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Based on the number and nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation of Governing Body was out of compliance.

The facility failed to have an effective governing body legally responsible for the conduct of the hospital as an institution. According to the Governing Board By-Laws, in pertinent part: Article IX, 9.6, Patient Care- "The Governing Board shall support and participate in an institutional process to periodically review, evaluate, and revise Hospital policies and procedures to enhance integrated patient care for all disciplines, including but not limited to nursing care and social services, based on standards of patient care for the respective disciplines and on practice standards for the respective disciplines."

The facility failed to:

1. Provided an effective Quality Assurance Performance Improvement Program.

2. Address the medical needs of all the patients admitted to the facility.

3. Provide comprehensive Social Services and discharge planning, including coordination with nursing staff and physicians to ensure an appropriate discharge to a facility, prior living arrangement or home.

4. Provide consistency in admitting appropriate patients to the facility, including poor communication with physicians regarding which patients can be provided quality care for their medical needs within the capability of the facility.

5. Have an organized nursing service that had the capability of providing nursing services with qualified, competent medical knowledge.

6. Ensure that patient's families are communicated with by the physicians and staff and that the families are included in the treatment plan during the phases of care.

7. Ensure that medical records include all documentation and are consistent and complete to reflect the comprehensive care of the patient.

8. To establish guidelines/protocols to provide consistency in caring for the medical needs of the patient.

9. To ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient.

10. To provide adequate supervision and evaluation of the clinical activities of all nursing personnel and agency staff.

11. Ensure there were adequate numbers of medical staff to provide consistency and quality care for the patients.

12. To identify and evaluate medical issues prior to discharge/transfer to another facility.

13. Comply with CMS (Centers for Medicare and Medicaid Services) requirements, specifically as follows:

A. 0043 Condition of the Governing Body

A. 0049 Medical Staff Accountability
A. 0057 Chief Executive Officer
A. 0067 Care of Patients-MD/DO on call

A. 0115 Condition of Patient Rights

A. 0130 Participation in Care Planning
A. 0144 Patient Rights; Care in a Safe Setting
A. 0145 Patient Rights; Free from Abuse and Harassment

A. 0263 Condition of QAPI

A. 0285 Patient Safety
A. 0288 QAPI Feedback and Learning
A. 0289 QAPI Improvement Actions
A. 0290 QAPI Improvement Measures
A. 0291 QAPI Sustained Improvement
A. 0309 Executive Responsibilities

A. 0385 Condition of Nursing Services

A. 0386 Organization of Nursing Services
A. 0392 Staffing and Delivery of Care
A. 0395 RN Supervision of Nursing Care
A. 0396 Nursing Care Plans
A. 0397 Patient Care Assignments
A. 0398 Supervision of Contract Staff

A. 0449 Content of Record
A. 0464 Content of Records- Consults

A. 0749 Infection Control Officer Responsibilities

A. 0806 Discharge Planning-Needs Assessment
A. 0811 Documentation of Evaluations
A. 0827 Discharge Planning Document
A. 0843 Reassessment of Discharge Planning Process

Based on the number and nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation of Patient Rights, was out of compliance. Cross Reference to A. 0130 Participation in Care Planning, A. 0144 Care in a Safe Setting and A. 0145 Free from Abuse/Harassment.

Based on the number and nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Quality Assurance Performance Improvement was out of compliance.

Review of the "Total System Evaluation" for 3/10/10 revealed that eighteen quality improvement projects had been discussed.
It was not evident the corrective actions were effectively monitored and that the deficient practice did not re-occur. Additionally, Quality indicators, e.g. fecal impactions and dehydration were not addressed in the Quality Improvement.
Cross Reference to:

A 0285 QAPI Patient Safety

A 0288 QAPI Feedback and Learning

A 0289 QAPI Take Improvement Actions

A 0290 QAPI Quality Improvement Measurements

A 0291 QAPI Sustained Improvement

A 0309 Executive Responsibilities

Based on the number and nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Nursing Services was out of compliance. Cross reference to A 0386 Organization of Nursing Services, A 0392 Staffing and Delivery of Care, A 0395 RN Supervision of Nursing Care, A 0396 Nursing Care Plans, and A 0397 Patient Care Assignments, A 0398 Supervision of Contract Staff.

Based on interviews with the facility's Medical Director and two physicians from the consultant medical group, it was determined the facility failed to have an organized medical staff and systems and protocols in place to ensure that quality of care was provided to patients. This failure created the potential for negative outcome to all patients in the facility. The findings were:

Interviews:

On 4/1/10 at 11:30 a.m., an interview was conducted with the facility's Medical Director. H/she stated the facility had one full time, one part time and one covering (PRN) psychiatrist. The average daily census is 25.5 patients (as stated by the Executive Director on 3/29/10) and stated that three full-time psychiatrists are needed when the census nears 30 patients. In regard to family calls h/she stated, "If I"m off duty and the family called for me, the nurses put the note in my box and I don't see it for four days until I'm back. Then the family is not addressed and by the time I talk to them, they are already angry." H/she continued to explain that her/his coworkers (the other psychiatrists) are usually very good about addressing family issues if they have time. H/she stated the nurses round with the psychiatrists every day and they ask how much the patient slept, how much they ate, the last bowel movement, and if vital signs are stable. In regard to nurses informing the psychiatrist of issues, h/she stated, "if we don't get information, the Medical Consultant Group doesn't either." If the nurse tells us that there is a medical issue, we usually follow up. In regards to Social Services team, h/she stated "there was a lot of turnover. There was no stable team for months and at some point, only one social worker." In regards to documentation h/she stated "we have mixed notes in the chart, which makes it so difficult to see who is who (which discipline is documenting.)" H/she continued "as far as BM (bowel movement) documentation, I always insist that the BMs be documented and I get all types of excuses. I think being vigilant about knowing your patient is much more important than giving scheduled Colace." H/she stated although h/she speaks with other physicians there are no formal meetings.

On 4/1/10 at 2:00 p.m., an interview was conducted with one of the Medical Group Physician Consultants. H/she stated they see the new admits and complete history and physical exam. Then they do not see the patient again unless they are called to see the patient by the nurse. H/she stated, "Most of the orders we give over the phone and we have to remember that we wrote it then follow back up with the nurse. There is a big problem with discharges. It isn't the Docs fault, really it is the case manager" as they are in charge of discharge. H/she continued, "Lately, I've said please write in discharge, patient needs to follow-up on......after discharge. Usually, 95% of the time I would be able to come over and see the patient to be discharged. Protocols would be very helpful and they should be very specific." The facility has "no interest in a contract to round." The CNAs are estimating amounts of fluid intake and pass the information on to the nurses and the nurses trust the CNAs to what they are documenting. Hand off communication is poor between shifts. The nurses are not passing on medical things. "There really isn't anyone to talk to, the DON is overwhelmed." H/she stated "wound care is probably the worst thing." H/she stated the "Director of the Medical Group went to a meeting which included corporate, about two weeks ago, and reported to them they have had impactions, dehydrations and these are Quality Indicators."

On 4/12/10 at 3:10 p.m., an interview with the Medical Director of the Medical Consulting Group was conducted. H/she stated that they are strictly medical consultants. They do a medical clearance to see that the patient is suitable for treatment in the facility. They address medical issues. H/she stated, "We are not involved in discharge planning. There are no medical workups here. Stat labs take 7 to 8 hours to get results. The patients are very ill. They are mostly on 'Black Box' warning medications for psych issues." H/she stated h/she offered to set up parameters or to proceduralize basic issues with "tight" requirements.

Based on review of the Governing Board By-Laws, it was determined the Executive Director failed to provide an effective operation, organization and management of the Hospital and its services and departments. Due to the number and nature of the standard and condition level deficiencies the facility failed to meet this requirement. Cross reference to A. 0309 Executive Responsibilities and A. 049 Medical Staff Accountability

According to the Governing Board By-Laws, in pertinent part:
ARTICLE X (c) Management. "Effective operation, organization and management of Hospital and its services, departments, and subdivisions; delegation of duties and establishment of formal means of accountability of subordinate; establishment of information and support system; recruitment and maintenance of staff; provision of internal controls protecting human, physical, financial and information assets; and management of resources to meet the identified needs of the Hospital and its patients."

