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Based on interview and document review, the hospital failed to develop a written plan of care for 1 of 6 discharged patients (P8) reviewed in the sample.

Findings include:

P8 was admitted to the hospital on 11/9/11 for open shoulder rotator cuff repair, and had diagnoses which included chronic hypercapnia (high blood levels of carbon dioxide) and hypoxemia (low blood levels of oxygen). Review of P8's clinical record revealed the lack of a written plan of care to address specific health concerns, and the lack of individualized patient goals and interventions to assist P8 to manage her health conditions.

Review of the hospital's policy titled, Plan of Care, revised 4/12, and indicated each inpatient would have an individualized, outcome-directed plan of care documented in the medical record. The plan of care would be initiated upon admission and reviewed and revised each shift based on the patient's condition. The policy further identified the plan of care was to include, but not limited to identification of current or ongoing needs, realistic, individualized patient care outcomes with established time frames and interventions to assist in achieving patient outcomes.

During interview at 10:20 a.m. on 6/14/12, the director of nursing of systems and process (DON)-B confirmed the lack of a nursing care plan for P8. DON-B confirmed the current hospital policy and stated she would expect all patients to have a nursing care plan.

Based upon interview and document review, the hospital did not ensure physician progress notes included the time the entry was made in the medical record for 6 of 30 patient medical records reviewed (P12, P13, P11, P8, P6 and P7).

Findings include:

P12's medical record was reviewed at 10:45 a.m. on 6/13/12. Physician progress notes dated 6/12/12 and 6/13/12, lacked a time to indicate when the progress notes had been written. The clinical director of maternity care was interviewed at 11:10 a.m. on 6/13/12, and verified the physician had not indicated the time the progress notes had been written.

P13's medical record was reviewed at 10:00 a.m. on 6/13/12. Physician progress notes dated 6/12/12, lacked a time to indicate when the progress note had been written. The clinical director of maternity care was interviewed at 11:10 a.m. on 6/13/12, and verified the physician had not indicated the time the progress notes had been written.



15508


P11's medical record was reviewed at approximately 2:50 p.m. on 6/12/12. The record had a pulmonary consults dated 3/17/12 and 3/19/12. The record lacked times to indicate when the consultation notes were written. The record also included a spiritual care progress note dated 3/19/12. The note lacked a time. In an interview with the Medical Records Manager at 3:45 p.m. on 6/12/12, it was verified these progress notes should have been timed when written.

P8's medical record was reviewed at approximately at 3:40 p.m. on 6/13/12. The orthopedic progress note dated 11/10/11. The record lacked the times when both the progress note and orders were written.

In an interview with the Medical Records Manager at 4:05 p.m. on 6/13/12, it was verified that both the physicians order and the progress note were to be timed when written.




18623


P6's medical record was reviewed at 1:30 p.m. on 6/13/12. Physician progress notes dated 6/13/12, lacked a time to indicate when the progress notes had been written. The clinical director (CD)-B was interviewed at 1:35 p.m. on 6/13/12, and verified the physician had not indicated the time the progress notes had been written.

P7's medical record was reviewed at 1:40 p.m. on 6/13/12. Physician progress notes dated 6/10/12 and 6/11/12, lacked a time to indicate when the progress notes had been written. The clinical director (CD)-B was interviewed at 1:45 p.m. on 6/13/12, and verified the physician had not indicated the time the progress notes had been written.

Based on observation, interview, and document review, the hospital failed to ensure medications were securely stored in 1 of 2 intensive care units (west) and 1 of 2 neonatal intensive care units.

Findings include:

A tour of the east and west intensive care units was conducted with a registered nurse (RN)-A at 1:00 p.m. on 6/12/12. During the tour it was noted the lights in the west ICU were off and the entrance doors to the unit were closed; however, the doors to the unit were not locked. There was no staff or patients in the west ICU at the time of the observation. RN-A stated the west ICU was closed due to a low census. Stored in the closed ICU was a Code Blue Crash Cart containing multiple medications including: Adenosine (used to bring your heart back into a normal rhythm), Atropine (used as the sulfate salt to relax smooth muscles and increase and regulate the heart), Calcium Chloride (treatment of hypocalcemia in those conditions requiring a prompt increase in plasma calcium levels), Dextrose (a simple sugar used for major fuel for cell function in the human body), Sodium Bicarbonate (an antacid used to relieve heartburn and acid indigestion), Flumazenil (reverses the effects of certain types of sedatives from the benzodiazepine group of drugs), Lidocaine (a common local anesthetic and antiarrhythmic drug), Magnesium Sulfate (used to treat pre-eclampsia, eclampsia and preterm labor), Naloxone (a special narcotic drug that reverses the effects of other narcotic medicines), Vasopressin (antidiuretic hormone), Amiodarone (an antiarrhythmic agent used for various types of cardiac dysrhythmias), Dopamine (a neurotransmitter produced in the brain), Epinephrine (a hormone and a neurotransmitter), and Norepinephrine (a hormone and a neurotransmitter). The medications were stored in a drawer that was wrapped in plastic. The drawer was secured to the cart using a small red plastic tab. The drawer was open at the time of the observation approximately three-four inches. RN-A pushed the drawer back into the crash cart and tightened the tab.

