HospitalInspections.org

Based on medical record review, policy review and staff interview, it was determined that for 1 of 2 (50%) patients (Patient #1) in the sample that required plan of care representation, staff failed to include a designated family member in the development and implementation of the plan of care. Findings include:

The hospital policy entitled "Interdisciplinary Treatment Plan" stated, "...The patient's participation in the treatment planning process and his/her signature must be noted on the initial problem list and the master treatment plan...Master treatment plan will be reviewed and signed by the patient..."

Patient #1
Medical record review revealed that Patient #1 was admitted to the facility on 4/3/10 and had a diagnosis of traumatic brain injury. Review of the "Certificate for Involuntary Admission..." dated 4/4/10 at 3:00 PM and signed by Physician B, revealed that Patient #1's condition rendered the patient unable to make responsible decisions with respect to his hospitalization.

Review of the "Medical Power of Attorney..." and the "Final Order for Appointment of Guardian of the Person..." revealed Legal Guardian A was Patient #1's legal representative for all health care decisions.

Review of the 4/5/10 "Master Treatment Plan: Part II" included an area for "Patient Participation" and an area for the patient or guardian to sign. The entry "refused to participate" was "checked", however, there was no documentation in the medical record to support that Legal Guardian A was notified of the Treatment Team meeting or the ability to be included if the Guardian chose to do so.

The 4/7/10 "Social Service Progress Note" timed 6:00 PM - 7:00 PM, documented Social Worker A (case manager) had conducted a family session with Legal Guardian A, Patient #1 and three other family members. Social Worker A documented that the meeting discussion included Patient #1's treatment options and treatment expectations. Social Worker A documented that he would contact Legal Guardian A with further treatment and discharge plans.

On 5/12/10 at 3:15 PM, Surveyor A and the Chief Nursing Officer reviewed Patient #1's medical record. The Chief Nursing Officer confirmed that staff failed to ensure that Legal Guardian A was given the information necessary to be an active and informed participant in the development and implementation of Patient #1's plan of care.

Based on medical record review, policy review and staff interview, it was determined that for 1 of 2 (50%) patients in the sample (Patient #1) that required plan of care representation, staff failed to ensure that the representative was kept informed and involved in care planning and treatment. In addition, staff failed to address the legal guardian's request for treatment. Findings include:

Medical record review revealed that Patient #1 was admitted to the facility on 4/3/10 and had a diagnosis of traumatic brain injury. Review of the "Certificate for Involuntary Admission..." dated 4/4/10 at 3:00 PM and signed by Physician B, revealed that Patient #1's condition rendered the patient unable to make responsible decisions with respect to his hospitalization.

Review of the "Medical Power of Attorney..." and the "Final Order for Appointment of Guardian of the Person..." revealed Legal Guardian A was Patient #1's legal representative for all health care decisions.

The hospital policy entitled "Informing Patients About Treatment Expectations and Outcomes" stated, "...It is the policy of Rockford Center to fully disclose to the patient and family/significant other as required all outcomes of care...adverse occurrences and outcomes that differ significantly from expectations...The attending physician shall keep the patient and family...informed of...progress and outcomes of care during the course of hospitalization...Events requiring notification of the patient/family...Patient injury...falls...Medical conditions not present upon admission...Emergency medical treatments...The physician/designees shall advise the patient of consequences and recommended changed [sic] in the course of treatment when...adverse occurrences and outcomes that differ significantly from expectations occur."

I. Right to be informed of health status

A. Review of "occurrence" documentation describing a fall at 3:50 AM on 4/15/10, revealed that Legal Guardian A was notified of the fall at 8:45 AM, however, there was no documentation in the medical record regarding the fall notification. Interview with the Chief Nursing Officer on 5/13/10 at 9:55 AM confirmed that nursing staff failed to document in the legal record that Legal Guardian A was notified of the fall.

B. Review of the "Master Treatment Plan" revealed that the plan of care was updated on 4/10/10 to include a new diagnosis of urinary tract infection. There was no documentation in the medical record to support that Legal Guardian A was notified of the order for treatment of a urinary tract infection as required by hospital policy.

