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Based on record review and interview, staff at this facility failed to ensure that the Important Message from Medicare informing Medicare recipients of their discharge appeal rights was given to eligible patients within 48 hours of admission and/or discharge in 7 out of 15 Medicare eligible medical records reviewed out of a total of 30 (Patient #9, 13, 14, 16, 25, 29, and 30).

Findings include:

Per review of medical record for patient #9 on 2/19/2018 at 2:50 PM revealed patient #9 was admitted to the hospital on 11/8/17 and was discharged on 11/11/2017. Patient #9 was provided the first copy of the Important Message from Medicare on 11/8/2017, a second copy was not provided to the patient. Findings were confirmed with Nurse Manager E on 2/19/2018 at 3:15 PM.

A medical record review was conducted on Patient #25's closed medical record on 2/19/2018 at 2:51 PM accompanied by Chief Nursing Officer B who confirmed the following finding at the time of record review: The medical record revealed that Patient #25, a Medicare recipient, was admitted on 12/8/2017 for a spinal fusion and was discharged on 12/12/2017. There was no Important Message from Medicare form in the medical record.

Per interview with Nurse Manager E on 2/20/2018 at 9:05 AM regarding the completion of the Important Message from Medicare, Manager E stated that in 2017 the facility's registration staff would give the form to patients on admission and the second copy was given within 4 hours of discharge of the hospital. Manager E also stated that for 2018 the process changed to the first copy being given on admission and a dated signature from a staff member that the information was also presented prior to discharge.

Per review of medical record for patient #14 on 2/20/2018 at 11:22 AM revealed patient #14 was admitted to the hospital on 11/13/17 and was discharged on 11/17/2017. Patient #14 was provided the first copy of the Important Message from Medicare on 11/13/2017, a second copy was not provided to the patient. Findings were confirmed with Nurse Manager E on 2/20/2018 at 12:00 PM.

Per review of medical record for patient #13 on 2/20/2018 at 12:00 PM revealed patient #13 was admitted to the hospital on 11/3/17 and was discharged on 11/6/2017. Patient #13 was provided the first copy of the Important Message from Medicare on 11/3/2017, a second copy was not provided to the patient. Findings were confirmed with Nurse Manager E on 2/20/2018 at 12:30 PM.

A medical record review was conducted on Patient #29's closed medical record on 2/20/2018 at 12:44 PM. Manager E confirmed the following finding on 2/20/2018 at 1:55 PM: The medical record revealed that Patient #29, a Medicare recipient, was admitted on 1/15/2018 for a right total knee replacement and was discharged on 1/19/2018. There was not a signature indicating that the Important Message from Medicare information was presented to Patient #29 prior to discharge. Per interview with Manager E on 2/20/2018 at 1:12 PM, Manager E stated, "Looks like they didn't document the second time."

Per review of medical record for patient #16 on 2/20/2018 at 1:05 PM revealed patient #16 was admitted to the hospital on 11/16/17 and was discharged on 11/18/2018. There is no documentation that Patient #16 was provided the first copy of the Important Message from Medicare. Documentation of the second copy signed by the staff on 11/18/2017 was noted. Findings were confirmed with Nurse Manager E on 2/20/2018 at 1:30 PM.

A medical record review was conducted on Patient #30's closed medical record on 2/20/2018 at 1:27 PM. Manager E confirmed the following finding on 2/20/2018 at 1:55 PM: The medical record revealed that Patient #30, a Medicare recipient, was admitted on 1/31/2018 for a left hip replacement and was discharged on 2/2/2018. There was not a signature indicating that the Important Message from Medicare information was presented to Patient #30 prior to discharge.

Per interview with Quality Manager D on 2/21/2018 at 11:00 AM regarding the facility's policy titled, "Medicare Patient Rights and Appeal Process Upon Denial," #AD204, dated 10/2017, Manager D stated that the policy does not address that the second notice is to be given and signed by staff but it is an expectation.


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Based on record review and interview, the staff failed to provide the correct phone number for the State of Wisconsin to patients if concerns remain unresolved in review of 1 of 1 patient rights.

Findings include:

Per review on 2/19/2018 at 1:20 PM of facility policy titled "Patient's Rights and Responsibility", AD517, dated 10/2017, revealed 26.1. If your concern remains unresolved, the concern may be addressed to: State of Wisconsin Department of Health and Family Services...or phone (608) 243-2024.

On 2/19/2018 at 1:30 PM, attempted to call the phone number listed on the patients rights for contact of State of Wisconsin, the phone number was disconnected.

Per interview with Manager C on 2/19/2018 at 1:30 PM, Manager C stated not being aware that the phone number was not the correct number to reach State of Wisconsin and that it had been disconnected. Manager C stated, "we will get that updated".

Based on record review and interview, staff at this facility failed to ensure that the grievance policy specifies a time frame for grievance review and contact to the respondent in 1 of 1 grievance policy reviewed involving 1 of 2 complaint investigations reviewed (Patient #33).

Findings include:

The facility complaint log was reviewed on 2/19/2018 at 10:00 AM. Patient #33 filed a complaint on 5/25/2017 and spoke with Chief Nursing Officer B on that day. Chief Nursing Officer B and Patient #33 made a verbal arrangement to contact Patient #33 the week of Memorial Day. Phone contact from B to Patient #33 occurred again on June 6, 2017 and a resolution letter was mailed on June 12, 2017.

The facility policy titled, "Grievance Procedure Patient Notice of Rights," #AD145, dated 5/2017, was reviewed on 2/19/2018 at 10:35 AM. The policy does not specify time frames for grievance reviews or when patients can anticipate a response.

Per interview with Quality Manager D on 2/19/2018 at 11:00 AM regarding time frames not being specified in the policy, Manager D stated, "It's usually 7 days, but it is not specified in the policy."

Based on record review and staff interview the facility failed to include the required rights to not restrict visitation in 1 of 1 patient rights.

Findings include:

Per review on 2/19/2018 at 1:20 PM of document titled, "Patient Rights", dated 7/2011. Information revealed, "Have visitors, phone calls and mail". There is no documentation that the facility will not restrict visitation based on race, color, national origin, religion, sex, gender identity, sexual orientation, or disability or that visitors will enjoy full and equal visitation privileges consistent with patient preferences.

Per interview with Manager C on 2/19/2018 at 1:30 PM, Manager C stated, "The information regarding restriction of visitation is not included in the patient rights information".

