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1. Based on interview and review of hospital policies and procedures, the hospital failed to follow its' policy and procedure for informing patient's of their rights when admitted to the hospital according to 42 CFR 482.13(a)-(d).

Failure to inform patients of their rights limits the patient's ability to exercise those rights.

Findings:

a. On 11/16/2010 at 1:05 PM, an interview with the admitting department supervisor (Staff #S3) revealed that registration staff members gave patients a list of their rights and responsibilities on their first admission to the hospital. The supervisor stated patients were not given a list of rights on subsequent admissions.

b. The hospital's policy and procedure entitled "Patient Rights and Responsibilities" (Effective September 2004) read as follows: "Virginia Mason Medical Center staff will distribute a copy of the Patient Rights and Responsibilities to each patient upon entry or admission to the medical center for healthcare treatment".


2. Based on review of information distributed to patients to inform them of their rights, the hospital failed to fully inform patients of their rights as specified by the regulation.

Failure to inform patients of their rights limits the patient's ability to exercise those rights

Findings:

a. On 11/16/2010 at 1:05 PM, an interview with the admitting department supervisor (Staff #S3) revealed that registration staff members gave patients a list of their rights and responsibilities on their first admission to the hospital.

b. Review of the handout entitled "Patient Rights and Responsibilities" (VMMC Form 900608; March 2007) revealed this handout did not include all of the patient's rights identified in current hospital regulations, including the right to be free from all forms of abuse or harassment [42 CFR 482.13.(c)(3)]; and the right to access information contained in his or her clinical records within a reasonable time frame [42 CFR 482 (d)(2).


3. Based on record review and interview, the hospital failed to ensure that Medicare patients were notified within two calendar days of discharge of their right to appeal their discharge to a designated Quality Improvement Organization for 3 of 3 patients reviewed (Patients #M2, #M3, #M4)

Reference: 42 CFR 405.1205(b) - Hospitals must provide each Medicare beneficiary who is an inpatient a standardized notice, the "Important Message From Medicare", within two days of their admission and again within two calendar days before discharge.

Findings:

a. The hospital's policy and procedure entitled "Standard Process Description: Important Message From Medicare" (Approved January 11, 2008) stated that the patient flow coordinator would deliver a copy of the "Important Message From Medicare" to patients and/or their beneficiary within 48 hours of discharge but not less than 4 hours of discharge.

b. Review of the medical records of three Medicare patients who were hospitalized longer than three days revealed that the records of lacked evidence that the patients had been notified of their discharge appeal rights and the appeal process within 48 hours of discharge as directed by hospital policy (Patients #2, #3, #4).

c. On 11/18/2010 at 3:00 PM, an interview with a director of the hospital's quality program (Staff #S4) confirmed that these records lacked this evidence.

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Based on review of personnel file information and administrative staff interview, the hospital failed to ensure that a Washington State Patrol background inquiry was obtained prior to staff being placed in positions allowing unsupervised access to patients for 3 of 8 personnel files reviewed (S19, S20, S21).

Failure to obtain a background inquiry places all patients at risk of receiving care from staff that may have potentially dangerous background information.

Findings:

Review of personnel file information on 11/19/2010 revealed that Staff members #S19, #S20, #S21 were hired on 3/23/2009, 7/22/2010, and 4/13/2009, respectively. Background checks for S19, S20, and S21 were conducted by a contracted service that did not include a Washington State Patrol background check. Separate Washington State Patrol background checks were not completed.

An interview with the human resources director revealed that background checks were obtained through a contracted service. Upon investigation, the human resources director discovered that the background check conducted by the contracted service did not include a Washington State Patrol background inquiry.


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Based on review of personnel files and job descriptions, the hospital failed to ensure that 2 of 10 staff members (S19, S20) met the minimum qualifications for his/her position, specifically, the hospital failed to ensure a process for documentation of cardiopulmonary resuscitation certification (CPR).

Failure to maintain accurate records for staff CPR certification and failure to ensure minimum competency for emergency response risks inability of hospital personnel to respond correctly to a cardiac or respiratory emergency.

Findings:

1. Review of the job description for the hospital Registered Nurse (RN) (Approved 8/2003) revealed that minimum requirements for the RN included CPR certification every two years.