Based on interviews with the Medical Consultant Group (Hospitalists) and review of medical records it was determined the facility failed to have a MD/DO available at all times to provide care to the medically compromised patient. The findings were:

On 3/30/10 the record of sample #4 was reviewed. The patient was a female in her seventies, admitted to the facility on 3/5/10 for dementia/Alzheimers Disease and psychosis. According to the History & Physical Exam, the patient had been transferred from an Assisted Living Facility where she had been only four days. She was transferred to this facility due to agitation. The patient had been not eating, expressing a wish to die. A dietary consult was provided for Failure to Thrive Syndrome and a feeding tube was recommended. Initial weight was 84 lbs. height 5'3". An interview with the DON on 3/30/10 revealed h/she did not want to accept this patient due to not eating/drinking/Failure to Thrive, indicating this patient did not meet the admission criteria. However, the Psychiatric Medical Director did accept the admission. A critical event analysis was completed. It was identified that the Hospitalist was notified at 3:00 p.m. on 3/8/10 that the patient would need a feeding tube. (The patient would have to be transferred out, due to the facility not being able to provide the care for the patient with a feeding tube.) According to the nursing progress notes the CNA came to the desk at 6:00 p.m. stating we should check the patient. The Hospitalist was called again to see the patient immediately. The patient had been on continuous oxygen per nasal cannula for a diagnosis of COPD (Chronic Obstructive Pulmonary Disease), but the patient kept removing the oxygen. The patient's family member was there to observe and requested the nurse call 911 to take the patient to the hospital. Before h/she could call, the family member called 911 on his/her cell phone. The Hospitalist Physician arrived when the Paramedics arrived to transport. An interview with the nurse who was there at the time of the event stated that the patient had vital signs and was aware of her surroundings. However, there was no documentation in the patient's record regarding vital signs. The Hospitalist physician was providing emergency care to a patient in the Long Term Acute Care Hospital (LTACH) which is within the building. There is only one physician available to provide emergency services and his/her priority is for the LTACH. As a result, the physician was unable to respond timely. This created the potential for negative outcome for all patients in the Psychiatric Hospital.

Based on medical record review and family interview it was determined the facility failed to ensure that families were communicated with by the physicians and staff and were included in the treatment plan during the phases of care, including discharge planning. Three (sample #1, #2 and #23) of twenty-three patients' families had little or no communication with the facility after the patient had been admitted.

Sample #1 was a female in her seventies admitted to the facility on 2/16/10 and discharged one month later. The only family contact or discussions that were documented in the chart were by the psychiatrist on admit, the social workers on admit, and the social workers during discharge planning. The record contained a copy of a form with nine typed questions that were compiled by the patient's Power of Attorneys. The patient's psychiatrist answered eight of nine questions in writing and signed it. There was documentation in the form that a copy was given to the patient's family member on 3/1/2010. The question, "How do we talk to the Psychologist and Doctor" did not have a written answer. There is no evidence that family was informed of how to contact and obtain further information from a physician regarding the patient's care.

Sample #2 was a female in her sixties admitted to the facility on 3/5/10 and removed by the POA and the local police department on 3/11/10 at 2:00 a.m. According to the H&P (History & Physical) the patient had been "transferred from an Assisted Living Facility following an altercation with another resident. The patient was physically abusive and was agitated. The patient had a history of dementia and depression. Past medical history COPD (Chronic Obstructive Pulmonary Disease), GERD (Gastro Esophageal Reflux Disease), hypothyroidism and chronic diarrhea."

Review of the facility investigation which was conducted by the DON (Director of Nursing) and the Administrator indicated that the family was not notified after the first apparent fall. At that time nursing staff should have implemented "fall precautions" and observed the patient on a 1:1 or "in line of sight." Other interventions were not initiated such as bed and wheelchair alarms. Additionally, the DON was not notified by nursing of the first apparent fall. The family was notified of the second fall. However, the surveyor noted that in the record there was no documentation by nursing as to "who" had been notified, but that "family" had been notified. The recommended solutions to prevent this from occurring again was to re-educate nursing staff. Due to the lack of communication between facility staff and family, the family had been very concerned about the patient's care and had the patient removed from the facility alleging abuse.

Sample #23 was a female in her eighties admitted to the facility on Thursday, 3/18/10 and discharged 4/12/10. At the time of discharge a family interview was conducted. The interview was conducted on 4/12/10 at 11:00 a.m. with four of the patient's adult children. One of the family members stated that the family had issues with the facility from the beginning due to lack of communication and not being included in the treatment and discharge plan. The patient had been admitted from an ALF (Assisted Living Facility) on an M-I (Mental Health) hold due to aggressive behaviors. The POA and other family members came to the facility on the day of the patient's admission, 3/18/10. The family stated there was no communication with the admitting physician and little, with the nurse. They were told by the nurse "they needed to leave". A Social Worker called that Friday night 3/19/10, and left a message; to this day that Social Worker had never called back. "No treatment plan was ever discussed, no plan for discharge and no doctor spoke with the family." Little or no information was given over the phone by nursing staff and they did not know who the patient's nurse was. On 3/29/10, the Executive Director had called the family and after that there was no issue with communication. The family members stated however, it was evident to them that the nursing staff was conflicted and disorganized with "negotiation techniques" when caring for their mother. When they did speak with the psychiatrists, they had different opinions as to which medications would be harmful or effective.

Based on medical record review, staff interview and policy/procedure review it was determined the facility failed to provide a safe environment for one (sample #2) of twenty-three patients. Facility staff failed to follow their "fall protocol" to protect these vulnerable patients. The potent effects of the psychiatric medications, the patient's ages, and co-morbidities put all these patients at risk for falls. This failure created the potential for negative outcome for all patients in the facility. The findings were:

Sample #2 was a female in her sixties admitted to the facility on 3/5/10 and removed by the POA and Local Police Department on 3/11/10 at 2:00 a.m. According to the H&P (History & Physical) the patient had been "transferred from an Assisted Living Facility following an altercation with another resident. The patient was physically abusive and was agitated. The patient had a history of dementia and depression. Past medical history COPD (Chronic Obstructive Pulmonary Disease), GERD (Gastro Esophageal Reflux Disease), hypothyroidism and chronic diarrhea."

Review of the Psychiatric Evaluation, dated 3/5/10, documented by the attending psychiatrist revealed the patient had been diagnosed with dementia. H/she was admitted from an assisted living facility due to combativeness and hitting other residents. "H/she displays the same behaviors here." The patient was admitted to stabilize his/her behaviors.

On 3/29/10 review of the progress notes in the patient's medical record revealed on 3/8/10 at 5:20 a.m., "the staff heard a sound, patient had nightstand tipped and lying on left knee. Slight redness, no swelling or tenderness at this time. Examined left knee, no change in range of motion (ROM). Able to bear weight. No swelling, positive reddened area on left knee. Will monitor for swelling or tenderness or decreased ROM (Range Of Motion)."

On 3/8/10 at 11:00 a.m., "patient found on the floor lying on left side. Patient sustained an abrasion and bruise to right forehead 4 cm X 1 cm. The Hospitalist MD notified (the medical intensivist group). New orders implemented. Neuro checks done-within normal limits-UA (urinalysis) specimen collected and sent to lab. Blood draw done STAT. Vitals taken per Lippincott and facility policy. Family members notified."

A progress note from the Hospitalist Medical Group, was reviewed. The entry dated 3/9/10 at 10:00 a.m. documented "Status post fall on 3/8/10 at 11:00 a.m. on face sustaining bruise around right eye, no active bleeding. Was medicated last nite with Zyprexa and Klonopin and not able to do a full neuro assessment now. Per nursing staff, was ambulating during the day. Denies pain. Gen: Sleeping, eyes open PERRLA (Pupils Equal Round, Reactive to Light and Accomodation), Vital signs T. 97.7, 115/62 p. 90 r. 20. Neuro: no focal deficits. Continue neuro checks, monitor bruise on right eye area."

A progress note dated 3/9/10 at 3:15 p.m., documented by nursing, revealed "Patient was in her room this a.m., talking to self, mumbling in-coherently", bruise noted on both eyes and right side of face are from previous fall. In wheelchair attempting to get out of wheelchair. Vital signs stable. Takes meds, crushed in pudding. Attempted to re-direct-confused, disorganized. Monitor behavior and medications."

A progress note dated 3/10/10 at 6:00 p.m., documented by nursing revealed "Patient has been alert, confused, co-operative. Both eyes are bruised also some facial bruising from previous fall. Vital signs stable, taking meds without difficulty. Co-operative."

A progress note dated 3/10/10 at 12:00 a.m., documented by nursing revealed "Patient up in wheelchair with lap buddy, sitting with head down, refusing to make eye contact. Quiet, withdrawn, black eyes right and left, patient does not respond when asked about pain. Vital signs stable. Took meds crushed into pudding without difficulty. No agitation or aggression noted. Continue to monitor for sedation, moods, behaviors and pain. Observe fall precautions."

