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Based on interview and record review, the hospital failed to provide documented evidence of advance notice of non-covered medicare services for 10 of 30 sampled patients (50, 51, 52, 53, 54, 55, 56, 57, 58, and 59) upon admission. This had the potential to result in the patients being unaware of their rights.

Findings:

1. During a concurrent interview and review of the clinical record for Patient 50 with Intensive Care Unit Director (ICUD), on 7/18/16, at 3:05 PM, it was noted Patient 50 was admitted on 7/11/16. There was no documented evidence Patient 50 was provided advance notice of the medicare non-covered services. The ICUD verified there was no copy of the notice in the clinical record (EMR - electronic medical record).

2. During a concurrent interview and review of the clinical record for Patient 51 with the ICUD, on 7/18/16, at 3:15 PM, it was noted Patient 51 was admitted on 7/10/16. There was no documented evidence Patient 51 was provided advance notice of the medicare non-covered services. The ICUD verified there was no copy of the notice in the clinical record.

3. During a concurrent interview and review of the clinical record for Patient 52 with the ICUD, on 7/18/16, at 3:20 PM, it was noted Patient 52 was admitted on 7/14/16. There was no documented evidence Patient 52 was provided advance notice of the medicare non-covered services. The ICUD acknowledged there was no copy in the clinical record.

4. During a concurrent interview and review of the clinical record for Patient 53 with the ICUD, on 7/18/16, at 3:25 PM, it was noted Patient 53 was admitted on 6/3/16. There was no documented evidence Patient 53 was provided advance notice of the medicare non-covered services. The ICUD acknowledged there was no copy in the clinical record.

5. During a concurrent interview and review of the clinical record for Patient 54 with the ICUD, on 7/18/16, at 3:30 PM, it was noted Patient 54 was admitted on 7/16/16. There was no documented evidence Patient 54 was provided advance notice of the medicare non-covered services. The ICUD verified there was no copy of the notice in the clinical record.

6. During a concurrent interview and review of the clinical record for Patient 55 with the ICUD, on 7/18/16, at 3:35 PM, it was noted Patient 55 was admitted on 7/18/16. There was no documented evidence Patient 55 was provided advance notice of the medicare non-covered services. The ICUD verified there was no copy of the notice in the clinical record.

7. During a concurrent interview and review of the clinical record for Patient 56 with the ICUD, on 7/18/16, at 3:39 PM, it was noted Patient 56 was admitted on 7/14/16. There was no documented evidence Patient 56 was provided advance notice of the medicare non-covered services. The ICUD acknowledged there was no copy of the notice in the clinical record.

8. During a concurrent interview and review of the clinical record for Patient 57 with the ICUD, on 7/18/16, at 3:44 PM, it was noted Patient 57 was admitted on 7/11/16. There was no documented evidence Patient 57 was provided advance notice of the medicare non-covered services. The ICUD acknowledged there was no copy of the notice in the clinical record.

9. During a concurrent interview and record review of the clinical record for Patient 58 with the ICUD, on 7/18/16, at 3:46 PM, it was noted Patient 58 was admitted on 7/15/16. There was no documented evidence Patient 58 was provided advance notice of the medicare non-covered services. The ICUD verified there was no copy of the notice in the clinical record.

10. During a concurrent interview and record review of the clinical record for Patient 59 with the ICUD, on 7/18/16, at 4:02 PM, it was noted Patient 59 was admitted on 7/14/16. There was no documented evidence Patient 59 was provided advance notice of the medicare non-covered services. The ICUD verified there was no copy of the notice in the clinical record and she stated the Director of Case Management (DCM) was responsible in providing the notices to the patients.

During an interview with the DCM, on 7/19/16, at 9:30 AM, he stated he was unaware of the advance notice but insisted he would provide information to the patients of non-covered supplies or equipments upon discharge. He was unable to provide evidence of the notice for medicare non-covered services. The DCM also stated the hospital did not have current policy on Medicare Advance Beneficiary Notice of Non-coverage.

Based on interview and record review, the hospital failed to provide documented evidence nine of 30 sampled patients (41, 42, 43, 44, 45, 46, 47, 48, and 49) received patient rights information. This had the potential to violate the patients' rights.

