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Based on the information obtained through staff interview and record review, the hospital failed to provide adequate supervision to one patient who was able to elope from the facility.
Refer to A 144.

Based on observation and interview, the facility failed to ensure patient names were not posted in a public area. Findings include:

Per observation during a tour of the inpatient rehabilitation unit on 2/2/10, patient names were fully visible on medical records stored in the "wheel" which is located on a counter between the nursing station and the public hallway. Per interview on 2/2/10 at 2:20 PM, the Director of the Unit confirmed that the patient names were visible from the hallway. Per interview on 2/3/10, the Director of Medical Records confirmed that the location of the "wheel" posed a privacy violation.

Based on record review and confirmed by interview, the facility failed to assure that care in a safe setting was provided for 1 of 9 patients in the sample (Patient #1). Findings include:

Per record review on 11/23/09 and 11/24/09, Patient #1 was admitted to the hospital in November 2009 after taking an overdose of medications in a suicide attempt. A suicide risk assessment was conducted, and the patient was transferred to the intensive care unit (ICU) and was placed on 1:1 supervision for safety. While on 1:1 supervision, Patient #1 successfully eloped from the shared bathroom of the room and was able to leave the hospital through the adjacent, unoccupied ICU room. Patient #1 was not located for approximately 46 hours. During this absence, Patient #1 again overdosed on medication and was readmitted to the facility with suicidal ideation. Laboratory tests conducted on the day of readmission confirmed a new diagnosis of pancreatitis.

Per interview at 1:45 PM on 11/23/09, the Director of Security stated "There appear to be a couple of mistakes. It seems [Security Officer #1] didn't know there was a back door [to the bathroom]. It definitely was a contributing factor".

Per interview at approximately 11 AM on 11/24/09, the Unit Manager of the ICU stated that the expectation is that if the 1:1 observation takes place in a room with a secondary bathroom door, the current 1:1 staff person is to inform the oncoming 1:1 staff person of that secondary point of egress.

Per telephone interview on 11/24/09 at 11:20 AM, the Licensed Nursing Assistant (LNA#1) assigned to the 1:1 observation of Patient #1 on the day of the elopement stated that their report to the next staff person assuming the 1:1 duty does not include any review of secondary points of egress. LNA #1 stated "They should know that. I don't mention it. They have the layout of the bathrooms. They know that stuff". LNA #1 further stated that it was the unit secretary that assumed the 1:1 observation of Patient #1 on that particular day.

Per interview on 11/24/09 at 11:50 AM, the Unit Secretary confirmed "I don't know exactly what rooms have a 2 door bathroom. ...I never had to leave a 1:1 with a security officer taking over. I don't know if [Security Officer #1] knew. I don't tell them".

During a second interview at 2:50 PM on 11/23/09, the Director of Security further stated that there is no formal process to educate the security officers on the environment, but it was "standard operating procedure" that security officers familiarize themselves with each nursing unit. "Its the first thing we do: go in a room and do a quick look around. I would have expected [Security Officer #1] to look in the bathroom, to visualize the doors".

Per interview at 2:00 PM on 11/23/09, Security Officer #1 stated "I've watched multiple patients on that (ICU) unit. I did not know that some bathrooms have a second door. I need a little more knowledge of the room itself".

Per interview at 5:20 on 11/23/09, Security Officers #1 and #2 also confirmed that they were not aware that some of the bathrooms off of patient rooms in the ICU have a second points of egress.

Based on survey findings, the Condition of Participation for Quality Assessment and Performance Improvement Program was not met based on deficiencies cited relating to Nursing Services and the failure to assure policies were implemented and an accurate and timely review was conducted of an Adverse Patient Event. Refer to Tag A-287, A-385 and A-395

Based on interviews and record review, the hospital's Quality Assessment and Performance Improvement failed to conduct an accurate and timely analysis of an adverse patient event thereby creating a delay in appropriate response to assure patient safety. Findings include:

1. Per record review on 2/3/10 Patient #25, a patient in the acute Progressive Care Unit (PCU), experienced a cardiorespiratory arrest on 1/31/10 between 10:45 AM and 11:30 AM. At the time of the cardiorespiratory arrest, and per physician orders, the patient's heart rate, cardiac rhythm and oxygen levels were to be continuously monitored via telemetry. Per staff interview and record review on 2/3/10 and 2/4/10, there was an interruption in the continuous cardiorespiratory monitoring. The audible and visual monitor alarm described as "the blue alarm" was not acted upon by nursing staff. The patient was subsequently found, with the telemetry monitoring leads unattached, in cardiorespiratory arrest approximately 40 minutes after the last recorded monitoring via the the telemetry unit worn by Patient #25. As the result of the Adverse Event, staff are required to complete an Event Report. Per interview on the morning of 2/3/10, the PCU Director confirmed a Report was initiated by nursing staff on the evening of 1/31/10, the report was not finished until 2/1/10. A review of the event by the Performance Improvement (PI) staff was not completed until 2/3/10.

Both nursing staff and PI staff failed to identify the potential malfunctioning of the telemetry unit at the time of the event on 1/31/10 and failed to remove the equipment from further patient use until tested by the Biomedical Department. Per interview on 2/3/10 at 4:40 PM the Biomedical Engineer stated he was not made aware of the event until 1:00 PM on 2/3/10 when testing was conducted of the telemetry unit.

Per review of the investigation summary of the adverse event, received on 2/4/10 at 9:30 AM from the Director of Performance Improvement, inaccurate findings were noted specific to the "...planning for the care of the patient". Per review of the "Patient Integrated Plan of Care", nursing staff failed to address Patient #25's behavioral challenges related to developmental delay and interventions to address issues encountered during the care for Patient #25. The conclusion of the PI report stated "There were no deviations from policy", however staff failed to follow Event Report procedures resulting in a delay in action from Administrative staff. "The actions were appropriate and timely" is also inaccurate. The internal investigation by the PI department did not initiate staff interviews until 2/3/10, 3 days after the event.

Refer to Tags A-385 & A-395

Based on observation, interviews and record reviews, the Condition of Participation for Nursing Services was not met based on hospital nursing staff failure to maintain cardio/pulmonary monitoring as per physician orders, failure to consistently respond to telemetry monitor alarms and failure to immediately remove from patient use telemetry equipment associated with a cardiorespiratory arrest.

Refer to Tag A-395

I. Based on observation, interview and record review, nursing staff failed to assure continuous cardio/pulmonary monitoring was maintained as per physician order and failed to respond to telemetry monitor alarms for approximately 40 minutes for 1 applicable patient who experienced a cardiorespiratory arrest. (Patient #25)

. Per review on 02/03/10 Patient #25, with developmental disabilities, was admitted to the hospital on 1/28/10 with decreased mental status and respiratory compromise. The patient was admitted to the Progressive Care Unit (PCU) for continuos monitoring of his/her oxygen saturation levels and cardiac monitoring. From the day of admission, Patient #25 was described by nursing in "Patient Chart Summary Notes" to be confused, at times combative and unable to comprehend health teaching or instructions by nursing staff. Per interview on 2/3/09 at 5:36 PM Nurse #1, assigned to Patient #25 on 1/31/10, confirmed the patient was periodically removing the telemetry leads (which attach to electrodes placed on the patient's chest and transmit cardiac signals to the monitor at the nursing station) and oxygen nasal cannula requiring the nurse to reapply the leads and oxygen during the morning of 1/31/10.

Per interview on 2/3/10 at 5:00 PM, Staff Nurse #2 confirmed that at approximately 11:30 AM on 1/31/10, upon entering the room of Patient #25, he/she observed the patient in bed "...with eyes closed and color dusky...." and unresponsive when sternal rub was attempted. The nurse also confirmed the telemetry unit leads were not on the patient and the oxygen nasal cannula was also not in use. Per record review, a Code 99 was called and CPR was initiated. A physician progress note dated 1/31/10 states "The cardiac arrest was paged between 11:35 and 11:40 AM...For some reason, whether he/she pulled the leads off or not. The nurses found (the patient) cyanotic and mottled at the time of Code 99 call. The initial rhythm was asystole" (absence of heart beat). Per interview on 2/3/10 at 5:38 AM, Nurse #1 stated s/he was not aware Patient #25 had a cardiorespiratory arrest until several minutes after the event because he/she was involved with another patient who was also experiencing a medical emergency. Nurse #1 further stated s/he did not recall hearing any blue alarms during that period of time.