II. Right to be involved in care planning and treatment

A. Review of e-mail communication between Legal Guardian A and Social Worker A included Legal Guardian A's desire to be included in Patient #1's psychiatric and medical plan of care. Requested plan of care/treatment information included:

4/9/10 at 4:18 PM Legal Guardian A requested information regarding:

- medication status
- whether Physician A had ordered a daily visit from family
- the game plan for treatment during hospitalization
- "what was being done" since she was concerned that Patient #1 was on the sixth day of hospitalization

4/12/10 at 9:17 AM Social Worker A wrote: "...off on Friday and just received your message. I will speak with the doctor during treatment team meeting and contact you this afternoon..."

4/16/10 at 11:59 AM Legal Guardian A requested the following information as a follow-up to a telephone conversation with Social Worker A on 4/15/10:

- the reason Patient #1 was still under committal status
- the reason the status was not changed since Legal Guardian A voluntarily admitted Patient #1
- the reason the psychiatrist took Patient #1's files to court
- the name of the court to which the files were taken and the outcome of the hearing
- whether Physician A wrote an order for off-hours family/friend visitation
- a list of all medication administered from admission on 4/3 - 4/16/10
- whether MRI's (magnetic resonance imaging), CT (computed tomography) or PET (positron emission tomography) scans were ordered following the three falls that resulted in head injuries and if so, what the results of the tests were
- whether a neurologist had seen Patient #1 and what the findings were - questioned if Patient #1 had suffered additional brain damage as a result of the three falls with head injuries
- treatment done as a result of the head injuries
- a copy of the physician's plan of care and all amendments for Patient #1 from admission on 4/3 - 4/16/10
- Patient #1's current status
- ordered treatment following falls on 4/15 and 4/16/10
Legal Guardian A requested that responses be addressed in writing and that requested documents be sent via fax.

4/16/10 at 3:10 PM Social Worker A wrote: "...The psychiatrist wrote an order for off hours visitation...The doctor left your father on commitment in order to refer him to (initials of psychiatric hospital)...received a cat scan...suffered no damage to his brain...If you would like to come in on Monday we can discuss the medication regimen and any other questions you may have..."

4/18/10 at 11:15 AM Legal Guardian A requested:

- a physician's order for off-hours visitation

Review of the medical record revealed a lack of communication between the hospital and Legal Guardian A. In an effort to achieve involvement/inclusion in the plan of care, Legal Guardian A requested specific treatment plan/care plan information. There was no documentation in the medical record to support that Legal Guardian A received the following requested information:

- list of all medications administered from admission on 4/3 - 4/16/10
- whether physician wanted family to visit daily
- physician's order for off-hours visitation
- communication with Patient #1's neurologist and/or discussion regarding a neurology consult
- fall prevention plan
- copy of the doctor's plan of care including all amendments
- current status
- type of treatment following falls with injury

B. The hospital policy entitled "Guidelines for the Use of Restraints and Seclusion" stated, "...The patient's treatment plan will be modified to reflect any changes as a result of the outcomes from restraint or seclusion...Notification of the Patient's Family...Restraint use with patients over the age of 18...shall require notification of a family member...Nursing standards during the use of restraints and/or seclusion...need for the use of restraints and/or seclusion will be added to the patient's treatment plan..."

Review of the hospital document entitled "Seclusion/Restraint Form" presented to Legal Guardian A on the date of Patient #1's admission to the hospital stated, "...In the adult program...your family will be involved in your treatment. This will include notification...of a restraint and seclusion episode..." Legal Guardian A signed the form on 4/3/10 and indicated by the use of a "check mark" that she would "like notified in this instance".

Review of the restraint and seclusion documentation revealed the following:

1. "Restraint/Seclusion Order/Record" dated 4/5/10, revealed that staff attempted to de-escalate Patient #1's agitated behavior beginning at 10:30 PM. Attempts were unsuccessful and Patient #1 was placed in seclusion for patient safety.

Review of the 4/5/10 "Treatment Plan Review Seclusion/Restraint" document included an area for "Patient Participation" and an area for the patient or guardian to sign. The entry "notified of plan content" was "checked" and Patient #1 signed the document. There was no documentation in the medical record to support that Legal Guardian A was notified of Patient #1's change in treatment plan (seclusion).