Based on record review and interview, nursing staff failed to perform assessments and/or reassessments of patient care in 21 out of 30 records reviewed (Patient #7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, and 29).

Findings include:

Per review on 2/20/2018 at 8:20 AM of policy titled, "Standards of Nursing Practice for Inpatient Care", SS202, dated 4/2017 revealed under "6. Comfort 6.1 Process Criteria; 6.1.5. Document effectiveness of pain relief interventions."

A medical record review was conducted on Patient #25's closed medical record on 2/19/2018 at 2:51 PM accompanied by Chief Nursing Officer B and again on 2/20/2018 at 9:55 AM accompanied by Nurse Manager E. The medical record revealed that Patient #25 was admitted on 12/8/2017 for a spinal fusion and was discharged on 12/12/2017. There was no initial nursing assessment documented when Patient #25 was admitted to the post-surgical floor on 12/8/2017. On the following dates there were missed pain reassessments: 12/8/2017 after medication intervention at 5:50 PM and 8:40 PM; 12/9/2017 after medication intervention at 4:00 AM; 12/10/2017 after medication intervention at 6:00 AM 10:00 AM, and 12:30 PM; 12/11/2017 after medication intervention at 1:10 AM; and 12/11/2017 after medication intervention at 7:15 PM. These findings were confirmed per interview by Manager E on 2/20/2018 at 10:05 AM.

A medical record review was conducted on Patient #26's closed medical record on 2/20/2018 at 10:07 AM accompanied by Nursing Manager E. The medical record revealed that Patient #26 was admitted on 12/26/2017 with spinal stenosis and discharged on 12/29/2017. On the following dates there were missed pain reassessments: 12/27/2017 after medication intervention at 6:10 AM; 12/28/2017 after medication intervention at 3:30 AM; and 12/29/2017 after medication intervention at 2:40 AM. These findings were confirmed per interview by Supervisor E on 2/20/2018 at 10:53 AM.

A medical record review was conducted on Patient #27's closed medical record on 2/20/2018 at 10:55 AM. The medical record revealed that Patient #27 was admitted on 1/4/2018 for a rotator cuff repair and was discharged on 1/8/2018. On the following dates there were missed pain reassessments: 1/6/2018 after medication intervention at 7:15 AM. This finding was confirmed per interview by Manager E on 2/20/2018 at 10:53 AM.

A medical record review was conducted on Patient #28's closed medical record on 2/20/2018 at 11:25 AM. The medical record revealed that Patient #28 was admitted on 1/5/2018 with a failed left hip replacement and new hip fracture and was discharged on 1/8/2018. On the following dates there were missed pain reassessments: 1/7/2018 following medication intervention at 6:00 PM; and 1/8/2018 after medication intervention at 5:35 PM. These findings were confirmed per interview by Manager E on 2/20/2018 at 12:00 PM.

A medical record review was conducted on Patient #29's closed medical record on 2/20/2018 at 12:44 PM. The medical record revealed that Patient #29 was admitted on 1/15/2018 with osteoarthritis of the right knee and was discharged on 1/19/2018. On the following dates there were missed pain reassessments: 1/15/2018 after medication intervention at 10:00 PM and 1/17/2018 after medication intervention at 7:25 AM. These findings were confirmed per interview by Manager E on 2/20/2018 at 1:10 PM.

A medical record review was conducted on Patient #22's closed medical record on 2/20/2018 at 2:55 PM. The medical record revealed that Patient #22 was admitted on 12/7/2017 with left knee degenerative joint disease and was discharged on 12/10/2017. On the following date there was a missed pain reassessment: 12/7/2017 following medication intervention at 4:46 PM. On 12/18/2017 the pain rating at reassessment is indicated with two dots over a curved line which appears to look like a smiley face at 9:00 AM, 2:00 PM, and 5:15 PM. These findings were confirmed per interview by Manager E on 2/20/2018 at 3:30 PM. Manager E stated, "I'm not sure what that is supposed to be, looks like a smiley face to me...that is not an appropriate response."

A medical record review was conducted on Patient #23's closed medical record on 2/21/2018 at 7:15 AM. The medical record revealed that Patient #23 was admitted on 12/12/2017 with right knee degenerative joint disease and had a total right knee replacement. Patient #23 was discharged on 12/15/2017. On the following dates there were missed pain reassessments: 12/13/2017 following medication intervention at 3:30 AM; 12/13/2017 following medication intervention at 11:00 AM; 12/14/2017 following medication intervention at 12:10 AM and 10:10 PM. These findings were confirmed per interview by Manager E on 2/21/2018 at 8:15 AM.

A medical record review was conducted on Patient #24's closed medical record on 2/21/2018 at 7:49 AM. The medical record revealed that Patient #24 was admitted on 11/16/2017 with persistent drainage and hematoma following a left total knee replacement and needed surgical debridement. Patient #24 was discharged on 11/19/2017. On the following dates there were missed pain reassessments: 11/17/2017 following medication intervention at 8:15 AM; 11/18/2017 following medication intervention at 7:15 AM and 12:50 PM. These findings were confirmed per interview by Manager E on 2/21/2018 at 8:15 AM.


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Per review on 2/19/2018 at 2:10 PM of patient #7's medical record revealed a pain management flowsheet dated 11/9/17 at 12:15 PM, a pain medication was given, no re-assessment was completed. On 11/9/2017 at 1:30 AM, 3:30 AM, 1:30 PM, 4:40 PM, and 7:40 PM, pain medications were given, no re-assessment was completed. On 11/10/2017 at 6:05 AM, a pain medication was given, no re-assessment was completed.

Per review on 2/19/2018 at 2:50 PM of patient #9's medical record revealed a pain management flowsheet dated 11/9/17 at 1:00 AM, 4:00 AM, 8:10 AM, 10:00 PM, 11:50 PM a pain medication was given, no re-assessment was completed. On 11/10/2017 at 10:20 AM, no re-assessment was completed.

Per review on 2/19/2018 at 3:20 PM of patient #10's medical record revealed a pain management flowsheet dated 11/13/17 at 5:25 PM and 7:30 PM, a pain medication was given, no re-assessment was completed. On 11/15/2017 at 4:45 PM, no re-assessment was completed.