A progress note dated 3/11/10 at 2:00 a.m., documented by nursing revealed "At 1:00 a.m. Police requested entrance to unit. Officer, accompanied by patient's POA. Stated they wished to escort patient to hospital now for evaluation of injuries sustained here as part of an on-going investigation. The psychiatrist on duty was notified and gave permission to release patient to police for transport to hospital. Also requested that all patient belongings be given to POA. Patient left unit with police escort via ambulance at 1:30 a.m."

Review of the (ED) Emergency Department record for the patient dated 3/11/10, revealed "Apparently, the sister who is the DPOA thought that the patient was physically abused because she fell 4 or 5 days ago, hit her face and they would not let the sister see her, and when she finally saw her, she was very upset about the bruises on the face and around the eye, and she called the police, and she took the sister to the hospital." The patient was admitted to the hospital for hydration. The patient sustained facial bruising secondary to a fall. The patient has dementia with psychotic features, possibly delirium and severe dehydration with hypernatremia. X-rays and CT (Computerized Tomography) of the face revealed no fractures and no intraorbital abnormality.

According to the Police Report, "the patient did not sustain Serious Bodily Injury. Talking with the doctors at the ED, they believe that the patient did fall and was not assaulted."

Interview with the DON (Director of Nursing) and the Administrator on 3/31/10 indicated that the family was not notified after the first apparent fall. At that time nursing should have implemented "fall precautions" and observed the patient on a 1:1 or "line of sight." Other interventions were not initiated such as bed and wheelchair alarms. Additionally, the DON was not notified by nursing of the first apparent fall. The family was notified of the second fall. However, the surveyor noted that in the record there was no documentation by nursing as to "who" had been notified, but that "family" had been notified. The recommended solution to prevent this from occurring again was to re-educate nursing staff.

Based on medical record review and staff interview it was determined the facility failed to investigate an allegation of sexual abuse for one (sample #2) of twenty three patients. The failure was a lack of communication by physician and staff to the DON, who investigates all allegations. Cross reference information from A. 0144 Care in a Safe Setting. The findings were:

Sample #2 was a female in her sixties admitted to the facility on 3/5/10 and removed from the facility by the police and POA (Power Of Attorney) on 3/11/10. The patient was admitted for dementia and depression and had been transferred from an Assisted Living Facility (ALF) due to being physically abusive to other residents. The medical record revealed, in pertinent part, Nursing Progress Notes on 3/7/10 at 11:30 a.m., "initially refused male RN (Registered Nurse), "I'm afraid of being molested." Took oral medications from female nurse with encouragement. Audio/visual hallucinations, preoccupied with sexual theme if being molested, guarded, oriented to person only. Female RN to give medications to patients. The psychiatric progress note dated 3/7/10 stated "talking about sexual abuse that happened in the last few hours." The Discharge Summary from the attending psychiatrist, dated 3/14/10, in pertinent part, Hospital Course: "Immediately after admission, she was whispering to self, tearful at times, preoccupied with internal stimuli, talking about sexual abuse that happened in the last few hours, although there was no abuse that was witnessed by staff."

Interview with the DON on 4/12/10 revealed h/she was not aware of the patient's allegations. H/she stated usually the Medical Director, (who was the patient's doctor), was very good at reporting any allegations. The DON stated if s/he had known about the allegation it would have been addressed.

In summary, the facility failed to have a system in place for communicating information to the DON regarding allegations of abuse and other reportable occurrences. A State deficiency was cited under CHAPTER II.

Based on review of Governing Board By-Laws and the number and nature of the deficiencies cited it was determined this requirement was not met. The Governing Board and Executive Director failed to provide assistance and guidance to operate an effective hospital and to ensure all patient requirements were met. Cross reference to A 0049 Medical Staff Accountability, A 0057 Chief Executive Officer, A 0067 Care of Patients-MD/DO on call, A 0115 Condition of Patient Rights, A 0130 Participation in Care Planning, A 0144 Patient Rights; Care in a Safe Setting A 0145 Patient Rights; Free from Abuse and Harassment, A 0263 Condition of QAPI, A 0285 Patient Safety, A 0288 QAPI Feedback and Learning, A 0290 QAPI Improvement Measures A 0291 QAPI Sustained Improvement, A 0385 Condition of Nursing Services, A 0386 Organization of Nursing Services, A 0392 Staffing and Delivery of Care, A 0395 RN Supervision of Nursing Care, A 0396 Nursing Care Plans, A 0397 Patient Care Assignments, A 398 Supervision of Contract Staff, A 449 Content of Record, A 464 Content of Records-Consults, A 0749 Infection Control Officer Responsibilities, A 0806 Discharge Planning-Needs Assessment, A 0811 Documentation of Evaluations, A 0827 Discharge Planning Document, A 0843 Reassessment of Discharge Planning.

Under Article IX GOVERNING BOARD OPERATION, In pertinent part:

9.3 Medical Administrative Liaison. "The Hospital Executive Director shall function as a liaison between the Governing Board and the Medical Staff."

9.5 Performance Improvement. "The Governing Board shall require the Medical Staff and each of the Hospital Department or services to implement and report on mechanisms for monitoring and evaluating the quality of patient care, for identifying opportunities to improve patient care, and for identifying and resolving problems at the Hospital. The foregoing mechanisms shall include without limitation the following: (a) a plan for an ongoing quality management program that includes at a minimum all components required by applicable federal and state law; (b) a requirement for documented reports to be submitted to the Governing Board identifying concerns or actions taken as a result of the identification of concerns about the delivery of hospital services."

"The Governing Board, through the Executive Director, shall support these activities and mechanisms. The Governing Board, with the authorization of the Member, shall provide resources and support systems for quality assessment and improvement and for risk-management functions relating to Hospital patient care and safety."

Based on staff interviews and review of personnel files, it was determined that the facility failed to ensure that all employee files contained a written job description for the position hired. Review of 12 personnel files revealed that 5 did not have job descriptions. This failure did not properly delineate the authority and responsibility for patient care throughout the facility and created the potential for a negative outcome.

The findings were:

A review of personnel files on 3/30/2010 revealed that 5 (samples #s 3, 5, 6, 7 & 12) out of 12 files did not have job descriptions. None were provided during the survey.

An interview with the facility's corporate VP of Clinical Services on 3/31/10 at 1:10 p.m., revealed that she intends to get job descriptions for employees formed and distributed. She acknowledged that there were not any job descriptions for several employees, including two social workers, the executive director, the patient advocate/medical records clerk, and an agency nurse.

Based on staff interviews, review of medical records and facility internal documents, it was determined that the registered nurses failed to deliver adequate patient neurological care and complete proper medical record documentation. Review of 23 medical records revealed that 4 did not contain complete neuro exams and 5 did not contain complete nursing documentation. This failure created the potential for a negative patient outcome.

The findings were:

A review of 23 medical records on 4/1/2010 and 4/12/2010 revealed that 4 (sample #s 2, 3, 22 & 23) did not contain complete neurological examination documentation when neuro checks were ordered by a physician. In addition, inadequate nursing documentation existed in 5 (sample #s 1, 4, 5, 10 & 15) medical records.

Neurological Examinations:

Sample #2 was a female in her 60's admitted on 3/5/10 for psychosis. On 3/8, the patient fell on two occasions. The physician was notified after the second fall and orders were obtained. The nursing Progress Notes stated, in pertinent part: "new orders implemented. neuro check done - WNL ..." Approximately five hours later the same nurse charted, in pertinent part: "Will continue to assess and monitor for change in mood and behavior. Speech as usual - no headache ..." In addition to the graphics form in the record, which contained vital signs documented twice a day and intake/output record, there was an unsigned handmade form titled "Nuros" which contained vital signs recorded every 15 minutes. These were recorded five times after the first fall and six times after the second fall. The documentation included temperature, pulse, blood pressure, respiratory rate, and oxygen saturation. There was no documentation on these forms of any type of neuro assessment. The progress notes did not contain any further documentation of neurological assessments or routine checks performed. The progress note from the internal medicine physician, dated the day after the falls occurred, stated the following, in pertinent part: "s/p fall - cont. neuro checks ..."

Sample #3 was a female in her 70's admitted on 11/19/2009 for Alzheimer's psychosis. A nurse's progress note on 11/26/2009 stated, in pertinent part: "Fell this shift (witness). Neurochecks WNL ..." It also stated that the physician and family were notified. On 11/26 an unsigned handmade form titled "Neuro checks" was documented on three times. The first entry contained complete vital signs (temp, pulse, resp rate, oxygen saturation, and blood pressure) and the following: "Pupils Reactive & Equal, Hard Hand Grip, Strong in Each Side." Two hours later, the second entry contained complete vital signs and the following: "Pupils reactive & equal. Pt is awake." The third and final entry contained only complete vital signs. The record did not contain any further reference to neurological assessments or exams done by nursing staff, although the progress note by the internal medicine physician, timed two hours after the final entry on the neuro checks form, stated, in pertinent part: "s/p fall with no obvious trauma. Continue neuro checks."