At 1:37 p.m. on 6/13/12, the RN-B in the ICU stated when one of the ICUs was closed there was no staff on the unit. RN-B stated pharmacy staff shut down the automatic (medication) dispensing unit in the west ICU when the unit was not in use. At 1:37 p.m. on 6/13/12, the Code Blue Crash Cart remained in the unsecured, closed unit.

At 9:45 a.m. on 6/14/12, the director of pharmacy stated when the ICU was not in use the Code Blue Crash Cart needs to be supervised. The director of pharmacy was asked to provide the hospital's policy regarding the security of the Code Blue Crash Carts when a unit was closed. The hospital provided their Closing /Re-Opening Nursing Units policy, dated 8/11 and the Code Blue Cart Supply-Acute Hospitals and Bethesda Hospital policy dated 5/11. The policies did not address the security of the Code Blue Crash Cart in a closed nursing unit.

A tour of the neonatal intensive care unit (NICU) was conducted with the unit's clinical director (CD)-E at 12:45 p.m. on 6/13/12. During the tour it was noted the main entrance to the NICU was secured and visitors had to ring to gain entrance to the unit. The visitors were buzzed in remotely by staff utilizing video surveillance. Once inside, the NICU was divided into three parts: an entrance where visitors were able to wash their hands and two patient areas, one of which was closed. Each of the parts was separated from the other by a solid wall and door. Visitors had to traverse through the closed portion of the NICU to gain access to the open NICU where the patients were. During the tour an unlocked refrigerator was observed in the closed portion of the NICU. Within the refrigerator were two bottles of proparacaine ophthalmic solution (an anesthetic used in the eye) and one glycerin suppository.

Although visitors traveled unescorted through the closed portion of the NICU medications stored in the unit were not secured to prevent access by unauthorized persons. At the time of the observation CD-E verified these findings and stated staff did not accompany visitors as they travel to the open NICU.

Based on observation, interview, and document review, the hospital was not found to be in compliance with the Condition of Participation related to the Physical Environment (42 CFR 482.41). The hospital failed to follow their fire safety practices and procedures to reduce the risk for surgical fires. In addition, the hospital failed to comply with the Life Safety Code requirements.

Findings include:

FIRE SAFETY IN THE SURGICAL SUITES: Refer to findings at A951 where there was no clear evidence that the policies for fire safety in the surgical suites were being followed. The surgical staff failed to ensure that the alcohol-based skin prep solution was completely dry and had not soaked into the patient's hair, or linens prior to initiating the surgical procedure. This occurred for 2 of 3 surgical cases observed during the surgery.

Review of the Application Instructions for the product 3M Duraprep Surgical Solution under the dry section, dated 2009, the following was documented: "Allow solution to dry thoroughly on skin (3 minutes on hairless skin; up to an hour in hair.) As it dries it turns from shiny to dull appearance, at which point it is no longer flammable. Do not use towel to blot dry. Use gauze to wick away any pooling. Once dry, proceed to draping."

The Healtheast Skin Prep policy, last revised 12/11, was reviewed and identified the the following under the procedure section (number 11): "Allow prepped area to dry before: *drape application* cautery activation."

The policy title: Fire Safety in Surgical Services, revised 10/2008, was reviewed. Under the section Risk Reduction Strategies the policy identified: "Assure all alcohol preps are completely dry (minimum of 3 minutes)."

LIFE SAFETY CODE: The hospital was found not in compliance with the Condition of Participation related to the Physical Environment (42 CFR 482.41) as evidenced by deficiencies issues as a result of a Life Safety Code Inspection. The hospital was found not in compliance with Life Safety Code Standards.

See the following K tags:
K011
K012
K029
K038
K045
K048
K056
K077
K144

The accumulative effect of these systemic problems resulted in the hospital's inability to ensure safety therefore they were not unable to meet this condition.

