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A Federal (validation) life safety survey code inspection was conducted on April 13, 2010 through April 15, 2010. Based on observation and staff interview it was determined that the life safety code requirement was not met on the condition level. One of the facility's storage closets, room 1115, had no sprinkler head, sprinkler heads were painted in rooms 3017 and 3204 , and sprinkler heads in the main kitchen were dust laden and had grease build up.

The findings include:

A. During the walk through inspection conducted during the survey, a storage closet, room 1115, was identified as not having a sprinkler head.

B. During the walk through inspection conducted during the survey, sprinkler heads in rooms 3010 and 3204 were painted.

C. During the walk through inspection conducted during the survey sprinkler heads in the main kitchen were dust laden and had grease build up.


Environmental staff persons were with the surveyors during the inspection and were made aware of the findings.

Details of the deficient practices are cross referred under the life safety code National Fire Protection Association applicable citations (see K130 Miscellaneous).

Based on medical record review and staff interview it was determined that the governing body and attending medical staff failed to ensure that the resident on call notified family regarding change in the patient's plan of care (Patient #19).

The findings include:

Patient #19 was admitted on February 15, 2010 with diagnoses of Status post Aortic Valve Repair on November 23, 2009, Cardiomyopathy, idiopathic , Heart Failure, status post BiV- ICD (biventricular implantable cardioverter-defibrillator) placement, Respiratory Failure; status post Tracheotomy, Dysphagia, status post PEG-J (percutaneous endoscopic gastrojejunostomy) placement, Weight Loss, and Malnutrition. Review of the EMR[Electronic Medical Record] notes entered by the medical and nursing staff indicated the patient's tracheostomy tube came out on February 16, 2010

Assessments were completed by medical and nursing staff. An attempt was made to replace the tracheostomy tube without success. The physician wrote an order to transfer the patient to [another hospital] for replacement of the tracheostomy tube at 11:10 PM on February 16, 2010.

Further review revealed a notarized Power of Attorney that the patient's wife would make all the " decisions about my medical treatments which includes my heart surgery, medications, life support machines and everything that belongs to the subject, and will bye by Power of Attorney for everything else if anything happens to me ..."

The medical record lacked documented evidence that the patient's wife was notified that the patient's tracheostomy tube was out and that the patient was transferred to the hospital for replacement of tracheostomy.

Interview with the Chief Nurse Officer on April 15, 2010 at approximately 10:10 AM as a part of a multidisciplinary team meeting revealed that the resident on call did not notify the family that the patient's tracheostomy tube was out and that the patient was transferred to another hospital for the tube replacement.

Cross reference A Tag 0130 Patient Rights

Based on medical record and documentation review and staff interview it was determined that the medical staff failed to ensure that he patient's representative was informed of a change in the plan of care for the patient (Patient #19).

Cross reference A Tag 0049

1. Based on observations, medical record and policy review it was determined that the hospital staff failed to follow the policy regarding patient hand off of care upon the return of patients from outside facilities in three (3) of three (3) records reviewed
(Patient #11, 12, and 13).

The findings include:

NRH Policies and Procedures number 100.8 entitled Patient Hand Off Communications effective June 15, 2007, within Section 3, item C stipulates " Handoffs occur during but are not limited to, the following circumstances: 3. transport to another service or location for procedure or testing; 4. transfer to and from facility ... "

NRH Patient Handoff Travel Form designates Section B as an area for the temporary care giver to document events occurring during the period the patient was away from the main care area.

A. Patient #11 was admitted March 31, 2010 with diagnoses of Gangrene status post Left Below Knee Amputation, End Stage Renal Disease requiring Hemodialysis, Diabetes Mellitus and Hypertension. Review of the medical record revealed the patient required dialysis treatments three (3) times weekly on Monday, Wednesday, and Friday. The record lacked documented evidence of a post dialysis handoff of care communication.

