk, S16 Stock Clerk II, and S28 Manager of Loading Dock on 9/18/12 at 2:40 p.m. They stated when the mail truck arrives at the hospital, whoever is present signs the slip for the certified mail and gives it back to the mail carrier. They no longer keep a record of certified mail they receive. They stated the hospital receives very little certified mail. S16 stated if a letter is addressed to administration, the letter is sent to S11Administrative Assistant to S1COO (Chief Operating Officer).

An interview was conducted with S11 Administrative Assistant on 9/18/12 at 2:45 p.m. She reported when she received the mail, she would stamp a date on the mail and route it the appropriate person. She further reported very seldom does the letter need to the go the S1 COO. S11 stated she kept a list of patients S1COO wrote correspondence to about their grievance. Patient #7 was not on the list.

Permission was obtained from the complainant by state office, S27 Wife to Patient #7, to inform the hospital who wrote the grievance the surveyors were investigating to assist with the investigation.

An interview was conducted with S13 Supply/Receiving Clerk on 9/19/12 at 9:50 a.m. He was shown the copy of the receipt for the certified letter and identified his initials were the one documented as having received the certified letter. He went on to state that when he gets a certified letter, he takes the letter to S16 Stock Clerk II in the mail room. He did not remember the specific letter.

An interview was conducted with S2 Divisional Director, Regulatory Management on 9/19/12 at 9:05 a.m. She reported the hospital was unable to locate what happened to the grievance letter after it was signed for on the loading dock. Also the hospital has been unable to locate the letter sent by regular mail by the mother of Patient #7.

Review of the policy titled Patient Rights, Complaint, and Grievance Process, policy reference # OrgClin/020, revealed in part, " ...All expressed concerns regarding care or treatment are entered into the approved complaint tracking software program ...Whenever possible, the investigation should be completed within an average of seven working days from receiving the grievance. If the investigation cannot be completed within seven working days, the hospital may send a written response to the patient or the patient representative. This written response will include the name and phone number of the hospital contact person. "

Based on observation and interview, the facility failed to ensure the patient's rights to privacy were maintained in the Emergency Department as evidenced by displaying patient's full names and diagnosis on a dry erase board in full view of patients, visitors and hospital staff. The facility also failed to ensure measures were taken to verbally collect patient information in a confidential setting.

Findings:

On 9/19/12 at 3:20 p.m., a tour was conducted of the ED (Emergency Department) at the main campus of the hospital. On hall "c" , three patients were observed on stretchers placed end to end with approximately three feet between them. A visitor was at the bedside of one of the patients. No dividers or privacy screens were in use for the patients in the hallway. A dry erase board observed on hall "c" in full view of patients, visitors and staff had 5 patients first and last names written on it with diagnosis listed.
In an interview with ED Supervisor S18 at 8:15 a.m. on 9/20/12, she stated the dry erase board was used to write the names of direct admissions that were held in the ED so they would not be admitted into the department. She said usually the first and last names were not written on the board.
In an interview on 9/20/12 at 8:40 a.m. with Vice President of Patient Care Services S17, she stated she realized patients being interviewed while placed in "c" hall of the ED while waiting for a room could cause a privacy issue. She said the hospital does not divert patients, so they do what they have to do. S17 said although they try, they could not guarantee patient privacy.
In an interview on 9/20/12 at 10:55 a.m. with ED Charge Nurse S34, he stated that while patients were held in the hallway, information was gathered from the patients by staff members. He said the staff just had to be discreet as possible. S34 said sometimes the ED may have had 12 people lined up in the hallway, so the staff did the best they could, but could not guarantee patients and families could not overhear other patient's information.

Based on record review and interview the hospital failed to ensure that a patient's family and physician was notified after a fall for 1 (#7) out of 8 patient at risk for falls (#1-8) out of a sample of 10.
Findings:

Review of the medical record for Patient #7 revealed he was admitted to the hospital on 5/25/12. He was a 41 year old male with the following diagnoses: Stage 4 non-Hodgkin's lymphoma, Squamous cell carcinoma at base of tongue, severe pain, neoplasm related, acute respiratory failure, dyspnea, history of hypertension, Do not resuscitate, and comfort care only.

Continued review of his medical record revealed S27 Wife to Patient #7 had notarized papers in his medical record revealing she was the Manadary/Representative for Patient #7.