On 2/3/10 and 2/4/10 the telemetry-monitor screens located inside the nurses' station were observed to alarm frequently emitting different sounds depending on the reason the telemetry alarm was triggered. Per interview on 2/3/10 at 5:15 PM Nurse #3 confirmed the telemetry-monitor will display a blue bar on the assigned patient screen when a patient becomes disconnected from the telemetry unit or if the battery becomes low. In addition, the blue alarm emits a distinct sound which is repeated continuously approximately every 30 - 45 seconds until acted upon by nursing staff. On the morning of 2/4/10 the Alarm Review sheets of the telemetry unit assigned to Patient #25 was reviewed with Nurse #3. It was confirmed that Patient #25's telemetry unit was recording a heart rate of 122 BPM (beats per minute) at 10:45:17; that only 1 of the 2 rhythm strips was recorded and oxygen levels were not being monitored. No further monitoring is noted for a 40 minute period until 11:32:59 when the alarm "Pause" was recorded followed by "Asystole"at 11:33:09. When interviewed Staff Nurse #2, had confirmed the telemetry leads were reapplied to Patient #25 at around 11:30 AM when the nurse found Patient #25 in cardiorespiratory arrest and Code 99 initiated.

Per review of staffing schedules, on the afternoon of 2/4/10, the Director of PCU confirmed the unit was staffed sufficiently with 5 nurses plus a charge nurse, 2 Licensed Nursing Assistants and unit secretary. Nurses would be assigned either 3 or 4 patients and the expectation is that the staff works as a team to assist each other as needed. It was also confirmed by the Director of PCU on the evening of 2/3/10 that nursing staff on PCU are expected to respond to all alarms regardless of level and to resolve the alarm issue ensuring patients remain continuously monitored as ordered by the physicians. The Director confirmed staff had failed to acknowledge the blue alarm for Patient #25.

In addition, staff failed to identify the potential malfunctioning of the telemetry pack at the time of the event on 1/31/10 and failed to remove the equipment from further patient use until tested by the Biomedical Department. Per interview on 2/3/10 at 4:40 PM the Biomedical Engineer stated he was not made aware of the event until 1:00 PM on 2/3/10. However, he did confirm the telemetry pack used for Patient #25 had been tested on 2/3/10 and was found to be operational and functioning properly at the time of cardiorespiratory event on 1/31/10.

Staff recognized an Adverse Event had occurred as a result of Patient #25 not being continuously monitored and the resulting Code 99, however although an Event Report was initiated on 1/31/10, the Administrator On-Call was not notified. Per hospital policy, " Event Reporting", (approved 4/23/09) "In the absence of the supervisor the staff member will contact the Administrator On-Call". Per interview on 2/4/10 at 12:15 PM, Nurse #3 confirmed he/she did not receive a return call from the PCU Director, and failed to call the Administrator On-Call who would ".....conduct an initial investigation and put in place immediate corrective action to ensure patient safety". Per interview on 2/3/10 at 11:20 AM the Director of PCU stated, due to phone issues the call and message from Nurse #3 was not received and he/she was not made aware of the event on 1/31/10 until the morning of 2/1/10.


II. Based on record review and staff interview the hospital failed to assure that nursing on the Psychiatric Services Inpatient Unit (PSIU) provided adequate supervision for each patient in 7 of 10 records reviewed. (Patient #13, #14, #15,#, 20, #21, #22, #23) Findings include:

1. Per record review, Patient #14 ' s treatment plan dated 1/30/10 identified the patient as being a ' high suicidal risk ' . One of the treatment plan interventions assigned to nursing stated " SI (suicidal ideation) assessment Q (every) shift. " Per review of nursing documentation, there was no evidence of nursing assessment for suicidal ideation during the day and night shifts on 1/31/10 and for all shifts on 2/1/10 in accordance with the treatment plan. This was confirmed by the Clinical Manager on 2/3/10 at 3:05 PM.
2. Per review of the " Time Flow Sheet " for Patient #15 who was on 15-minute checks, there was no evidence staff observed the patient on 12/15/09 at 3:35 PM. The flow sheet was not completed to reflect Patient #15 ' s location and the staff conducting the checks. In addition, another " Time Flow Sheet " was not dated. This was confirmed by the Clinical Manager on 2/3/10 at 11:10 AM.
3. Per review of the " Time Flow Sheet " for Patient #21, no checks were documented as being done on 12/14/09 at 8:00 AM, 8:15 AM and 11:45 PM, on 12/15/09 at 3:45 PM, on 12/16/09 at 7:15 AM, 7:30 AM, 7:45 AM, 1:00 PM and 12:45 PM. In addition, another undated flow sheet showed no evidence Patient # 21 was observed for a 30-minute period (8:00 AM & 8:15 AM). This was confirmed by the Clinical Manager on 2/3/10 at 11:10 AM.
4. Patient #22, who was on 15-minute checks had no checks documented for the following days:
12/9/09 at 7:45 AM and 8:00 AM, 12/10/09 at 8:00 AM 8:15 AM 8:30 AM and 8:45 AM, 12/13/09 at 8:45 AM and 7:15 PM, 12/16/09 at 2:00 PM, 12/18/09 at 8:00 AM, 8:15 AM and 12/24/09 at 2:00 PM, 6:15 PM, 6:30 PM and 6:45 PM. In addition, one of two undated flow sheets revealed the lack of checks at 10:30 PM and 10:45 PM.
5. Patient #23, who was on 30-minute checks on 12/24/09 had no check documented at 6:30 PM. Another undated flow sheet for 15-minute checks revealed no checks being done at 9:45 AM and 1:45 PM.
6. Patient #20, who was on 15 minute checks, had no checks documented on the
following days; 12/21/09 3:45 PM, 12/22/09 7:45 AM, 1/1/10 1:45 and 2:00 PM,
1/2/10 9:45 and 10:00 PM, 1/4/10 7:45 AM, 1/5/10 7:30 - 8:00 AM, 1/12/10 7:45,
and 1/14/10 2:45 and 3:00 PM. In addition, one Time Flow Sheet for Patient #20 was
undated.
7. Patient #13, who was on 15 minute checks on 1/29/10, had no checks documented
from 7:30 AM through 8:00 AM.

During interview on 2/3/10 at 11:10 AM the Director and Clinical Manager of the Inpatient Psychiatric Unit confirmed that staff assigned to the checks must visualize the patient , note their location and sign the flow sheet.

III. Based on observation record review and staff interview, nursing staff on the Psychiatric Services Inpatient Unit (PSIU) failed to assess or document the type of bed used for 3 of 10 patients ( #12, #13, #19). Findings include:

During a tour of the PSIU on 2/1/10 and staff interview, patient beds were equipped with 4 half rails. Per review of the PSIU ' s policy and procedure " Assessment and Assignment of Appropriate bed " an assessment must be conducted by nursing on admission to assure the patient is assigned to the most appropriate type of bed. The policy and procedure stated; " Documentation should include a thorough assessment of the patient's psychological, physiological, and safety needs of the patient. It should also include the type of bed that the patient is assigned to, and the rationale for that assignment. "

a. Per record review on 2/1/10, Patient 12 was assessed to be a low fall risk and was assessed to be a moderate suicide risk. Per review of nursing notes, the patient utilized two side rails on one occasion. Per interview on 2/3/10, the Clinical Manager confirmed that there was no evidence of an assessment for the safe use of a bed with side rails for this patient.

b. Per record review on 2/1/10, Patient #13 was assessed to be a high risk for suicide and at high risk for falls. Per review of nursing notes, Patient #13 utilized a bed with two side rails up on at least two occasions. Per interview on 2/3/10, the Clinical Nurse Manager confirmed that there was no evidence of an assessment for the safe use of a bed with siderails for Patient #13.

c. Per record review on 2/2/10, Resident #19 was assessed to be a high risk for suicide. On 2/1/10 and 2/2/10, the two top siderails were observed in the up position throughout the day. Per review of nursing notes, Resident #19 utilized the two top side rails on at least two occasions. Per interview, the Clinical Manager confirmed that there was no evidence of an assessment for the safe use of a bed with siderails for Patient #19.

