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Based on review of the Medical Staff Rules & Regulations, clinical record review, and staff interview, the hospital failed to ensure the medical staff enforced its rules & regulations as evidenced by reports being completed , and signed by the surgeon prior to the beginning or end of a surgical procedure for 7 (#1, #3, #5, #12, #14, #15, #19) of 18 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #19, #20, #21) surgical records reviewed out of a total sample of 21 patient records reviewed.
Findings:


Review of the Medical Staff Bylaw, Rules & Regulations, approval date of 05/23/12, provided by S3RN Director of Quality, revealed in part the following: ....III. Medical Records: B. Documentation Requirements: 5. Surgical Reports: Operative reports shall include a detailed account of the findings at surgery as well as the details of the surgical technique. All surgical procedures performed in the Operating Room must have a dictated operative noted. This not must be dictated immediately following the operation. The attending physician is required to sign the operative report.....A brief written operative note must also be written in the chart immediately following the operation. This note should include the following: 1. Date of procedure; 2. Name of surgeon, assistants; 3. Pre-operative diagnosis, postoperative diagnosis; 4. Procedure performed; 5. Anesthetic agent used; 6. Estimated blood loss; 7. Findings and condition of patient.
7. Discharge Summary: A narrative discharge summary shall be documented in the final progress note for each patient discharged from [hospital]....

Patient #1
An observation was made 4/23/13 at 10:10 a.m. of Patient #1 in a preoperative bay #5, with his mother, waiting to be taken to the OR (operating room) for his surgical procedure.

Review of the medical record for Patient #1 on 4/23/13 at 10:10 a.m. revealed he was a 6 year old admitted on 4/23/13 for an outpatient Bilateral PE (Perieustachian) Tube insertion (a tube inserted into the ear for prevention of fluid accumulation and keep the eardrum aerated). Review of an Operating Room Record revealed Patient #1 entered the OR at 10:46 a.m. and left the OR at 11:14 a.m. The surgical procedure was documented with a start time of 10:53 a.m. and an ending time of 11:07 a.m. Further review of the medical record revealed a Post Procedure Note signed by S6Physician, dated 4/23/13 and timed for 11:30 a.m. The post procedure note listed the surgeon (S6Physician), a pre-operative and post-operative diagnosis of Acute Otitis Media, the procedure as Bilateral PET (Patulous Eustachian Tube) tubes insertion, amount of blood loss as 0, type of anesthesia as General, and complications: no (none). Review of a Discharge summary on the same page as the Post Procedural Note had a signature of S6Physician and a time of 11:45 a.m.

In an interview on 4/23/13 at 10:23 a.m. S15RN (Registered Nurse) verified, after review of Patient #1's medical record, that a Post Procedure Note was filled out and signed by S6Physician, and dated and timed as 4/23/13 at 11:30 a.m., as well as a Discharge Summary dated and timed 4/23/13 at 11:45 a.m. S15RN verified that the current time was 10:23 a.m., Patient #1 was in Pre-Op (pre-operative) holding , and had not gone to OR for his surgical procedure yet. S15RN stated that "S6Physician always brings his paperwork in already filled out."

In an interview 4/23/13 at 10:30 a.m. in the preoperative area S6Physician was asked to review the post procedural note located on Patient #1's chart, and was asked if he had completed and signed the document. S6 Physician stated, while pointing to the Post Procedure Note for Patient #1, " That shouldn't be on the chart." S6Physician then reported that Patient #1 was already out of surgery; the procedure was finished. When informed that Patient #1 had just been observed in the pre-op holding area, and asked if he (S6Physician) had filled out the post procedure note prior to the scheduled procedure, he replied, "Yes."

Patient #3
An observation was made 4/23/13 at 11:05 a.m. of Patient #3 leaving Recovery bay/room #12, after discharge, with his mother.