Findings:

1. During a concurrent interview and review of the clinical record for Patient 41, with Registered Nurse (RN) 20, on 7/19/16, at 9 AM, it was noted the patient was admitted on 7/17/16. There was no documented evidence the patient was provided a copy of the patient rights. RN 20 acknowledged no documented evidence the patient was provided a copy of the patient rights information to ensure patient was aware of their rights. She stated it should be scanned into the electronic medical record (EMR).

2. During a concurrent interview and review of the clinical record for Patient 42, with RN 20, on 7/18/16, at 3:45 PM, there was no documented evidence the patient was provided a copy of the patient rights information. RN 20 acknowledged no documented evidence the patient was provided a copy of the patient rights information to ensure patient was aware of their rights.

3. During a concurrent interview and review of the clinical record for Patient 43, with RN 20, on 7/19/16, at 9:05 AM, there was no documented evidence the patient was provided a copy of the patient rights information. RN 20 acknowledged no documented evidence the patient was provided a copy of the patient rights information to ensure the patient was aware of their rights.

4. During a concurrent interview and review of the clinical record for Patient 44, with RN 20, on 7/19/16, at 9:35 AM, there was no documented evidence the patient was provided a copy of the patient rights information. RN 20 acknowledged no documented evidence the patient was provided a copy of the patient rights information to ensure the patient was aware of their rights.

5. During a concurrent interview and review of the clinical record for Patient 45, with RN 20, on 7/19/16, at 10:10 AM, there was no documented evidence the patient was provided a copy of the patient rights information. RN 20 acknowledged no documented evidence the patient was provided a copy of the patient rights information to ensure the patient was aware of their rights.

6. During a concurrent interview and review of the clinical record for Patient 46, with RN 20, on 7/19/16, at 10:20 AM, there was no documented evidence the patient was provided a copy of the patient rights information. RN 20 acknowledged no documented evidence the patient was provided a copy of the patient rights information to ensure the patient was aware of their rights.

7. During a concurrent interview and review of the clinical record for Patient 47, with RN 20, on 7/19/16, at 11 AM, there was no documented evidence the patient was provided a copy of the patient rights information. RN 20 acknowledged no documented evidence the patient was provided a copy of the patient rights information to ensure the patient was aware of their rights.

8. During a concurrent interview and review of the clinical record for Patient 48, with RN 20, on 7/19/16, at 11:05 AM, there was no documented evidence the patient was provided a copy of the patient rights information. RN 20 acknowledged no documented evidence the patient was provided a copy of the patient rights information to ensure patient was aware of their rights.

9. During a concurrent interview and review of the clinical record for Patient 49, with RN 20, on 7/19/16, at 11:15 AM, there was no documented evidence the patient was provided a copy of the patient rights information. RN 20 acknowledged no documented evidence the patient was provided a copy of the patient rights information to ensure patient was aware of their rights.

The hospital policy and procedure titled, "Patient Rights and Responsibilities" effective date 8/88, indicated in part, "To assure that patient rights and responsibilities are understood and adhered to by patients and Hospital Staff..."

Based on interview and record review, the hospital failed to ensure advance directive information was provided to eight of 30 sampled patients (40, 41, 42, 43, 45, 46, 47, and 48) and/or failed to determine if the patients have an advance directive on file. This had the potential for the patients' wishes to go unnoted regarding care.

Findings:

1. During a concurrent interview and review of the clinical record for Patient 40, with Registered Nurse (RN) 20, on 7/18/16, at 2:30 PM, there was information the patient had an advance directive but there was no copy of the advance directive in the patient's clinical record. RN 20 acknowledged there was no copy of the advance directive in the patient's clinical record.

2. During a concurrent interview and review of the clinical record for Patient 41, with RN 20, on 7/19/16, at 9 AM, there was no advance directive information or evidence the patient was provided the information in the patient's clinical record. RN 20 acknowledged there was no copy of advance directive information in the patient's clinical record.

