HospitalInspections.org

Based on contract review, patient medical record review, and staff interview, the facility failed to assure contracted lab services reported a stat lab specimen result in the required time frame.

Findings:
1. at 5:12 PM on 11/6/13, review of the contract with the contracted lab company, signed March 1, 2012, for contracted lab services, indicated:
a. under section 1 "Responsibilities of Foundation", it reads in section C. "...Stat orders for routine testing (not a specialty lab procedure) will be completed within 3 hours of receipt in the laboratory. All stat and critical values will be phoned to the Hospital..."

2. review of Pt. N8 medical records indicated:
a. at 4:30 PM on 8/1/13, nursing noted a change in patient's condition which included an oxygen saturation of 83%, with oxygen started at 3 Liters per nasal canula.
b. an order at 5:00 PM on 8/1/13 for stat CBC (complete blood count), UA (urinalysis) and BMP (basic metabolic profile) that was written as a telephone order by nursing staff
c. the CBC was noted as drawn at 1747 on 8/1/13 with a "reported" time of 2054 and a "printed" time of 2148
d. the BMP result on the lab result form from the contracted lab reads that the specimen was "collected: 08/01/2013 at 1747", received "08/01/2013 at 2023", and "reported: 08/02/13 0013" (another form noted "reported: 08/02/2013 0203"), with an elevated glucose, BUN (blood urea nitrogen), Creatinine, Sodium, Potassium, and Chloride (none were critical levels, per the contracted lab document provided that indicates which lab values are considered critical for reporting, however, results were not reported within the 3 hours of receipt by lab required by contract for stat labs to be reported)
e. the UA report also indicated the same collection times and reporting times as in b. above
f. nursing documentation at 8:00 PM and 10:00 PM on 8/1/13 read: "pt. in bed, emesis on gown, lungs coarse throughout, wet, rattling breaths...CXR (chest x-ray) done, labs done but results waiting...MD...aware of CBC result but that BMP was delayed..."
g. there was no documentation in the medical record as to why the BMP was delayed

3. interview with staff member #50, the chief clinical officer, at 4:10 PM on 11/6/13 indicated:
a. the hospital is at the mercy of the contracted lab service as they are the only provider of blood and blood products in the area
b. a facility cannot get blood products from the contracted lab supplier unless they are also used for other lab procedures
c. the contract indicates that the contracted lab service will install an online method of ordering tests and expediting test results (page 2 of the contract), but this staff member says it doesn't work most of the time which can delay getting test results

Based on document review, employee file review and staff interview, the facility failed to ensure that nursing staff were trained and able to demonstrate competency in applying restraints, implementing seclusion, and the monitoring and assessment of patients in restraint or seclusion for one RN (registered nurse), and one LPN (licensed practical nurse). (RN P4 and LPN P6)

Findings:
1. The staffing page for 8/28/13, 7 PM to 7 AM, was reviewed and indicated that agency nurse P4 was the RN (registered nurse) working that shift for 19 neuropsych patients

2. at 1:35 PM on 11/6/13, review of the personnel file for staff member P4 indicated there was no documentation of having education, and demonstration of competency, for restraint and seclusion

3. one LPN, P6, was also scheduled on 8/28/13 for the 7 PM to 7 AM shift and review of their education file indicated they lacked CPI (crisis prevention intervention) training and education

4. interview with staff members #50, the chief clinical officer, and #56, the human resources director, at 2:40 PM on 11/6/13, indicated:
a. there is no policy/procedure related to which staff are required to have CPI training--it is only stated in individual job descriptions
b. per the job description for RNs, CPI is required within 180 days of hire and P4, the agency RN, is still within that time frame
c. agency staff are not required to have CPI training
d. agency RN P4 did not have documentation of restraint/seclusion training/education and competency
e. per the LPN job description, CPI is not required
f. it was thought that patients could be appropriately cared for by CNAs who are trained in both restraint and seclusion and CPI, even though licensed nursing staff, who working with them, were not

Based on medical record review and interview, the medical staff failed to identify in the medical record any follow-up provided to pt. N12 related to an elevated fasting blood sugar of 211 found at facility B prior to transfer to facility D.