Per review on 2/20/2018 at 9:30 AM of patient #11's medical record revealed a pain management flowsheet dated 11/14/17 at 1:45 PM and 8:00 PM, a pain medication was given, no re-assessment was completed. On 11/15/2017 at 12:05 AM, 2:40 AM, 6:30 AM, 8:30 AM, 1:50 PM, and 8:45 PM, a pain medication was given, no re-assessment was completed. On 11/16/2017 at 4:00 AM, 6:30 AM, 9:30 AM, and 11:30 AM, a pain medication was given, no re-assessment was completed.

Per review on 2/20/2018 at 10:00 AM of patient #12's medical record revealed a pain management flowsheet dated 11/15/17 at 1:35 PM, a pain medication was given, no re-assessment was completed. On 11/18/2017 at 5:20 AM, a pain medication was given, no re-assessment was completed.

Per review on 2/20/2018 at 10:45 AM of patient #13's medical record revealed a pain management flowsheet dated 11/22/2017 at 9:35 PM, a pain medication was given, no re-assessment was completed.

Per review on 2/20/2018 at 11:22 AM of patient #14's medical record revealed a pain management flowsheet dated 11/14/17 at 9:30 AM, 11:10 AM, 1:00 PM, 7:00 PM, and 10:30 PM, a pain medication was given, no re-assessment was completed. On 11/15/2017 at 5:10 AM, 9:40 AM, 5:20 PM, 7:00 PM, 9:50 PM, 11:30 PM, a pain medication was given, no re-assessment was completed. On 11/16/2017 at 12:10 AM, 5:20 AM, 6:00 AM, 8:00 AM and 12:30 AM, a pain medication was given, no re-assessment was completed.

Per review on 2/20/2018 at 12:45 PM of patient #15's medical record revealed a pain management flowsheet dated 11/29/2017 at 10:45 AM, 11:55 AM, 4:00 PM, and 11:30 PM, a pain medication was given, no re-assessment was completed. On 11/30/2017 at 6:30 AM, a pain medication was given, no re-assessment was completed. On 12/1/2017 at 7:00 AM and 10:30 AM, a pain medication was given, no re-assessment was completed.

Per review on 2/20/2018 at 12:45 PM of patient #16's medical record revealed a pain management flowsheet dated 11/17/2017 at 9:00 AM, 2:20 PM, and 12:00 AM, a pain medication was given, no re-assessment was completed. On 11/18/2017 at 7:00 AM, a pain medication was given, no re-assessment was completed.

Per review on 2/20/2018 at 2:00 PM of patient #17's medical record revealed a pain management flowsheet dated 11/28/17 at 5:15 PM and on 11/29/2017 at 7:50 AM, 11:45 AM, and 2:40 PM, a pain medication was given, no re-assessment was completed. On 11/30/2017 at 6:00 AM, a pain medication was given, no re-assessment was completed.

Per review on 2/20/2018 at 3:05 PM of patient #19's medical record revealed a pain management flowsheet dated 12/5/2017 at 11:32 AM, a pain medication was given, no re-assessment was completed. On 12/6/2017 at 9:50 AM and 12:00 PM, a pain medication was given, no re-assessment was completed.

Per review on 2/21/2018 at 8:30 AM of patient #20's medical record revealed a pain management flowsheet dated 12/1/2017 at 8:10 PM, a pain medication was given, no re-assessment was completed.

Per review on 2/21/2018 at 8:50 AM of patient #21's medical record revealed a pain management flowsheet dated 12/7/2017 at 5:30 AM, a pain medication was given, no re-assessment was completed. On 12/8/2017 at 6:00 AM and 10:20 AM, a pain medication was given, no re-assessment was completed.

Findings for Patients #7, 9, 10, 11, 12, 13, 14, 15, 16, 17, 19, 20, and 21, were discussed with and confirmed per interview by Nurse Manager E on 2/21/2018 at 10:15 AM. Per interview on 2/20/2018 at 8:20 AM, Nurse Manager E stated, "I can see pain re-assessments are not being completed, that is something we can improve."

Based on record review and interview, staff at this facility failed to follow facility policy in reviewing the care plan every shift and/or resolving goals upon discharge in 21 out of 30 medical records reviewed (Patient #8, 9, 10, 11, 12, 13, 14, 15, 17, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, and 30).

Findings include:

A medical record review was conducted on Patient #25's closed medical record on 2/19/2018 at 2:51 PM accompanied by Chief Nursing Officer B and again on 2/20/2018 at 9:55 AM accompanied by Nursing Manager E. The medical record revealed that Patient #25 was admitted on 12/8/2017 for a spinal fusion and was discharged on 12/12/2017. The nursing care plan was not reviewed every shift, and was not reviewed at all on 12/10/2017. This finding was confirmed per interview by Manager E on 2/20/2018 at 10:05 AM.

A medical record review was conducted on Patient #26's closed medical record on 2/20/2018 at 10:07 AM accompanied by Nursing Manager E. The medical record revealed that Patient #26 was admitted on 12/26/2017 with spinal stenosis and discharged on 12/29/2017. The nursing care plan was reviewed one time per day and not every shift. This finding was confirmed per interview by Manager E on 2/20/2018 at 10:53 AM. Manager E stated that the expectation is not to review them daily, but every shift, "And they know that."

A medical record review was conducted on Patient #27's closed medical record on 2/20/2018 at 10:55 AM. The medical record revealed that Patient #27 was admitted on 1/4/2018 for a rotator cuff repair and was discharged on 1/8/2018. The nursing care plan was not reviewed every shift. This finding was confirmed per interview by Manager E on 2/20/2018 at 12:46 PM.

A medical record review was conducted on Patient #28's closed medical record on 2/20/2018 at 11:25 AM. The medical record revealed that Patient #28 was admitted on 1/5/2018 with a failed left hip replacement and new hip fracture and was discharged on 1/8/2018. The nursing care plan was not reviewed every shift. This finding was confirmed per interview by Manager E on 2/20/2018 at 12:00 PM.

A medical record review was conducted on Patient #29's closed medical record on 2/20/2018 at 12:44 PM. The medical record revealed that Patient #29 was admitted on 1/15/2018 with osteoarthritis of the right knee and was discharged on 1/19/2018. The nursing care plan was not reviewed every shift. This finding was confirmed per interview by Manager E on 2/20/2018 at 1:10 PM.

A medical record review was conducted on Patient #30's closed medical record on 2/20/2018 at 1:27 PM. The medical record revealed that Patient #30 was admitted on 1/31/2018 with osteoarthritis of the left hip and was discharged on 2/2/2018. The nursing care plan was not reviewed every shift. This finding was confirmed per interview by Manager E on 2/20/2018 at 1:55 PM.