3. During a concurrent interview and review of the clinical record for Patient 42, with RN 20, on 7/18/16, at 3:45 PM, there was no advance directive information or evidence the patient was provided the information in the patient's clinical record. RN 20 acknowledged there was no copy of advance directive information in the patient's clinical record.

4. During a concurrent interview and review of the clinical record for Patient 43, with RN 20, on 7/19/16, at 9:05 AM, there was no advance directive information or evidence the patient was provided the information in the patient's clinical record. RN 20 acknowledged there was no copy of advance directive information in the patient's clinical record.

5. During a concurrent interview and review of the clinical record for Patient 45, with RN 20, on 7/19/16, at 10:10 AM, there was no advance directive information or evidence the patient was provided the information in the patient's clinical record. RN 20 acknowledged there was no copy of advance directive information in the patient's clinical record.

6. During a concurrent interview and review of the clinical record for Patient 46, with RN 20, on 7/19/16, at 10:20 AM, there was no advance directive information or evidence the patient was provided the information in the patient's clinical record. RN 20 acknowledged there was no copy of advance directive information in the patient's clinical record.

7. During a concurrent interview and review of the clinical record for Patient 47, with RN 20, on 7/19/16, at 11 AM, there was no advance directive information or evidence the patient was provided the information in the patient's clinical record. RN 20 acknowledged there was no copy of advance directive information in the patient's clinical record.

8. During a concurrent interview and review of the clinical record for Patient 48, with RN 20, on 7/19/16, at 11:05 AM, there was no advance directive information or evidence the patient was provided the information in the patient's clinical record. RN 20 acknowledged there was no copy of advance directive information in the patient's clinical record.

The hospital policy and procedure titled, "Advanced Health Care Directives" effective date 2/1997, indicated in part, "To ensure patient participation in the Health Care Decision Making Process by assuring that Beverly Hospital recognizes the patient's right to direct future medical treatment using... Advanced Health Care Directives... Beverly Hospital observes all provisions of the Advanced Health Care Directives... and assures that every adult patient receiving medical care is asked, if they have an Advanced Health Care Directives... or is given information about Advanced Health Care Directives..."

Based on observation, interview, and record review, the hospital failed to ensure a safe environment was provided in the labor and delivery (L&D) recovery area, when the blanket warming cabinet was not maintained within an acceptable temperature and when the hospital failed to monitor the temperature of the blanket warming cabinet. This had the potential to harm patients secondary to burns.

Findings:

During an observation in the L&D recovery area, with the Chief Nursing Officer (CNO) and the L&D Unit Secretary (US) 1, on 7/18/16, at 11:50 AM, the blanket warming cabinet was observed with patient gowns and blankets inside the unit. There was no visible thermometer to determine the temperature of the cabinet. US 1 stated the temperature is computerized and is done through the "temp tracker". The "temp tracker" temperatures for the L&D recovery area blanket warming cabinet were requested from the CNO. The CNO stated the Biomed Engineer (BE 1) would access the temperatures in the computer.

During a concurrent interview BE 1 and review of the L&D blanket warming cabinet temperatures, on 7/18/16, at 12:50 PM, the temperature entire day averages for 6/23/16 to 7/18/16, were reviewed. Twenty-two of 27 entries for the entire day's average were greater than 130° F. The maximum temperatures range for the same time frame was reviewed. Twenty of the 27 entries for the maximum temperatures were greater than 140° F and of those five were greater than 150° F. BE 1 stated he did not monitor the temperatures to the blanket warming cabinet in the L&D recovery area, it was the responsibility of the L&D staff to monitor the temperatures of the blanket warming cabinet. The temp tracker policy and procedure was requested, BE 1 acknowledged there was no temp tracker policy and procedure.

During an interview with the L&D Director (D 1), on 7/18/16, at 1:45 PM, she acknowledged the blanket warming cabinets should be monitored daily. She was unable to see the blanket warming cabinet's temperature on the computer (through the temp tracker) after attempting to access them. She acknowledged, the temperatures have not been monitored since the implementation of the temp tracker which was approximately one month ago.

The "BLANKET WARMING CABINETS LOG" was reviewed. The log indicated the blanket chamber's maximum temperature should be "130° F".