Findings:
1. review of the medical record for pt. N12 indicated:
a. the patient transfer orders from fac. B, authenticated by the NP at 2 PM on 8/26/13, do not include accuchecks to monitor the 211 fasting blood sugar found at fac. B
b. there was no oral diabetic medication ordered
c. a regular diet was ordered
d. the "Patient Education Flowsheet", initiated 8/26/13 at this facility, indicated NA [not applicable] for "Diabetes education"
e. A routine lab specimen was drawn at 3:58 AM on 8/31/13 with a fasting glucose result of 675 (normal = 64 to 105)--which was reported after the patient required ambulance transfer to a higher level of care

2. interview with staff member #51, the internal medicine physician and chief of staff, at 12:55 PM on 11/5/13, and by phone on 11/20/13 at 1:30 PM, indicated:
a. pt. N12 had:
I. no medical history on admission
II. not seen a physician in years
III. occasional elevated (mildly elevated) glucose results at fac. B, prior to admission at fac A, and was "followed to determine if this increased BS could be diet controlled or would need an oral agent"

3. it could not be determined that the patient "was followed", as stated by the physician in 2. above, as there were no accuchecks ordered, or performed, for pt. N12, no oral diabetic agents/meds were ordered, and a regular diet was ordered for pt. N12 on admission 8/26/13

Based on review of the medical staff rules and regulations, patient medical record review, and staff interview, the medical staff failed to ensure the implementation of the requirements related to admission history and physical exams for 5 of 12 closed patient medical records reviewed. (pts. N1, N6, N10, N11 and N12)

Findings:
1. at 9:30 AM on 11/16/13, review of the medical staff rules and regulations, last approved 2/2013, indicated:
a. on page 8, under section "I. Medical Records", it reads: "...a. History and Physical: A medical history and physical examination shall in all cases be written or dictated, placed on the medical record within 24 hours...The history and physical shall include a comprehensive current physical assessment of pertinent systems of the body and must also include ...If a history and physical has been obtained within 7 days prior to admission,...this report may be used...This history and physical must then be updated...with the date and any changes that have occurred since the original physical exam. If there are no changes, the physician must indicate so and sign the updated note. The update (interval note) could include language such as concurrence with the H & P conducted on the specified date 'with the following additions and/or exceptions...'"

2. review of medical records indicated:
a. pt. N1 was admitted to the facility on 5/24/13 and had a H & P from the transferring hospital, dictated on 5/22/13 and signed on 5/23/13, that lacked any update after admission to this facility as required by medical staff rules and regulations
b. pt. N6 was admitted 10/22/12 and had a H & P by a NP (nurse practitioner) on 10/23/12 that lacked a physical exam of pertinent systems (under "Physical Examination", it read: "Remains unchanged", but failed to note the specific date of H & P referring to)
c. pt N10 was admitted 8/20/13 and had a H & P from the 8/16/13 other hospital admission that was dictated on 8/20/13--the "Physical Examination" section read: "Remains unchanged" but failed to note the specified date of H & P referring to)
d. pt. N11 was admitted on 7/15/13 and had a H & P by a NP that lacked any physical examinations/systems check notation
e. pt. N12 was first admitted on on 8/26/13, had a H & P by a NP on 8/26/13 with notation in the "Physical Examination" section that read: "Remains unchanged" but failed to note the specified date of H & P referring to)
f. the second admission for pt. N12 was on 9/6/13 and had a H & P by a NP that was not dictated until 9/16/13 and in the "Physical Examination" section they noted: "Remains unchanged" but failed to note the specified date of H & P referring to)

3. interview with staff member #50, the chief clinical officer, at 4:00 PM on 11/6/13, indicated:
a. practitioners are allowed to utilize an "interval H & P", as stated in the rules and regulations, but it is unclear, with current documentation which H & P they are referring to when noting "remains unchanged"
b. currently, the medical staff rules and regulations are not being adhered to

Based on policy and procedure review, patient medical record review and staff interview, it was determined that the hospital failed to ensure nursing staff implemented the policy and procedure related to patient falls and completion of an incident report (Refer to A 386), failed to ensure nursing staff implemented the patient care standards policy in relation to following the physician orders for a wound culture order and evaluated a patient's blood pressure status when found to be abnormally low (Refer to A 395), failed to ensure the development of nursing care plans for all patients (Refer to A 396) and failed to ensure documentation of medications on the medication administration records (Refer to A 405).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure nursing services that were furnished and supervised by a registered nurse.