2. "MHW (mental health worker)/Nursing Progress Note" dated 4/8/10, revealed that staff attempted to de-escalate Patient #1's combative behavior beginning at 10:15 PM. Attempts were unsuccessful and Patient #1 was placed in seclusion for patient safety. There was no documentation to support that Legal Guardian A was notified of Patient #1's change in treatment plan (seclusion).

3. "Restraint/Seclusion Order/Record" dated 4/9/10, revealed that staff attempted to de-escalate Patient #1's combative behavior without success. Patient #1 was placed in a physical restraint between 4:15 PM - 4:20 PM. The section of the form identified as "Notifications" of a family member of the intervention was checked "No" along with the explanation "Patient is adult and no consent".

Review of the 4/9/10 "Treatment Plan Review Seclusion/Restraint" document included an area for "Patient Participation" and an area for the patient or guardian to sign. The entry "unable to participate" was "checked". There was no documentation in the medical record to support that Legal Guardian A was notified of Patient #1's change in treatment plan (physical restraint).

4. Review of the "MHW/Nursing Progress Note" dated 4/10/10, revealed that staff attempted to de-escalate Patient #1's physically threatening behavior beginning at 7:00 PM. Attempts were unsuccessful and Patient #1 was placed in seclusion for patient safety.

Review of the 4/10/10 "Restraint/Seclusion Order/Record" revealed that at 7:00 PM, Patient #1 was placed in seclusion after threatening to hit staff and trying to elope. The section of the form identified as "Notifications" of a family member of the intervention was checked "No" along with the explanation "Patient is adult and no consent". There was no documentation to support that Legal Guardian A was notified of Patient #1's change in treatment plan (seclusion).

On 5/12/10 at 3:15 PM, Surveyor A and the Chief Nursing Officer reviewed Patient #1's medical record. The Chief Nursing Officer confirmed that staff failed to ensure that Legal Guardian A was given the information necessary to be an active and informed participant in the development and implementation of Patient #1's plan of care. In addition, the Chief Nursing Officer confirmed that documentation did not support that Legal Guardian A was notified of the changes in the plan of care (restraint and seclusion episodes). The Chief Nursing Officer reported that it was the expectation that staff should have notified the responsible party secondary to guardianship.

III. Right to be able to request treatment

Review of "occurrence" documentation describing a fall at 3:50 AM on 4/15/10, revealed that Legal Guardian A was notified of the fall at 8:45 AM. When Legal Guardian A was notified of the fall, she requested that Patient #1's physician notify Patient #1's private neurologist. In addition, in an e-mail communication dated 4/16/10 to Social Worker A, Legal Guardian A requested follow-up information to determine if a neurologist had seen Patient #1 and, if so, what the findings were. There was no documentation in the medical record to support that this information was communicated to the physician or other Treatment Team members nor was there any documentation that this request was discussed or addressed.

During an interview with Social Worker A on 5/11/10 at 12:25 PM and 2:00 PM, Social Worker A reported that he had spoken to the Treatment Team about Legal Guardian A's concerns related to falls and her request for a neurologist.

During an interview with registered nurse (RN) A (Charge Nurse on Patient #1's assigned Unit) on 5/12/10 at 1:10 PM, RN A reported that he did not recall being asked to initiate a consult for a neurologist and was not present in Treatment Team when/if a consult was discussed.

During an interview with Physician A, Patient #1's psychiatrist, on 5/12/10 at 1:30 PM, Physician A reported that although falls were discussed, she was unaware of Legal Guardian A's request for a neurologist. Physician A reported that a signed release by Legal Guardian A would have been required to consult a physician that was not on staff at the hospital and a release for a neurologist was never signed.

During an interview with the Chief Nursing Officer on 5/12/10 at 1:45 PM, the Chief Nursing Officer reported that the hospital had a process in place for communicating information obtained during an occurrence/incident to the Treatment Team. The Chief Nursing Officer confirmed that nursing staff had failed to communicate the request for a neurologist to the Treatment Team.