2. Review of personnel files on 11/19/2010 revealed that there was no evidence of CPR certification for RNs S19 and S20.


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Based on observation, records review, and interview, the hospital failed to develop a process for planning nursing care in the outpatient Oncology Infusion Center (OIC).

Failure to develop and update a nursing care plan for patients receiving ongoing chemotherapy and biologic product infusions limits the nurse's ability to recognize and treat complications of the patient's treatment regimen.

Findings:

1. On 11/18/2010 at 9:30 AM, Patient #8 was interviewed in the Outpatient Infusion Center (OIC). The patient had been diagnosed with colon cancer and metastasis in February 2010. In April 2010, the patient began outpatient chemotherapy and was receiving his 16th treatment.

2. During an interview on 11/18/2010 at 9:35 AM, an OIC staff nurse (Staff #S7) indicated that Patient #8 had been assessed using nursing assessment tools that were not specific to oncology patients. The patient's treatment plan had been developed by the patient's physician. A nursing care plan had not been developed based on the patient's individual nursing care needs.

3. During an interview on 11/18/2010 at 10:35 AM, the OIC Nurse Manager (Staff #S8) confirmed that the OIC had no process for developing nursing care plans for patients receiving care in the oncology infusion area.

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Based on record review, review of hospital policies and procedures, and interview, the facility failed to ensure that medication orders were dated and timed as directed by hospital policy for 2 of 2 oncology patient records reviewed (Patient #1, #7)

Failure to date and time medication orders increases the risk for medication errors and misinterpretation.

Findings:

1. The hospital's policy and procedure entitled "Medication Management: Ordering Medications" stated that a complete medication order includes the date and time the order was written. The hospital's quality program coordinator (Staff #S6) confirmed that this was current hospital policy on 11/19/2010 at 8:45 AM.

2. Review of the records of two patients who received chemotherapy during their hospital stay revealed the following:

a. On 11/16/2010, Surveyor #13692 reviewed the records of Patient #1, a current patient on the inpatient oncology unit. The records included pre-printed order sets entitled "Autologous Peripheral Blood Stem Cell Infusion Orders", "Lymphoma (Hodgkin's) BEAM", and "Antiemetic Order Sheet for Inpatient Chemotherapy". The order sets were signed and dated but were not timed.

b. On 11/19/2010, Surveyor #13692 reviewed the records of Patient #7, a current patient on the inpatient oncology unit. The records included pre-printed order sets entitled "Lymphoma (HIV-Associated Burkitt's) Regimen B, R-CODOX-M/IVAC" and "Antiemetic Order Sheet for Inpatient Chemotherapy". The order sets were signed and dated but were not timed.

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Based on record review and review of facility policies, the facility failed to ensure nursing staff members performed blood transfusion procedures according to facility policy and procedure for 2 of 5 patients reviewed (Patients #5, #6).

Failure to perform blood transfusion procedures according to acceptable standards of practice risks transfusion reactions and complications.

Findings:

1. The hospital's policy and procedure entitled "Blood Components: Administering" (Approved July 2010) stated that two individuals would participate in the blood component identification process. These two individuals would verify that the type of blood component matched the patient's order for transfusion; that the patient's name and medical record number on the patient's identification band matched those on the blood component unit "Transfusion "Report" form; and that the ABO/Rh label on the blood component matched the ABO/Rh on the "Transfusion Report".

Review of the records of Patient #5 on 11/18/2010 revealed that only one individual signed the "Transfusion Record" for one of two units of fresh frozen plasma administered on 11/10/2010. This was verified by Surveyor #18001 during an interview with an administrative staff member (Staff #S5) on 11/18/2010 at approximately 10:00 AM.

2. The hospital's policy and procedure entitled "Blood Components: Administering" (Approved July 2010) stated that nursing staff would assess and document the patient's vital signs before starting the transfusion; after the first 15 minutes of the transfusion; hourly during the transfusion; and at the completion of the transfusion. Vital signs assessed were to include the patient's temperature, pulse, respiration, and blood pressure.

Review of the records of Patient #6 on 11/17/2010 revealed that the nurse administering the blood did not assess and document the patient's temperature at the completion of the first of two units of packed red blood cells. The nurse also did not assess and document the patient's temperature, pulse, respirations, and blood pressure at the completion of the second of two units of packed red blood cells.

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Based on observation and staff interview, the facility failed to meet the provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association (NFPA).