B. Patient #12 was admitted March 26, 2010 with diagnoses of Second Degree Burn of Right Lower Extremity status post Skin Graft, End Stage Renal Disease requiring Hemodialysis, and Hypertension. Review of the medical record revealed the patient required dialysis treatments three (3) times weekly on Tuesday, Thursday, and Saturday. The record lacked documented evidence of a post dialysis handoff of care communication.

C. Patient #13 was admitted March 31, 2010 with diagnoses of Gangrene status post Left Below Knee Amputation, End Stage Renal Disease requiring Hemodialysis, Peripheral Neuropathy, and Hypertension. Review of the medical record revealed the patient required dialysis treatments three (3) times weekly on Tuesday, Thursday, and Saturday. The record lacked documented evidence of a post dialysis handoff of care communication.

The findings were reviewed with the hospital staff member present at the time of record review. S/he acknowledged the findings. S/he stated that the handoff of care form is used when the patient leaves the hospital for treatment, but not upon return. S/he further stated that the dialysis center forwards the dialysis treatment record as evidence of events that occurred during the patient ' s time away from the hospital.

Cross reference A Tag 0395 RN Supervision of Nursing Care

2. Based on observation, medical record and policy review it was determined that the nursing staff failed to assess the tracheostomy of an isolated patient (Patient 10).

Patient #10 was admitted April 8, 2010 with diagnoses of Right Hemi paresis status post Cerebrovascular Accident, Hypertension, Atrial Fibrillation, and History of Laryngeal Cancer with status post Laryngectomy. Review of the Nursing Flowsheets revealed the lack of documentation of assessment of the patient ' s tracheostomy. Further, the nursing staff failed to monitor the patient ' s proficiency at performing self tracheostomy care.

Interview with the supervisory and staff members at the time of survey revealed that for patients with long-standing history of tracheostomy, routine tacheostomy care and monitoring is not performed.

3. Based on observation, medical record and policy review it was determined that the nursing staff failed to follow the policy and intervene on complaints of pain in an isolated incident ( Patient 13).

The findings include:

NRH policy 230.2 entitled Pain Management effective September 8, 2006 within Section 3.3, item 3.3.1 stipulates " Treatment is initiated if patient reports a score of 3/10 or if otherwise unacceptable. " Section 3.5 stipulates " Interventions may follow established program-specific protocols but in all cases patients must be re-evaluated 1 hour after an intervention is performed. " Section 5, Item 5.1 stipulates "Documentation of pain assessment and interventions follows a uniform format .... "

NRH policy 113.001 entitled Nursing Documentation, effective July 27, 2006, within Section E, Part 3, item a. stipulates " Care is delivered according to physician ' s orders and NRH Standards of Care " and item c stipulates " Interventions are documented on the Patient Care Flowsheet. The interventions should reflect nursing actions taken including assessment data obtained and treatments provided. "

A. Patient #13 was admitted March 31, 2010 with diagnoses of Gangrene status post Left Below Knee Amputation, End Stage Renal Disease requiring Hemodialysis, Peripheral Neuropathy, and Hypertension. Review of the medical record revealed on April 8, 2010 a physician's order directed "Dilaudid 1 (one) mg (milligram) q (every) 4 (four) hours for pain rating 4 - 10 (four to ten); Dilaudid 2 (two) mg q 4 (four) hours for pain rating 6 - 10 (six to ten). The Patient Assessment Notes revealed that the patient ' s pain levels were assessed as follows: April 9, 2010 at 13:25, rates seven of ten (7/10) and 20:07, rates eight of ten (8/10); April 10, 2010 at 08:53 rates four of ten (4/10) and at 25:52 rates eight of ten (8/10); April 11, 2010 at 0900 rates eight of ten (8/10); April 12, 2010 at 08:44 rates seven of ten (7/10); and April 13, 2010 at 08:21 rates eight of ten (8/10).