Based on observation, interview, and document review the hospital failed to ensure infection control policies were developed and practices implemented for the use and storage of ice packs used for patient treatments; the hospital failed to store biological waste in a manner that restricted access by unauthorized persons in 1 of 7 units (the Maternity Care Center-MCC) within the hospital; the hospital failed to store food items in a manner that would minimize the risk of food bourne illness. In addition, the hospital failed to ensure infection control practices were adhered to for 5 of 5 computed tomography (CT scan-used for medical imaging) procedures in the radiology department. These practices had the potential to affect all patients who utilized the ice packs, any patient who received their meals from the kitchen and all patients who receive a CT scan.

Findings include:

Ice packs used for patient treatments were not stored in a manner that would prevent and/or minimize the risk of infection.

At 9:00 a.m. on 6/12/12, a tour of the 4th floor ortho/respiratory nursing unit was conducted with the units clinical manager (CM)-C and the director of nursing (DON)-A. A copy room on the unit contained a refrigerator that was used to stored ice packs. Within the refrigerator were several small, blue, plastic bins many of which were empty; however, 18 of the bins contained ice packs that are used for patient treatments. The ice packs were stored in plastic bags in 12 of the 18 bins. The remaining six bins contained ice packs that were not stored in plastic bags.

During the observation CM-C stated the ice packs were used for patient treatments. When asked to describe the procedure for using the ice packs CM-C stated each bin was labeled for each patient. Ice packs come from the pharmacy in Ziploc bags labeled with the patient's name. The ice packs were stored in the bins until the patient requests one at which time the ice pack was removed from the refrigerator placed in a plastic bag and wrapped in a towel or pillowcase. When the patient was finished with the ice pack was cleaned and returned to the patient's bin to be reused on the patient.

At 9:49 a.m. on 6/12/12, a registered nurse (RN)-J working on the 4th floor was questioned regarding the procedure for using ice packs. RN-J stated she does not clean the ice packs used for patient treatment prior to returning them to their bins in the refrigerator.

During the tour of the hospital's intensive care unit (ICU) at 1:00 p.m. on 6/12/12, the refrigerator freezer in the east ICU contained six ice packs used for patient treatments stored with food items including: ice cream, health shakes and healthy choice dinners. The sign on the outside of the refrigerator indicated the refrigerator was for patient food items only. During the observation the RN-A verified these findings and stated the ice packs are clean and were not used on patients.

At 12:39 p.m. on 6/14/12, the 4th floor clinical director (CD)-G stated ice packs should be cleaned prior to retuning them to the refrigerator. At 12:39 p.m. on 6/14/12, the RN educator stated ice packs do not need to be cleaned if they go from the patient directly back into the Ziploc bag designated for the patient when they are returned to the refrigerator and ice packs used for patient treatments should not be stored with food items.

The hospital's New Cold therapy-B-Cool policy (no date) directed staff to clean the ice pack with a Sani-cloth wipe (Germicidal Disposable Wipes) prior to placing the bag back into the freezer. The policy further directed staff to keep all ice packs in a patient identified bag and in the designated spot for that room number. The hospital provided a sign that indicated "Before going in the freezer..." all products must be in an individually labeled plastic Ziploc bag before being placed in the freezer.

During a tour of the the Maternity Care Center (MCC) at 12:45 p.m. on 6/13/12, a refrigerator labeled biohazardous waste was observed in an unlocked soiled utility room. Within the refrigerator was at least four red bags containing placentas. The soiled utility room also contained two large gray barrels lined with red bags marked biohazardous waste. Although the soiled utility room door had a key lock on it, the room was not locked at the time of the observation. The soiled utility room was around the corner from the nursing station and was not continuously monitored by the staff who worked in the unit.

During the tour, the unit's Clinical Director (CD-E) verified these findings and stated one of the barrels in the room contained blood that resulted from the delivery process. CD-E verified the soiled utility room was not locked and stated the room has never been kept locked.

The facility's Management of Infectious Waste/Use & Disposal of Needles policy (revised 5/12) did not address the security of biohazardous waste to prevent access by unauthorized persons.

At 12:35 p.m. on 6/14/12, the hospital's Director of Plant Operations, Safety and Security verified these findings and stated the soiled utility room on the MCC unit would now be locked to restrict the access to the room to personnel only.