According to the ECRI ([Emergency Care Research Institute] is an independent non profit organization that researches approaches to improve patient care) article titled, "ECRI Institute Continues to Recommend Maximum Temperatures Setting of 130 degrees Fahrenheit for Blanket Warming Cabinets" dated 4/1/14, the article indicated in part, "...ECRI Institute...continues to recommend that blanket warming cabinets settings be limited to 130° F (54° C [Celsius]). Our continuing recommendation is based on our in-hospital investigations of multiple cases of patient burns resulting from blankets that were in cabinets set to greater than 130° F..."



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Based on interview and record review, the hospital failed to ensure comprehensive nursing care plans were developed for 11 of 30 sampled patients (40, 42, 43, 45, 46, 50, 51, 52, 59, 66, 67). This had the potential for unmet care needs.

Findings:

1. During a concurrent interview and review of the clinical record for Patient 40, with Registered Nurse (RN) 20, on 7/18/16, at 2:30 PM, it was noted the patient was receiving Hemodialysis (HD - a process used to treat patients whose kidneys are not working properly. It involves a special machine and tubing that removes blood from the body, cleanses it of waste and extra fluid and then returns it back to the body) treatment every Monday, Wednesday and Friday. A review of the patient's nursing care plans was conducted and there was no care plan developed for the HD. RN 20 acknowledged there should be a care plan developed for the HD treatment.

2. During a concurrent interview and review of the clinical record for Patient 42, with RN 20, on 7/18/16, at 3:45 PM, it was noted the patient was receiving HD. A review of the patient's nursing care plans was conducted and there was no care plan developed for the HD. RN 20 acknowledged there should be a care plan for the HD treatment.

3. During a concurrent interview and review of the clinical record for Patient 43, with RN 20, on 7/19/16, at 9:05 AM, the patient's chief complaint on admit included anemia (a condition where there is in inadequate number of red blood cells to carry adequate oxygen to the body's tissues) and hypoglycemia (low blood sugar levels). A review of the patient's nursing care plans was conducted and there was no care plan developed for the anemia or the hypoglycemia. RN 20 acknowledged there should be a care plan developed for the anemia and the hypoglycemia.

4. During a concurrent interview and review of the clinical record for Patient 45, with RN 20, on 7/19/16, at 10:10 AM, the patient's chief complaint on admit included gastrointestinal bleed (GI bleed is bleeding in the digestive tract) and cirrhosis of the liver (a late stage of scarring of the liver caused by many forms of liver disease and conditions). A review of the patient's nursing care plans was conducted and there was a care plan for the GI bleed but the care plan did not include approaches nursing would implement to assist the patient reach the goal. There was no care plan developed for the cirrhosis of the liver. RN 20 acknowledged the care plan for the GI bleed was incomplete and there should have been a care plan developed for the cirrhosis of the liver.

5. During a concurrent interview and review of the clinical record for Patient 46, with RN 20, on 7/19/16, at 10:20 AM, the patient's chief complaint on admit included pancreatitis (inflammation of the pancreas) and alcohol intoxication (consequences of drinking more alcohol than your body can handle). A review of the patient's nursing care plans was conducted and there was a care plan for the pancreatitis but the care plan did not include approaches nursing would implement to assist the patient reach the goal. There was no care plan developed for the alcohol intoxication. RN 20 acknowledged the care plan for the pancreatitis was incomplete and there should have been a care plan developed for the alcohol intoxication.



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6. During a review of the clinical record for Patient 50, the Physician's Order dated 7/17/16, indicated Patient 50 was to receive "Total Parenteral Nutrition (TPN - a solution consisting of glucose, protein hydrolysates [substance that split into component parts by the addition of water], minerals and vitamins, that are administered intravenously) IV Q 24H [intravenous every twenty four hours] 1 protocol injection per Pharmacy." During further review of the clinical record, the nutrition care plan did not indicate Patient 50 was receiving TPN.

During an interview with the Intensive Care Unit Director (ICUD), on 7/18/16, at 3:05 PM, she reviewed the clinical record for Patient 50 and verified there was no care plan for the use of TPN.