Further review of the medication administrative record (MAR) revealed the patient was not administered Dilaudid for pain relief corresponding to the assessed pain levels. The medical record lacked documented evidence that the nursing staff followed the physician orders to take action to control and/or alleviate pain.

4. Based on observation, medical record and policy review it was determined that the nursing staff failed to clarify the physician ' s order in an isolated incident(Patient 13).

The findings include:

NRH policy 113.001 entitled Nursing Documentation, effective July 27, 2006, within Section E, Part 3, item a. stipulates " Care is delivered according to physician ' s orders and NRH Standards of Care. "

A. Patient #13 was admitted March 31, 2010 with diagnoses of Gangrene status post Left Below Knee Amputation, End Stage Renal Disease requiring Hemodialysis, Peripheral Neuropathy, and Hypertension. Review of the medical record revealed on April 8, 2010 a physician ' s order directed " Dilaudid 1 (one) mg (milligram) q (every) 4 (four) hours for pain rating 4 - 10 (four to ten); Dilaudid 2 (two) mg q 4 (four) hours for pain rating 6 - 10 (six to ten). The medical record lacked documented evidence that the nursing staff contacted the physician to clarify the pain scale range as related to the administration of Dilaudid.

5. Based on medical record review and staff interview it was determined that the nursing staff failed to follow physician orders in five (5) of 11 records reviewed. (Patients 14, 15, 16, 20 and 22)

The findings include:

A. Patient #14 was admitted one April 1, 2010 with diagnoses of Post Laminectomy Cervical (C ) Kyphosis, status post C2- C4 laminectomy and C2 -thoracic 4 fusion, with Epidural Hematoma, Hypertension, Hepatitis C with history of Platelet Atelectasis. Review of the medical record revealed the physician ordered Incentive spirometry every (q) six (6) hours. There was no documented evidence in the electronic medical record (EMR) that the spirometry was documented q6 hours.

The entry in the EMR under Respiratory Care was titled incentive spirometry effort; however the documentation was not completed q 6 hours per physician order.

Interview with the Clinical Coordinator on April 13, 2010 at approximately 11:00 AM revealed that the patient used the incentive spirometer as ordered and more frequently.

B. Patient 15 was admitted on April 9, 2010 with diagnoses of Coronary Artery Disease, status post myocardial infarction, Congestive Heart Failure, End Stage Renal Disease (ESRD) on hemodialysis, Anemia, Diabetes Mellitus, and a history of Cerebral Vascular Accident. Review of the medical record revealed, the physician ordered "Within first 8 hours toilet patient on a commode and measure PVR by I/O Cath [Postvoid urine Residual by In and Out Catherization]or Ultrasound Scan; Notify MD if greater than 100." There was no documented evidence that the in and out cath or ultrasound scan of the bladder were completed after the patient toileted.

Interview with the Clinical Coordinator on April 13, 2010 at approximately 3:45 PM revealed that the bladder scans are done when the physician writes this particular order. The Clinical Coordinator stated the information is written on the Kardex.

C. Patient #16 was admitted on March 3, 2010 with a diagnosis of Spinal Cord Injury. Review of the medical record revealed that the physician ordered "Abdominal binder when out of bed on April 2, 2010. There was no documented evidence that the nursing staff documented the use of an abdominal binder in the EMR.

D. Patient #20 was admitted on March 19, 2010 with diagnoses of Traumatic Brain Injury (TBI), Double Hemiparesis, Craniectomy Defect Right, Right Clavicle Fracture, and Left Hand (lst Metacarpal) Fracture. Review of the medical record revealed the physician ordered "Chest PT to all lobes Vest TID with nebs". Nebulization Treatment: Albuterol 25 mg (milligram) TID with Vest and Atrovent 500 mcg BID with Vest on March 19, 2010. The medical record lacked document evidence that the Chest PT was completed with nebulization treatments TID (three times a day) on March 22, 25, and 30. 2010.