Sample #22 was a male patient in his 80's admitted on 2/28/10 for paranoid schizophrenia. A nurse's progress note, dated 2/28, stated, in pertinent part: "Pt. fell backwards hitting his head on the door knob, abrasion to back of his head (occipital area), which was witnessed by CNA ... R.O.M. WNL (range of motion within normal limits), No other s/s (signs & symptoms) of injury noted at this time ..." The physician was notified and the nurse also documented, "Neuro checks performed per facility protocol. Hand grasps equal & strong, Pupils +3 equal & reactive to light. VSS (vital signs stable). Resting quietly & sleeping at this time. Easily to arouse ..." Again, an unsigned handmade form was documented on 11 times after the patient's fall. The entries all contained complete vital signs, but no neurological assessment components. The internal medicine physician's verbal order obtained immediately after the fall stated the following: "Clean Abrasion & apply TAO (triple antibiotic ointment) & leave open to air until heal q (every) day. Continue to monitor pt for any change r/t fall." The chart did not contain any further documentation related to neurological assessments.

Sample #23 was a female patient in her 80's admitted on 3/18/10 for Alzheimer's dementia. On 3/22 the patient had an unwitnessed seizure and the internal medicine physician along with the patient's family were notified thereafter. The physician's verbal order obtained immediately after the seizure stated: "Neuro checks for 24 hours post seizure - Notify MD if abnormal." The nurse's note stated the following, in pertinent part: "Neuro checks done & patient kept safe, laid into bed." The next nurse's progress note documented approximately 24 hours later stated, in pertinent part, "Neuro check's complete for 24 hour check's after last NOC's seizure. All check's WNL (within normal limits) for patient..." The medical record did not contain any specific documentation in regards to neurological assessments.

Nursing Documentation:

Sample #1 was a female patient in her 70's admitted on 2/16/10 for atypical psychosis and dementia. The patient had over four days of diarrhea prior to her discharge. The admitting psychiatrist ordered imodium as needed (PRN). In the progress notes, nurses documented that imodium was given on three separate occasions, although it was not documented on the medication administration record (MAR). However, the patient's other scheduled medications and PRN medications were documented on the MAR, even when they were also mentioned in the progress notes. Each MAR contains a section to document scheduled medications and a portion to document PRN medications along with the effect. This medical record contained inconsistent and incomplete nursing documentation.

Sample #4 was a female patient in her 70's admitted on 3/5/10 for Alzheimer's dementia/psychosis. On 3/8 the patient was transferred to another hospital suddenly via ambulance per a family member's request. Upon review of the medical record, it contained no specific details as to the events preceding or during the transfer. Prior to the transfer a nurse documented the following in pertinent part: "CNA came to the desk & informed we should check patient immediately. MD was called to come to see pt immediately ..." The medical record also did not have documentation from a physician related to the patient's transfer. During survey, the surveyors requested a late entry from a nurse who was present on the day of the incident. The late entry contained details regarding the events of the family member's interaction and the patient's transfer. However, the nurse did not provide any vital sign documentation related to the time of the patient's transfer. This medical record contained incomplete nursing documentation.

Sample #5 was a male patient in his 70's admitted on 3/3/10 for Alzheimer's dementia. On 3/11 the patient was found suddenly unresponsive by the nurse after patient's medications had been administered. The patient was assessed, vital signs were obtained, a blood sugar was checked, and the internal medicine physician was notified. The physician ordered vital signs to be documented every two hours overnight. At midnight, one hour after the physician's order was written, the nurse documented the patient's complete vital signs in the Progress Notes. Two hours later, at 2:00 a.m., the nurse again documented vital signs in the Progress Notes. Five hours later, at 7:00 a.m., a low blood pressure, but no other vital signs, were documented by the oncoming nurse in the Progress Notes. At 8:00 a.m., all vital signs except for the patient's blood pressure were documented on the graphics flow sheet. This medical record contained inconsistent and incomplete nursing documentation.

Sample #10 was a male patient in his 70's admitted on 1/14/10 for dementia. The patient experienced hypertension beginning upon admit. On 1/18 a nurse's note stated the MD was notified that the patient's blood pressure was elevated and an order was obtained to monitor the blood pressure every six hours for one day. The nurse also stated, in pertinent part: "Continue to assess B/P and monitor safety." The corresponding internal medicine physician's order stated: "Check BP & HR Q 6 hours x 4 times (24 hours) then continue BID. Inform MD if consistently greater than 140/80." The medical record did not show evidence that the patient's blood pressure was monitored every six hours for one day. The only documentation that existed were vital signs obtained twice a day throughout the rest of the patient's admission. This medical record contained incomplete nursing documentation.

Sample #15 was a male patient in his 80's admitted on 2/17/10 for aggressive behavior dementia. The medical history and physical examination, completed on the patient's admit, stated "pressure sores both heels, bruise L arm, scabs on knees, scabs LE (lower extremities)" in regards to the skin assessment. The nursing assessment, also completed upon admit, documented that the patient had pressures sores on both heels, along with scabbed knees and left foot and a bruised left forearm. The internal medicine physician wrote skin care treatment orders on three separate occasions, as well as a "Wound care consult re: stage II pressure sores on bilateral heels." The nursing documentation revealed that wound care was completed on several occasions, however no specific documentation existed related to the size, color, or description of the patient's heel pressure sores from physicians or nurses. The record contained no evidence that a wound care nurse or specialist evaluated and treated the patient, despite the physician's order. This medical record contained incomplete nursing documentation.

Interviews:

An interview with the facility's Director of Nursing (DON) on 4/1/2010 at approximately 2:00 p.m., revealed that the facility and nursing staff refer to Lippincott, Fundamentals of Nursing, to ensure that proper nursing care is implemented. The DON stated that Lippincott's Glascow Coma Scale (GSC) is used to assess patient's neurological status when neuro checks are needed. The DON stated that even though the medical records do not contain adequate documentation, "the nursing staff is doing all the work, they just aren't taking credit for it and documenting enough."

In regards to wounds and medical complications the DON stated, "We never expected to have all these medical issues. Wounds are one of our exclusions, but facilities lie and we get patients that have issues. We are looking at the intake process more closely. We did have some wound training, but we wouldn't document measurements because none of us are trained. We don't have a problem consulting with a wound care nurse." However, the facility does not currently have a process to consult or contract with a wound care nurse.

On 3/31/10 at approximately 1:10 p.m., the surveyors and the facility's corporate VP of Clinical Services (VPCS) discussed that it was evidenced PRN medications were documented on the Progress Notes instead of on the Medication Administration Record (MAR) in several charts were discussed. The VPCS stated, "The nurses know that meds must be on the PRN (section of the) MAR." S/he stated that this issue would be addressed with all the nurses and would no longer occur.

In an interview with a staff nurse on 4/12/2010 at approximately 11:30 a.m., it was revealed that the Certified Nursing Assistants (CNAs) provide the majority of patient care in the facility. S/he stated that the nurses pass medications and perform physical assessments on the patients, but that CNAs perform and documents vital signs, intake/output, 15-minute checks, and most patient hygiene.

Document Review:

Internal nursing documents were provided by the DON on 3/31/2010 and consisted of the following: bathing assignments and record, vital signs and intake/output records, nurse care manager sheet, monthly weights form, and "RN's Report To Psychiatrist" tool. Multiple internal forms require nursing staff to complete duplicate documentation instead of charting only on the patients' medical records.

On the internal document "Instruction Sheet of RN Care Manager," the goal of the Care Manager is stated at the following, in pertinent part:
"To ensure quality care to each patient by assigning a Registered Nurse to manage patient's hospitalization from admit to discharge. RN assigned to the patient will ensure deficiencies are corrected ...All patients are the responsibility of ALL staff ..."

According to Lippincott, Fundamentals of Nursing, Third Edition, page 106, in pertinent part: DOCUMENTATION
"Although most nurses prefer to spend their time interacting with clients rather that writing in a client's record, careful documentation is a critical legal safeguard for the nurse. Documentation must be factual, accurate, complete, and entered in a timely fashion. The presumption of the law is that if something was not documented, it was not done. This includes even routine acts such as taking vital signs, repositioning clients and ensuring the client's safety."