Findings:

Refer to deficiencies written in the Fire Safety Survey Report 2000 Code-Health Care, Medicare-Medicaid dated 11/19/2010.


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Based on observation and interview of hospital staff, the hospital failed to maintain a level of safety and quality of the patient equipment and supplies by not providing the separation of clean equipment and supplies from soiled equipment during storage.

Failure to provide the separation between patient clean items and patient soiled items places the patients at risk for possible cross-contamination of patient supplies and the spread of infections.

Finding:
MIXING OF CLEAN AND SOILED PATIENT ITEMS IN THE NEGATIVE AIR SOILED UTILITY ROOMS
On 11/17/2010 the surveyor found patient clean supplies mixed with patient dirty supplies in the soiled utility rooms designed and dedicated for patient soiled supplies. The soiled utility rooms on the 10th and 12th floors had "Clean Utility" signs posted on the top half of the walls and "Dirty Utility" signs posted on the lower half of the walls to separate patient clean equipment and supplies from soiled equipment in the same soiled utility rooms. The surveyor found patient clean equipment (cane, crutches, and walkers) and clean supplies (gloves, gowns and masks) stored in the soiled utility rooms on the 10th and 12th floors. The hospital staff (#S2) reported to the surveyor that the patient equipment above the clean line was clean and the area was dedicated for clean storage of patient equipment and supplies in the soiled utility room. The two soiled utility rooms with negative air flow were designed and maintained to store dirty equipment instead of the storage of patient clean supplies and equipment.

This finding was reported by the hospital staff (#S2) to be corrected during the survey.

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14866


Based on observation and interview, the hospital failed to maintain the sterile processing department in a condition that would ensure an acceptable level of safety and quality.

Failure to maintain an acceptable level of safety and quality in the sterile processing department risks patient infection and injury to personnel.

Findings include:

During a tour of the sterile processing department on 11/18/10, it was observed that:

a) An unprotected sewer line ran along the wall at the south end of the sterile packaging room. According to sterile processing staff, a portion of the sewer line had leaked in the past and was enclosed, but the remainder of the line was exposed to the room

b) Dust was observed on high surfaces in the sterile packaging room, and the floors appeared dirty. Sterile processing department personnel stated that the environmental services staff assigned to the department had resigned, and the department was not receiving as many hours of service since that time

c) Carts used to transport contaminated instruments from the surgery department to the sterile processing department were draped with plastic covers that did not indicate that the carts contained biohazardous material. These carts passed through public corridors and were intermingled with clean supplies in a staging area outside the decontamination room

d) The cart washer between the decontamination room and the sterile supplies storage room had a visible water leak along the south side of the washer. Several towels had been placed on the floor of the decontamination room to soak up the water. Sterile processing department personnel stated that the washer "always" leaked and that repairs had not corrected the problem. Personnel in the decontamination room stated that they feared slipping in the standing water

e) The cart washer noted in (d) above did not have a ventilation system to evacuate steam following a wash cycle. This left sterile processing personnel in a position of evacuating the steam by either opening the washer door into the decontamination room , or opening the door to the sterile supplies storage room. Opening the door to the decontamination room exposed the clean carts to the contaminated environment in that room. Opening the door to the sterile supplies storage room exposed sterile packaged products to a burst of steam, rendering them unusable

f) The ramp of the cart washer was observed to be slippery to stand on, despite non-skid strips that had been applied to the surface. Sterile processing department personnel stated that some people had slipped and been injured on this ramp while pushing carts up into the washer

g) Additonal washers located on the south side of the decontamination room were observed to be leaking onto the floor and creating a similar slipping risk

h) A domestic washer/dryer was located in the southeast corner of the decontamination room. This was a wet area, but according to hospital facilities management the washer/dryer was not connected to a ground-fault circuit for protection against electrical shock

i) The soiled equipment decontamination room had no physical barrier to separate it from the sterile supplies storage room. This permitted air to flow from the room where patient equipment was being decontaminated into the large adjacent room where sterile supplies were stored

j) The wall at the junction between the soiled equipment decontamination room and the sterile supplies storage room had a significant gouge, exposing the interior of the wallboard to the sterile supplies storage room

All of the above observations were verified by sterile processing department management and by hospital facilities management.