Review of the medical record for Patient #3 4/23/13 at 11:05 a.m. revealed he was a 2 year old male admitted 4/23/13 for outpatient surgery to include Bilateral PET tube insertion and Adenoidectomy. Review of the Operating Room Record revealed the time into the OR was 9:43 a.m. and out of the OR was 10:32 a.m. The start of the surgical procedure was documented with a start time of 9:54 a.m. with an ending time of 10:24 a.m. Further review revealed a Post Procedure Note filled out and signed by S6Physician with a date of 4/23/13 and a time of "10:30 a.m." written over a time of "9:30 a.m." A discharge summary on the same page was signed by S6Physician with a time of "11:30 a.m." written on top of "10:30 a.m."

In an interview 4/23/13 at 11:05 a.m. S16RN and S17RN both nurses verified that the time written on the Post Procedure Note by S6Physician was 10:30 a.m., and that it had been written on top of an entry of "9:30 a.m." The nurse also verified that a discharge summary signed by S6Physician on the document page was timed as "11:30 a.m." and had been written over an entry of "10:30 a.m." Both RNs verified that the time of their review and interview was 11:05 a.m. and the time of the signature time of S6Physician was documented with a future time.


Patient #5
Review of the medical record for Patient #5 revealed the patient was a 57 year old female admitted to the hospital on 04/22/13 for a Laparoscopic Vertical Sleeve Gastrectomy. The record revealed the procedure was performed on 04/22/13 and the patient was admitted to the inpatient unit after the surgery. The patient was currently hospitalized.

Review of the Operating Room Record dated 04/22/13 revealed the surgery start time was 1450 and the surgery stop time was 1615. Review of the Post Procedure Note revealed S25 Physician (Bariatric surgeon) signed the note on 04/22/13 at 1600,15 minutes before the surgery stop time.


Patient #12
Review of the medical record for Patient #12 revealed he was a 41 year old male admitted as an outpatient 4/23/13 for and I & D (Incision and Drainage) of the right Achilles and wound closure. Review of the Operating Room Record revealed Patient #12 entered the OR at 9:52 a.m. and left the OR at 11:14 a.m. The beginning time and ending time of the procedures were 10:28 a.m. and 11:04 a.m., respectively. Further review of the medical record revealed a Post Procedure Note filled in and signed by S20Physician with a date and time documented as 4/23/13 at 10:15 a.m., 49 minutes before the surgery was completed. On the same page as the Post Procedure Note was a Discharge Summary that was signed by S20Physician with the date and time of 4/23/13 at 10:00 a.m.

In an interview 4/23/13 at 11:40 a.m. S22RN, after review of Patient #12's medical record verified the times on documents noted in the previous paragraph, and confirmed that the time on the Post Procedure note was prior to the OR record procedure stop time, as well as the Discharge Summary time of 10:00 a.m. was before the surgery start time.

Patient #14
Review of the medical record for Patient #14 revealed she was 48 year old female admitted to the hospital 4/23/13 as an outpatient for a scheduled Right Shoulder Arthroscopy (a surgical procedure, using an endoscope, to evaluate and/or treat a joint). Review of the OR Record revealed the patient entered the OR at 8:32 a.m. and left the OR at 10:10 a.m. Her surgical procedure started at 9:09 a.m. and ended at 9:52 a.m. Further review of the medical record revealed a Post Procedure Note signed by S20Physician with a date and time of 4/23/13 at 7:00 a.m., and hour and 32 minutes before the start of Patient #14's surgery.

In an interview 4/23/13 at 3:10 p.m. S4RN, Director of Outpatient Services reviewed the medical record of Patient #14 and verified the Post Procedural note time and OR Record times. She confirmed that the Post Procedure Note was timed before the start of Patient #14's surgical procedure.


Patient #15
Review of the medical record for Patient #15 revealed the patient was a 59 year old female admitted to the hospital on 02/06/13 for a Left Total Knee Arthroplasty. Review of the record revealed the surgical procedure was performed on 02/06/13 and the patient was admitted as an inpatient on 02/06/13. The patient was discharged on 02/11/13.

Review of the Operating Room Record dated 02/06/13 revealed the surgery start time was 0947 and the surgery stop time was 1051. Review of the Post Procedure Note revealed S21 Physician (Orthopedic surgeon) signed the note on 02/06/13 at 8:00 a.m., 1 hour and 47 minutes before the surgery start time. The documentation on the post procedure note revealed no complications was documented and no blood was administered. The section for estimated blood loss was left blank.