According to Lippincott, page 509, in pertinent part:
"The neurologic assessment is conducted to detect normal and abnormal findings for cerebral function, cranial nerve function, cerebellar function, motor and sensory function, and reflexes. Cerebral function is assessed by observing the client's behavior throughout the interview and assessment, and includes mental status, memory, emotional status, cognitive abilities, and behavior. Cerebellar function is evaluated by assessing fine motor skills, coordination, and balance. The sensory system is assessed by having the client identify various sensory stimuli, and the reflexes are evaluated by contraction of specific muscles." Lippincott states that the mental status assessment has many components, one of which is level of consciousness. "Two methods to assess consciousness are (1) level of consciousness and (2) the Glasgow Coma Scale." It is clear by this text that the Glasgow Coma Scale, when performed, is only one component of the neurologic assessment.

Based on staff interviews, review of medical records, facility internal documents, and policy/procedures, it was determined that the facility's nurses failed to evaluate and document the nursing care for each patient. In 16 of 23 sample medical records, patients did not have a documented bowel movements for three or more consecutive days. This failure created the potential for a negative patient outcome.

The findings were:

A review of 23 medical records on 4/1/2010 and 4/12/2010 revealed that 16 patients (sample #s 1, 2, 3, 4, 5, 7, 10, 11, 12, 13, 14, 16, 18, 19, 22 & 23) did not have a documented bowel movement for three or more days. In addition, the medical record did not consist of an area in which to document specific patient hygiene care and when it was completed, unless done so in the written Progress Notes.

A review of medical records revealed the following:

Sample record #1 did not have bowel movements (BMs) documented on 3, 5 and 9 consecutive days.
Sample record #2 did not have BMs documented on 3 consecutive days.
Sample record #3 did not have BMs documented on 8 consecutive days.
Sample record #4 did not have BMs documented on 3 consecutive days.
Sample record #5 did not have BMs documented on 4 consecutive days.
Sample record #7 did not have BMS documented on 5 consecutive days.
Sample record #10 did not have BMs documented on 7 consecutive days.
Sample record #12 did not have BMS documented on 5 consecutive days.
Sample record #13 did not have BMs documented on 5 and 3 consecutive days.
Sample record #14 did not have BMs documented on 5 consecutive days.
Sample record #16 did not have BMs documented on 7 consecutive days.
Sample record #18 did not have BMs documented on 3 consecutive days.
Sample record #19 did not have BMs documented on 4, 5, 11, 4 and 4 consecutive days.
Sample record #22 did not have BMs documented on 4 consecutive days.
Sample record #23 did not have BMs documented on 3, 5, 3 and 4 consecutive days.

Further review of the medical record revealed that Nursing Flow Sheet contained several different boxes wherein to document patient care. The box titled "Hygiene - Self=S, Assisted=A or NA" contained a separate area for each shift (Nights, Days, and Evening) to chart how the hygiene was performed. However this box, or another area of the medical record, did not contain an area to document the specific patient hygiene that was completed or when it was completed. The nurses may document hygiene care in the narrative Progress Notes, but the lack of a designated area in which to document hygiene care does not ensure that care will be completed regularly and does not provide a consistent way to monitor care that has been completed.

Internal nursing documents were provided by the Director of Nursing (DON) on 3/31/2010 and consisted of the following: bathing assignments and record, vital signs and intake/output records, nurse care manager sheet, monthly weights form, and "RN's Report To Psychiatrist" tool. These internal documents were not a permanent part of the medical record. Multiple internal forms require nursing staff to complete duplicate documentation instead of charting only on the patients' medical records.

An interview with the DON on 3/20/2010 at approximately 2:40 p.m., revealed that baths are done regularly by the Certified Nursing Assistants (CNAs) and that perineal care is done routinely with toileting. The expectations of nurses and CNAs is written out on their specific expectation sheets and include taking patients to the bathroom every two hours, providing fluids every two hours, and giving regular baths, oral care, and linen changes. There are no policies and procedures that specifically state these expectations. Further interview with the DON on 4/12/2010 at approximately 10:00 a.m., revealed that s/he was aware of 3-4 patients that had dehydration and also patients that had fecal impactions. S/he stated that all were treated by the consulting internal medicine group physicians, however no documentation was provided that evidenced these patients' complications and treatment.

In an interview with a staff nurse on 4/12/2010 at approximately 11:30 a.m., it was revealed that the Certified Nursing Assistants (CNAs) provide the majority of patient care in the facility. S/he stated that the nurses pass medications and perform physical assessments on the patients, but that CNAs perform and document vital signs, intake/output, 15-minute checks, and most patient hygiene.

On 3/30/2010 at approximately 3:00 p.m., the following two internal documents were reviewed: bathing assignments/record and vital signs/intake/output record. The bathing record revealed that each patient received a complete bath or shower on average of every three days. However, this documentation is not routinely transferred into the medical record. The DON suspected that the vital signs/intake/output records had accurate bowel movements charted for each patient and that they were just not transferred correctly to the permanent medical record. However, comparison of these records and two sample medical records (#1 and #5) revealed accurate transfer of information.

According to Lippincott, Fundamentals of Nursing, Third Edition, page 1268, in pertinent part: "The normal frequency of bowel movements cannot be stated arbitrarily. Although many adults pass one stool each day, healthy people have been observed to have more frequent or less frequent bowel movements. Some people have a bowel movement two or three times a week; others, as often as two three times a day." Lippincott, page 1270, also states, in pertinent part: "Other types of medications may affect bowel elimination and stool characteristics. Narcotic analgesics (opioids), antacids containing aluminum, and anticholinergic medications all have the potential to cause constipation by decreasing gastrointestinal motility." It is clear that patients may go several days without having a bowel movement, but often medications that Gero-Psych patients are prescribed put them at a higher risk of constipation and attention must be paid to each patient's bowel routine.

Based on staff interviews, review of medical records and policy/procedures (P&P), it was determined that the facility did not ensure the nursing staff kept current a nursing care plan for each patient. In 3 of 23 sample medical records, the patients did not have a fall treatment plan problem and intervention per the facility's P&P, despite that each of the three patients fell while hospitalized. This failure created the potential for further patient harm.

The findings were:

A review of 23 medical records on 4/1/2010 and 4/12/2010 revealed that 3 patients (sample #s 2, 3 & 22) did not have a fall care or treatment plan, despite evidence that each patient had fallen during his or her hospitalization.

A review of medical records revealed the following:

Sample #2 was a female in her 60's admitted on 3/5/2010 for psychosis. Nursing documentation in the progress notes revealed that the patient fell on two occasions within the same day (3/8). The only interdisciplinary treatment plan evidenced was titled "Behavioral Disturbances." It contained short-term goals and interventions related to its title, but none related to falls. The other treatment plans did not contain evidence of fall prevention or interventions.

Sample #3 was a female in her 70's admitted on 11/19/2009 for Alzheimer's psychosis. A nurse's progress note, dated 11/26, stated, in pertinent part: "Fell this shift (witness). Neurochecks WNL ..." The treatment plans did not contain evidence of fall prevention or interventions.

Sample #22 was a male patient in his 80's admitted on 2/28/2010 for paranoid schizophrenia. On 2/28 a nurse's progress note stated, in pertinent part: "Pt. fell backwards hitting his head on the door knob ..." The only interdisciplinary treatment plan evidenced was titled "Paranoia." It contained short-term goals and interventions related to its title, but none related to falls. The other treatment plans did not contain evidence of fall prevention or interventions.

The P&P titled "Falls - Care of the Patient at Risk" was reviewed on 4/1/2010. It stated the following, in pertinent part:

"Policy:
Staff will follow guidelines for the prevention of injury to patients who have been identified as a 'fall risk'
Procedure ...
RN will develop a treatment plan problem and intervention once the patient is identified to be at risk for a fall ..."

In the admission nursing assessment, all patients are assessed for fall risk potential and preventative steps are to be taken if the patients are identified as a fall risk. The "Fall Risk Potential" evaluation includes assessing the patient's gait, age, mobility, mental status, neurological condition and medications. If the total score received is 5 or greater, the patient should be placed on "Fall Prevention."

In an interview with the Director of Nursing on 3/29/2010 at approximately 2:40 p.m., s/he stated, "we only care plan the acute medical problems," along with the psych problems. The DON also stated, on 4/1/2010 at approximately 2:00 p.m., that the facility and nursing staff refer to Lippincott, fundamentals of Nursing, to ensure that proper nursing care is implemented.

According to Lippincott, Fundamentals of Nursing, Third Edition, page 106, in pertinent part: Nursing should be sure that the nursing plan of care is part of the client's permanent record...The nurse should write a comprehensive nursing note for each client problem the nurse addressed during his or her time of duty. The note should include the current nature of the problem, how the nurse intervened, the client's response, and, when appropriate, future priorities for care. Once a problem is noted, nursing documentation should evidence continuity care until the problem is resolved."