Interview with the Charge Nurse on April 14, 2010 at approximately 12:00 noon revealed that the time frame for administering the neb treatments were 8:00 AM, 4:00 PM and 8 to 10 PM depending upon if the child is awake. Patient # 20 is eight years old.

Further review of the medical record revealed that the Chest PT was not completed near the times that the Charge Nurse stated of 8:00 AM, 4:00 PM, and 8:00 to 10 PM. For example on March 27, 2010, the chest PT was documented at 3:00 AM, and 11:00 AM; on March 28, 2010 the Chest PT was documented at 3:12 AM, 10:10 AM, 11:08 AM, 6:00 PM and 7:21 PM, and on March 31, 2010 at 12:45 AM, 8:00 AM, 10:40 AM, 4:00 PM and 6:00 PM.

The Chest PT was not completed per the physician's written order. The physician ordered Chest PT three times a day (TID) with nebulization. The nebulizations were ordered three (3) times a day and two (2) times a day. The Chest PT was done less than three (3) times or more than three (3) times a day.

E. Patient 22 was admitted on March 26, 2010 with diagnoses of Traumatic Brain Injury, Pancreatic, Skull Fracture and Facial Fracture. Review of the medical record revealed the physician ordered "Vital signs q-shift" on admission at "1941" (7:41 PM). There was no documented evidence by the nursing staff of the vital sign monitoring every (q) shift.

Review of the EMR documentation revealed the vital signs were documented twice and day from March 27 to April 9, 11, and 13, 2010. The patient's vital signs were documented once a day on April 10 and 12, 2010. The nursing staff failed to follow the physician's order.

6. Based on medical record review documentation review and staff interview it was determined that hospital staff failed to maintain an emotionally safe environment to ensure patient's respect and dignity.

The findings include:
Hospital policy number 700.5 entitled Patient Rights, section one (1) A. stipulates: " ...The patient shall have the following rights: 1. To receive considerate, courteous, and respectful care with sensitivity to cultural, racial, linguistic, religious, age, gender, disability and other differences.."

Patient #19 was admitted on February 15, 2010 with diagnoses of Status post Aortic Valve Repair on November 23, 2009, Cardiomyopathy , idiopathic , Heart Failure, status post BiV- ICD Placement ( biventricular implantable cardioverter-defibrillator) placement, Respiratory Failure; status post Tracheotomy, Dysphagia,, status post PEG-J (percutaneous endoscopic gastrojejunostomy) placement, Weight Loss, and Malnutrition. Review of the medical record revealed that the physician ordered the patient to be transferred to another hospital on February 21, 2010 because of low oxygen saturation.

Interview with multidisciplinary team on April 15, 2010 at 10:00 AM to 11:00 AM and interview with the nursing staff that cared for the patient on February 21, 2010 revealed that the family members heard one of the unit's staff state that s/he could not accompany the Registered Nurse (RN) to transfer the patient to another hospital's Emergency Department (ED)

Interview with the RCT #1 by telephone on April 21, 2010 confirmed that s/he made the statement however s/he was caring for another patient at the time and s/he did not know the family was present when the statement was made. RCT #1 stated s/he was in the room next to the patient when she heard the Charge Nurse stated that s/he would accompany the RN to the ER

According to the allegations in the letter of complaint by the patient's wife, the nursing staff was arguing about who would transfer the patient to another hospital's ED. However according to the nursing staff that was assigned to the patient, once the RCT stated s/he could not to the Emergency Room (ER) another RN accompanied the RN assigned to the patient. There was no arguing between the staff.

The hospital staff failed to provide an emotional safe environment (respect and dignity) for the patient and family during ad emergency. The patient's family overheard hospital staff member state that s/he could not transfer a patient in an emergency.

Based on medical record review and staff interview it was determined that the medical staff failed to write an order for restraint in one of four (4) record reviewed (Patient #23)..