A medical record review was conducted on Patient #22's closed medical record on 2/20/2018 at 2:55 PM. The medical record revealed that Patient #22 was admitted on 12/7/2017 with left knee degenerative joint disease and was discharged on 12/10/2017. The nursing care plan was not reviewed every shift and there was no indication of the outcome of the goal/goal resolution at the time of discharge. These findings was confirmed per interview by Manager E on 2/20/2018 at 3:30 PM.

A medical record review was conducted on Patient #23's closed medical record on 2/21/2018 at 7:15 AM. The medical record revealed that Patient #23 was admitted on 12/12/2017 with right knee degenerative joint disease and had a total right knee replacement. Patient #23 was discharged on 12/15/2017. The nursing care plan was not reviewed every shift. There are no interventions marked for the activated patient problems of acute pain, impaired physical mobility, risk for infection, discharge planning, self-care deficit, risk for falls. The goal resolution date was indicated as 12/16/2017, after Patient #23 was discharged. These findings were confirmed per interview by Manager E on 2/21/2018 at 8:15 AM.

A medical record review was conducted on Patient #24's closed medical record on 2/21/2018 at 7:49 AM. The medical record revealed that Patient #24 was admitted on 11/16/2017 with persistent drainage and hematoma following a left total knee replacement and needed surgical debridement. Patient #24 was discharged on 11/19/2017. The nursing care plan was not reviewed every shift. This finding was confirmed per interview by Manager E on 2/21/2018 at 8:15 AM.


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Per record review of Patient #8's closed medical record on 2/20/2018 at 12:00 PM revealed patient #8 was admitted on 11/3/2017 for a left total knee arthroplasty and was discharged on 11/6/2017. The nursing care plan was not reviewed every shift. This finding was confirmed with Nurse Manager E on 2/20/2018 at 12:30 PM.

Per record review of Patient #9's closed medical record on 2/19/2018 at 2:50 PM revealed patient #9 was admitted on 11/8/2017 for a left total knee arthroplasty and was discharged on 11/11/2017. The nursing care plan was not reviewed every shift. This finding was confirmed with Nurse Manager E on 2/19/2018 at 3:00 PM.

Per record review of Patient #10's closed medical record on 2/19/2018 at 3:20 PM revealed patient #10 was admitted on 11/13/2017 for a lumbar laminectomy and was discharged on 11/16/2017. The nursing care plan was not reviewed every shift. This finding was confirmed with Nurse Manager E on 2/19/2018 at 3:30 PM.

Per record review of Patient #11's closed medical record on 2/20/2018 at 9:30 AM revealed patient #11 was admitted on 11/14/2017 for a left total knee arthroplasty and was discharged on 11/16/2017. The nursing care plan was not reviewed every shift. This finding was confirmed with Nurse Manager E on 2/20/2018 at 10:00 AM.

Per record review of Patient #12's closed medical record on 2/20/2018 at 10:00 AM revealed patient #12 was admitted on 11/15/2017 for a posterior lumbar fusion and was discharged on 11/18/2017. The nursing care plan was not reviewed every shift. This finding was confirmed with Nurse Manager E on 2/20/2018 at 10:45 AM.

Per record review of Patient #13's closed medical record on 2/20/2018 at 10:45 AM revealed patient #13 was admitted on 11/20/2017 for a left total knee arthroplasty and was discharged on 11/23/2017. The nursing care plan was not reviewed every shift. This finding was confirmed with Nurse Manager E on 2/20/2018 at 11:15 AM.

Per record review of Patient #14's closed medical record on 2/20/2018 at 11:22 AM revealed patient #14 was admitted on 11/13/2017 for a left total knee arthroplasty and was discharged on 11/6/2017. The nursing care plan was not reviewed every shift. This finding was confirmed with Nurse Manager E on 2/20/2018 at 12:30 PM.

Per record review of Patient #15's closed medical record on 2/20/2018 at 12:45 PM revealed patient #15 was admitted on 11/29/2017 for a laminectomy with fusion and was discharged on 12/1/2017. The nursing care plan was not reviewed every shift. This finding was confirmed with Nurse Manager E on 2/20/2018 at 1:00 PM.

Per record review of Patient #17's closed medical record on 2/20/2018 at 2:00 PM revealed patient #17 was admitted on 11/28/2017 for a right total knee arthroplasty and was discharged on 12/1/2017. The nursing care plan was not reviewed every shift. This finding was confirmed with Nurse Manager E on 2/20/2018 at 2:45 PM.

Per record review of Patient #19's closed medical record on 2/20/2018 at 3:05 PM revealed patient #19 was admitted on 12/5/2017 for a lumbar fusion and was discharged on 12/8/2017. The nursing care plan was not reviewed every shift. This finding was confirmed with Nurse Manager E on 2/20/2018 at 3:30 PM.

Per record review of Patient #20's closed medical record on 2/21/2018 at 8:30 AM revealed patient #20 was admitted on 11/30/2017 for a decompression bilateral spinal fusion and was discharged on 12/3/2017. The nursing care plan was not reviewed every shift. This finding was confirmed with Nurse Manager E on 2/21/2018 at 10:00 AM.

Per record review of Patient #21's closed medical record on 2/21/2018 at 8:50 AM revealed patient #21 was admitted on 12/5/2017 for a right total knee arthroplasty and was discharged on 12/8/2017. The nursing care plan was not reviewed every shift. This finding was confirmed with Nurse Manager E on 2/21/2018 at 10:00 AM.

Based on record review and interview, staff at this facility failed to ensure that medical record entries are legible, accurate, and complete in 7 out of 30 medical records reviewed (Patients #12, 14, 18, 23, 24, 27 and 28)

Findings include:


The facility's policy titled, "Medical Record Documentation: Requirements for Medical Staff and Allied Health Professional Staff," #MD134, dated 10/2017, was reviewed on 2/20/2018 at 1:14 PM. The policy revealed in part, "All entries in the medical record shall be legible, permanently recorded in ink (preferably black), dated, timed, and authenticated promptly with the name and title of the person making the entry...Medical records must be completed within thirty (30) days of patient discharge. The discharge summary/note and face sheet must be authenticated by the author as soon as possible but no later than thirty (30) days post patient discharge...To correct an error, the author shall draw a single line through the incorrect entry and enter the words, "Charting Error," along with his or her initials, above the lined-out area..."