Based on staff interview, review of medical records and facility internal documents, the facility failed to ensure that appropriate patients were admitted, according to nursing capabilities, in 3 of 23 sample medical records. The facility's nursing staff was unable to provide the high acuity medical care necessary to deliver quality patient care. This failure created the potential for a negative patient outcome.

The findings were:
A review of 23 medical records on 4/1/2010 and 4/12/2010 revealed that 3 patients (sample #s 13, 15, 17) were inappropriate admissions due to their acuity level or medical needs.

Sample #13 was a male patient in his 70's admitted on 2/9/2010 for Alzheimer's dementia. The patient was admitted with a urostomy tube in place status post bladder removal due to bladder cancer. The only reference to the urostomy in the psychiatric history and physical (H&P) was that the urinary bag had leaked prior to the physician's assessment. A nursing note, dated 2/10, stated, in pertinent part: "Urostomy bag leaking, urostomy bags and wafers ordered." Two days after admission the patient was transferred to an outlying hospital after he had pulled out the catheter from the urostomy. The catheter was reinserted in the urostomy and the patient was not admitted to that outlying hospital as he was medically stable. The patient returned to the facility and again pulled out the catheter due to confusion. It was replaced by the on-call internal medical physician who wrote the following progress note, in pertinent part: "Pt will need to be kept in house tonight until a nonemergency transport can be arranged to transfer pt. back to (pt's previous facility) if the facility's nursing staff cannot manage pt's with urostomy and such pt's should not be admitted here in the first place ..." The following morning, the psychiatric physician's progress note recommends the patient be transferred as well. Thereafter, a Certified Nursing Assistant (CNA) monitored the patient at all times (1) The patient's urostomy catheter was dislodged and the patient was transferred to an outlying hospital for reinsertion on two more occasions during the patient's admission. The patient's psychological status was eventually stabilized and he was discharged. This patient was an inappropriate admission according the facility's admission criteria/exclusions and the capability of nursing staff.

Sample #15 was a male patient in his 80's admitted on 2/17/2010 for aggressive behavior dementia. The medical history and physical examination, completed on the patient's admit, stated "pressure sores both heels, bruise L arm, scabs on knees, scabs LE" in regards to the skin assessment. The nursing assessment, also completed upon admit, documented that the patient had pressures sores on both heels, along with scabbed knees and left foot and a bruised left forearm. The internal medicine physician wrote skin care treatment orders on three separate occasions, as well as a "Wound care consult re: stage II pressure sores on bilateral heels." The nursing documentation revealed that wound care was completed on several occasions, however no specific documentation existed related to the size, color, or description of the patient's heel pressure sores from physicians or nurses. The record contained no evidence that a wound care nurse or specialist evaluated or treated the patient, despite the physician's order. This patient was an inappropriate admission according the facility's admission criteria/exclusions and the capability of nursing staff.

Sample #17 was a female patient in her 80's admitted for dementia with behavioral disturbances. The patient was admitted with a past medical history that included congestive heart failure (CHF). The day after the patient's admission, the on-call internal medicine physician's progress note stated, in pertinent part, "Appears acutely ill - decompensated CHF ..." The patient was transferred to an outlying hospital for further evaluation. The following day, a nurse's progress note stated that the on-call medical physician cleared the patient for return. The nurse had spoken with the transferring nurse and the progress note stated, in pertinent part, "She states the patient has been on 2-3 liter of O2 per NC. Patient has received Lasix twice today. Has had 60 meq K+ today & had magnesium replaced ...." The same nurse documented that once the patient was readmitted, she had audible wheezes from the door and the ambulance staff reported the patient had wheezes in the hospital as well. Nebulizer treatments were given by the nursing staff to treat the patient's wheezes. Documentation evidenced the patient repeatedly removed her oxygen and acquired a skin tear on her right lower extremity. Three days after the patient's admission, she had a repeat CHF exacerbation again which required another transfer to an outlying hospital. The transfer order written by the on-call internal medicine physician stated the indication was "Acute CHF exacerbation, Large skin tear RLE (right lower extremity)." The patient was discharged and did not return the facility. This patient was an inappropriate admission according the facility's admission criteria/exclusions and the capability of nursing staff.

In an interview with the Director of Nursing (DON) on 4/1/2010 at approximately 1:00 p.m., s/he stated "We never expected to have all these medical issues. Wounds are one of our exclusions, but facilities lie and we get patients that have issues. We are looking at the intake process more closely." On 3/30/2010 at approximately 11:30 a.m., s/he also stated the following, in pertinent part: "We have issues with doctors and hospitals trying to get other types of patients admitted. Hospitals are not always honest..." The DON stated that intake is done by a designated staff member during the day and by the nurses in the evenings and overnight. There is a designated packet and list of questions used by whichever staff member completes the intake process.

The intake screen, provided by the DON on 4/1/2010, contained five pages of questions and evaluations. The Exclusion Criteria stated the following, in pertinent part:

"Exclusion Criteria (if any present the results of the screen are still to be communicated to attending physician) ...

Medically unstable and/or requiring general hospital level of care.
For example: ...
Non-Healing wounds (decubitus)"

Based on staff interview, review of personnel files, and policies and procedures, it was determined that the facility failed to ensure that all non-employee files contained proper orientation documentation for the position working, as evidenced in one contract-staff file reviewed. This failure did not ensure that non-employee nurses adhere to the policies and procedures of the hospital. This created the potential for a negative outcome.

The findings were:

A review of one contract staff personnel file on 3/30/2010 revealed that it (sample #12) did not have orientation documentation and none was provided during the survey.

In an interview with the Director of Nursing (DON) on 3/31/2010 at approximately 8:00 a.m. s/he stated, "All agency nurses go through orientation." S/he stated that they complete the same expectation checklist and education as the staff nurses. The facility generally uses about 6 contract/agency nurses per week, averaging about one per shift.

The policy and procedure titled "Nursing Agencies" was reviewed on 3/31/2010. It stated the following, in pertinent part:

"PROCEDURE ...
4. Agency personnel will be oriented to the hospital and instructed regarding their individual assignment by the shift Registered Nurse or Director of Nursing, prior to working. Agency personnel will be given an orientation packet upon arrival for their review. Orientation will be documented on the agency Orientation Checklist and include:
a. Fire b. Safety c. Infection Control d. Confidentiality e. Reading the Agency Orientation Manual.
5. Agency staff member will sign off on the Agency Orientation Sheet, verifying completion of these requirements. If the person has worked at the facility within the past 90 days, they do not have to complete a new orientation packet ..."

Based on staff interviews and review of medical records, the facility failed to ensure that medical records contained accurate and necessary documentation in 6 of 23 sample medical records. This failure created the potential for a negative outcome.

The findings were:

A review of 23 medical records on 4/1/2010 and 4/12/2010 revealed that 6 records (sample #s 1, 3, 4, 12, 17 & 22) did not contain social worker and physician signatures or documentation necessary to justify and support the patient's hospitalization and progress.

Sample record #1, admitted 2/16/2010 and discharged 3/16, contained three Progress Notes with "SW" documented in the discipline section. All three notes were in regards to discharge planning and without a practitioner's signature.

Sample record #3, admitted on 11/19/2009 and discharged on 12/2, contained a completed psychosocial assessment. The last page had an area for a "social services signature." This area was blank and there was no signature throughout the assessment.

Sample record #4, admitted on 3/5/2010 and discharged on 3/8, was a female patient that was transferred to another hospital suddenly via ambulance per a family member's request. The record contained no specific details as to the events preceding or during the transfer by the internal medicine physician that was paged or the nurse caring for the patient. Prior to the transfer a nurse documented the following in pertinent part: "CNA came to the desk & informed we should check patient immediately. MD was called to come to see pt immediately ..." The only note in regards to the transfer was documented by the nurse and stated which hospital the patient was transferred to and that the patient went by ambulance. During survey, a late entry progress note was requested and provided from a nurse who was present on the day of the incident.

Sample #12, admitted 1/30/2010 and discharged on 2/5, contained three Progress Notes and in regards to discharge planning, all documented on the same day. No discipline was specified and a practitioner's signature was not evidenced in any of the notes.

Sample records #12, 17 & 22, contained medical history and physical (H&P) examinations signed by a consulting internal medicine physician. In sample #12 the H&P had documentation of past medical history review, assessment/impression and plan. However, the entire section titled "REVIEW OF SYSTEMS" was blank. In addition, the entire section titled "PHYSICAL EXAM," except for the patient's weight and vital signs, was also blank. In sample #17, admitted on 3/19/2010, the section titled "REVIEW OF SYSTEMS" was blank, although the rest of the assessment was completed. In sample #22, admitted 2/28/2010, the "REVIEW OF SYSTEMS" section was crossed out and above it documentation stated, "not able to obtain, sedated." In the physical exam section, the "Neurological Exam" portion was blank with documentation that stated, "not able to exam - sedated." The record contained no evidence that an internal medicine physician returned to reassess the patient after the sedation had worn off.