Review of the Nursing Notes dated 5/26/12 at 07:10 (7:10 a.m.) entered by S6RN revealed, " Patient fell out of bed attempting to use the BSC (bedside commode). Patient lifted from the floor and put on BSC. Patient is awake, alert and orientated. Pupils are equal, round, and reactive, patient is able to follow commands. Bleeding observed from mouth and controlled with gauze. Suction set up in the room and in patient's reach. Small laceration noted to right forearm, bleeding controlled with pressure dressing. Redness and tenderness noted to right knee. Patient transported back to bed with assistance from two staff members. "

An interview was conducted with S6RN on 9/18/12 at 1:35 p.m. She reported she was the nurse taking care of Patient #7 when he fell. She stated the patient's mental status was he was awake, alert and he answered questions appropriately. She did not recall the patient being agitated. She didn't administer any Ativan to the patient. He was administered Ativan on 5/25/12 at 1715 (5:15 p.m.) and on 5/26/12 at 7:59 a.m. Prior to the patient's fall S6RN reported fall precautions were in place. His bedrails were up, his call light was within reach, the patient had anti-slip footwear on, the patient had on the yellow fall bracelet to signify he was a fall risk, and the wife was educated on the fall precautions. She further reported at 6:20 a.m., just prior to the patient falling, she had been in the patient's room inserting a Foley catheter. S6 stated no one was in the room when he fell, including his wife. Prior to the fall the patient s wife had told her she was leaving to go home for a minute. He was assessed after he fell and there was some bleeding in his mouth, his forearm was bleeding slightly and redness to his right knee. She reported she did not call the patient's wife to let her know about the fall because the fall occurred at change of shift and she thought the day nurse S5RN would notify the wife of the fall. S6RN further stated she did not call the patient's physician. She also stated she was not aware if the fall interventions changed for the patient after he fell.

An interview was conducted with S5RN on 9/18/12 at 12:45 p.m. She reported she was the nurse taking report from S6RN when it was discovered that Patient #7 had fallen. She further reported she went to the room when she heard he had fallen. She stated the patient was sitting by the bedside commode when she went into his room. There was no family present in the room. She also stated the patient had on a yellow armband on indicating he was at risk for falls. She further reported when the wife returned to the patient's room she asked why she was not notified of the fall. S5RN stated she had a long discussion with the wife because the wife was very upset. S5RN stated she told the charge nurse on the unit that the wife was upset.

An interview was conducted with S7RN Charge Nurse on 9/18/12 at 2:20 p.m. She reported she spoke to the wife of Patient #7 after S5RN informed her that the wife was very upset. S7Charge Nurse stated the wife wanted to know why she was not notified of the fall.

An interview was conducted with S3Nurse Manager of Oncology on 9/18/12 at 2:30 p.m. When questioned if she felt like her staff handled the fall appropriately, S3 Nurse Manager reported the family should have been notified and not walked into Patient #7's room to discover he had fallen while she was gone. Also there should have been documentation the physician was notified.

Review of the Quantros Actual Fall and Slip Event dated 5/26/12 at 08:10 (8:10 a.m.) revealed Patient #7 fell from his bed, his fall risk was an 85, the patient had been determined a fall risk, and medication was used within the past twelve hours. The description of what happened was documented as the patient was found on the floor by lab staff. Patient reported he was trying to get to the BSC (bedside commode). Under the question was the patient and/or family aware of the event, the answer section was blank. Under the section labeled what actions were taken as a result of this event, these items were listed: Nursing observation was increased, follow up with primary physician and minor first aid administration. The report was filled out by S6RN.

Review of the Physician's Progress Note by S30MD dated 5/26/12 at 07:42 (7:42 a.m.) revealed no indication the physician was aware of the patient's fall.

Review of the hospital's policy for Notification of a Physician Regarding Changes in Patient Status, policy reference #NNA-005, revealed in part, " ...The responsible physician or physician designee shall be notified of change in a patient's condition. It is the responsibility of the staff nurse caring for the patient for the patient at that time to initiate the call ... "

Review of the hospital's policy for Fall Prevention, Adult, policy reference # NPC-067, revealed in part, "...In the event of a fall, the Post-Fall Evaluation form will be completed and appropriate interventions will be implemented. The patient's treating physician and family will be notified of the patient's fall as soon as possible...Safety Interventions are implemented according to Fall Risk Assessment score and as appropriate for the patient ... Safety interventions are selected base upon the individual patient's need following assessment.

Review of the hospital's policy for Safety Event (Incident or Variance) Reporting, policy reference#; OrgOps/GN/019, revealed in part, "...The purpose of this policy is to communicate responsibilities for reporting safety events (variances) as defined ...Any safety event observed or discover by an employee should be reported ...Severity Category..Category E- Event/error increased the need for treatment/intervention and cause temporary harm ...It is appropriate to notify the patient's physician of all variance. If the physician was notified, indicate this on the Safety Event Report form and include the physician's name.