7. During a review of the clinical record for Patient 51, the History and Physical dated 7/10/16, indicated Patient 51 had bleeding and infection from the gastrostomy tube (an artificial opening into the stomach through the abdominal wall for the introduction of nutrient solution) site. Patient 51 had a diagnosis of Chronic Renal Failure [CRF - gradual loss of kidney function] and was receiving HD via access in his right upper extremity. During further review of the clinical record, Patient 51's care plan did not include a care plan for the gastrostomy tube bleeding and infection, or the hemodialysis.

During an interview with the ICUD, on 7/18/16, at 3:15 PM, she reviewed the clinical record for Patient 51 and verified there was no care plan for the care of gastrostomy and hemodialysis.

8. During a review of the clinical record for Patient 52, the Emergency Department (ED) Notes dated 7/14/16, indicated Patient 52 had infected heel ulcers and he received "Piperacillin Sod/Tazobactam Sod (antiinfective, broad spectrum antibiotic) 3.375 Gm (grams)/NS (normal saline) 100 mls (milliters, a unit of measurement) at 200 mls/hr PB (push bolus -a method of administration) at ED." Patient 52 was later diagnosed with Methicillin Resistant Staphylococcus Aureus (MRSA- an antibiotic resistant organism that causes infection) of the bilateral foot ulcers and placed in isolation for MRSA. During further review of the clinical record, Patient 52's care plan did not include a care plan for isolation for MRSA.

During an interview with the Clinical Information Consultant (CIC), on 7/18/16, at 3:25 PM, he stated he had just implemented a care plan development for isolation two weeks ago. The CIC also stated the licensed nurses were still learning the new process in care planning.

9. During a review of the clinical record for Patient 59, the History and Physical dated 7/14/16, indicated Patient 59 had a diagnosis of CRF and was on HD. She was receiving Hemodialysis treatment Monday, Wednesday and Friday to the left arm via an arteriovenous fistula (AV Fistula - a surgically created connection between an artery and vein for HD treatments). During further review of the clinical record, Patient 59's care plan did not include a care plan for the hemodialysis.

During an interview with the ICUD, on 7/18/16, at 3:35 PM, she reviewed the clinical record for Patient 59 and verified there was no care plan for hemodialysis.

10. During a review of the clinical record for Patient 66, the History and Physical dated 7/5/16, indicated Patient 66 had a diagnosis of end-stage renal disease and was on HD. Patient 66's care plan did not include a care plan for the HD with the AV shunt/fistula.

During an interview with the ICUD, on 7/19/16, at 9:40 AM, she reviewed the clinical record for Patient 66 and verified there was no care plan for the hemodialysis.

11. During a review of the clinical record for Patient 67, the History and Physical dated 7/13/16, indicated Patient 67 had a diagnosis of Sacral Stage IV [exposing muscle and/or bones] pressure ulcer (PU- an inflammation, sore or ulcer in the skin over a bony prominence per NPUAP [National Pressure Ulcer Advisory Panel] worsening and urinary tract infection [UTI]). Patient 67's care plan did not include a care plan for the pressure ulcer or the UTI.

During an interview with the ICUD, on 7/19/16, at 10 AM, she reviewed the clinical record for Patient 67 and verified there was no care plan for the pressure ulcer or the UTI. She gave no further information.

The hospital policy and procedure titled, "Care Planning" effective date 12/1999, indicated in part under the purpose subheading, "To provide a collaborative documented means of planning patient care using accurate and comprehensive data and information collected from assessment and regular reassessment of the patient... To communicate identified patient care needs and goals to members of the patient care team to ensure that those needs are...evaluated... To provide each patient with an individualized plan of nursing care... To determine priorities for nursing action... To aid the nursing staff in performing activities in a goal-directed manner..." Under the policy subheading it is indicated, "...The Patient Care Plan will include problems/Nursing diagnosis, measurable goals, interventions and outcomes..."



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Based on observation, interview, and record review, the hospital failed to follow policy and procedure for one contracted personnel (Registered Nurse [RN] 21). This had the potential to result in lack of quality of care provided to patients.