Based on medical record review, policy review and staff interview, it was determined that the medical record for 1 of 1 (100%) secluded patients in the sample (Patient #1), lacked a written modification to the plan of care addressing the use of seclusion. Findings include:

The hospital policy entitled "Guidelines for the Use of Restraints and Seclusion" stated, "...The patient's treatment plan will be modified to reflect any changes as a result of the outcomes from restraint or seclusion...Nursing standards during the use of restraints and/or seclusion...need for the use of restraints and/or seclusion will be added to the patient's treatment plan..."

Review of Patient #1's medical record revealed the following:

1. A physician's order dated 4/8 (no year entered) at 10:30 PM for "restraint/locked door" with a maximum duration of 4 hours.

Review of the "MHW (mental health worker)/Nursing Progress Note" dated 4/8/10, revealed that staff attempted to de-escalate Patient #1's behavior beginning at 10:15 PM. Attempts were unsuccessful and Patient #1 was placed in seclusion for patient safety.

Review of the medical record revealed no care plan modification for the use of seclusion.

2. A physician's telephone order dated 4/10/10 at 7:50 PM for seclusion with a maximum duration of 2 hours.

Review of the "MHW/Nursing Progress Note" dated 4/10/10, revealed that staff attempted to de-escalate Patient #1's behavior beginning at 7:00 PM. Attempts were unsuccessful and Patient #1 was placed in seclusion for patient safety.

Review of the medical record revealed no care plan modification for the use of seclusion.

On 5/12/10 at 3:15 PM, Surveyor A and the Chief Nursing Officer reviewed Patient #1's medical record. The Chief Nursing Officer confirmed that staff failed to modify the plan of care when Patient #1 was placed in seclusion.

Based on medical record review, policy review and staff interview, it was determined that for 1 of 1 (100%) secluded patients in the sample (Patient #1), a face-to-face evaluation was not conducted within 1-hour of restraint/seclusion initiation. Findings include:

The hospital policy entitled "Guidelines for the Use of Restraints and Seclusion" stated, "...One-Hour Evaluation: Within one hour of initiation of restraints or seclusion for management of violent or self destructive behavior, the patient shall be evaluated in person by a physician or a trained registered nurse. The evaluation will be documented on the Physician Assessment of Seclusion/Restraint form..."

Review of Patient #1's medical record revealed the following:

A physician's order dated 4/8 (no year entered) at 10:30 PM for restraint/locked door with a maximum duration of 4 hours.

Review of the "MHW (mental health worker)/Nursing Progress Note" dated 4/8/10, revealed that staff attempted to de-escalate Patient #1's behavior beginning at 10:15 PM. Attempts were unsuccessful and Patient #1 was placed in seclusion for patient safety.

Review of Patient #1's medical record revealed no documentation to support that a face-to-face evaluation was conducted within 1-hour of the 4/8/10 seclusion initiation.

On 5/12/10 at 3:15 PM, the Chief Nursing Officer reviewed Patient #1's medical record and confirmed this finding.

Based on medical record review, policy review and staff interview, it was determined that for 1 of 1 (100%) secluded patients in the sample (Patient #1), there was no documentation to support that a face-to-face evaluation was conducted within 1-hour of restraint/seclusion initiation. Findings include:

The hospital policy entitled "Guidelines for the Use of Restraints and Seclusion" stated, "...One-Hour Evaluation: Within one hour of initiation of restraints or seclusion for management of violent or self destructive behavior, the patient shall be evaluated in person by a physician or a trained registered nurse. The evaluation will be documented on the Physician Assessment of Seclusion/Restraint form..."

Review of Patient #1's medical record revealed the following:

A physician's order dated 4/8 (no year entered) at 10:30 PM for restraint/locked door with a maximum duration of 4 hours.

Review of the "MHW (mental health worker)/Nursing Progress Note" dated 4/8/10, revealed that staff attempted to de-escalate Patient #1's behavior beginning at 10:15 PM. Attempts were unsuccessful and Patient #1 was placed in seclusion for patient safety.

Review of Patient #1's medical record revealed no documentation to support that a face-to-face evaluation was conducted within 1-hour of the 4/8/10 seclusion initiation.

On 5/12/10 at 3:15 PM, the Chief Nursing Officer reviewed Patient #1's medical record and confirmed this finding.