In an interview on 04/24/13 at 2:45 p.m., S4RN Director of Outpatient Services reviewed the medical record for Patient #15 and verified the Post Procedure Note was documented, signed and dated at 8:00 a.m. on 02/06/13, over 1 hour prior to the start of the surgical procedure.


Patient #19
Review of the medical record for Patient #19 revealed the patient was a 66 year old male admitted to the hospital on 04/22/13 for a Right Total Knee Arthroplasty. Review of the record revealed the surgical procedure was performed on 04/22/13 and the patient was admitted as an inpatient on 04/22/13. The patient was currently hospitalized.

Review of the Operating Room Record dated 04/22/13 revealed the surgery start time was 0805 and the surgery stop time was 0933. Review of the Post Procedure Note revealed S23Physician (Orthopedic Surgeon) signed the note on 04/22/13 at 9:00 a.m., 27 minutes prior to the surgery stop time.

In an interview on 04/25/13 at 9:40 a.m., S3RN Director of Quality stated the Post Procedure Note and the Discharge Summary was included in the quality improvement chart reviews. S3RN Director of Quality stated they review the Post Procedure Notes and Discharge Summaries for signatures, dating, timing and completeness. S3RN Director of Quality stated they were aware the timing and completeness of the Post Procedure note and the Discharge Summaries was a problem. S3RN Director of Quality provided Quality Indicators for physician documentation for review. Review of the indicators for Post Procedures Notes for 2012 revealed the yearly average was 15% incomplete and 15% with incorrect timing. Review of the indicators for Discharge Summary for 2012 revealed the average incomplete rate was 29% and the incomplete timing rate was 32%. Review of the first quarter of 2013 revealed the average was 12% for timing and incomplete post procedure notes. The incomplete rate for 2013 for Discharge Summary was 35% incomplete and 42% with timing problems. When asked if any corrective actions had been taken to address the quality indicators, S3RN Director of Quality stated a letter was sent to the physicians informing them a suspension process was implemented for incomplete records on 03/01/13

Based on interviews and record reviews, the hospital failed to ensure that the pharmacy distributed medications in accordance with applicable standards of practice and consistent with Federal and State laws when it failed to ensure that all first doses of medications were not administered to patients before being reviewed by a pharmacist for known allergies, therapy contraindications, dose and route of administration, directions for use, duplication of therapy, interactions, and optimum therapeutic outcomes for all patients admitted after or before pharmacy working hours. This practice had the potential to affect 5 of 5 patients in the hospital.
Findings:
Review of the "Louisiana Administrative Code Title 46 - Professional and Occupational Standards Part III: Pharmacists Chapter 15. Hospital Pharmacy", revealed, in part, "...1511. Prescription Drug Orders A. The pharmacist shall review the practitioner's medical order prior to dispensing the initial dose of medication, except in cases of emergency...". Further review of definition revealed, in part, "...(13) "Drug regimen review" means and includes, but is not limited to, the following activities: (a) review of the prescription drug order and patient record for [i] known allergies, [ii] therapy contraindications, [iii] dose and route of administration, and [iv] directions for use, (b) review of the prescription drug order and patient record for duplication of therapy, (C) review of the prescription drug order and patient record for interactions, and (d) review of the prescription drug order and patient record for proper utilization including over-or under-utilization, and optimum therapeutic outcomes...".
Review of the hospital policy, titled "Pharmacy Order Verification" revised on 04/22/13 and provided by administration as the most current policy revealed in part: the pharmacist will review each order for appropriateness of medication prior to administration of the first dose.
Review of S9RPh Director of Pharmacy's job description signed by S9RPh on 03/19/13 revealed in part: Duties and Responsibilities: Develops and maintains policies, procedures and processes that promote safe, efficient..... medication use that comply with accreditation standards and federal and state regulatory agencies.
In a face-to-face interview on 04/25/13 at 1:00 p.m., S9RPh Director of Pharmacy was asked how a first dose review of the patient's medication profile was done before new medications were dispensed. S9RPh Director of Pharmacy indicated she reviewed and verified new orders when she arrived at work around 12:30 p.m. day. S9RPh Director of Pharmacy indicated her work hours are 12:30 p.m. to 4:30 p.m. Monday through Friday. S9RPh Director of Pharmacy indicated medications ordered after hours (after 4:30 p.m. and before 12:30 p.m. the next day) were reviewed by her the next day. S9RPh Director of Pharmacy verified new medications could be administered before the pharmacist's review by over-riding the medication dispensing system. S9RPh Director of Pharmacy verified there was no system in place yet for a first dose medication review prior to dispensing medications for medications ordered after hours. S9RPh Director of Pharmacy indicated she was aware of the revised policy for first dose review, but, indicated the hospital was still in the process of working out a system with the contracted Pharmacy.
In a face to face interview on 04/25/13 at 4:55 p.m with S2RN CNO and S3RN Director of Quality, they confirmed the "Pharmacy Order Verification" policy was revised on 04/22/13 to include the first dose review by a pharmacist in accordance with state and federal regulations. They further indicated the hospital was still in the process of working out a system with the contracted Pharmacy and indicated that the first dose review by a pharmacist had not been implemented yet.