Based on policy and procedure review, patient medical record review, and staff interview, the nursing executive failed to ensure that nursing staff implemented the policy and procedure related to patient falls and completion of an incident report for one patient (N6).

Findings:
1. review of the policy and procedure "Incident Reports", policy number III-B.11, with an issued date of 12/2011, indicated:
a. under "Procedure", it reads: "An Incident Report should be completed immediately when an incident occurs. The completed incident report reflects documentation that the following actions have occurred: Head to toe assessment...Documentation of all visible injuries...Attending physician notified within 1 hour...Family/significant other of patient notified...1. Incident Reports Incident Reports are completed following any situation where there has been harm or potential for harm to a patient...a. falls.."

2. review of patient medical records indicated that patient N6 fell on 11/7/12 but nursing documentation was lacking for:
a. completion of an incident report
b notification of the physician
c. notification of the family/significant other

3. interview with staff member #55, the chief nursing officer, at at 2:20 PM on 11/6/13 indicated:
a. an incident report related to the fall on 11/7/12 for pt. N6 cannot be located

Based on policy and procedure review, patient medical record review, and staff interview, nursing staff failed to implement the patient care standards policy in relation to following the physician orders for a wound culture order for one patient (N3); and failed to evaluate a patient's blood pressure status between 9:30 PM and 10:30 PM on 7/24/13 and 5:55 AM on 7/25/13 when found to be abnormally low for one pt. (N4).

Findings:

1. Review of the policy and procedure "Patient Care Standards", policy number II - C.1, issued 12/2012, indicated:
a. in section "III. Interventions", item "A. Safety", reads: "...2. 24-hour MD order check against Kardex/MAR (medication administration record form) done on night shift and signed by nurse on doctor's order sheet. Any changes in orders are signed by nurse with signature, date, time and all necessary changes on chart/Kardex are made..."

2. review of patient N3 medical record indicated:
a, on 10/4/13 at 12:00 PM (time unclear, may be 1:20 PM), the nurse practitioner wrote "Wound orders - buttocks & coccyx" that included: "...Wound culture."
b. no wound culture result for 10/4/13 could be found in the medical record

3. an e-mail from staff member #50, the chief clinical officer, at 9:55 AM on 11/21/13 indicated:
a. there is no wound culture result for pt. N3 for 10/4/13, only the one for 10/9/13

4. review of the medical record for pt. N4 indicated:
a. the "Patient Transfer Assessment", completed at 3 PM on 7/24/13, indicated the patient's BP was 138/64.
b. on 7/24/13, at 9:30 PM, nursing wrote: "HS (bedtime) meds given without difficulty. BS (blood sugar) 71. Attempted to give pt OJ (orange juice), but kept blowing into cup. Finally able to get 4 oz into [pt]. BP taken manually. now @ 84/50..."
c. at 10:30 PM on 7/24/13, the admission nursing assessment indicated the patient's blood pressure was 90/52 (admission assessment was within the time frame of facility policy, but occurred after the 9:30 PM BP check)
d. at 5:55 AM on 7/25/13, charting indicated: "CNA (certified nursing assessment) reported Pt not responding, breathing labored. O2 at 15 L mask started. Unable to get biox. (oxygen saturation level) Difficult to auscultate heart rate with stethoscope. Radial pulses very weak and irregular. Pt opened eyes and made faint sound. Manual B/P 60/36, 125, 32, 98.8 ax, 79% [pt] on 15 L mask."