At 12:52 p.m. on 6/14/12, the Director of Housekeeping (DH) stated the hospital does not have a policy regarding the security of biohazardous waste. The DH stated biohazardous waste was collected throughout the hospital and stored in a central location that was secured. The DH stated the hospital was making arrangements to secure the soiled utility room on the MCC to restrict the access to the room to personnel only.

At 1:35 p.m. on 6/14/12, the hospital's Director of Plant Operations, Safety and Security verified these findings and stated biohazardous waste was secured in most of the units in the hospital but, not in the MCC.



28230

Food was not stored properly in the walk-in cooler.

A tour of the kitchen was conducted at 3:00 p.m. on 6/11/12, with the director of hospitality services. At the time of the tour, a walk-in cooler was observed for cleanliness and proper food storage. A case of fresh yellow peppers was observed sitting on the floor of the cooler. The bottom of the cardboard case had openings to allow air circulation and one end of the case had been torn open. Both the damaged end and the openings allowed the peppers to come in direct contact with the floor.

The hospital's policy for food and supply storage, last revised 10/11, indicated all perishable food shall be stored off the floor on washable, corrosion-resistant shelving.

Patient equipment was not cleaned/disinfected between patients.

A tour of the radiology service area was completed at 10:55 a.m. on 6/13/12, and the lead CT technician (CT)-B was interviewed. When CT-B was questioned as to how the ultrasound tables were cleaned/disinfected between patients, she indicated the tables were only cleaned/disinfected if there were noticeable body fluids. She indicated she had not disinfected nor had she seen the tables being disinfected between the patients for 6/13/12. CT-B revealed that she was not looking to see if staff were cleaning/disinfecting the tables. A container of Sani-cloth wipes were noted to be on the counter in front of the lead CT-B at the time of the interview.

At 11:05 a.m. on 6/13/12, CT-A was interviewed and CT-A indicated he had five patients that morning for CT procedures that he completed and CT-A had not cleaned/disinfected the tables in between the procedures.

Based on interview and document review, the hospital failed to identify patients who were likely to suffer adverse health consequences upon discharge for 1 of 6 discharge patient records (P8) reviewed in the sample.

Findings include:

P8 was not identified for the possibility of adverse health consequences after discharge related to her medical diagnosis.

P8 was admitted to the hospital on 11/9/11 for open shoulder rotator cuff repair, and had diagnoses that included respiratory failure with chronic hypercapnia (high blood levels of carbon dioxide), hypoxemia (low blood levels of oxygen) and diabetes. Review of the nursing flow sheets from 11/9/11 through 11/11/11, revealed P8 was forgetful and at times lethargic. Review of the pulmonary consultation dated 11/11/11, revealed P8 respiratory status declined during the hospital stay, listed various recommendations that included supplemental oxygen at discharge and follow up medical care when returning to the community.

The clinical record revealed a respiratory therapy progress note written at 2:30 p.m. on 11/11/11, identified P8 blood oxygen levels (the blood oxygen level test should show at least a 95 percent level. Levels between 80 percent and 94 percent are considered low) without supplemental oxygen remained low (82%) and P8 had been directed to call a durable medical supplier when she returned home to set up home oxygen equipment. P8 was discharged home on 11/11/11 with written directive to use oxygen at two liters at home.

P8's clinical record lacked documentation of an interdisciplinary evaluation of equipment, educational and health needs upon discharge to ensure a safe transition to self-care at home.

Review of the hospital policy titled Care Planning (including discharge planning) Process and Implementation, reviewed 2/12, indicated patient needs or barriers to managing these needs would be assessed on admission and throughout the hospital stay and referrals to appropriate community resources will be done as needed.

During interview at 10:53 a.m. on 6/14/12, care management manager (CMM) confirmed the current hospital's policy and confirmed discharge planning for each patient was to be started on admission and as needed during hospital stay. CMM confirmed the lack of documentation of discharge planning for P8. The CMM indicated P8 was elderly and forgetful and had recent changes in her health condition. CMM stated she would have expected a referral for home care services to assist with educational needs, monitoring of oxygen levels and monitoring of compliance with health regimen for P8 at time of discharge.

Based upon interview, record review and policy review, the hospital was found not to be in compliance with the Conditions of Participation for Surgical Services (CFR 482.51) due to failure to the use of alcohol based surgical skin preparations, and the use of electrocautery devices.

Findings include:

Refer to findings at A0951 regarding the use of electrocautery equipment in the surgical suite.

The facility failed to allow alcohol based skin prep to adequately dry prior to draping the surgical patient when electrocautery equipment was involved.