Based on observation, interviews and policy review the Hospital failed to ensure all foods were stored and maintained under sanitary conditions as evidenced by the Dietary Manager not adhering to and maintaining established policies and procedures to assure safety practices for daily monitoring of temperatures for the refrigerators and the freezer and having no documented temperature monitoring log for the foods served to patients.

Findings:

A review of the policy entitled, "Temperature Chart Policy" dated 08/11/11 and provided by administration as the most current policy revealed the refrigerator and the freezer temperatures should be checked and recorded each morning by dietary staff.

A review of the temperature log sheets on 04/24/13 at 10:00 a.m. for Refrigerator #1, Refrigerator #2 and the Freezer in the presence of S14 Dietary Manager revealed Refrigerator #1, Refrigerator #2 and the Freezer had no documented temperature readings for the month of April on 04/06/13, 04/07/13, 04/14/13 and 04/21/13.

An interview on 04/24/13 at 10:10 a.m. was conducted with S14 Dietary Manager. S14 Dietary Manager was asked about the missing temperature readings on Refrigerator #1, Refrigerator #2 and the Freezer on the above dates. She indicated that the temperature readings are not done on weekends. She indicated that if she works on a weekend day, she would document the readings on the refrigerators and the freezer. S14 Dietary Manager was asked for the documentation of the temperature food logs taken on the foods before serving to patients. She indicated she takes the temperature on all foods before serving to patients, but she does not document it anywhere.

An interview on 04/24/13 at 11:50 a.m. was conducted with S3RN Director of Quality. She indicated that she was responsible for the kitchen quality controls. S3RN Director of Quality reviewed the temperature logs for Refrigerator #1, Refrigerator #2 and the Freezer for the month of April. She confirmed there were no documented readings of the temperatures on 04/06/13, 04/07/13, 04/14/13 and 04/21/13. She indicated she was not aware the temperatures on the refrigerators and the freezer were not being documented on the weekends and indicated the nurses were supposed to be monitoring those temperatures on the weekends. S3RN Director of Quality indicated she would in service nursing staff and the Dietary Manager on the need to do daily monitoring of the refrigerators and freezer temperatures. S3RN Director of Quality was made aware that the temperature of foods served to patients were not being documented by the Dietary Manager. S3RN Director of Quality indicated the food temperatures should be monitored and documented and she would develop a food temperature log for the Dietary Manager.

Based on observation, record review, and interview the hospital failed to ensure that an operative report describing techniques, findings, and tissues removed or altered was written immediately following the surgery and signed by the surgeon as evidenced by reports being completed , and signed by the surgeon prior to the beginning or end of a surgical procedure for 7 (#1, #3, #5, #12, #14, #15, #19) of 18 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #19, #20, #21) surgical records reviewed out of a total sample of 21 patient records reviewed.
Findings:

Patient #1
An observation was made 4/23/13 at 10:10 a.m. of Patient #1 in a preoperative bay #5, with his mother, waiting to be taken to the OR (operating room) for his surgical procedure.