The findings include:

NRH Polices and Procedures number 500.12 entitled "Restraint Use" effective date November 17, 2009, within section titled Policy A. stipulates " ...11. Orders for restraint must be written by a Licensed Independent Practitioner (LIP) ....Section "Orders: C. Orders for continued use of restraints must be renewed every calendar day with input from interdisciplinary team members, and after a fact to face evaluation.

Patient #23 was admitted on March 9, 2010 with diagnoses of arteriovenous malformation rupture and Global Decreased Function. Review of the medical record revealed the physician ordered an Enclosure Bed on admission. Review of the Electronic medical Record ( EMR) revealed the patient was in the Enclosure Bed on March 26 and April 7, 2010 without a written physician order. The medical and nursing staff failed to follow the policy regarding restraint use.

Cross reference A Tag 0144 Patients Rights: Care in a Safe Environment.
Based on Statement # 1.

1. Based on observations, medical record and policy review it was determined that the medical staff failed to authenticate the medication reconciliation in three (3) of nine (9) medical records reviewed (Patients 3, 10 and 15).

The findings include:

National Rehabilitation Hospital (NRH) Standard Practice Policy 360.38 entitled Medication Reconciliation, effective July 2006, within the section Responsibilities, item 1.2 stipulates ' the history collector/clinician will list medications and essential patient information obtained from all information sources available. " Item 1.5 stipulates " The Medication/Allergy History form will be treated as a fluid document that the prescriber will review prior to writing orders at transition points in care, inclusive of admission, transfer and discharge. " Item 2 stipulates " The author of the patient ' s medication orders will review the current MAR and the Medication/Allergy History notes and confirm in writing .... "

A. Patient #3 was admitted February 26, 2010 with diagnoses of Right Cerebrovascular Accident, Coronary Artery Disease and Cardiomyopathy. Review of the medical record revealed the Admission Medication Reconciliation Progress Note was signed by the pharmacist on February 26, 2010. The form lacked documented evidence of a physician/clinician signature; date and time to authenticate his/her review of medications at the time of survey.

B. Patient #10 was admitted April 8, 2010 with diagnoses of Right Hemi paresis status post Cerebrovascular Accident, Hypertension, Atrial Fibrillation, and History of Laryngeal Cancer status post Laryngectomy. Review of the medical record revealed the Admission Medication Reconciliation Progress Note was signed by the pharmacist on February 9, 2010. The form lacked documented evidence of a physician/clinician signature; date and time to authenticate his/her review of medications at the time of survey.

C. Patient #15 was admitted on April 9, 2010 with diagnoses of Coronary Artery Disease, status post myocardial infarction, Congestive Heart Failure, End Stage Renal Disease (ESRD) on hemodialysis, Anemia, Diabetes Mellitus, and a history of Cerebral Vascular Accident. Review of the medical record revealed the Admission Medication Reconciliation Progress Note was signed by the pharmacist on February 9, 2010. The form lacked documented evidence of a physician/clinician signature; date and time to authenticate his/her review of medications at the time of record review.

The findings were discussed with the hospital staff member present at the time of record review. S/he acknowledged the findings.


2. Based on medical record review it was determined that the medical staff failed to date and time an order in an isolated medical record (Patient#15)..

The findings include

Patient #15 was admitted on April 9, 2010 with diagnoses of Coronary Artery Disease, status post myocardial infarction, Congestive Heart Failure, End Stage Renal Disease (ESRD) on hemodialysis, Anemia, Diabetes Mellitus, and a history of Cerebral Vascular Accident.. Review of the medical record revealed, the physician order Rehabilitation Program Orders utilizing the pre printed form. The orders lacked documented evidence of a date and time; the order was signed however the signature was not authenticated with a title. The record was reviewed on April 13, 2010 at 11:10 AM.

Cross reference A Tag 0454 Based on statement # 2.

Cross reference A Tag 0450.

1. Based on observation, medical record and policy review it was determined that the hospital failed to obtain consent for treatment prior to providing care in five (5) of 13 records reviewed (Patients 1, 5, 6, 8, 9).