In an interview with the Director of Nursing on 3/29/2010 at 2:20 p.m. s/he stated, "RNs do care manager chart audits constantly." Further questioning about chart audits revealed that the facility does not have a medical records committee that routinely audits medical records.

In an interview with one of the consulting internal medicine physicians on 4/1/2010 at approximately 1:00 p.m., s/he stated the following in regards to incomplete medical history and physical (H&P) assessment documentation: "If I can't wake up the patient or the roommate is sleeping and it is 2:00 am, I do the first part of the H&P, but come back and do the rest later." The physician admitted that on one of the sample medical records, s/he had forgotten to come back and complete the rest of the H&P. However, s/he also was not alerted later by anyone at the facility that the H&P was incomplete.

Based on review of medical records it was determined that the facility failed to ensure consultative evaluations were conducted or arranged when ordered by physicians in 2 (#20 and #15) of 23 medical records. This failure created the potential for a negative patient outcome.

The findings were:

Sample record #20, admitted on 3/21/2010, was on open record reviewed two days prior to and on the day of the patient's discharge. The patient was hospitalized for ten days and an order was written two days after admission for a podiatry consult. A podiatrist did not see the patient prior to discharge and a future appointment had not yet been arranged prior to the patient's discharge from the facility. On survey, it was requested that a podiatry appointment be made for the patient. The social worker arranged for the patient's new facility to coordinate an appointment for the following week.

Sample #15 was admitted on 2/17/2010 and discharged on 2/26/2010. The medical history and physical examination, completed on the patient's admit, stated "pressure sores both heels, bruise L arm, scabs on knees, scabs LE (lower extremity)" in regards to the skin assessment. The internal medicine physician wrote skin care treatment on three separate occasions (2/17, 2/18 & 2/19), as well as a "Wound care consult re: stage II pressure sores on bilateral heels" that was ordered the day of admission. The nursing documentation revealed that wound care was completed on several occasions, however no specific documentation existed related to the size, color, or description of the patient's heel pressure sores from physicians or nurses. The record contained no evidence that a wound care nurse or specialist assessed and treated the patient, despite the physician's order. The facility does not currently have a process in place to consult or contract with a wound care specialist.

Based on staff interviews, review of policy/procedures, facility internal documents, medical records, and meeting minutes, the infection control officer failed to develop a quality system for identifying and investigating infections and communicable diseases. This created the potential for a negative outcome.

The findings were:

A review of 23 medical records on 4/1/2010 and 4/12/2010 revealed that one patient (sample #1) had symptoms consistent with the infectious process clostridium difficile (C. Dif.). The patient had diarrhea for four days prior to discharge and was transferred to an assisted living facility while still having diarrhea. The final nursing progress note exhibited evidence that the patient had very little oral intake in the two days prior to discharge and that the nurse suspected dehydration. The psychiatrist's discharge summary (DS) revealed that the patient had poor fluid/food intake throughout the hospital course. The DS stated that an order was written the day before discharge to push fluids as the patient had diarrhea. Additionally, the patient had low-grade temperatures in the four days prior to discharge. The patient was not tested for C. Dif. while at the facility and there was no documentation that an internal medicine physician was notified of the patient's symptoms.

In an interview with the Executive Director (ED) on 3/30/2010 at approximately 2:20 p.m., s/he stated that s/he got a voicemail from a family member "indicating that the patient had C. Dif." The ED stated s/he wasn't aware s/he needed to call the family member back. S/he stated that s/he thought s/he notified the Director of Nursing (DON) the next morning in their daily meeting, but they weren't alarmed as there was no confirmation of the patient's C. Dif. diagnosis.

In an interview with the DON on 4/12/2010 at approximately 10:00 a.m., s/he stated the following, in pertinent part: "I do a lot informally regarding infection control. I'll discuss things with the internal medicine physicians or call CDC. I do all this work and don't take credit for it. I should review it and bring it up in the Med Exec meetings." In an interview with the DON on 3/29/2010 at approximately 11:00 a.m., s/he stated s/he was unaware that sample #1 was diagnosed with possible C. Dif after discharge from the facility. In regards to infection monitoring, s/he stated that she expects the nurses and staff to inform him/her of patients with infections. It was not clear how that information was communicated. According to the DON, all patients with a diagnosed active infection are transferred to an outlying acute care hospital per the consulting medical physicians' recommendations.

In a review of the Medical Executive Committee Meeting Minutes, Infection Control was only addressed once since the facility opened in July 2009. The discussion entry on 10/16/2009 in regards to Infections Control was as follows: "Discussed Nosocomial Infection UTI. 3 identified in the month of September. CDC/APIC criteria used to determine nosocomial infection. Discussed appropriateness of antibiotic Levaquin use for UTI."

In a review of the facility's "INFECTION CONTROL LOG" on 3/30/2010, sample record #1 was not an entry. Further review of this log revealed inconsistent "FOLLOW-UP, RESULT OF TX" entries. The DON monitors an internal "FLU ASSESSMENT/ RISK ASSESSMENT FORM" for Infection Control. This form assesses flu symptoms on each patient, one of which is fever. There is no documentation that indicated the DON was alerted of sample records #1's low-grade fevers via this form and that any action was taken.

Based on review of medical records and policies/procedures, the facility failed to ensure that patients were discharged to an appropriate facility in 1 (#1) of 23 sample medical records. The facility failed to identify the patient's post-hospital needs. This failure created the potential for a negative patient outcome.

The findings were:

The medical record of sample record #1 was reviewed on 3/28/2010. It revealed that the patient had diarrhea for four days while in the facility and was transferred to an assisted living facility while still having diarrhea. The final nursing progress note exhibited evidence that the patient had very little oral intake in the two days prior to discharge and that the nurse suspected dehydration. The psychiatrist's discharge summary (DS) revealed that the patient had poor fluid/food intake throughout the hospital course. The DS stated that an order was written the day before discharge to push fluids as the patient had diarrhea. The physician documented the patient's condition on discharge as improved. Additionally, the patient had five documented temperatures of 99 degrees or greater over the four days prior to discharge. The patient was transferred to a facility that could not provide intravenous hydration or further medical evaluation to the patient.

On 3/30/2010 the Policy and Procedure titled "Discharge/Aftercare Planning" was reviewed. It stated the following, in pertinent part:

"PROCEDURE ...
3. The Discharge Plan should ...
D. Identify problems to be addressed in the next level of care, including any ongoing health issues.

6. The discharge/aftercare plan should define the following ...
C. The level of care which the patient will be discharged to (i.e., partial hospitalization, intensive outpatient, outpatient, etc.) ..."

Based on staff interview and review of medical records, the facility failed to ensure that medical records contained adequate documentation of the discharge planning process in 4 of 23 sample medical records. This failure created the potential for a negative outcome.

The findings were:

A review of 23 medical records on 4/1/2010 and 4/12/2010 revealed that 4 patients (sample #s 5, 13, 19 & 20) had inadequate discharge planning documentation and planning for the patients' needs.

Sample record #5, discharged 3/22/2010, contained a psychiatrist's discharge summary with the date of discharge as 3/18, four days before the actual date of the patient's discharge. The last entry in the "SOCIAL WORK CONTACT LOG," dated 3/15, stated that the social worker had scheduled ambulance transport for 3/17. However, the patient was discharged five days after the scheduled ambulance transportation and the record did not contain documentation from a nurse or social worker as to why the discharge was delayed. On survey, a late entry progress note was requested and provided from a social worker, which described why the patient's discharge was delayed.

Sample record #13 was a male patient admitted on 2/9/2010 for Alzheimer's dementia and discharged on 2/19. He had a complicated ten day hospital course which included three transfers to an outlying facility for medical care. The record contained the psychosocial assessment that was completed by the social worker the day after the patient's admission. It evidenced documentation of needs identified and discharge planning. The only progress note in regards to discharge was written by a social worker on 2/16, three days prior to discharge, and stated the following, in pertinent part: "SS spoke c wife & explained that pt needs LTC (long-term care) placement not ALF (assisted living facility). Encouraged & educated pt needing placement ASAP D/T medical issues. Encouraged to look @ other placement for back up ..." The only other documentation from a social worker was on the discharge instructions, which stated the facility the patient was being transferred to and the progress he had made. There was no evidence that the patient's wife was given choices and further assistance in finding placement for her husband during the three days prior to his discharge.