Review of the medical record for Patient #1 on 4/23/13 at 10:10 a.m. revealed he was a 6 year old admitted on 4/23/13 for an outpatient Bilateral PE (Perieustachian) Tube insertion (a tube inserted into the ear for prevention of fluid accumulation and keep the eardrum aerated). Review of an Operating Room Record revealed Patient #1 entered the OR at 10:46 a.m. and left the OR at 11:14 a.m. The surgical procedure was documented with a start time of 10:53 a.m. and an ending time of 11:07 a.m. Further review of the medical record revealed a Post Procedure Note signed by S6Physician, dated 4/23/13 and timed for 11:30 a.m. The post procedure note listed the surgeon (S6Physician), a pre-operative and post-operative diagnosis of Acute Otitis Media, the procedure as Bilateral PET (Patulous Eustachian Tube) tubes insertion, amount of blood loss as 0, type of anesthesia as General, and complications: no (none).

In an interview on 4/23/13 at 10:23 a.m. S15RN (Registered Nurse) verified, after review of Patient #1's medical record, that a Post Procedure Note was filled out and signed by S6Physician, and dated and timed as 4/23/13 at 11:30 a.m. S15RN verified that Patient #1 was in Pre-Op (pre-operative) holding bay #5, and had not gone to OR for his surgical procedure yet. S15RN stated that "S6Physician always brings his paperwork in already filled out."

In an interview 4/23/13 at 10:30 a.m. in the preoperative area S6Physician was asked to review the post procedural note located on Patient #1's chart, and asked if he had completed and signed the document. S6 Physician stated that that shouldn't be on the chart. S6Physician then reported that Patient #1 was already out of surgery; the procedure was finished. When informed that Patient #1 had just been observed in the pre-op holding area, and asked if he (S6Physician) had filled out the post procedure note prior to the procedure today, he replied, "Yes."

Patient #3
An observation was made 4/23/13 at 11:05 a.m. of Patient #3 leaving the surgery area from Recovery bay/room #12, after discharge with his mother.

Review of the medical record for Patient #3 4/23/13 at 11:05 a.m. revealed he was a 2 year old male admitted 4/23/13 for outpatient surgery to include Bilateral PET tube insertion and Adenoidectomy. Review of the Operating Room Record revealed the time into the OR was 9:43 a.m. and out of the OR at 10:32 a.m., and the start of the surgical procedure was 9:54 a.m. with an ending time of 10:24 a.m. Further review revealed a Post Procedure Note filled out and signed by S6Physician with a date of 4/23/13 and a time of 10:30 a.m. written over a time of 9:30 a.m.

In an interview 4/23/13 at 11:05 a.m. S16RN and S17RN both verified that the time entered by S6Physician was 10:30 a.m., and that had been written over "9:30 a.m." They also verified that a discharge summary signed by S6Physician on the document page was timed as "11:30 a.m." and had been written over " 10:30 a.m." Both RNs verified that the time of their review and interview was 11:05 a.m. and the time of the signature time of S6Physician was documented with a future time.


Patient #5
Review of the medical record for Patient #5 revealed the patient was a 57 year old female admitted to the hospital on 04/22/13 for a Laparoscopic Vertical Sleeve Gastrectomy. The record revealed the procedure was performed on 04/22/13 and the patient was admitted to the inpatient unit after the surgery. The patient was currently hospitalized.

Review of the Operating Room Record dated 04/22/13 revealed the surgery start time was 1450 and the surgery stop time was 1615. Review of the Post Procedure Note revealed S25 Physician (Bariatric surgeon) signed the note on 04/22/13 at 1600,15 minutes before the surgery stop time.


Patient #12
Review of the medical record for Patient #12 revealed he was a 41 year old male admitted as an outpatient 4/23/13 for and I & D (Incision and Drainage) of the right Achilles and wound closure. Review of the Operating Room Record revealed Patient #12 entered the OR at 9:52 a.m. and left the OR at 11:14 a.m. The beginning time and ending time of the procedures were 10:28 a.m. and 11:04 a.m., respectively. Further review of the medical record revealed a Post Procedure Note filled in and signed by S20Physician with a date and time documented as 4/23/13 at 10:15 a.m., 49 minutes before the surgery was completed.