During an interview on 2/3/10 at 11:10 AM with the Director and Clinical Manager, the Clinical Manager confirmed that the type of bed assigned should be documented.

Based on interview and record review nursing staff failed to develop a care plan that addressed the specific care needs and monitoring for 1 of 10 applicable patients in PSIU and for 1 of 8 patients in the Progressive Care Unit. (Patient #14, 25 ) Findings include:

1. Per review on 2/3/10 of the Patient Integrated Plan of Care for Patient #25, nursing staff failed to address the problems related to the patient's cognition and disability which interfered with continuous monitoring and staff ability to provide consistent care. Per review on 2/3/10, Patient #25 was admitted to the acute Progressive Care unit on 1/28/10 with respiratory compromise and a change in mental status. In addition, Patient #25 had cognition issues due to developmental disabilities and presented challenges to the PCU nursing staff regarding the use of cardiac monitoring equipment and respiratory therapy devices including C-PAP (Continuous Positive Airway Pressure) used for the treatment of sleep apnea and oxygen via nasal canula (NC). Per "Patient Chart Summary Report" nursing note on 1/29/10 at 0800 "Able to respond w/ 1 word/unclear at times, nods head"; 1600 "Vague responses to questions. Confusion noted" "Anxious at times and uncooperative with care"; 2210 Reapplied O2 via NC, pt. continues to pull off. Needs continuous reinforcement to not pull at NC and IVs". On 1/30/10 at 0730 "Pt combative when lab came to draw blood. 2 assists needed to hold hands during blood draw. Pt then refused meds and all other care......and is combative when caregivers approach"; 1500 "...pts inability to tolerate Bi Pap. Stressed importance of Pt's DPOA becoming involved, since pt at this time is not able to fully understand and make decisions appropriately." On 1/31/10 at 0815 "Pt continuously pulling off telemetry leads and taking off nasal cannula this morning"


2. Per record review, the suicide screening risk assessment for Patient # 14, admitted on 1/30/10, identified the patient as being at high risk for suicide. Per record review, Patient #14 had a history of multiple suicide attempts, the most recent attempt 3 days prior to admission. Per review of the nursing care plan, the high suicide risk was not addressed. This was confirmed on 2/2/10 at 4:05 PM by the evening nurse and on 2/3/10 at 3:05 PM by the Clinical Manager.

Based on record review and interview, the hospital failed to ensure documentation used for monitoring patients on the Psychiatric Services Inpatient Unit (PSIU) were completed by staff for 7 out of 10 patients (Patient #11, #13, #15, # 20, #21, #22, #23) Findings include:

Per record review, the ' Time Flow Sheets ' used on the PSIU to monitor patients on 15 or 30 minute checks were not completed.

1. Patient #11, who was on 15-minute checks had two 'Time Flow Sheets' that were not dated. In addition, one of the two flow sheets was improperly identified and lacked the patient's full name. This was confirmed by the evening Clinical manager on 2/1/10 at 4:35 PM.

2. Per review of the " Time Flow Sheet " for Patient #15 who was on 15-minute checks, there was no evidence staff observed the patient on 12/15/09 at 3:35 PM. The flow sheet was not completed to reflect Patient #15 ' s location and the staff conducting the checks. In addition, another " Time Flow Sheet " was not dated. This was confirmed by the Clinical Manager on 2/3/10 at 11:10 AM.

3. Per review of the " Time Flow Sheet " for Patient #21, no checks were documented as being done on 12/14/09 at 8;00 AM, 8:15 AM and 11:45 PM, on 12/15/09 at 3:45 PM, on 12/16/09 at 7:15 AM, 7:30 AM, 7:45 AM, 1:00 PM and 12:45 PM. In addition, another undated flow sheet showed no evidence Patient # 21 was observed for a 30-minute period (8:00 AM & 8:15 AM). This was confirmed by the Clinical Manager on 2/3/10 at 11:10 AM.