I. Based on medical record review, policy review, job description review and staff interview, it was determined that the registered nurse (RN) staff failed to evaluate and supervise the nursing care for 1 of 1 (100%) patients in the sample (Patient #1) with repeated falls resulting in 2 head injuries. Findings include:

The hospital policy entitled "Reassessment of the Patient" stated, "...Reassessment occurs on an ongoing basis via daily assessment by a Registered Nurse...Reassessment of the patient will be conducted...whenever there is a significant event...Change in diagnosis...Medical emergencies/complications...Medication changes..."

Review of the job description entitled "Registered Nurse" stated, "...nursing care duties...as dictated by the patient's condition in accordance with physician orders...documents patient care...Assists in...monitoring patient safety..."

Review of the job description entitled "Nurse Manager" stated, "...The Nurse Manager...is a working manager. Supervising and participating in the provision of general nursing care services..."

A. Medical record review revealed that Patient #1 was admitted to the facility on 4/3/10 and had a diagnosis of traumatic brain injury. Record review revealed that during Patient #1's hospitalization from 4/3 to 4/16/10, Patient #1 fell three (3) times (on 4/6, 4/15 and 4/16/10) hitting his head and sustaining injuries during 2 of the 3 falls. Nursing staff failed to assess Patient #1's neurological status as follows:

1. 4/6/10 - Fall at 3:00 AM
Review of the "Physician's Orders" dated 4/6/10 (no time of entry) revealed that Patient #1 was to be sent to the emergency department of an acute care hospital for an evaluation of a facial laceration that was sustained during a fall.

Review of the "MHW (mental health worker)/Nursing Progress Note" dated 4/6/10 at 6:00 AM, revealed that Patient #1 returned from treatment with "stitches" that were intact. Nursing staff documented that Patient #1 was alert and oriented, however, there was no documentation to support that a neurological check was performed by nursing staff or refused by Patient #1 over the next 24 hour period.

2. 4/15/10 - Fall at 3:50 AM
Review of the "MHW/Nursing Progress Note" dated 4/15/10 at 6:00 AM, revealed that Patient #1 fell upon getting up to go to the bathroom. It was reported that Patient #1 hit his head, but sustained no visible injuries. There was no documentation in the medical record to support that nursing performed a neurological check at the time of fall discovery.

3. 4/16/10 - Fall at 2:40 AM
Review of the "MHW/Nursing Progress Note" dated 4/16/10 at 6:00 AM, revealed that Patient #1 fell in his room and hit his head, sustaining a laceration on the right occipital (back of head) region that required six (6) staples for wound closure. There was no documentation in the medical record to support that nursing performed neurological checks on the 3:00 PM - 11:00 PM and 11:00 PM - 7:00 AM shifts after Patient #1's return from the acute care hospital emergency department.

During an interview with the Chief Nursing Officer on 5/12/10 at 2:00 PM, the Chief Nursing Officer reviewed Patient #1's medical record and confirmed that nursing staff had not always documented that neurological checks had been performed each shift. The Chief Nursing Officer reported that following a head injury, the expectation was that nursing staff would conduct neurological checks each shift for at least 24 hours.

B. Review of the "MHW/Nursing Progress Note" dated 4/15/10 at 6:00 AM, revealed that Patient #1 fell and hit his head at 3:50 AM, but sustained no visible injuries. Physician C was called and nursing staff was advised to place Patient #1's name in the H&P (history and physical) book. There was no documentation in the medical record to support that nursing followed up with Physician C or another medical physician to ensure Patient #1 was assessed following the 3:50 AM fall.

During interviews with the Chief Nursing Officer on 5/12 at 12:56 PM, 5/12 at 3:25 PM and 5/13/10 at 9:55 AM, the Chief Nursing Officer reported that following a fall with head injury, the medical physician was expected to assess the patient. The Chief Nursing Officer reviewed the medical record and confirmed that there was no documentation in the medical record to support that the medical physician assessed Patient #1 following the 4/15/10 fall.

II. Based on medical record review, policy review and staff interview, it was determined that nursing staff failed to obtain a physician's order for oxygen therapy for 1 of 2 (50%) patients in the sample (Patient #3) utilizing oxygen. Findings include:

The hospital policy entitled "Oxygen Therapy" stated, "Oxygen therapy will be used as ordered by the physician..."