In an interview 4/23/13 at 11:40 a.m. S22RN, after review of Patient #12's medical record verified the times on documents noted in the previous paragraph, and confirmed that the time on the Post Procedure note was prior to the OR record procedure stop time.

Patient #14
Review of the medical record for Patient #14 revealed she was 48 year old female admitted to the hospital 4/23/13 as an outpatient for a scheduled Right Shoulder Arthroscopy (a surgical procedure, using an endoscope, to evaluate and/or treat a joint). Review of the OR Record revealed the patient entered the OR at 8:32 a.m. and left the OR at 10:10 a.m. Her surgical procedure started at 9:09 a.m. and ended at 9:52 a.m. Further review of the medical record revealed a Post Procedure Note signed by S20Physician with a date and time of 4/23/13 at 7:00 a.m., and hour and 32 minutes before the start of Patient #14's surgery.

In an interview 4/23/13 at 3:10 p.m. S4RN, Director of Outpatient Services reviewed the medical record of Patient #14 and verified the Post Procedural note time and OR Record times. She confirmed that the Post Procedure Note was timed before the start of Patient #14's surgical procedure.

Patient #15
Review of the medical record for Patient #15 revealed the patient was a 59 year old female admitted to the hospital on 02/06/13 for a Left Total Knee Arthroplasty. Review of the record revealed the surgical procedure was performed on 02/06/13 and the patient was admitted as an inpatient on 02/06/13. The patient was discharged on 02/11/13.

Review of the Operating Room Record dated 02/06/13 revealed the surgery start time was 0947 and the surgery stop time was 1051. Review of the Post Procedure Note revealed S21 Physician (Orthopedic surgeon) signed the note on 02/06/13 at 8:00 a.m., 1 hour and 47 minutes before the surgery start time. The documentation on the post procedure note revealed no complications was documented and no blood was administered. The section for estimated blood loss was left blank.

In an interview on 04/24/13 at 2:45 p.m., S4RN Director of Outpatient Services reviewed the medical record for Patient #15 and verified the Post Procedure Note was documented, signed and dated at 8:00 a.m. on 02/06/13, over 1 hour prior to the start of the surgical procedure.


Patient #19
Review of the medical record for Patient #19 revealed the patient was a 66 year old male admitted to the hospital on 04/22/13 for a Right Total Knee Arthroplasty. Review of the record revealed the surgical procedure was performed on 04/22/13 and the patient was admitted as an inpatient on 04/22/13. The patient was currently hospitalized.

Review of the Operating Room Record dated 04/22/13 revealed the surgery start time was 0805 and the surgery stop time was 0933. Review of the Post Procedure Note revealed S23Physician (Orthopedic Surgeon) signed the note on 04/22/13 at 9:00 a.m., 27 minutes prior to the surgery stop time.

In an interview on 04/25/13 at 9:40 a.m., S3RN Director of Quality stated the Post Procedure Note was included in the quality improvement chart reviews. S3RN Director of Quality stated they review the Post Procedure Notes for signatures, dating, timing and completeness. S3RN Director of Quality stated they were aware the timing and completeness of the Post Procedure note was a problem. S3RN Director of Quality provided Quality Indicators for physician documentation for review. Review of the indicators for Post Procedures Notes for 2012 revealed the yearly average was 15% incomplete and 15% with incorrect timing. Review of the first quarter of 2013 revealed the average was 12% for timing and incomplete post procedure notes. When asked if any corrective actions had been taken to address the quality indicators, S3RN Director of Quality stated a letter was sent to the physicians informing them a suspension process was implemented for incomplete records on 03/01/13

Based on record review, staff interview, and review of Louisiana Physical Therapy Practice Act, the hospital failed to ensure that physical therapy (PT) services were provided only under the orders of a licensed practitioner by failing to obtain physician's orders for therapy services provided after the initial evaluation by the physical therapist for 2 of 2 sampled patients reviewed for physical therapy (#15 and #19) out of a total sample of 21. Findings:

Review of the hospital policy titled Physical Therapy, number RS. 1-3, revised 04/03/12, and provided as current by S3RN Director of Quality, revealed in part the following:
Policy: A Physical Therapist shall be available to patients when a physician's order is written for consult....
Procedure: The Physical Therapist will assess patients when requested by the physician as a written order.....It is policy that the physician indicate the type, amount, frequency and duration of services rendered through written orders indicated on the patient's medical record. All orders for physical therapy, including treatment plan, results, and notes must be documented in the patient's medical record in accordance with the accreditation requirements in the Medical Record (MS) chapter.....The patient care services provided will be completed by licensed physical therapists and shall conform to the standards of practice and ethical code of the American Physical Therapy Association and the Louisiana Physical Therapy Association.