Findings:

During an observation on 7/18/16, at 3:30 PM, in Patient 59's room, RN 21 was standing at the bedside wearing a yellow PPE (Personal Protective Equipment) gown. Patient 59 was in bed with the head of the bed slightly elevated at a 40 degree angle. Patient 59 was connected to a Hemodialysis (HD is a process used to treat patients whose kidneys are not working properly. It involves a special machine and tubing that removes blood from the body, cleanses it of waste and extra fluid and then returns it back to the body) machine.

During an interview with RN 21, on 7/18/16, at 3:32 PM, she stated it was her first time to do HD treatment in the hospital. She stated she connected Patient 59 to the HD machine at 3:15 PM and she was currently monitoring the patient.

During an interview with the Intensive Care Unit Director (ICUD), on 7/18/16, at 3:35 PM, she verified RN 21 was inside Patient 59's room providing HD treatment. She stated the HD company had just started their contract with the hospital patients on 7/15/16. She gave no further information.

During a review of the Competency Skills for RN 21, the personnel file dated 7/15/16, did not indicate RN 21 had her competency skills evaluated upon hire and prior to performing HD treatment. The hospital was unable to provide evidence of RN 21's competency skills document on 7/19/16.

The policy and procedure titled "Registry/Contract Agency Personnel" dated 3/2015, read in part, "...Registry/Contract Agency Personnel will be expected to perform only those functions which they have been prepared for by education and for which competency has been validated by Department Director or Designee..."

Based on interview and record review, the hospital failed to follow its policy and procedure for verbal or telephone orders when the physician failed to sign orders within 48 hours for three of 30 sampled patients (58, 60, and 61). This had the potential to result in medical errors and medical records are not maintained according to standards of practice.

Findings:

1. During a review of the clinical record for Patient 58, the Physician's Order dated 7/15/16, indicated Patient 58 was to receive Ondasetron (prevents nausea and vomiting) 4 mg (milligrams) IVP (intravenous push) every six hours as necessary. During further review of the clinical record, there was no documented information the verbal order for Patient 58 was authenticated by the physician since the date it was ordered.

2. During a review of the clinical record for Patient 60, the Physician's Order dated 7/10/16, indicated Patient 60 was to receive "Acetaminophen (for pain and fever) 650 mg Rectal Q 6H PRN (every six hours as necessary) Reason: Fever greater than 101." During further review of the clinical record, there was no documented evidence the verbal order for Patient 60 was authenticated by the physician since the date it was ordered.

3. During a review of the clinical record for Patient 61, the Physician's Order dated 7/14/16, indicated Patient 61 was to receive Levofloxacin (antiinfective/antibiotic) 500 mg/100 ml (milliliter) in 100 ml PB (push bolus) every 24 hours. There was no documented evidence the physician authenticated the order since the date it was ordered.

During an interview with the Intensive Care Unit Director (ICUD), on 7/19/16, at 9:30 AM, she reviewed the clinical record for Patient 58, Patient 60 and Patient 61 and she verified the verbal/telephone orders were not authenticated. She gave no further information.

The hospital policy and procedure titled "Physician's Orders: Telephone Orders" dated 11/2015, read in part, "To enable Clinical Staff to follow Physician's instructions for medications, treatments, and procedures... All telephone orders and telephonic reporting of critical test results will be documented in patient's Medical Record, read back to the originator of the order or test result and the originator will confirm accuracy of the order or test result... The responsible Physician is to authenticate all telephone orders within 48 hours by dating, timing and signing telephone orders..."

Based on observation and interview, the hospital failed to maintain a sanitary environment when clean hemodialysis (HD) machines, equipment and supplies were stored in a dusty and unkempt room. This had the potential to place the staff, patients and visitors at risk for hospital acquired infections.

Findings:

During an observation on 7/19/16, at 10:15 AM, in a small room (adjacent to the conference room by the basement), two HD machines, connecting tubes, sterile supplies and equipment were stored in a dusty and unkempt room. The room had no ceiling and there were exposed tube vents above it. A hamper that contained soiled linens was located close to the clean HD equipment and supplies.