5. it is unknown why there was no monitoring of the patient's vital signs between 10:30 PM (with the nursing admission assessment) and 5:55 AM when the patient was found to have an extremely low BP at 60/36

Based on medical record review, and staff interview, the facility failed to ensure the development of nursing care plans for 3 of 12 closed patient records reviewed. (pts. N4, N8, and N10)

Findings:
1. at 1:30 PM on 11/6/13, review of the policy and procedure "Behavioral Health Admission Assessment-Nursing", policy number I.C.14, issued 12/2011, indicated:
a. under "Purpose", it reads: "To collect data about the health status of a patient on admission and to be able to devise a patient plan of care."
b. under "Procedure", on page 5, it reads: "...When the information on the Nursing assessment has been collected, reviewed and integrated into the plan of care, the RN (registered nurse) will sign and date..."

2. Review of closed patient medical records indicated:
a. pt. N4 was care planned on 7/24/13 to "Remain safe and support safety of others" due to the patient's being a fall risk, but lacked any documentation of interventions implemented in the area of the form provided for this
b. pt. N8 was care planned on 7/19/13 to "Remain safe and support safety of others" due to the patient's being a fall risk, but lacked any documentation of interventions implemented in the area of the form provided for this
c. pt. N10 was care planned on 8/20/13 to "Remain safe and support safety of others" due to the patient's being a fall risk, but lacked any documentation of interventions implemented in the area of the form provided for this The patient was also documented on nursing flowsheets as being at risk for aspiration, with no care planning related to this issue

3. at 8:50 AM on 11/6/13, interview with staff member # 55, RN (registered nurse) and CNO (chief nursing officer), indicated:
a. the medical records, N4, N8, and N10, are lacking completion of the nursing care plans, especially in relation to the interventions implemented for patients at risk for falls, and other patient risks

Based on policy and procedure review, patient medical record review, and staff interview, the nursing executive failed to ensure the documentation of medications given on the medication administration records, by nursing staff in 5 of 14 records reviewed (pts. N2, N3, N11, N12, and N13).

Findings:
1. review of the policy and procedure "General Medication Administration", policy number II.C.88, with an issued date of 12/2012, indicated:
a. on page 3, it reads: "If a medication is held or refused, a notation will be made on the patient's medication administration record (MAR)..."

2. review of patient medical records indicated:
a. pt. N2 lacked documentation on the MAR (medication administration record) for the medication Abilify that was to be given at 9 AM and 9 PM daily-- both doses lacked documentation on 8/15/13 and 8/16/13
b. pt. N3 lacked documentation of medication given for the 9 AM dose of Vit B complex (daily) on 10/16/13 and for Exelon (daily) at 9 AM on 10/17/13
c. pt. N11 lacked:
A. documentation on the MAR on 7/18/13 for the following 9 AM medications: Aspirin 81 mg; Famotidine 20 mg; Flonase spray; Folic Acid; Furosemide; Glipzide; Levothyroxine; and Loratadine, which were all scheduled as daily doses
B. documentation on the MAR for 7/16/13 through 7/22/13 for the twice daily dosages of Risperidone 0.25 mg
d. pt. N12 lacked documentation on the MAR on 8/28/13 and 8/29/13 for the 9 PM dose of Seroquel
25 mg ordered to be given nightly
e. pt. N13 lacked documentation for the 9 AM daily dose of Nitroglycerin patch application on 11/3/13 and 11/4/13

3. interview with staff member #50, the chief clinical officer, at 4:20 PM on 11/6/13, indicated:
a. the open medical record, N13, was reviewed with the nurse on duty at 9 AM on 11/3/13 and 11/4/13, and it was determined that the nurse forgot to initial having given the doses of Nitroglycerin as scheduled
b. documentation by nursing staff for other medication is missing as noted in 2. above and not indicated as refused or held, as required by policy

Based on policy and procedure review, closed patient medical record review, and staff interview, the facility failed to ensure the accuracy and completion of medical records for 9 of 12 medical record (pts. N1, N2, N3, N5, N6, N7, N8, N10 and N12), and failed to follow their policy related to author identification.