Pt. #18's medical record was reviewed on 02/19/2018 at 3:15 PM. A physician's entry on 12/02/2018 at 1645 [4:45 PM] was signed but no discipline was indicated. This finding was confirmed by Quality Manager D at the time of discovery D stated that signatures on entries should include the writer's discipline.

Per review on 2/20/2018 at 10:00 AM of patient #12's medical record revealed a Discharge Summary dictated on 11/20/2017 for patient #12 who was discharged from the facility on 11/18/2017. The discharge summary is not signed by the provider. This finding was confirmed with Nurse Manager E on 2/20/2018 at 12:30 PM.

A medical record review was conducted on Patient #27's closed medical record on 2/20/2018 at 10:55 AM. The medical record revealed that Patient #27 was admitted on 1/4/2018 for a rotator cuff repair which started at 8:27 AM. On the surgical consent the time the physician signed is illegible. On the anesthesia record the time anesthesia started is illegible and it appears as though a time was written over a different time. These findings were confirmed per interview by Manager E on 2/20/2018 at 10:53 AM.

Per review on 2/20/2018 at 11:22 AM of patient #14's medical record revealed a telephone order dated 11/16/2017 at 9:45 AM, the authentication from the physician with the date and time is illegible. This finding was confirmed with Nurse Manager E on 2/20/2018 at 12:30 PM.

A medical record review was conducted on Patient #28's closed medical record on 2/20/2018 at 11:25 AM. The medical record revealed that Patient #28 was admitted on 1/5/2018 with a failed left hip replacement and new hip fracture. Surgical repair started at 1:01 PM and ended at 3:36 PM on 1/5/2018. The anesthesia record revealed that anesthesia services started at 12:23 PM and ended at 3:57 PM on 1/5/2018. On the anesthesia record the time for the post-anesthesia evaluation is illegible. On the nursing pain management flow sheet for 1/7/2018 there are two illegible entries for pain ratings. These findings were confirmed per interview by Manager E on 2/20/2018 at 12:00 PM. Regarding the post-anesthesia evaluation time Manager E stated, "Could be 5:20 or 3:20...it doesn't really make sense."

A medical record review was conducted on Patient #23's closed medical record on 2/21/2018 at 7:15 AM. The medical record revealed that Patient #23 was admitted on 12/12/2017 with right knee degenerative joint disease and had a total right knee replacement. There was not a signed Operating Room report for the procedure in the medical record. These findings were confirmed per interview by Manager E on 2/21/2018 at 8:15 AM. Manager E contacted the medical record department regarding this and reported per interview on 2/21/2018 at 8:30 AM that there was still no signed report for Patient #23's surgery.

A medical record review was conducted on Patient #24's closed medical record on 2/21/2018 at 7:49 AM. The medical record revealed that Patient #24 was admitted on 11/16/2017 with persistent drainage and hematoma following a left total knee replacement and needed surgical debridement. The Stage I PACU [post-anesthesia care unit] form revealed that Patient #24 arrived in the PACU at 3:02 PM from the operating room with frequent "PVC's" [premature ventricular contractions, where the ventricles of the heart are not functioning properly] and an order for labetalol [a beta-blocker medication] was received from the anesthesiologist. There was no documentation regarding this complication on the post-anesthesia evaluation which was completed at 3:17 PM. The discharge instruction sheet did not include a date or time Patient #24 signed it and did not include a time the Registered Nurse signed it. These findings were confirmed per interview by Manager E on 2/21/2018 at 8:15 AM.


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Surveyor: Gilbertson, Karl M.


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Based on record review and interview staff at this facility failed to ensure orders were timed and dated in the medical record. In 5 of 30 medical records reviewed (Patient #17, 18, 28, 29, and 30) orders were not timed and/or dated.

Findings include:

The Medical Staff Bylaws, dated 6/11/2010, were reviewed on 2/19/2018 at 10:15 AM. The Bylaws revealed in part, "Per Federal requirements a physician (to include covering physicians) has 48 hours to sign verbal/telephone orders..."

The facility's policy titled, "Medical Record Documentation: Requirements for Medical Staff and Allied Health Professional Staff," #MD134, dated 10/2017, was reviewed on 2/20/2018 at 1:14 PM. The policy revealed in part, "All entries in the medical record shall be legible, permanently recorded in ink (preferably black), dated, timed, and authenticated promptly with the name and title of the person making the entry. All verbal and telephone orders must be authenticated, dated and timed within 48 hours..."

Per interview on 2/19/2018 at 10:05 AM with Registered Nurse N stated, "Telephone orders should be signed right away".

A medical record review was conducted on Patient #28's closed medical record on 2/20/2018 at 11:25 AM. The medical record revealed that Patient #28 was admitted on 1/5/2018 with a failed left hip replacement and new hip fracture and was discharged on 1/8/2018. On 1/7/2018 there was a telephone order written by a Registered Nurse that was not acknowledged by the physician until 1/19/2018. This finding was confirmed per interview by Manager E on 2/20/2018 at 12:00 PM.

A medical record review was conducted on Patient #29's closed medical record on 2/20/2018 at 12:44 PM. The medical record revealed that Patient #29 was admitted on 1/15/2018 with osteoarthritis of the right knee and was discharged on 1/19/2018. There was no time on the discharge order from the physician. This finding was confirmed per interview by Manager E on 2/20/2018 at 1:10 PM

A medical record review was conducted on Patient #30's closed medical record on 2/20/2018 at 1:27 PM. The medical record revealed that Patient #30 was admitted on 1/31/2018 with osteoarthritis of the left hip and was discharged on 2/2/2018. There was no time on the discharge order from the physician. This finding was confirmed per interview by Manager E on 2/20/2018 at 1:55 PM.


29963

Per review on 2/20/2018 at 2:00 PM of patient #17's medical record revealed a telephone order dated 11/29/2017 at 7:30 AM, was not authenticated by the physician until 12/12/2017. Telephone order written on 11/30/2017 at 8:40 AM, was not authenticated by the physician until 12/27/2017. Telephone order written on 11/30/2017 at 9:30 AM, was not authenticated by the physician until 12/12/2017. Findings were confirmed with Chief Nursing Officer B on 2/20/2018 at 2:45 PM.



20878

Based on observation, record review and interview, staff at this facility failed to ensure that food for patient use was either dated upon opening or removed if expired in 2 of 3 food storage areas (dry storage and walk in refrigerator), and failed to keep the floor and area surrounding the stove clean and free of debris in 1 of 3 food preparation areas (area around the stove) in 1 of 1 kitchen.