The findings include:

NRH policies and Procedure number 500.3 entitled Consent for Treatment, effective July 22, 2007 within Section 1 stipulates " Consents/release forms shall be completed and executed prior top providing care and treatment within the NRH Medical Rehabilitation Network. " Item 1.A.1. stipulates " at the time of admissions to the NRH, the Admissions Office representative is responsible for explaining the General Consent Form and obtaining the appropriate signature on the form for care, medications and/or treatment and financial agreement. "

A. Patient #1 was admitted March 18, 2010 with diagnoses of Intracerebral Hemorrhage, Non-compliant Diabetes Mellitus, Hyperlipidemia and Hypertension. Review of the medical record revealed the Consent and Release forms for Inpatient Care, Financial Agreements, Patient Privacy and Medicare Rights were signed by the patient ' s representative and the witness on March 24, 2010.

B. Patient #5 was admitted February 23, 2010 with diagnoses of Anoxic Brain Injury, Cerebral Palsy, Seizure Disorder and Folate Deficiency Syndrome. Review of the medical record revealed the Consent and Release forms for Inpatient Care, Financial Agreements, Patient Privacy and Medicare Rights were signed by the patient ' s representative and the witness on March 1, 2010.

C. Patient #6 was admitted April 7, 2010 with diagnoses of Recurrent Cerebrovascular Accident, Parkinson ' s Syndrome, and Hypertension. Review of the medical record revealed the Consent and Release forms for Inpatient Care, Financial Agreements, Patient Privacy and Medicare Rights were signed by the patient ' s representative and the witness of April 9, 2010.

D. Patient #8 was admitted March 6, 2010 with diagnoses of Traumatic Brain Injury and Left Tibial - Fibular Fracture secondary to motor vehicle accident. Review of the medical record revealed the Consent and Release forms for Inpatient Care was signed by the patient ' s representative on March 6, 2010 and signed by the witness on March 11, 2010.

E. Patient #9 was admitted April 6, 2010 with diagnoses of Traumatic Brain Injury secondary to gun shot wound, status post Hemicraniotomy and Debridement of Head Wound. Review of the medical record revealed the Consent and Release forms for Inpatient Care was signed by the patient ' s representative and the witness on March 8, 2010. Further, the patient and representative were recognized as English as a Second Language and in need of an interpreter. The medical record lacked documented evidence that the representative received information and/or instructions in a language other than English.

Based on medical record review it was determined that the medical staff failed to complete the medical record with 30 days following discharge in an isolated medical record.

The findings include:

Patient #19 was admitted on February 15, 2010 with diagnoses of Status post Aortic Valve Repair on November 23, 2009, Cardiomyopathy, idiopathic , Heart Failure, status post BiV- ICD (biventricular implantable cardioverter-defibrillator) placement, Respiratory Failure; status post Tracheotomy, Dysphagia,, status post PEG-J (percutaneous endoscopic gastrojejunostomy) placement, Weight Loss, and Malnutrition. Review of the EMR revealed the patient was discharged on February 21, 2010 however the Discharge Summary was dictated and completed until April 13, 2010 more than 30 days post discharge.

The record was reviewed on April 14, 2010.

Based on observations during the survey period, it was determined that dietary services were not adequate to ensure that food is prepared and served in a safe and sanitary manner.

The findings include:

1. The interior areas of open drains in the cooks preparation areas were soiled with accumulated debris in two (2) of two (2) observations at 9:45 AM on April 13, 2010.

2. Loaves of breads were held in the walk in refrigerator beyond the expiration date as evidenced by four (4) of five (5) loaves of Sour Dough Bread with an expiration date of April 11, 2010, five (5) of five (5) loaves of Kaiser Rolls with an expiration date of April, 2010 and Kosher Rolls in eight (8) of eight (8) observations with an expiration date of April 11, 2010.