Review of the Louisiana Revised Statutes, 37:2401-37:2424 Chapter 29. Louisiana Physical Therapy Practice Act revealed in part the following:
?2418. Authority to practice as a physical therapist or physical therapist assistant
A. A physical therapist or physical therapist assistant licensed in Louisiana is authorized to practice physical therapy as defined in this Chapter. A physical therapist is responsible for managing all aspects of the physical therapy care of each patient. B. Without prescription or referral, a physical therapist may perform an initial evaluation or consultation of a screening nature to determine the need for physical therapy and may perform physical therapy or other services provided in Subsection C of this Section. However, implementation of physical therapy treatment shall otherwise be based on the prescription or referral of a person licensed to practice medicine, surgery, dentistry, podiatry, or chiropractic. C. Except as to an initial evaluation or consultation, as provided in Subsection B of this Section, physical therapy services may be performed without a prescription or by referral only under the following circumstances: (1) To a child with a diagnosed developmental disability pursuant to the child's plan of care. (2) To a patient of a home health care agency pursuant to the patient's plan of care. (3) To a patient in a nursing home pursuant to the patient's plan of care. (4) Related to conditioning or to providing education or activities in a wellness setting for the purpose of injury prevention, reduction of stress, or promotion of fitness.(5) To an individual for a previously diagnosed condition or conditions for which physical therapy services are appropriate after informing the health care provider rendering the diagnosis. The diagnosis shall have been made within the previous ninety days. The physical therapist shall provide the health care provider who rendered such diagnosis with a plan of care for physical therapy services within the first fifteen days of physical therapy intervention..."

Patient #19
Review of the medical record for Patient #19 revealed the patient was a 66 year old male admitted to the hospital on 04/22/13 for a Right Total Knee Arthroplasty. Review of the record revealed the surgical procedure was performed on 04/22/13 and the patient was admitted as an inpatient on 04/22/13. The patient was currently hospitalized.

Review of the physician's orders dated 04/22/13 revealed an order, "Physical Therapy in AM - Ambulation with walker PWB (Partial weight bearing) right." There was no documented evidence of any further physician orders for physical therapy. There was no documented evidence of any specific treatment orders that included the modalities and the duration of therapy.

Review of the Physical Therapy Notes revealed a Physical Therapy Evaluation was done on 04/23/13 at 9:30 a.m. The PT notes revealed therapy was continued twice a day until 04/24/13 at 2:00 p.m.


Patient #15
Review of the medical record for Patient #15 revealed the patient was a 59 year old female admitted to the hospital on 02/06/13 for a Total Knee Arthroplasty. Review of the record revealed the surgical procedure was performed on 02/06/13 and the patient was admitted as an inpatient on 02/06/13. The patient was discharged on 02/11/13.

Review of the physician's orders dated 02/06/13 revealed an order to "Consult Physical Therapy BID (twice a day); OOB (Out of Bed) Surgery Day." There was no documented evidence of any further physician orders for physical therapy. There was no documented evidence of any specific treatment orders that included the modalities and the duration of therapy.

Review of the Physical Therapy Notes revealed a Physical Therapy Evaluation was done on 02/08/13 at 8:30 a.m. The PT notes revealed therapy was continued twice a day until 02/11/13 at 8:30 a.m.

In an interview on 04/25/13 at 11:30 a.m., S7PT reviewed the above patient medical records and verified the only order for physical therapy was the consult order. S7PT verified there were no specific orders for the physical therapy provided to the patients after the order for the consult. S7PT stated he had worked with the orthopedic surgeons for 20 years and knew what they wanted.