Review of "Physician's Orders" revealed that Patient #3 used CPAP (continuous positive airway pressure) for sleep apnea (sleep disorder with periods of no respiration). Review of "Geriatric Flowsheet" documentation revealed that in the absence of the CPAP machine, nursing staff had placed oxygen at 2 liters per minute via nasal cannula (airflow tubing) on Patient #3 at bedtime on 5/8 and 5/9/10. However, there were no physician's orders for the use of oxygen via nasal cannula.

During an interview with the Chief Nursing Officer on 5/12/10 at 9:40 AM, the Chief Nursing Officer reviewed the medical record and confirmed that nursing staff failed to obtain a physician's order for the application of oxygen via nasal cannula.

Based on medical record review, policy review and staff interview, it was determined that for 2 of 3 (33%) patients in the sample (Patient #'s 1 and 3) with documented changes in their plan of care, staff failed to develop and/or revise the plan of care. Findings include:

The hospital policy entitled "Interdisciplinary Treatment Plan" stated, "...Initial problem list is based on assessment of the patient's presenting problems, physical health...Any objectives on the nursing care plan, which exceeded three (3) days to achieve, will be transferred onto the Master Treatment Plan...While the emphasis of the initial problem list is on the immediate needs, the design does not preclude inclusion of other less acute problems..."

The hospital policy entitled "Fall Prevention Guidelines" stated, "Communicate fall-risk status to patient and family...It is important that patients and their families be informed of the patient's risk of falling...information includes why the patient may be at risk to fall...family education on fall reduction is documented in the patient's medical record..."

A. Patient #1
1. Review of the medical record revealed nursing staff failed to update the plan of care at the following times:

a. 4/6/10 - Fall at 3:00 AM
Review of "Physician's Orders" dated 4/6/10 (no time of entry) revealed that Patient #1 was to be sent to the emergency room for an evaluation of a facial laceration that was sustained during a fall.

Review of the "MHW (mental health worker)/Nursing Progress Note" dated 4/6/10 at 6:00 AM, revealed that Patient #1 returned from treatment with "stitches" that were intact.

The "Master Treatment Plan" contained a "Risk for Fall" problem, initiated on 4/3/10, however, nursing staff failed to update the plan of care to include an actual fall with an intervention to assess Patient #1's neurological status over the next 24 hour period. In addition, the plan failed to address the actual wound and interventions related to wound observation and care.

b. 4/15/10 - Fall at 3:50 AM
Review of the "MHW/Nursing Progress Note" dated 4/15/10 at 6:00 AM, revealed that Patient #1 fell upon getting up to go to the bathroom. It was reported that Patient #1 hit his head, but sustained no visible injuries.

Review of the "Master Treatment Plan" problem, "Risk for Fall" failed to provide evidence that nursing staff updated the plan of care to include the 4/15/10 fall with an intervention to assess Patient #1's neurological status over the next 24 hour period.

c. 4/16/10 - Fall at 2:40 PM
Review of the "MHW/Nursing Progress Note" dated 4/16/10 at 6:00 AM, revealed that Patient #1 fell in his room and hit his head, sustaining a laceration on the right occipital (back of head) region that required six (6) staples for wound closure.

Review of the "Master Treatment Plan" problem, "Risk for Fall" failed to provide evidence that nursing staff updated the plan of care to include the 4/16/10 fall with an intervention to assess Patient #1's neurological status over the next 24 hour period. In addition, the plan failed to address the actual wound and interventions related to wound observation and care.

During an interview with the Chief Nursing Officer on 5/12/10 at 2:05 PM, the Chief Nursing Officer reviewed Patient #1's medical record and confirmed that nursing staff had failed to update the plan of care to reflect changes. The Chief Nursing Officer reported that the plan of care should have included actual injury, wound observation - monitoring for signs and symptoms of wound infection and neurological checks each shift for at least 24 hours after a head injury.

2. Review of the medical record revealed nursing staff failed to revise the plan of care to include family education related to falls. Review of the medical record revealed no documentation to support that staff provided Legal Guardian A with fall reduction education as per hospital policy.