3. Ceiling tiles over cooks preparation and serving areas were soiled, stained and in need of replacement in two (2) of two (2) observations at 10:05 AM on April 13, 2010.

4. A staff person and a delivery person, failed to cover his/her hair while performing duties in food preparation areas during preparation of the lunch meal in two (2) of two (2) observations between 10:30 AM and 12:30 PM on April 13, 2010.

5. Wall surfaces were soiled with accumulated grease and food spillages on the sides and rear surfaces of the deep fryer, flat skillet and open grill in cooks preparation areas in three (3) of three (3) observations between 10:15 and 10:30 AM on April 13, 2010.

6. Cold foods were served on the cafeteria tray line above 41 degrees Fahrenheit such as: Broccoli 66 degrees Fahrenheit, Chicken Chopped 50 degrees F, Pasta 53 degrees F, Tuna 42 degrees F, Yogurt and Blueberries 49 degrees F, Eggs 43 degrees F, Tuna Pasta Salad 42 degrees F and Kidney Beans 46 degrees F in eight (8) of 18 observations at 12:30 PM on April 13, 2010.

7. Seasoning jars in the cook ' s preparation area were soiled with spillages on the exterior surfaces in 30 of 30 observations at 1:45 PM on April 13, 2010.

8. Floor surfaces were damaged, uneven and in a state of disrepair in food preparation and serving areas throughout the Main Kitchen and Support Areas in one (1) of one (1) observations between 9:45 AM and 2:30 PM on April 13, 2010.

9. Anti skid strips in walk refrigerators and freezer were worn and separated from floor surfaces, in three (3) of three (3) observations between 9:45 AM and 10:00 AM on April 13, 2010.

The findings were observed in the presence of the Food Dervice Director,

Based on observations made during the environmental tour of the facility from April 13, 2010 through April 15, 2010, it was determined that the facility failed to provide a safe, sanitary and comfortable environment.

The findings include:

1. Entrance doors, door jambs and/or bathroom doors were marred in 20 of 41 patient rooms sampled: rooms# 200, 210, 211, 219, 223, 227, 230, 231, 232, 239, 305, 306, 307, 308, 310, 311, 312,, 313, 321, 323 and the hydro pool area.

2. Walls in patient rooms and bathrooms were stained and marred in 18 of 41 patient rooms sampled: rooms #200, 201, 203, 206, 211, 220, 223, 232, 234, 239, 300, 305, 308, 311, 312, 319, 321, 322, the physical therapy gym and the hydro pool area.

3. Panel windows were either missing slats or the slats were too short in 10 of 41 rooms sampled: rooms #201, 203, 206, 227, 232, 234, 306, 307, 313, 342 and the therapy room in the pediatric unit.

4. Call stations were inoperable in three (3) of 41 patient rooms sampled: room # 239, 306, 312.

5. A surge protector in the therapy room and another surge protector in the cardiac gym were not mounted on the wall as required.

6. The carpet on 3 south was soiled and discolored in many areas.

7. The entrance door to the bathroom in room #203 was equipped with a lock that could be engaged from the inside.

8. Ice machines on 2 east and 3 east were soiled with mineral deposits and needed to be cleaned.

9. Preventive maintenance was not completed on five (5) of 17 pieces of equipment on 2 west between January 1, 2010 and March 31, 2010.

These observations were made in the presence of the director of environmental
services and the director of the engineering department.


01300

Based on observations during the survey period the facility, which is a 137 bed two level patient facility (5 units), it was determined that ceiling tiles were soiled, missing and failed to fit securely into grids, boxes in the Staging and Storage Room were less than 18 inches from the ceiling, bricks were observed to be damaged in the courtyard outer wall area of the fountain, the asphalt walkway in the courtyard was worn and damaged, wall and floor surfaces in the bridge area between National Rehabilitation Hospital and Washington Hospital Center were damaged and the Air Handler in the Machine Room was observed to have a protruding shaft and lacked a protective cover.