Findings:
1. at 5:05 PM on 11/6/13, review of the policy and procedure "Timeliness of Medical Record Completion", policy number III - A.9, last revised 4/2012, indicated:
a. under "Procedure", it reads: "1. All medical record entries must be legible, complete, dated, timed and authenticated promptly..."

2. Review of patient medical records indicated:
a. pt. N1 had documents with wrong patient account/ID (identification) number listed on them (fac. B ID numbers were on the medical records for fac. A--this facility)
A. History and physical
B. Geropsych Consultation
C. Behavioral Health Consultation
D. MAR (medication administration record) numbered as pages 37, 48, and 49
E. Daily Nursing Assessment forms/flowsheets dated 5/22/13 (4 pages)
F. Patient care flowsheet (labeled as page 42)

b. pt. N2:
A. lacked indication to continue or discontinue medications on the "Physician's Order: Medication Reconciliation" forms dated 8/11/13
B. had another hospital (fac. B) progress note (dated 8/12/13) in the hospital record for the patient at fac. A (correct patient, wrong form)
C. had another hospital (fac. B) nursing note form (entries dated 8/10/13 and 8/11/13) in the hospital record for the patient at fac. A (correct patient, wrong form); also the wrong ID was on the page
D. had the wrong ID number (from fac. B) on the Patient care flow sheet labeled as page 82 and on the Blood Sugar Report form labeled as page 85

c. pt. N3 had an EKG (electro cardiogram) in the medical record dated 10/24/13 that lacked the patient's name or ID number on the document (labeled as pg. 249)

d. pt. N5:
A. had a History and Physical dated 12/1/12 that listed the patient as an 83 year old when the patient was 93 years old
B. had nursing documentation on 12/13/12 that indicated the patient was in restraints, when interview with the chief nursing officer at 8:50 AM on 11/6/13, stated this was incorrect electronic charting by the nurse

e. pt. N6 was admitted to the facility on 10/22/12 and had nursing notes dated 11/8/12 with the wrong ID number and documentation at 1:45 PM that the patient was placed on telemetry (interview with the chief nursing officer indicated this facility, (fac A), does not have telemetry capability)

f. pt. N7 was admitted on 7/9/13 and discharged 8/14/13:
A. had a pre admission assessment from a previous hospital in the hospital chart
B. had the wrong ID number (from fac. B) on this patient's progress notes by the psychiatrist on 7/10/13, 7/11/13, 7/15/13, 7/23/13, and 7/24/13
C. had the wrong hospital (fac. B) progress note form on 8/2/13 (this is hosp. A)
D. had two different EKGs dated 7/14/13 with another hospital name on the heading
E. had an EKG dated 7/10/13 with a wrong patient name on it (first name the same, but last name different)

g. pt. N8 had:
A. an Interval Psychiatric evaluation dated 7/22/13 stating that the patient was 77 years old when the patient was 95 years of age
B. had the wrong patient ID number (from fac. B) on the psychiatrist's progress notes of 7/22/13, 7/23/13, and 7/24/13

h. pt. N10 had:
A. a history and physical with the wrong ID number (from fac. B) for the patient
B. had 3 EKG documents in the chart (dated 8/28/13) with a different hospital name on the heading
i. pt. N12 had:
A. a Behavioral Health Consultation with a patient ID number from fac. B
B. an EEG (electro encephalogram) report for another patient

3. interview with staff member #50, the chief clinical officer, at 9:00 AM on 11/6/13, indicated:
a. the physicians want documents from the other hospital admissions (especially fac B) in this hospital's chart for easy reference
b. other hospital forms/documents (from fac. B) are intermingled with this hospital's documents making it difficult to determine what happened where
c. some of the practitioners use the two hospital progress notes interchangeably in patient charts, thus the wrong ID numbers in this facility medical records

4. interview with staff member # 53, the administrator, at 8:45 AM on 11/5/13 and 4:20 PM on 11/6/13, indicated:
a. it had been noted previously that the psychiatrist was using progress notes from fac B (with wrong ID numbers) and this was "corrected"
b. when it was found that the open/current record for pt. N13 was reviewed at 4:20 PM on 11/6/13, and that the progress notes by the psychiatrist (for 11/1/13 and 11/5/13) had the form from fac. B and ID number (crossed out and a new sticker applied) this staff member stated this was not supposed to be occurring

5. at 11:15 AM on 11/6/113, review of the policy and procedure "Authentication", policy number III - A.8, issued 12/2011, indicated:
a. on page 2 under section C., it reads: "...The Human Resource Director will maintain a Ledger book for authentication of signatures for hospital employees..."
b. under "Procedure for Employees", it reads: "1. At the time of hire, the allied health professional employee will print, sign, initial and date the Signature ledger book..."