The hospital did not implement policies and procedures to ensure compliance with applicable federal regulations and guidelines related to the use of alcohol based skin preparations in the surgical department. The Centers for Medicare and Medicaid Services (CMS) issued a Survey and Certification Memo on 1/12/07, which addressed risk reduction techniques to permit safe use of alcohol based skin preparation in inpatient anesthetizing locations in hospitals. The use of alcohol based skin preparations in inpatient or outpatient anesthetizing locations is not considered safe, unless appropriate fire risk reduction measures are taken, preferably as part of a systemic approach by the hospital to prevent surgery related fires.

Upon interview at 7:54 a.m. on 6/12/12, in Maternity Suite 1, with clinical director-E of MCC verified staff did not document the dry time following the use of alcohol based skin prep. At the same date and time she further verified staff did not perform a visual inspection of the skin, looking for any pooling and checking to see if the DuraPrep solution was dry, prior to draping of the patient.

An interview at 10:10 a.m. on 6/13/12, with the lead anesthesiologist MD-C specified the facility should have a better practice in order to make certain that alcohol based skin solution used for surgical prep was dry prior to draping of the surgical patient.

An interview at 11:20 a.m. on 6/13/12, with the RN-E, stated the hospital's skin prep policy included drape dry time, which dried in about three minutes. Further adding, the staff in MCC should be well versed on dry time of skin prep usage and their fire safety components should be the same time.

Based on observation, interview, and document review, the facility failed to follow their policy to assure surgical services were provided consistent with needs and resources in accordance with acceptable standards of practice related to the fire hazards for 2 of 3 (P10 and P9) operative patients reviewed.
Findings include:

The Fire Safety in Surgical Services Policy was not followed during procedures in the operating room.

Review of the HealthEast policy with the subject title of: Fire Safety in Surgical Services revised date of 10/08, the following was specified under the procedure section B: Assure all alcohol preps are completely dry (minimum of three minutes).

During observations on 6/12/12 and 6/13/12, it was identified that the staff did not allot proper dry time when using alcohol based skin prep (DuraPrep-an alcohol patient preoperative skin preparation). There was no clear evidence that the policies for fire safety in the surgical suites were being followed. The surgical staff failed to ensure that the alcohol-based skin prep solution was completely dry and had not soaked into the patient's hair or linens prior to initiating the surgical draping.

P10 was 39 weeks gestation and was scheduled for a repeat cesarean section on the morning of 6/12/12. At 7:51 a.m. on 6/12/12, P10's abdomen and part of the perineal area was prepped with DuraPrep by the circulating registered nurse (RN)-F. The part of the perineal area that was prepped with DuraPrep was noted to be applied to the pubic hair and skin. The medical doctor who was a surgeon (MD)-A then picked up the surgical drape and with the assistance of staff draped P10 at 7:53 a.m. Only two minutes had elapsed for the dry time before the patient was draped.

Upon interview at 7:54 a.m. on 6/12/12, in Maternity Suite 1, with clinical director (CD)-E of Maternal Child Care (MCC) verified staff does not document the dry time following the use of alcohol based skin prep. At the same date and time she further verified no staff did a visual inspection of the skin, looking for any pooling and checking to see if the DuraPrep solution was dry prior to draping of the patient.

Interview at 11:20 a.m. on 6/13/12, with the surgery educator (RN)-E, stated the hospital's skin prep policy included DuraPrep dry time, which dried in about three minutes. Further adding, the staff in MCC should be well versed on dry time of skin prep usage and their fire safety components should be the same time.

During interview at 9:00 a.m. on 6/14/12, with the clinical director of MCC RN-E verified the staff in MCC did not document the time the prep was applied, the time the prep was dry nor the time the patient was draped.

P9 was scheduled for a right femoral to peroneal bypass with vein, possible cadaver vein under spinal anesthesia with sedation on 6/13/12. Following the spinal anesthesia, P9 was positioned on the surgical table and at 12:13 p.m. on 6/13/12, RN-I with the assistance of RN-E, began to prep P9 with DuraPrep, which was from the right lower abdomen to the foot, front and back which included both sides and part of the scrotum (which had visible hair) and the perineal fold on the right side. RN-I finished the prep at 12:17 p.m. MD-B began to drape P9 immediately following the prep finish time. None of the staff present inspected the area for pooling or verified that the prep was dry, prior to draping.