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Based on observation, the hospital failed to provide proper ventilation for pathology and patient procedure room.

Failure to provide negative air pressure in pathology and positive air flow in procedure rooms puts patients, staff and visitors in the hospital at risk for possible exposure to chemical and biological contaminants.

Finding:

1. On 11/18/2010 the surveyor used a piece of tissue paper to observe the direction of air flow and found that the air pressure for pathology was positive. The air from surgical pathology was blowing into the main corridor. Also, there was a pass-through window opening from pathology into the hallway and the air was blowing through the window into the hallway. The surveyor observed a warning sign posted on the hallway side of the door to pathology which read, "contaminated area" and the pathology staff were examining tissue samples in the room. This positive air flow allowed for possible chemical and biological contaminates from the pathology lab to blow into the hallway and into the adjoining areas.

2. On 11/17/2010 the surveyor used the tissue test and observed that the ventilation in one of two Electrophysiology (EP) labs was negative to the outside space. The air from outside was flowing into #2 EP procedure room. The EP lab air pressure was not positive to prevent outside air contaminates from entering into the procedure room.



14867


Based on observations, the hospital failed to maintain ventilation consistent with CDC Guidelines for Environmental Infection Control in Health Care Facilities, 2003, Table B.2.

The hospital failure to maintain ventilation relationships consistent with CDC Table B.2, places patients at risk of infection and compromises the quality of patient care.

Findings:

During a tour of the Gastroenterology Short Stay Surgery Center on 11/16/10, observation of a lightweight tissue showed air pressure for the Scope Cleaning Work Room was positive to the adjacent corridor.

Facility staff confirmed this observation.


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Based on observation, interview, and record review by three surveyors, the facility failed to develop and/or implement certain systems and procedures for controlling/preventing infections.

Failure to do so places patient, visitors, and staff at risk for health-care acquired infections, resulting in debility, pain, suffering, extended hospital stays, increased health-care costs, and death.

Findings include:

I.
During tour of the peri-operative areas on 11/16/10 surveyor 18001 observed housekeeping staff members cleaning an operating room (OR) on floor H5 following a surgical procedure, and preparing it for the next case. This process is called a " turnover " . Several breaches of standard infection control procedures were noted:

· Staff #S14 wiped down cables from a portable monitor with a disinfecting solution, but could not reach far enough to hang the coiled cable on its designated hook, so s/he handed it to staff #S15 to hang it up. At the time staff #S15 had been emptying soiled trash and linen hampers, and took the cleaned cables in his/her contaminated hands.
· Staff #S16, while mopping the floor, picked up two pieces of debris from the OR floor, contaminating his/her gloves. Without performing hand hygiene and donning new gloves, s/he continued to mop, moving equipment around with contaminated gloved hands. Some of this equipment had been wiped down with the disinfecting solution and was considered clean and ready for the next case.
· Staff #S15 removed the soiled trash and laundry bags from the OR and returned with empty ones which he attached to their frames. The surveyor asked if s/he had removed the old gloves, performed hand hygiene, and put on new gloves. Staff #S15 stated " No these are the same gloves " .
· Staff #S14 was engaged in wiping down equipment and other surfaces with a cloth dampened in disinfecting solution. The surveyor observed him/her push up from the floor using gloved hands, thus contaminating them, and continue with his/her work without removing gloves, performing hand hygiene, and donning clean gloves.
· Staff #S14 was observed to repeatedly wipe from more soiled to cleaner surfaces. S/he began his/her process by wiping horizontal surfaces, some of which would be used to hold sterile instruments and supplies. S/he then wiped down the equipment legs and supports, down to floor level, allowing the wiping cloth to contact the floor. Without changing to a new, clean cloth, staff #S14 began wiping another horizontal surface and continuing the same process.

These observations were reported to managerial staff (#S11) and an infection control practitioner (staff #S17) was summoned to accompany the surveyor. Together they watched an OR turnover on floor H6. The surveyor observed further, similar examples of moving from soiled to clean surfaces while housekeeping staff were in the process of disinfection wiping of the OR.