Findings include:

A tour of the kitchen was conducted on 2/20/2018 at 8:45 AM accompanied by Quality Manager D and Director of Dietary Services L.

On 2/20/2018 at 8:50 AM an opened package of slivered almonds in the dry storage area was marked to expire on 2/1/2018. Per interview with Director L at the time of the observation, Director L stated, "Oh, I see. You got me by one day."

On 2/20/2018 at 8:52 AM a package of brown sugar and a package of cornstarch in the dry storage area were observed to be opened but not dated. Per interview with Director L at the time of the observation, Director L stated that staff are to be dating all opened food items.

On 2/20/2018 at 8:56 AM 6 individually packed pork loins were observed in the walk in refrigerator with a preparation date of 2/5/2018 and a use by date of 2/17/2018. Per interview with Director L at the time of the observation, Director L stated that the preparation date is the date items are taken out of the freezer and put in the refrigerator to thaw, the use by date is the last day the item should be used.

On 2/20/2018 at 9:00 AM the floor and area in front of and around the stove was observed to be quite dirty with debris and build up of greasy residue. Per interview with Director L at the time of the observation, Director L stated that the contracted cleaning service is to clean that area every night.

Per review of the contracted cleaning service's duty list on 2/20/2018 at 12:28 PM, the list revealed that the floors in the kitchen are to be done daily. Per interview with Manager D on 2/20/2018 at 12:28 PM regarding the appearance of the floor around the stove in the kitchen, Manager D stated, "I agree, that has not been done for awhile."

Per review of the kitchen staff meeting minutes on 2/20/2018 at 12:30 PM, the minutes revealed that kitchen staff received education on dating and labeling food items on August 30th, 2017 and January 31st 2018. Under the subject, "Sanitation," in both the August 30th, 2017 and January 31st, 2018 minutes is the following entry: "*Date and Label everything including spices."

The facility's policy titled, "Food and Beverage Supplies for Nursing and Ancillary Units," #FS247, dated 3/2017, was reviewed on 2/20/2018 at 1:00 PM. The policy does not address undated items in the kitchen. Per interview with Quality Manager D on 2/21/2018 at 6:45 AM regarding the policy not referring to dating items in the kitchen, Manager D stated, "There is none for the kitchen, I looked last night."

Based on observation, staff interviews, and review of maintenance records on February 19, 2018 the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

42 CFR 482.41 Condition of Participation: Physical environment was NOT MET

Findings include:

The facility was found to contain the following deficiencies.
K-0321 Hazardous Areas
K-0345 Fire Alarm System
K-0353 Sprinkler System

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation, staff interviews, and review of maintenance records on February 5, 2018 the facility failed to construct, install and maintain the building systems to ensure life safety to patients.

42 CFR 482.41 (b) Standard: Life safety from fire was NOT MET

Findings include:

The facility was found to contain the following deficiencies.
K-0321 Hazardous Areas
K-0345 Fire Alarm System
K-0353 Sprinkler System

Refer to the full description at the cited K tags.

The cumulative effect of environment deficiencies result in the Hospital's inability to ensure a safe environment for the patients.

Based on observation and interview, staff at this facility failed to maintain an environment that ensures the ability to disinfect the surface on the bedside stands in 9 of 30 inpatient rooms (#30, 24, 20, 14, 11, 9, 6, 5, and 4).

Findings include:

Per observation on 2/19/2018 at 10:15 AM of the inpatient rooms on the 3rd floor, noted bedside stands that the laminate surface was damaged exposing porous wood, making the surface an area that can not be disinfected, in patient rooms #30, 24, 20, 14, 11, 9, 6, 5, and 4. Findings were confirmed with Registered Nurse N on 2/19/2018 at 10:15 AM.

Per interview on 2/19/2018 at 10:30 AM, Registered Nurse N stated, "Yes, I see they are damaged, they are ten years old, we just need to get rid of them."

Based on observation, record review and interview, staff at this facility failed to maintain an environment that was free from potential contamination and/or failed to follow national standards of practice in 4 out of 10 observations of patient care (Patient #1, 3, 6, and 31)

Findings include:

Per review on 2/20/2018 at 8:15 AM of policy titled, "Hand Hygiene", AD707, dated 6/2017, stated, "2. Indications for Hand Hygiene- Alcohol-Based Hand Rub- before and after touching any patient, before and after any invasive procedures such as administering injections, after removing gloves..."

Per The Centers of Disease Control, October 12, 2007, IV.A. Hand Hygiene:
Perform hand hygiene:
IV.A.3.a. Before having direct contact with patients.
IV.A.3.b. After contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings.
IV.A.3.c. After contact with a patient's intact skin (e.g., when taking a pulse or blood pressure or lifting a patient).
IV.A.3.d. If hands will be moving from a contaminated-body site to a clean-body site during patient care.
IV.A.3.e. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient .
IV.A.3.f. After removing gloves.

Hand Hygiene examples:
Per observation on 2/20/2018 at 8:59 AM of outpatient procedure (Epidural Steroid Injection) on patient #6, noted Medical Doctor O to complete the procedure, remove gloves and leave the room without completing hand hygiene. The Medical Doctor O then went to the computer to complete documentation on procedure. Patient Care Technician P removed gloves after the procedure and left the room with patient #6 without completing hand hygiene.

Per interview with Nurse Manager D on 2/20/2018 at 9:15 AM, Nurse Manager D stated, "Hand gel/hygiene should be completed when staff leave the room after providing patient care."

An observation of laboratory technician K performing a venipuncture on Patient #1 was conducted on 2/20/2018 at 1:23 PM. Technician K placed the laboratory basket on to the top of the trash can upon room entry and placed a roll of tape from the laboratory basket on to Patient #1's bed next to Patient #1. After completing the venipuncture, with the same gloves, Technician K used a pen to document on a form, then put the pen that was touched with the contaminated gloves back in the laboratory basket with the clean supplies. With the same gloves Technician K handled the roll of tape to tape a dressing over Patient #1's venipuncture site and put the roll of tape back in the laboratory basket with the clean supplies. Technician K then removed gloves, performed hand hygiene and left the room. These observations were discussed with and confirmed per interview by Technician K and Manager E on 2/20/2018 at 1:30 PM. Technician K asked, "Where do you want me to put it [the basket]?" Technician K was encouraged to discuss placement of the basket with the department supervisor.