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Based on observation, record review and interview,
1. the facility failed to ensure the nursing staff developed a current care plan for patients being recognized as having increased fall risks for 2 (#6, #8) out of 8 (#1 - #8) patients reviewed for being at risk for falls out of a sample of 10.
2. the facility failed to ensure the nursing staff changed or develop a new intervention for decreasing the patient's risk for a fall after a fall occurred for 1(#7) out 8 patients (#1-8) reviewed for risk for falls out of a sample of 10.
3. the facility failed to implement all the hospital fall interventions for a patient at risk for falls for 1 (#2) out of 8 sample patients reviewed for fall risk (#1-8) out of a sample of 10.
Findings:
Review of the Policy titled Falls Prevention, Adult, Policy reference # NPC-067, revised October 10, 2011 revealed in part:
Purpose: To establish a means of identifying patients at risk for falls on the inpatient hospital setting.
Policy: On admission, all patients 15 and older will be assessed for risk for fall using the Morse scale. The registered nurse will develop a plan of care for risk for injury for patients with a score of 45 or greater. Subsequent Morse scales will be performed each day, in the event of a patient fall and upon in-house transfer of the patient.
At the hospital the color coded fall risk ID indicator is yellow.
Procedure:
2. The patient's plan of care is reviewed daily by the RN (Registered Nurse), at which time a Falls Risk Re-Assessment is completed.
4. According to the Fall Risk Assessment tool, the level of the risk (i.e.-safety category) is calculated by the computer system.
-with a score of 0-44 the nurse will implement Standard Fall Risk Precautions.
-An in-patient with a score of 45 or greater, the nurse will implement the Risk for Injury Problem 2 in the Plan of Care along with appropriate interventions.
Risk for Injury Problem 2- Score 45 or greater: Standard fall risk precautions AND additional interventions appropriate to the patient as follows:
Apply color coded fall risk ID indicator to patient (required)
Assess need for 1:1 monitoring
Mark the patient's door/entry way with visual reminder
1:1 supervision for walking or transfers
Request sitter for patient
Stay with patient when toileting
Use bed or chair alarm as appropriate
Place color coded reminder on patient assignment board in nurse's station

1. Patient #6
Review of the medical record for patient #6 revealed he was a 69 year old male admitted to the hospital on 6/20/12 with diagnosis which included Sepsis, Parkinson's disease, hypertension, and degenerative joint disease. His past surgeries included left knee replacement.
Review of the Nurse's Notes for Patient #6 dated 6/21/12 at 05:35 (a.m.) revealed a notification to the medical doctor that Patient #6 had an un-witnessed fall at 5:05 a.m. while transferring. Further review revealed Patient had to receive a CT (computerized tomography) scan of his head after the fall for a reddened left temple.
Review of the Nursing Notes for Patient #6 dated 6/20/12 at 9:00 a.m. revealed a Morse Fall Risk Evaluation with a score of 45. According to the hospital policy on Falls Prevention, a score of 45 or greater required the Risk for Injury Problem 2 to be initiated on the care plan along with appropriate interventions.
Review of the Plan of Care for Patient #6 revealed the Risk for Injury 2 plan had not been initiated until 6/21/12 at 05:45 (a.m.), after Patient #6 had fallen.
In an interview at 9/18/12 with Clinical Nurse Specialist S4, she said Patient #6 should have had a Risk for Injury Problem 2 on his care plan on 6/20/12 based on his Morse score of 45. S4 said the update in the care plan would have initiated Patient #6 to have increased measures for fall prevention such as a yellow bracelet and a sign on the door indicating he was an increased fall risk. S4 said Patient #6 did not appear to have had a yellow bracelet or a fall risk sign on his door prior to his fall on 6/21/12.
Patient #8
Review of the medical record for Patient #8 revealed he was a 95 year old male admitted to the hospital on 7/28/12 at 19:13 (7:13 p.m.) with diagnosis which included acute renal failure.
Review of an Actual Fall and Slip Report dated 8/1/12 at 19:55 (7:55 p.m.) revealed Patient #8 had an un-witnessed fall on 8/1/12 at 09:05 (a.m.). The document read in part:
Was a sensor device in use prior to fall? No
Prior to the fall was a risk assessment performed? Yes
Documented fall risk assessment: Morse
Risk score: 45
Is there documentation that a fall prevention protocol was implemented prior to the fall? No