4. Patient #22, who was on 15-minute checks had no checks documented for the following days:
12/9/09 at 7:45 AM and 8:00 AM, 12/10/09 at 8:00 AM 8:15 AM 8:30 AM and 8:45 AM, 12/13/09 at 8:45 AM and 7:15 PM, 12/16/09 at 2:00 PM, 12/18/09 at 8:00 AM, 8:15 AM and 12/24/09 at 2:00 PM, 6:15 PM, 6:30 PM and 6:45 PM. In addition, one of two undated flow sheets revealed the lack of checks at 10:30 PM and 10:45 PM.

5. Patient #23, who was on 30-minute checks on 12/24/09 had no check documented at 6:30 PM. Another undated flow sheet for 15-minute checks revealed no checks being done at 9:45 AM and 1:45 PM.

6. Patient #20, who was on 15 minute checks, had no checks documented on the following days; 12/21/09 3:45 PM, 12/22/09 7:45 AM, 1/1/10 1:45 and 2:00 PM, 1/2/10 9:45 and 10:00 PM, 1/4/10 7:45 AM, 1/5/10 7:30 - 8:00 AM, 1/12/10 7:45, and 1/14/10 2:45 and 3:00 PM. In addition, one Time Flow Sheet for Patient #20 was undated.

7. Patient #13, who was on 15 minute checks on 1/29/10, had no checks documented from 7:30 AM through 8:00 AM.

Interview on 2/3/10 at 11:10 AM with the Director and Clinical Manager of PSIU, confirmed staff assigned to the checks must visualize the patient, note their location and sign the flow sheet.

Based on staff interview and record review the facility failed to assure that all physician orders were dated and/or timed for 3 of 54 patient records reviewed. (Patients #33, #34 and #36). Findings include:

1. Per review of active patient records, conducted on the afternoon of 2/2/10 and the morning of 2/3/10, on the PCU (Progressive Care Unit) the following omissions were noted in the physician orders:

a. Patient #33's record was lacking the dates and times of physician signatures on 3 separate sets of telephone or verbal orders dated 1/28/10 at 3:00 PM, 6:15 PM and 6:30 PM; 2 separate sets of telephone orders dated 2/1/10 at 6:20 PM and 10:10 PM; and 3 separate sets of telephone orders dated 2/2/10 at 8:00 AM, 8:15 AM and 9:00 AM. In addition physician orders dated 2/3/10 which included, Lasix 60 mg IV every 12 hr, Lisinopril 2.5 mg po every AM, (hold for BP < 100), daily weight were lacking the time the orders were written.

b. Patient #34's record was lacking the date and time of the physician's signature for 2 separate telephone orders dated 1/25/10 at 2:05 PM and 5:25 PM; 2 separate sets of telephone orders dated 1/28/10 at 8:00 AM and 12:20 PM; 4 separate sets of telephone orders, dated 1/29/10 at 7:40 AM, 4:30 PM, 5:20 PM and 5:30 PM; 1 telephone order, dated 1/30/10 at 12:10 AM and 1 telephone order dated 1/31/10 at 10:25 PM.

c. Patient #36's record lacked the date and time of the physician's signature for one telephone order dated 2/1/10 at 1:05 PM and 2 separate sets of telephone orders dated 2/3/10 at 12:50 AM and 8:45 AM.

The lack of date and/or times for the aforementioned physician orders was confirmed by the Director of PCU during interviews on the afternoon of 2/2/10 and the morning of 2/3/10.

Based on staff interview and record review the facility failed to assure that all medical records were complete within 30 days post discharge. Findings include:

Per review of the medical records service, at 8:00 AM on 2/2/10, the Director of Health Information Services confirmed that, as of that date, there were 40 incomplete medical records that were greater than 30 days post discharge.