Per observation on 2/20/2018 at 2:22 PM of Registered Nurse N was in the medication room preparing medications for patient #31. After grabbing supplies and syringe of morphine, Registered Nurse N placed, medication syringe, normal saline syringes, and alcohol wipes in front pocket of scrub top. Registered Nurse then walked to patient room #328, no hand hygiene was completed upon entering patient #31's room or prior to administering medications.

An observation of Patient Care Assistant R performing blood glucose check on Patient #3 was conducted on 2/21/2018 at 6:57 AM. After completing the blood glucose procedure, with the same gloves on Assistant R used a pen to document on a form, then removed the gloves, performed hand hygiene and then handled the glucometer and case (that was touched with the contaminated gloves) to clean the items, and put the pen in R's pocket. Assistant R put the glucometer and case back in the nursing station report room and did not perform hand hygiene again. These observations were discussed with and confirmed by Manager E on 2/21/2018 at 11:50 AM.


An interview with Infection Preventionist M was conducted on 2/20/2018 at 2:40 PM. Infection Preventionist M stated that the facility follows the national standards of practice for CDC (Centers for Disease Control), APIC (Association of Professionals in Infection Control and Epidemiology), AORN (Association of peri-Operative Registered Nurses), and others.

In this same interview on 2/20/2018 at 2:40 PM, regarding Technician K placing the laboratory basket on the trash can, Infection Preventionist M stated, "No, [gender] should not have put in on the trash can. [Gender] should have removed [gender] gloves, did hand hygiene and then handled the equipment."

In this same interview on 2/20/2018 at 2:41 PM, regarding staff member putting patient care items in pockets, Infection Preventionist M stated, "Patient care items should not be in their pocket. I am not sure if the policy speaks to this but I will check."






29963

Based on record review, observation, and interview, the facility failed to allow the surgical skin prep to dry prior to draping the surgical area in 1 of 2 surgical procedures observed (patient #6).

Findings include:

Per review on 2/20/2018 at 9:20 PM of policy titled, "Surgical Skin Prep", SS332, dated 6/2017, revealed "Procedure when active ingredient is alcohol 7.3 Let dry 2-3 minutes 7.4 Avoid draping until dry".

Per observation on 2/20/2018 at 8:50 AM, Medical Doctor O applied chloraprep to lower back area on patient #6, immediately applied drape to cover the area where chloraprep was applied. Area was not allowed to dry prior to draping procedure area.

Per interview on 2/20/2018 at 9:15 AM, Chief Nursing Officer B stated, "In a perfect world, the surgical site should be dry before it was draped."

Based on record review and interview, staff at this facility failed to obtain a properly completed surgical consent form prior to surgery in 16 out of 30 medical records reviewed (Patient #2, 4, 5, 8, 10, 11, 19, 22, 23, 24, 25, 26, 27, 28, 29, and 30).

Findings include:

The facility's policy titled, "Informed Consent," #MD111, dated 10/2017, was reviewed on 2/20/2018 at 9:00 AM. The policy revealed in part, "Informed consent is the responsibility of the physician. A witness is simply the person who sees/observes a person signing a document." The policy does not address the witness dating and timing the witness's signature.

A medical record review was conducted on Patient #25's closed medical record on 2/19/2018 at 2:51 PM accompanied by Chief Nursing Officer B. The medical record revealed Patient #25 was admitted on 12/8/2017 for a spinal fusion. The surgical consent form did not identify the credentials of the witness signing, or the date and time the witness signed the form. These findings were confirmed per interview Chief Nursing Officer B on 2/19/2018 at 2:55 PM. Chief Nursing Officer B stated that the witness who signed this form is a Registered Nurse and should be putting credentials next to the signature.

A medical record review was conducted on Patient #26's closed medical record on 2/20/2018 at 10:07 AM accompanied by Nursing Manager E. Patient #26 was admitted on 12/26/2017 for back surgery. The surgical consent form did not identify the credentials of the witness signing, or the date and time the witness signed the form. These findings were confirmed per interview by Manager E on 2/20/2018 at 12:46 PM.

A medical record review was conducted on Patient #27's closed medical record on 2/20/2018 at 10:55 AM. The medical record revealed Patient #27 was admitted on 1/4/2018 for a rotator cuff repair. The surgical consent form did not identify the date and time the witness signed the form. This finding was confirmed per interview by Manager E on 2/20/2018 at 12:46 PM.

A medical record review was conducted on Patient #28's closed medical record on 2/20/2018 at 11:25 AM. The medical record revealed Patient #28 was admitted on 1/5/2018 and had surgery to fix the fracture and a recent hip replacement Patient #28 had in December 2017. The physician did not sign, date or time the surgical consent. This finding was confirmed per interview by Manager E on 2/20/2018 at 12:00 PM.

Per interview with Chief Nursing Officer B on 2/20/2018 at 12:15 PM regarding the witness signing, dating, and timing the consent form, Chief Nursing Officer B stated that the form is missing a line for date and time. B stated, "It is an expectation that the nurse does date and time when they sign it."

A medical record review was conducted on Patient #29's closed medical record on 2/20/2018 at 12:44 PM. The medical record revealed Patient #29 was admitted on 1/15/2018 for a right knee replacement. The physician did not sign, date or time the surgical consent. This finding was confirmed per interview by Manager E on 2/20/2018 at 1:10 PM.

A medical record review was conducted on Patient #30's closed medical record on 2/20/2018 at 1:27 PM. The medical record revealed Patient #30 was admitted on 1/31/2018 for a left hip replacement. The physician did not sign, date or time the surgical consent. This finding was confirmed per interview by Manager E on 2/20/2018 at 1:55 PM.

A medical record review was conducted on Patient #22's closed medical record on 2/20/2018 at 2:55 PM. The medical record revealed Patient #22 was admitted on 12/7/2017 for a left knee replacement. The surgical consent form did not identify the date and time the witness signed the form. This finding was confirmed per interview by Manager E on 2/20/2018 at 3:30 PM.

A medical record review was conducted on Patient #23's closed medical record on 2/21/2018 at 7:15 AM. The medical record revealed Patient #23 was admitted on 12/12/2017 with right knee degenerative joint disease and had a total right knee replacement. The surgical consent form did not identify the date and time the witness signed the form and the physician did not sign, date or time the surgical consent. These findings were confirmed per interview by Manager E on 2/21/2018 at 8:15 AM.