Review of a Falls Risk Evaluation entered for Patient #8 on 7/29/12 at 09:00 (a.m.) revealed a Morse Fall Risk score of 45. According to the hospital policy on Falls Prevention, a score of 45 or greater required the Risk for Injury Problem 2 to be initiated on the care plan along with appropriate interventions.
Review of the care plan for Patient #8 revealed no Risk for Injury Problem 2 had ever been initiated.
In an interview on 9/18/12 at 3:45 p.m. with the Nephrology Nurse Manage S8, she stated since Patient #8 had a Morse Fall Risk score over 44, he should have had his care plan updated with increased fall risk precautions, but he did not.
2. Patient #7
Review of the medical record for Patient #7 revealed he was admitted to the hospital on 5/25/12. He was a 41 year old male with the following diagnoses: Stage 4 non-Hodgkin's lymphoma, Squamous cell carcinoma at base of tongue, severe pain, neoplasm related, acute respiratory failure, dyspnea, history of hypertension, Do not resuscitate, and comfort care only.

Review of the Nursing Notes dated 5/26/12 at 07:10 (7:10 a.m.) entered by S6RN revealed, " Patient fell out of bed attempting to use the BSC (bedside commode). Patient lifted from the floor and put on BSC. Patient is awake, alert and orientated. Pupils are equal, round, and reactive, patient is able to follow commands. Bleeding observed from mouth and controlled with gauze. Suction set up in the room and in patient's reach. Small laceration noted to right forearm, bleeding controlled with pressure dressing. Redness and tenderness noted to right knee. Patient transported back to bed with assistance from two staff members. "
Review of the Initiate Plan of Care dated 5/25/12 at 16:30 (4:30 p.m.) revealed his Morse Fall Risk was a 85 due to falling in the last 3 months, being weak, and forgetting his limitations. The interventions on the problem for Risk for injury was to apply appropriate color coded fall risk ID indicator, ensure staff remains with the patient when assisted to the bathroom or BSC (bedside commode), mark patient's door/entry with visual reminder, and use chair or bed alarm as appropriate.

Review of the medical record for Patient #7 revealed a High Fall Risk Color Coded visual was on the patient on 5/25/12 at 2100 (9 p.m.) and 5/26/12 at 09:00 ( 9 a.m.) and Standard Fall Risk Precautions were in place. The standard fall risk precautions were listed as Communication device/call bell in reach, ensure that anti-slip, well fitting footwear is applied to patient, when out of bed, Family/significant other in room, Keep floors and surfaces dry, clean spills promptly, Keep patient area uncluttered, keep personal possession with reach, offer to assist patient to the bathroom or BSC (bedside commode) every 2 hours while awake, Patient ID bracelet on, perform frequent checks, remind to call for assistance, side rail x3. The entry was documented by S6RN and documented as performed at 21:00 on 5/25/12.

An interview was conducted with S6RN on 9/18/12 at 1:35 p.m. She reported she was the nurse taking care of Patient #7 when he fell. She stated the patient's mental status was he was awake, alert and he answered questions appropriately. She did not recall the patient being agitated. She didn't administer any Ativan to the patient. He was administered Ativan on 5/25/12 at 1715 (5:15 p.m.) and on 5/26/12 at 7:59 a.m. Prior to the patient's fall S6RN reported fall precautions were in place. His bedrails were up, his call light was within reach, the patient had anti-slip footwear on, the patient had on the yellow fall bracelet to signify he was a fall risk, and the wife was educated on the fall precautions. She further reported at 6:20 a.m., just prior to the patient falling, she had been in the patient's room inserting a Foley catheter. S6 stated no one was in the room when he fell, including his wife. Prior to the fall the patient's wife had told her she was leaving to go home for a minute. He was assessed after he fell and there was some bleeding in his mouth, his forearm was bleeding slightly and redness to his right knee. She reported she did not call the patient's wife to let her know about the fall because the fall occurred at change of shift and she thought the day nurse S5RN would notify the wife of the fall. S6RN further stated she did not call the patient's physician. She also stated she was not aware if the fall interventions changed for the patient after he fell.