6. interview with staff member #56, the Human Resources Director, at 11:20 AM on 11/6/13, indicated:
a. review of medical records indicated that with some of the nursing authentication, it could not be determined who had made entries in the medical records
b. there is no Signature ledger book, as indicated in the Authentication policy, which might help with determining author identification in the medical records
c. there is no ledger/log of hospital employee signatures

Based on policy and procedure review, patient medical record review, and staff interview, the nursing executive failed to ensure the completion of daily nursing flowsheets by nursing staff in 4 records reviewed (pts. N2, N3, N7, and N10), and failed to ensure documentation of follow up to an elevated white blood count for pt. N3.

Findings:
1. at 5:05 PM on 11/6/13, review of the policy and procedure "Timeliness of Medical Record Completion", policy number III - A.9, last revised 4/2012, indicated:
a. under "Procedure", it reads: "1. All medical record entries must be legible, complete, dated, timed and authenticated promptly..."

2. review of patient medical records indicated:
a. pt. N2:
A. lacked documentation on the nursing flowsheet for the 7 PM to 7 AM shift on 8/11/13
b. pt. N3 lacked:
A. documentation on the nursing flow sheet for the 7 AM to 7 PM shift on 10/10/13
c. pt. N7 lacked completion of the nursing flowsheets for the 7 AM to 7 PM shift for two days: 7/12/13 and 7/15/13
d. pt. N10 lacked:
A. documentation on the nursing flowsheet for the 7 PM to 7 AM shift for 8/26/13
B. authentication, date, and time on the last page (4) of the psychosocial assessment

3. interview with staff member #50, the chief clinical officer, at 4:20 PM on 11/6/13, indicated: documentation by nursing staff is missing as noted in 2. above

4. review of the medical record for pt. N3 indicated:
a. on 10/18/13, the patient's WBC (white blood count) went up to 18.47 (normal = 4.0 to 11.0)
b. at 10:15 AM on 10/22/13, a progress note indicated: "Sleepy this am refused bkfst (breakfast) Not eating or drinking well lethargic...18.5 (WBC)...re [check] CBC and CXR (complete blood count and chest x-ray)..."
c. a progress note dated 10/22/13 or 10/23/13 (unable to determine date on page) read: "...Very confused, lethargic & weak...does have a high WBC..."
d. on 10/23/13, progress notes at 10:50 AM read: "Discussed at ITC Eating poorly...CBC WBC 16, was 18 - U/A (urinalysis) C&S (culture and sensitivity)..."
e. documentation by the nurse practitioner on 10/24/13 at 11:50 AM indicated: "...very confused...VS stable...lethargic...19 (?WBC)...altered MS (mental status) repeat EEG (electroencephalogram) & Head CT (computed tomography) EKG (electrocardiogram) tachy...r/o (rule out) seizure...leukocytosis - ?UTI (urinary tract infection)"
f. on 10/25/13 at 10:40 AM, the progress note indicated: "...Disoriented elevated WBC - consistently...Very sick ?CA (cancer) vs infection...acute leukomoid reaction - etiology undetermined r/o sepsis, myeloid prolif...acute Transfer to [fac. B]"
g. the medical record lacked sufficient information to identify the reason medications, such as antibiotics, were not implemented over the 7 day time frame noting the consistently elevated white count, lethargy and decline of patient prior to transfer to facility B with discharge summary from facility B indicating cause of death as likely that pt died range of motion sepsis.