During an interview with Intensive Care Unit Director (ICUD), on 7/19/16, at 10:25 AM, she stated the storage room was temporary and another storage room was being prepared in the Intensive Care Unit (ICU). The ICUD also stated, "All the Hemodialysis machines, and equipment are clean and good to go."



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Based on interview and record review, the hospital failed to ensure discharge planning was developed for eight of 30 sampled patients (40, 41, 43, 45, 46, 47, 51, and 53). This had the potential to impact the continuation of care after the patients are discharged from the hospital.

Findings:

1. During a concurrent interview and review of the clinical record for Patient 40, with Registered Nurse (RN) 20, on 7/18/16, at 2:30 PM, it was noted the patient was admitted on 7/13/16 from an Extended Care Facility (ECF). There was no indication in the discharge planning notation if the plan was for the patient to return to the same ECF or if there was a different plan.

During an interview with the Director of Case Management (DCM), on 7/18/16, at 3:15 PM, he stated the discharge note is documented in the hospital's electronic medical record (EMR) and it is his responsibility to free text (or document each patient's discharge disposition). The DCM stated the discharge planning should be initiated within 24 to 48 hours after the patient is admitted.

2. During a concurrent interview and review of the clinical record for Patient 41, with RN 20, on 7/19/16, at 9 AM, it was noted the patient was admitted on 7/17/16 at 1:44 AM, and there was no discharge plan initiated for the patient. RN 20 acknowledged there was no discharge planning noted in Patient 41's clinical record.

3. During a concurrent interview and review of the clinical record for Patient 43, with RN 20, on 7/19/16, at 9:25 AM, it was noted the patient was admitted on 7/8/16, and there was no discharge plan noted for the patient. RN 20 acknowledged there was no discharge planning noted in Patient 43's clinical record.

4. During a concurrent interview and review of the clinical record for Patient 45, with RN 20, on 7/19/16, at 10:10 AM, it was noted the patient was admitted on 7/14/16, and there was no discharge plan noted for the patient. RN 20 acknowledged there was no discharge planning noted in Patient 45's clinical record.

5. During a concurrent interview and review of the clinical record for Patient 46, with RN 20, on 7/19/16, at 10:45 AM, it was noted the patient was admitted on 6/26/16, and the discharge planning was initiated on 7/6/16. RN 20 acknowledged the discharge planning was initiated late.

6. During a concurrent interview and review of the clinical record for Patient 47, with RN 20, on 7/19/16, at 11 AM, it was noted the patient was admitted on 7/17/16, and a discharge planning noted dated 7/18/16 had no planned discharge disposition. RN 20 acknowledged there was no planned discharge disposition.



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7. During a concurrent interview and review of the clinical record for Patient 51, with Intensive Care Unit Director (ICUD), on 7/18/16, at 3:15 PM, it was noted Patient 51 was admitted on 7/10/16. Patient 51 was admitted from a convalescent home. There was no documented evidence a discharge plan was initiated and whether Patient 51 would go back to the nursing home. The ICUD verified there was no discharge plan in the clinical record.

8. During a concurrent interview and review of the clinical record for Patient 53, with the ICUD, on 7/18/16, at 3:25 PM, it was noted Patient 53 was admitted from home on 6/10/16. There was no documented evidence a discharge plan was initiated and whether Patient 53 would be ready to go back home or would need continuity of skilled care/need in another facility. The ICUD acknowledged there was no discharge plan in the clinical record.

During an interview with the Clinical Information Consultant, on 7/18/16, at 3:30 PM, he reviewed the clinical record for Patient 53 and verified a discharge plan had not been initiated.

The hospital policy and procedure titled, "Discharge Planning" effective date 1/1998, indicated, "The goal of Discharge Planning is to identify the patient's needs in the early phases of hospitalization and to develop an individual Discharge Plan that will maximize the patient's outcome once discharged from the Hospital...Each inpatient will have a Discharge Planning Evaluation completed by Case Management Staff...within 24 to 48 hours upon admission...The continuity of patient care, during and after their hospitalization, will systematically planned in order to promote the maximum potential for recovery for each patient..."



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