Sample record #19, admitted on 1/12/2010, was an open record that was reviewed on the patient's 75th and 77th consecutive days as a patient in the facility. The record contained multiple social work notes, but only two in the previous 30 days. Both notes were in reference to the patient's discharge plans and court attorney appointment. The most recent note, dated 3/18, stated the patient's court appointed attorney was scheduled to see the patient "today or tomorrow" to speak to him/her about guardianship and discharge plans. On 3/31 the social worker had not documented any further notes in the record. On survey, a late entry progress note was requested and provided from a social worker, which described details in regards to the court appointed attorney's visit, further discharge plans, discussions with family members, and the patient's finances. The social worker had been continually working on the patient's discharge plans, but not documenting the work and plans.

Sample record #20 was a patient admitted on 3/21/2010 and discharged on 3/31. The record was reviewed two days prior to and on the day of the patient's discharge. An order was written on 3/23 for a podiatry consult. A podiatrist did not see the patient prior to discharge and a future appointment had not yet been arranged prior to the patient's discharge from the facility.

In an interview with the Director of Social Work (DSW) on 3/30/2010 at approximately 10:15 a.m., s/he stated the following, "We usually look at the patient's issues daily." S/he also stated that all of the social workers meet every morning, Monday through Friday, to discuss the patients and that there is now a social worker on each weekend. The DSW stated that s/he had just started at the facility in the past month and had implemented the "SOCIAL WORK CONTACT LOG" for SWs to document their notes and family/facility discussions. However, each SW does not use the contact log and may still document in the record's progress notes.

REASSESSMENT OF DISCHARGE PLANNING

Based on review of policy/procedures and staff interview, the facility failed to routinely reassess its discharge planning process. This failure did not ensure that quality discharge planning was provided and implemented and that the facility was in compliance with it Policies and Procedures. This created the potential for a negative outcome.

The findings were:

In an interview with the Director of Social Work on 3/30/2010 at approximately 10:30 a.m., s/he stated the following, in pertinent part: "We are putting an audit together as we speak. I'll be auditing treatment and discharge plans and I'm required to do a certain number per month."

On 3/30/2010 the Policy and Procedure titled "Social Work Scope of Services" was reviewed. It stated the following, in pertinent part: "The Lead Social Worker is responsible for the effective implementation and monitoring of performance improvement activities. They will report on any performance improvement activities to the Quality Council as scheduled."

The Policy and Procedure title "Discharge Planning" was also reviewed on 3/3/2010 and stated the following, in pertinent part:
"PROCEDURE ...
2. Ongoing discharge planning takes place during the interdisciplinary meeting with the patients at a minimum of twice (2) a week during weekly rounds. Family may be involved in this process.
3. The above is documented in the medical record and list of disciplines of staff involved.
4. Once the discharge needs have been identified, the social worker or appropriate discipline will present the list of Medicare certified agencies to the patient/family ..."

Based on interview, review of patient medical records and of the Quality Improvement Total System Evaluation, dated 3/10/10, the facility failed to address areas of high risk, problem prone areas affecting patient safety and health outcomes. Two of the quality indicators, fecal impactions and dehydration, were not addressed in the Quality Improvement. It was evidenced by review of twenty-three patient medical records that dehydration and lack of BMs were a continual issue. The patients in the facility are at high risk for these complications due to the geriatric/dementia population and that they are on many medications including psychotropics. The facility had discussed developing protocols, however, no evidence was provided that these protocols had been established at time of survey. This failure created the potential for negative patient outcome. The findings were:

Areas of concern: Dehydration, fecal impactions, falls, documentation in patient charts, communication with patient families and infection control.

In an interview with the DON on 4/12/10 at approximately 10:00 a.m., revealed that s/he was aware of 3-4 patients that had dehydration and also patients that had fecal impactions. S/he stated that all were treated by the consulting internal medicine group physicians.

Additionally, there was no evidence provided that all patient transfers out to a higher level of care (acute care facility) for emergency treatment were investigated for quality of care and identified for areas of improvement.

In review of twenty-three patient medical records it was determined the facility's charting/documentation process needed improvement. The documentation by nursing staff was incomplete and inconsistent. The nursing documentation charting was based on BIRP (Behaviors, Interventions, Response and Plan). The nursing documentation did not reflect continuity of care of the patient. Specifically, sample #4 was transferred to an acute care facility. The patient was a female in her seventies admitted to the facility on 3/5/10 and emergently transferred on 3/8/10. The patient's family member called 911 on his/her cell phone because h/she felt that his/her mother was not responsive. When reviewing the nursing documentation in the patient's record during survey on 3/31/10, it was evident there was lack of nursing documentation regarding details as to what happened. No vital signs had been documented other than "vital signs were stable" and there was no documentation regarding pulse oximetry. On 3/31/10 an interview with the nurse on duty 3/8/10 was conducted. A late entry was requested by the surveyor to document what exactly did occur. H/she stated that the CNA (Certified Nurses Assistant) was asked to take vital signs and pulse ox. on this patient. There was no evidence in the patient's record that this occurred. If vital signs were obtained, they were not documented.

Patient falls had been identified by the facility as an area of concern. Fall protocols had been established, however, there was no evidence provided that the facility had audited 100% of the patient falls to assess if the protocol was effective and being implemented. Specifically, sample #2, a female in her sixties admitted to the facility on 3/5/10 and removed by the POA and the local Police Department on 3/11/10 at 2:00 a.m. The fall protocol and fall precautions had not been implemented after the patient's first fall. The patient was at high risk for falls due to the psychotropic medications and behaviors. Possibly by implementing the fall precautions initially after the first fall, the second fall could have been prevented. The family had been very upset, thinking the patient had been abused after observing facial bruising, and by feeling they had not been communicated with, the family removed the patient from the facility.

Based on review of facility documents of Performance Improvement Activities and the review of twenty-three patient medical records the facility failed to track medical errors and adverse patient events, analyze their causes, and implement effective preventive actions and mechanisms that included feedback and learning throughout the hospital. This failure created the potential for negative patient outcome.
Cross Reference to A 0285 Patient Safety.

Review of items discussed by the facility on 3/10/10 was "Quality/Risk Management". It was stated although the DON was certified in Quality Management, "due to numerous time consuming and competing priority demands, (the DON) was unable to adequately initiate process across hospital," including remedial education and falls.

Based on review of Quality issues addressed by the facility in March, it was determined the facility failed to take actions aimed at performance improvement. The facility had not ensured there were processes and systems in place to specifically address areas that needed improvement. Cross Reference to A 0263, A 0285 and A 0288.

Based on review of Quality issues addressed by the facility in March, it was determined the facility failed to measure success of actions taken to ensure that processes and systems which had been implemented were successful. Cross Reference to A 0263 Condition of QAPI, A 0285 Patient Safety, A 0288 QAPI Feedback and Learning and A 0289 QAPI Improvement Actions.

Based on review of the facility's Quality Program the hospital failed to take actions aimed at performance improvement and after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. Cross Reference to A 0285 Patient Safety, A 0288 QAPI Feedback and Learning, A 289 QAPI Improvement Actions and A 290 QAPI Improvement Measures.

Based on medical record and policy/procedure review it was determined that the facility failed to ensure discharge planners offered a list of available facilities to patients and/or their families. This failure created the potential for a negative outcome.

The findings were:

A review of 23 medical records on 4/1/2010 and 4/12/2010 revealed that 5 patients (sample #s 1, 5, 7, 10 & 13) did not have documentation in the medical record that a list of post-discharge medical providers or facilities had been provided to the patient or family.

Sample record #1 was admitted on 2/16/2010 from a rehabilitation/ long-term care facility and discharged on 3/16/2010 to an assisted living facility. Sample record #5 was admitted on 3/3/2010 from one health care facility and discharged on 3/22 to a different healthcare facility. Sample record #7 was admitted on 12/15/2009 from a psychiatric hospital and discharged on 12/21 to a dementia unit within a different facility. Sample record #10 was admitted on 1/14/2010 from an acute care hospital and discharged home on 1/22 with assistance of home health. Sample record #13 was admitted on 2/9/2010 from one health care facility and discharged on 2/19 to a different healthcare facility.

The Policy and Procedure title "Discharge Planning" was also reviewed on 3/3/2010 and stated the following, in pertinent part:
"PROCEDURE ...
2. Ongoing discharge planning takes place during the interdisciplinary meeting with the patients at a minimum of twice (2) a week during weekly rounds. Family may be involved in this process.
3. The above is documented in the medical record and list of disciplines of staff involved.
4. Once the discharge needs have been identified, the social worker or appropriate discipline will present the list of Medicare certified agencies to the patient/family ..."