Based on policy and procedure review, review of the medical staff rules and regulations, patient medical record review, and staff interview, the facility failed to ensure that the policy and rules and regulations were followed related to the authentication of practitioner orders in 5 of 12 closed patient records reviewed. (pts. N2, N4, N7, N8, and N12)

Findings:
1. at 5:05 PM on 11/6/13, review of the policy and procedure "Timeliness of Medical Record Completion", policy number III - A.9, last revised 4/2012, indicated:
a. under "Procedure", it reads: "1. All medical record entries must be legible, complete, dated, timed and authenticated promptly..."
b. under "Procedure", it reads in item 6.: "Authentication of all diagnostic and therapeutic orders, including verbal orders, shall be obtained...Any practitioner who is responsible for the care of the patient is required to sign, date, and time the order promptly..."

2. at 9:30 AM on 11/6/13, review of the medical staff rules and regulations, last approved 2/2013, indicated:
a. on page 13 under item 5., "Record Completion Guidelines:", it reads: "The medical records of patients shall be completed within a period of time that will in no event exceed thirty (30) days following discharge from care..."

3. review of patient medical records indicated:
a. pt. N2 lacked authentication of patient transfer orders dated 8/17/13 (four pages total lacked authentication)
b. pt. N4 lacked authentication on the "Physician's Order: Medication Reconciliation" form dated 7/24/13
c. pt. N7 lacked authentication on the "Physician's Order: Medication Reconciliation" forms (2) dated as faxed on 7/10/13, and authentication on the third page of the "Admission Orders" for 7/9/13
d. pt. N8 lacked authentication on the "Physician's Order: Medication Reconciliation" forms (2) dated 7/19/13; the Dietary Suggested Orders on 8/1/13; and the 8/1/13 order of clarification for a DNR (do not resuscitate) for the patient
e. pt. N12 lacked authentication on the 8/31/13 order to "send to ...ER (emergency room) per 911"

4. interview with staff member #55, the chief nursing officer, at 3:53 PM on 11/5/13 and 12:40 PM on 11/6/13 indicated:
a. patient medical records are lacking physician authentication as listed in 3. above

Based on review of the medical staff rules and regulations and patient medical record review, the facility failed to ensure the implementation of the rules and regulations related to the discharge summary for pt. N5.

Findings:
1. at 9:30 AM on 11/6/13, review of the medical staff rules and regulations, last approved 2/2013, indicated:
a. on page 13 under item 5., "Record Completion Guidelines:", it reads: "The medical records of patients shall be completed within a period of time that will in no event exceed thirty (30) days following discharge from care..."

2. review of patient medical records indicated that pt. N5 had a discharge summary that listed the patient's death as occurring on 12/12/12 that wasn't dictated until 4/12/13 (and authenticated electronically on 4/22/13)

Based on document review, and interview, the facility failed to develop a method of assessment of its discharge plans that would ensure responsiveness to discharge needs.

Findings:
1. at 9:30 AM on 11/6/13, review of the facility Quality Improvement Plan titled "Organizational Performance Improvement Plan", policy number I - E.1, issued 12/2011, indicated:
a. on page two under "Review Processes", it reads: "...E. Discharge Planning: will report to the Quality Council on discharge quality measures..."

2. review of Quality Council meeting minutes indicated:
a. the 10/22/13 meeting listed "Total admissions: 133 Total discharges: 138"
b. the 7/23/13 meeting listed "Total admissions 142 Total discharges: 136" and under "Mortality Review" 1 death was noted (no other information listed)
c. the 4/29/13 meeting listed "Total admissions: 101 Total discharges: 102"

3. interview with staff member #50, the chief clinical officer, quality assurance director, and compliance officer, at 9:00 AM and 11:50 AM on 11/6/13, indicated:
a. this staff member logs all transfers and deaths and discusses them with the chief of staff before reporting at the Quality Council meetings
b. the report given at Quality Council meetings is an aggregate of discharges with no determination of indicators or quality standards to be met, and whether they are, or are not, met
c. the only quality measure currently reviewed and reported is whether the "notice of non coverage" has been signed by patients' significant party/poa (power of attorney)