An interview was conducted with S5RN on 9/18/12 at 12:45 p.m. She reported she was the nurse taking report from S6RN when it was discovered that Patient #7 had fallen. She further reported she went to the room when she heard he had fallen. She stated the patient was sitting by the bedside commode when she went into his room. There was no family present in the room. She also stated the patient had on a yellow armband on indicating he was at risk for falls. She further reported when the wife returned to the patient's room she asked why she was not notified of the fall. S5RN stated she had a long discussion with the wife because the wife was very upset. S5RN stated she told the charge nurse on the unit that the wife was upset. When questioned if any other interventions to prevent falls were put in place after the fall, she stated the patient was given platelets because she was concerned about bleeding. When questioned if a bed alarm was put in place, she stated her and the wife discussed it, but she felt it wouldn't help with preventing the patient from falling. No other interventions were put in place to prevent more falls. There was no documentation of the discussion with the wife about the fall or the discussion of the fall interventions.

An interview was conducted with S3Nurse Manager of Oncology on 9/18/12 at 2:30 p.m. When questioned if she felt like her staff handled the fall appropriately, S3 Nurse Manager reported the family should have been notified and not walked into Patient #7's room to discover he had fallen while she was gone. Also there should have been documentation the physician was notified. She further stated sometimes she feels there are no other interventions to put in place to prevent a patient from falling, like in this case.

Review of the Quantros Actual Fall and Slip Event dated 5/26/12 at 08:10 (8:10 a.m.) revealed Patient #7 fell from his bed, his fall risk was an 85, the patient had been determined a fall risk, and medication was used within the past twelve hours. The description of what happened was documented as the patient was found on the floor by lab staff. Patient reported he was trying to get to the BSC (bedside commode). Under the question was the patient and/or family aware of the event, the answer section was blank. Under the section labeled what actions were taken as a result of this event, these items were listed: Nursing observation was increased, follow up with primary physician and minor first aid administration. The report was filled out by S6RN. There was no documentation in the record of the physician being notified or the nurse increasing her observation of the patient.

3. Patient #2

Review of the medical record for Patient #2 revealed he was a 83 year old male admitted on 09/03/12 for fever, disorientated, and AML (Acute Myeloid Leukemia).

Review of the patient's Initiate Plan of Care dated 09/03/12 at 4:05 p.m. revealed his Morse Fall risk was a 45 due to being weak. His plan of care revealed a problem for risk for injury related to his fall risk being greater than 44. The interventions listed that were implemented to decrease his risk of falling were: apply appropriate color coded fall risk id indicator, ensure staff remains with the patient when assisted to the bathroom or BSC (bedside commode), mark patient's door/entry way with visual reminder.

Review of the Physician Order's dated 9/04/12 at 9 a.m. revealed an order for bed alarm and fall risk.

An observation was made on 9/17/12 at 1 p.m. with S3 Nurse Manager of the Oncology Unit. Patient #3's yellow at risk for falls armband was taped to his bed and no visual reminder was on the patient's door indicating he was at risk for falls. S3 confirmed the findings. S3 reported the magnet must have fallen off the door and the patient may have not wanted the armband on his arm.

Based on record review and interview, the hospital failed to ensure patient's medical records were accurately written as evidenced by nursing documentation of events being written prior to the documented time of the events for 1 (#6) of 10 (#1 - #10) sampled patients.

Findings:

Review of the medical record for patient #6 revealed he was a 69 year old male admitted to the hospital on 6/20/12 with diagnosis which included Sepsis, Parkinson's disease, hypertension, and degenerative joint disease.

Review of the Nursing Notes for Patient # 6 revealed the following documentation:

Activity: Turn Entered On: 6/20/2012 04:57 (a.m.)
Performed On: 6/20/2012 06:00 (a.m.) by Registered Nurse (RN) S31
Assistance needed with mobility: None, patient turned self

Activity: Turn Entered on: 6/21/2012 04:34 (a.m.).
Performed on: 6/21/2012 06:00 by RN S31
Assistance needed with mobility: None, Patient turned self.

Activity: Turn Entered On: 6/22/2012 00:46 (a.m.)
Performed On: 6/22/2012 02:00 (a.m.) by RN32
Assistance needed with mobility: Patient turned self

Activity: Turn Entered On: 6/22/2012 02:12
Performed On: 6/22/2012 04:00 (a.m.) by RN32
Assistance needed with mobility: None, patient turned self

Activity: Turn Entered On: 6/22/2012 04:37 (a.m.)
Performed On: 6/22/2012 06:00 (a.m.) by RN32
Assistance needed with mobility: Patient turned self.

In an interview on 9/18/12 at 12:18 a.m. with Oncology Nurse Manager S3, she stated according to the documentation on Patient #6's Nursing Notes, his turns had been charted prior to the documented times on the above noted entries. She stated she did not know why the turns had been charted in advance of the action, but this was not correct procedure.