II.
During unit environmental tours on 11/17-18/10 surveyor 14866 observed several breaches of infection control standard procedures involving isolation precautions, hand hygiene performance, and use of personal protective equipment (PPE):

· On 11/17/10 at approximately 2:22PM surveyor 14866 observed a provider (staff #S9) in room 959 speaking to a patient. The room was marked with a " contact precautions " sign. The provider entered the room, donning gloves and then gown (which is a reversal of the recommended practice), then proceeded to interact with the patient. The provider then removed his gown and then gloves (opposite of the recommended practice) and left the room without performing hand hygiene. Approximately 26 feet down the corridor, he used an alcohol-based hand rub dispenser.
· The provider (staff #S9) re-entered the same room on 11/17/10 at approximately 2:34PM, and interacted with the patient. He was not wearing any PPE at the time of the surveyor ' s observation, although the surveyor did not see whether s/he had already removed any PPE s/he may have been wearing. S/he left the room and returned to the nurses ' station without performing any hand hygiene.
· On 11/18/10, at approximately 11:00AM surveyor 14866 observed that a contact precautions sign was taped to the door of operating room #5. The words " Droplet and " were hand written over the printed instructions for contact precautions. No droplet precautions instructions had been added to the sign. The contact precautions sign stated that PPE must be donned at the door before entering the room. The surveyor observed OR personnel carry a yellow PPE gown into the room and don the gown at the patient ' s bedside. These observations were witnessed by managerial staff (#S11).
· In the same operating room at the same time the surveyor observed OR personnel with facial hair not wearing a beard covering. Managerial staff (#S11) confirmed the observation and stated that this was not acceptable practice.


III.
On 11/17/2010 at 10:10 AM surveyor 00210 observed two ungloved and ungowned nursing staff enter patient room #1564 while three other gloved and gowned hospital staff attended to the patient in the room. A Contact precautions sign was posted at the patient room door. The patient was reported by nursing staff to have a Methicillin-Resistant Staphylococcus aureus (MRSA) blood infection. The hospital policy was that nursing staff wear gloves and gown when entering into a patient room when a contact precaution is posted to protect against the spread of MRSA infections.


IV.
During tour of the GI Endoscopy unit on 11/17/10 surveyor 18001 observed a red metal toolbox-type of container marked for Pharmacy use. The box was on the floor in a main corridor, next to a supply cart. Staff #S18 stated that this was where the box was always stored between uses, and that it was also stored on the floor in the Pharmacy.

According to unit staff, this box was used to transport scheduled drugs daily between the endoscopy unit and the Pharmacy. The process described involved picking up the drugs from Pharmacy in the morning, distributing them to each of the six endoscopy procedure rooms, and returning any leftover drugs to the Pharmacy at the end of the day. Staff acknowledged that this process involved placing the box on various counter-tops, that there was no defined routine procedure for cleaning the box, and that it should not be stored on the floor.



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Based on observation, interview and record review, the hospital leadership failed to ensure that the hospital-wide quality assurance program and training programs address problems identified by the infection control officer.

Failure to correct infection control problems in a timely way risks hospital-acquired infection among patients.

Findings include:

1) During tours of the hospital on 11/16/10 - 11/18/10, surveyors observed the following breeches of correct practice in the use of personal protective equipment (PPE):

a) On 11/17/10 at approximately 2:22 pm a provider was observed in room 959 speaking to a patient. The room was marked with a " contact precautions " sign. The provider entered the room, donning gloves and then gown (which is opposite of the recommended practice), then proceeded to interact with the patient. The provider then removed his gown and then gloves (opposite of the recommended practice) and left the room without performing hand hygiene. Approximately 26 feet down the corridor, he used an alcohol-based hand rub dispenser.
b) The same provider re-entered the same room at approximately 2:34 pm, and interacted with the patient. He was not wearing any PPE at the time of my observation, although I did not see whether he had already removed any PPE he may have been wearing. He left the room and returned to the nurses ' station without performing any hand hygiene.
c) On 11/18/10, at approximately 11 am it was observed that a contact precautions sign was taped to the door of operating room 5. The words " Droplet and " were written over the printed instructions for contact precautions. No droplet precautions instructions were added to the sign. The contact precautions sign stated that PPE must be donned at the door before entering the room. OR personnel were observed to carry a yellow PPE gown into the room and don the gown at the patient ' s bedside.
d) In the same operating room at the same time OR personnel with facial hair were observed not wearing a beard covering. The OR manager confirmed the observation and stated that this was not acceptable practice.
2) During an interview on 11/18/10, hospital infection prevention officers stated that they had measured compliance with hospital PPE practices beginning in January, 2010 and extending until the present date. The study had identified unacceptable levels of conformance with hospital policies regarding proper use of PPE, including a downward trend in compliance. However, no intervention had occured as of the date of this interview. The plan stated was to post educational materials and discuss the issue with the managers of high-noncompliance units, starting in 2011.