During interview at 1:02 p.m. on 6/13/12, with RN-E, RN-E verified the area that was prepped with DuraPrep on P9 was not allotted the proper dry time prior to draping of P9's surgical site. She further verified that 3M, who manufactured DuraPrep, specified the solution should be allowed to dry thoroughly on the skin for a minimum of three minutes on hairless skin and up to one hour on hair. She did indicate that she was aware that the DuraPrep was applied to part of the scrotal area which had not been shaved.

Review of the Application Instructions for the product 3M DuraPrep Surgical Solution under the dry section, the following is documented: Allow solution to dry thoroughly on skin (three minutes on hairless skin; up to an hour in hair). " As it dries, it turns from shiny to a dull appearance, at which point it was no longer flammable. Do not use towel to blot dry. Use gauze to wick away any pooling. Once dry, proceed to draping."

The HealthEast Skin Prep policy was reviewed and identified the following under the procedure section (number 11): "Allow prepped area to dry before: * drape application * cautery activation."

Review of the Surgery Education for 2012 included the following: "1. Fire Safety. 2. Electro cautery Safety. 3. HealthEast policy update skin prep. 4. Staff meeting on January 11, 2012 on Fire Safety and two videos was shown involving patients experiencing burns from fires on the operating room (OR). Information from the FDA {Food and Drug Administration} Surgical Fire Safety Site was presented. 5. Surgical audits performed in March and skin prep dry time and pooling were specifically addressed. 6. Note placed in communication book on 6/7/12 warning the Chloroprep (Patient Preoperative Skin Preparation) dry time is 3 minutes and that Chloroprep and DuraPrep have similar alcohol contents."

During interview at 9:18 a.m. on 6/14/12, RN-E verified the surgical staff did not document the time the prep was applied, the time the prep was dry nor the time the patient was draped which would be in violation of the policy Fire Safety in Surgical Services.

Based on interview and document review, the hospital failed to develop and implement a plan of care for 1 of 12 patients' (P14) in the sample who had a physician's order for an occupational therapy (OT) evaluation and treatment.

Findings include:

P14 did not receive OT as ordered by the patient's physician and the physician was not notified that P14 had not received OT.

P14 was admitted to the hospital on 6/8/12, for surgical repair of a left hip fracture. The patient underwent surgical repair of the hip fracture on 6/9/12. Review of a physician's order dated 6/9/12, revealed the physician had ordered an OT evaluation and treatment per the weight bearing as tolerated total hip arthroplasty (THA-surgery to relieve pain and restore range of motion by realigning or reconstructing a joint) and total hip arthroplasty revision protocol for activities of daily living assessment and indicated training per HealthEast's Rehab Services. At approximately 2:00 p.m. on 6/13/12, P14's medical record lacked evidence to indicate the OT evaluation was completed. Furthermore, the medical record lacked a documented rationale to explain why the physician's order was not implemented and evidence to indicate the physician had been informed that the OT order had not been implemented.

At approximately 3:00 p.m. on 6/13/12, the physical therapy supervisor (PTS) stated the OT evaluation was usually completed the second post-operative day. The PTS stated the patient had not had an OT evaluation because the physical therapist believed the patient to be too weak to participate and OT would be of little benefit to the patient at that time. The PTS verified the patient's medical record lacked documentation regarding the delay of the patient's occupational therapy evaluation.

At 9:30 a.m. on 6/14/12, the occupational therapy supervisor (OTS) verified the patient had not received an OT evaluation and the patient was being discharged today. The OTS stated physical therapy (PT) begins on post-operative day one, PT and OT staff meet daily to communicate the patient's progress and the PT staff will report to the OT staff when they believe the patient was ready to start OT. When asked what the physical therapist utilized as a guideline to determine when a patient was ready to start OT the OTS replied, the patient needs to be able to transfer with one assist, the patient needs to be able to sit in a chair and the patient needs to be alert enough to understand and follow directions.

Review of physical therapy progress notes (PN) dated 6/10/10 through 6/13/12, revealed the patient was alert and orientated to person, place and time. The PN's dated 6/11/12 through 6/13/12, revealed the patient had minimal pain and required minimal assistance of one person with bed mobility and transfers. The PN's indicated the patient ambulated 15-50 feet with minimal contact guard assistance of one person and the patient tolerated the activities well.

The HealthEast Physical Medicine Protocol THA and THA Revision and Hip Fracture Repair policy revised 6/14/12, indicated OT shall begin on post-operative day one or two as tolerated, and progressing the protocol as tolerated.

The Rehab Services Evaluations (Physical and Occupational Therapy) policy (revised 3/12) indicated when a physician referral was received an evaluation is completed in all inpatients by a registered therapist within 24 hours of receipt of the order.