During an interview with the Chief Nursing Officer on 5/13/10 at 1:20 PM, the Chief Nursing Officer confirmed that there was no documented evidence of fall reduction education in the medical record. The Chief Nursing Officer reported that staff was expected to follow the "Fall" policy which included family education.

B. Patient #3
Review of the 5/8/10 "Admission Note" entered at 12:45 AM, revealed that Patient #3 reported that he used a CPAP (continuous positive airway pressure) machine at bedtime.

Review of "Physician's Admission Orders" dated 5/8/10 revealed that Patient #3 used a CPAP machine for sleep apnea (sleep disorder with periods of no respiration).

Record review revealed and interview with the Chief Nursing Officer on 5/12/10 at 4:03 PM, confirmed that nursing staff failed to develop a care plan for sleep apnea and the use of CPAP.

Based on medical record review, policy review and staff interview, it was determined that the medical records for 2 of 5 (40%) patients in the sample (Patient #'s 1 and 3) failed to contain accurate information. Findings include:

The hospital policy entitled "Chart Documentation Requirements" stated, "...documentation must be accurate...Documentation in the progress notes (using the narrative format) is performed by...nursing staff...Events which significantly impact patient's status...Significant interactions with...guardian...changes in treatment plan interventions for nursing..."

The hospital policy entitled "Guidelines for the Use of Restraints and Seclusion" stated, "...The use of restraints and/or seclusion will be thoroughly documented in the patient's medical record on...Physician's Assessment Seclusion/Restraint Record...Debriefing Form..."

A. Patient #1
1. Review of the medical record revealed no documentation to support that a "Physician's Assessment Seclusion/Restraint Record" and "Debriefing Form" had been completed by staff as required, when Patient #1 was placed in seclusion on 4/8/10.

During an interview with the Chief Nursing Officer on 5/12/10 at 3:15 PM, the Chief Nursing Officer reviewed the medical record and confirmed that staff had failed to complete the required forms during the use of seclusion.

2. Review of Patient #1's medical record revealed that the dates on the "Precautions Record" documentation for face checks every 15 minutes on 4/15, 4/16 and 4/17/10, were inconsistent with either Patient #1's location (acute care hospital emergency department) at the time of assessment or there was more than one assessment for an identified date.

On 5/12/10 at 1:50 PM, the Chief Nursing Officer reviewed Patient #1's medical record and confirmed that the dates on the front and back pages of the "Precautions Record" were inconsistent. The Chief Nursing Officer reported that the date on the back of the "Precautions Record" was the correct date and that staff would receive education related to accurate documentation.

B. Patient #3
1. Review of the "Master Treatment Plan" initiated on 5/7/10, contained a "Risk for Fall" problem. Review of the "Nursing Assessment" dated 5/8/10 at 2:00 AM revealed Patient #3 required a brace and walker for ambulation.

Review of the "Geriatric Flowsheet" documentation revealed a walker was not used during ambulation at the following times:

5/8/10 - Day and Evening Shifts
5/9/10 - Day, Evening and Night Shifts
5/10/10 - Night Shift

During an interview with the Chief Nursing Officer on 5/12/10 at 8:40 AM, the Chief Nursing Officer reviewed ambulation documentation and confirmed that staff should have been following the plan of care established for Patient #3 including the use of the walker for ambulation. The Chief Nursing Officer reported that staff should have been documenting that Patient #1 was either using or refusing the walker.

2. On 5/12/10 at 9:05 AM, Surveyor A copied the "Risk for Fall" treatment plan for Patient #3. On 5/12/10 at 4:00 PM, Surveyor A reviewed Patient #3's "Risk for Fall" treatment plan. It was identified at that time that the care plan contained two additional interventions that were not on the treatment plan at 9:05 AM. The new entries were backdated to 5/8 (no identified year).

On 5/13/10 at 9:55 AM, Surveyor A presented the two care plan copies to the Chief Nursing Officer. The Chief Nursing Officer confirmed that the entry dates were not consistent with the time the care plan was actually updated. The Chief Nursing Officer reported that she had told staff to update the care plan, but staff should have entered the date on which the care plan was actually amended. The Chief Nursing Officer reported that when asked, the identified nurse reported that she had used the date (5/8) because the interventions had been in place "since the day of admission".