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Based on interview and record review, the hospital failed to follow its Medical Staff Bylaws for completing operative reports for surgeries performed in clinic locations.

Failure to do so results in a record that is incomplete, and lacks information that is potentially important to patient care in the post-operative period.

Findings include:

The hospital ' s Medical Staff Bylaws read, in part (page 23):

" Brief Operative Note
12.8 Must be documented in the record immediately after surgery, on the Brief Operation Report form or in the Progress Notes or electronically in CIS. " Staff #S6 stated that this requirement applies to any patient undergoing a surgical procedure, including clinic patients.

During tour of the Dermatology Clinic on 11/17/10 the surveyor inquired as to the types of surgical procedures performed in that location. The list included biopsy of skin lesions and MOHS procedures.

MOHS procedures involve removing the visible lesion, examining it under a microscope to determine if the entire lesion has been removed, and if necessary, removing further layers or sections until there is microscopic evidence that the entire lesion has been removed. The procedure is designed to spare as much normal tissue as possible and according to staff #S12, can last the better part of a day, due to the need for careful microscopic examination and subsequent closure of the wound.

The surveyor reviewed the medical record for Patient #13, who had undergone a MOHS procedure. No surgeon ' s operative report was found in the patient ' s paper or record. Staff #S12 stated that the surgeons in the clinic did not write brief operative notes in patient records, but dictated such notes, and that it could take 48 hours for them to be transcribed.

The surveyor toured the Plastic Surgery Clinic on 11/17/10. Staff #S13 identified the following as typical surgical procedures performed in the clinic: removal of minor lesions and cysts, revision of scars, removal of tattoos, and hand tendon procedures. When asked about operative notes, Staff #S13 described the same process that the surgeons followed in the Dermatology Clinic.

The above was confirmed by administrative staff (#S6).


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Based on interview and record review, the facility failed to develop and follow policies and procedures for post-anesthesia evaluation that meet the regulation and reflect professional standards of anesthesia care.

Failure to do so places patients at risk of unrecognized complications of anesthesia care and potential delays in any necessary treatment.

Findings include:

On 11/16/10 the surveyor reviewed the medical record for one patient who had undergone surgery using general anesthesia (Patient #9). Incomplete documentation of the post-anesthesia evaluation by an individual qualified to administer anesthesia was found.

Patient #9's post-anesthesia evaluation did not reflect the time it had been performed; therefore it was not possible to determine at what point following surgery it had occurred.

"Practice Guidelines for Post-anesthetic Care", in the journal Anesthesiology, Volume 96, #3, March, 2002, and cited by CMS as best practice, provides guidelines from the American Society of Anesthesiologists (ASA) for routine post-anesthesia assessment. These include assessment of the following patient parameters:

· Respiratory function, including respiratory rate, airway patency, and oxygen saturation
· Cardiovascular function, including pulse rate and blood pressure
· Mental status
· Temperature
· Pain
· Nausea and vomiting
· Postoperative hydration

Per staff #S11, the facility policy is to document the post-anesthesia evaluation in the designated area on the reverse of the form titled "Anesthesia Record, VMMC FORM 900344", dated 1/10. Reviewing Patient #V1 ' s record, the form was found to contain a box approximately 2" X 4" at the bottom of the reverse page, labeled "POSTOP NOTE". This box contains prompts to fill in or check off certain types of information regarding the patient's status. However, the anesthesia provider did not address each item individually for Patient #V1, but wrote " no issues " once in the box.

The form did not provide prompts or sufficient room to document the following parameters outlined in ASA ' s guidelines:

· Respiratory function, including rate, airway patency, and oxygen saturation
· Pulse rate and blood pressure
· Temperature
· Pain
· Nausea and vomiting
· Post-operative hydration

Records for patients #10 - #12 were reviewed on 11/17-18/10 for content of post-anesthesia evaluations. The previously-described form was used for all three patients, and all evaluations failed to address the parameters listed above.


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