A medical record review was conducted on Patient #24's closed medical record on 2/21/2018 at 7:49 AM. The medical record revealed Patient #24 was admitted on 11/16/2017 with persistent drainage and hematoma following a left total knee replacement and needed surgical debridement. The surgical consent form did not identify the date and time the witness signed the form and the physician did not sign, date or time the surgical consent. These findings were confirmed per interview by Manager E on 2/21/2018 at 8:15 AM.

A medical record review was conducted on Patient #2's open medical record on 2/21/2018 at 9:09 AM. The medical record revealed Patient #2 was admitted on 2/20/2018 for a left hip replacement. The surgical consent form did not identify the date and time the witness signed the form. This finding was confirmed per interview by Manager E on 2/21/2018 at 10:00 AM.

A medical record review was conducted on Patient #4's open medical record on 2/21/2018 at 10:05 AM. The medical record revealed Patient #4 was admitted on 2/19/2018 for a left knee replacement. The surgical consent form did not identify the date and time the witness signed the form. This finding was confirmed per interview by Manager E on 2/21/2018 at 10:00 AM.


29963

A medical record review was conducted on Patient #8's closed medical record on 2/20/2018 at 12:00 PM. The medical record revealed Patient #8 was admitted on 11/3/2017 with left knee degenerative joint disease and had a left total knee arthroplasty. The surgical consent form did not identify the date and time the witness signed the form and the physician did not sign, date or time the surgical consent. These findings were confirmed per interview by Nurse Manager E on 2/21/2018 at 12:30 PM.

A medical record review was conducted on Patient #10's closed medical record on 2/19/2018 at 3:20 PM. The medical record revealed Patient #10 was admitted on 11/13/2017 for A lumbar laminectomy. The surgical consent form did not identify the date and time the witness signed the form. These findings were confirmed per interview by Nurse Manager E on 2/19/2018 at 3:30 PM.

A medical record review was conducted on Patient #11's closed medical record on 2/20/2018 at 9:30 AM. The medical record revealed Patient #11 was admitted on 11/14/2017 for a left total hip arthroplasty. The surgical consent form did not identify the date and time the witness signed the form and the physician did not sign, date or time the surgical consent. These findings were confirmed per interview by Nurse Manager E on 2/20/2018 at 10:05 AM.

A medical record review was conducted on Patient #19's closed medical record on 2/20/2018 at 3:05 PM. The medical record revealed Patient #19 was admitted on 12/5/2017 for a lumbar decompression posterior fusion with instrumentation hardware removal. The surgical consent form did not identify the date and time the witness signed the form. These findings were confirmed per interview by Nurse Manager E on 2/20/2018 at 3:30 PM.

A medical record review was conducted on Patient #5's medical record on 2/21/2018 at 9:50 AM. The medical record revealed Patient #5 was admitted on 2/19/2017 for a left total knee arthroplasty. The surgical consent form did not identify the date and time the witness signed the form. These findings were confirmed per interview by Nurse Manager E on 2/21/2018 at 10:15 AM.

Based on record review and interview, therapy staff at this facility failed to complete therapy plans for care upon discharge in 3 of 24 closed medical records out of a total of 30 records reviewed (Patient #25, 28, and 29) and failed to document the frequency/duration for therapy on the occupational therapy evaluation in 1 of 30 patient (patient #10) medical records reviewed.

Findings include:

Per review on 2/20/2018 at 8:15 AM of policy titled, "Assessment/Reassessment, Patient", SS222, dated 4/2017, revealed under "Rehab Services 1.3. A Registered Therapist (Occupational or Physical) will complete the initial patient assessment within 24 hours of receiving referral and physical order. 1.4. The components of the assessment consist of: 1.4.1. Occupational Therapy: 1.4.1.1. Initial cursory screening to identify immediate patient needs.

A medical record review was conducted on Patient #25's closed medical record on 2/19/2018 at 2:51 PM accompanied by Chief Nursing Officer B and again on 2/20/2018 at 9:55 AM accompanied by Nursing Manager E. The medical record revealed Patient #25 was admitted on 12/8/2017 for a spinal fusion and was discharged on 12/12/2017. There was no resolution of goals upon discharge from physical or occupational therapy at the final visit. This finding was confirmed per interview by Manager E on 2/20/2018 at 10:05 AM.

Per interview with Manager E and Quality Manager D on 2/20/2018 at 10:05 AM regarding therapy goal resolution at the final visit before discharge, Manager E stated that there should be documentation indicating the status of the goals, if they are to be continued in a sub-acute setting or if they are resolved.

A medical record review was conducted on Patient #28's closed medical record on 2/20/2018 at 11:25 AM. The medical record revealed Patient #28 was admitted on 1/5/2018 with a failed left hip replacement and new hip fracture and was discharged on 1/8/2018. The occupational therapy plan on the day of discharge revealed that the plan was to be continued and the goals were not resolved at the time of discharge. This finding was confirmed per interview by Manager E on 2/20/2018 at 12:00 PM.

A medical record review was conducted on Patient #29's closed medical record on 2/20/2018 at 12:44 PM. The medical record revealed Patient #29 was admitted on 1/15/2018 with osteoarthritis of the right knee and was discharged on 1/19/2018. The final occupational therapy note did not clearly resolve the occupational therapy goals. The assessment by the occupational therapist on the day of discharge was written as follows, "Pt [patient] somewhat confused, forgetful, [with] activity/tasks." The plan on the day of discharge was written as, "Plans d/c [discharge] home [with] [family] assist." The plan did not indicate when Patient #29 was going home or the status of the occupational therapy goals. This finding was confirmed per interview by Manager E on 2/20/2018 at 1:10 PM. Manager E stated that E agreed that the resolution of the occupational therapy goals upon discharge was not clear.


29963

Per review on 2/19/2018 at 3:20 PM of patient #10's medical record, patient #10 was admitted on 11/13/2017 following lumbar laminectomy. The occupational therapy evaluation was initiated on 11/14/2017 at 12:44, under the plan, the frequency/duration was not completed. The plan does not indicate how often and for how many days the patient would be seen from the occupational therapist. Findings were confirmed with Nurse Manager E on 2/19/2018 at 3:45 PM.

Per interview on 2/19/2018 at 3:45 PM, Nurse Manager E stated, "the frequency/durations should be completed by the therapist during the completion of the evaluation".