Based on observation and staff interview, the facility failed to ensure that all drugs are kept in a secure area and locked when appropriate. Findings include:

Per observation during a tour of the operating room on 2/1/10 at 2:40 PM accompanied by the Director of Surgical Services (DSS), an anesthesia cart drawer containing medications utilized by anesthesia staff was found unlocked in operating room #5. This observation was confirmed by the DSS at the time of the observation. The DSS stated during a 3:00 PM interview on 2/2/10 that the cart had been unlocked for at least 2 hours and that the carts are designed to auto-lock. The cart did not auto-lock because it had been left unplugged.

Based on observation and interview, the hospital failed to maintain the physical environment of the Gross Lab used by Pathology and the sterile dryer in the Respiratory Department in a manner that assured the safety and well being of patients. Findings include:

1. Per observations on 2/1/10 at 3:05 PM, the "Olympic Sterile Dryer" used by the sleep center to process sleep masks was heavily soiled. A plastic tray at the base of the dryer was heavily soiled with dried on colored debris and the metal shelves were soiled dust and debris. This was confirmed with the Manager of Respiratory Services who accompanied the surveyor on the tour of the Respiratory Services area.

2. Per observations in the gross dissection lab on 2/4/10 at 11 AM, a paper type covering taped over an unused sink (near the microwave) was heavily soiled and stained. This was confirmed with the technician accompanying the team on the laboratory tour.

Based on interview and record review, the hospital failed to incorporate the Organ Procurement Program within the Quality Assurance Performance Improvement Program.

Per review of facility OPO programmatic documentation on 2/1/10, there was no evidence of a quality improvement program to address potential concerns regarding timely referrals to the OPO. Per interview on 2/1/10, the Director of Nursing Excellence confirmed that there was currently no internal OPO quality improvement program. On 2/2/10, the Director provided a new action plan for Improving Timeliness of Tissue Referrals which was initiated that day.

Based on record review and staff interview, the Respiratory Therapy Department failed to provide services in accordance with physician orders for 5 of 5 patients. ( Patients # 38, 39, 40, 41 & 42) Findings include:

1. Per record review, Patient #38, who was placed on a ventilator upon admission on 7/24/09, had a physician's order for Combivent inhaler every four hours. Per review of the MAR (Medication Administration Record) dated 7/29/09 07:01 to 7/30/09 07:00 there was no evidence the medication was administered at 8:00 AM and 4:00 PM on 7/29/09, and at 12:00 AM and 4:00 AM on 7/30/09. This was confirmed during interview on 2/4/10 at 2:25 PM with the Director of Respiratory Services. The Director of Respiratory Services confirmed that a Respiratory Therapist was responsible for administration of inhalers for ventilator dependent patients.

2. Per record review, Patient #39 did not receive nebulizer treatments by the Respiratory Therapist as ordered on 8/1/09. Xopenex was not administered at 3:30 PM and 7:30 PM, Atrovent was not administered at 7:30 PM, and Pulmicort was not administered at 7:00 PM. This was confirmed by the Director of Respiratory Services on 2/4/10.

3. Per record review, Patient #40 was not provided a respiratory treatment in a timely manner. Nursing documentation on 2/8/09 at 2:52 AM stated "... SOB (short of breath), DOE (dyspneic on exertion) - breath sounds clear. O2 3 liters via Per review (nasal cannula). Pt requests nebulizer treatment. Respiratory therapist notified." Per review of the 'Respiratory Therapy Documentation Record/Plan of Care Continuation' there was no evidence the nebulizer treatment was provided until 4:25 AM, which was approximately and hour and one-half later. This was confirmed by the Director of Respiratory Services on 2/4/10.

4. Per review of the MAR, a respiratory treatment consisting of Xopenex and Atrovent was not signed off as being administered to Patient # 41 on 3/5/09 at 8:00 PM. This was confirmed by the Director of Respiratory Services on 2/4/10.

5. Per review of the MAR dated 10/19/09 at 7:01 to 10/20/09 at 7:00 AM, there was no evidence that Douneb ordered to be administered every 6 hours was provided by Respiratory Therapy to Patient # 42.

During interview on 2/4/10 at 2:25 PM, the Director of Respiratory Services stated that medications administered by Respiratory Therapists could be documented on the MAR, Respiratory Flow Sheet or both. The Director Of Respiratory Services was unable to confirm that these medications had been given.