The findings include:

1. Ceiling tiles near the Staging Area were soiled and failed to fit securely into grids in three (3) of ten observations between 11:00 AM and 11:15 AM on April 14, 2010.

2. Ceiling tiles were missing and boxes were stored less than 18 " inches from the ceiling and the entrance door and door jams were marred and scarred in the Laundry Storage Area at 11:20 AM on April 14, 2010.


3. Bricks were observed to be damaged and crumbling along the outer wall areas of the fountain in the courtyard in one (1) of one (1) observation at 11:45 AM on April 14, 2010.

4. The asphalt sidewalk in the courtyard was observed to be worn, damaged and uneven, with cracks and openings in walking surfaces in one (1) of one observation between 11:45 AM and 11:50 AM on April 14, 2010.

5. Wall and floor surfaces were observed to be cracked and damaged in the bridge area between National Rehabilitation Hospital and Washington Hospital Center in one (1) of one (1) observation between 11:50 AM and 11:55 AM on April 14, 2010.

6. One air handler in the Machine Room was observed to have a shaft that was protruding from the motor, which presents an accidental hazard to staff when preventive maintenance duties are performed in one (1) of two (2) observations between 11:55 AM and 12:20 PM on April 14, 2010.

7. The Radiology entrance door and door jam were marred on the frontal surfaces in one (1) of one (1) observation at 11:58 AM on April 14, 2010.

8. Floor surfaces were soiled, dusty and were in need of repainting in the Boiler Room in one (1) of one (1) observation at 12:20 PM on April 14, 2010.

Based on review of documents (All Station Events reports , physicians ' orders and patient ' s Medication Administration Records [MAR]), it was determined that, nurses removed controlled substances, Schedule II, from the automated dispensing machine without documenting the administration and wasting of the controlled substance on the patient ' s Medication Administration Record (MAR) (Patient #34,35,36,37,38,39,40 and 41)

The findings include:

On April 14, 2010, a (72) seventy-two hours " All Transaction " report of all patients receiving: oxycodone/acetaminophen 5/325mg tablets, oxycodone 5mg tablet, methadone 10mg tablets, Hydromorphone 2 mg tablets and oxycodone CR 20mg tablet was requested. Patients were selected at random. The physicians ' orders and patients ' MAR for those patients were also requested.

In the presence of hospital staff, the physician ' s order and patient ' s MAR were compared with corresponding withdrawals from the Automated Dispensing Machine (based on the " All Transaction " report). It was found that documentation of administration and wasting of controlled substances was not done in accordance with Federal and State laws and regulations.

A. Patient #34 was admitted on April 7, 2010. On April 7, 2010 at 4:30PM, the physician wrote an order, " Dilaudid 4 mg, by mouth, every 4 hours as needed for pain " . There is documentation of administration recorded on the MAR that Hydromorphone 4mg was administered on April 12, 2010 at 2104 (9:04PM). There is no documentation of a withdrawal from the ADM machine that corresponds to the time recorded on the patient ' s MAR.

On April 12, 2010 at 9:04PM, at 12:48 AM, one (1) Hydromorphone 2mg syringe was removed from the ADM machine. There is no documentation of administration recorded on the MAR that corresponds to the time that the medication was withdrawn from the ADM machine.

B. Patient #35 was admitted on April 1, 2010. On April 2, 2010 at 15:11 (3:11PM), the physician wrote an order, " Oxycodone 5mg, by mouth, every 6 hours as needed for moderate to severe pain (6-10/10) " .

On April 11, 2010 at 5:45AM, the nurse withdrew a oxycodone 5mg tablet from the ADM. At 6:15AM, that same day, the medication was returned and witnessed. However, there is documentation of administration recorded on the MAR that oxycodone 5mg was administered on April 11, 2010 at 5:46AM.

On April 11, 2010 at 14:17 (2:17PM), the nurse withdrew a oxycodone 5mg tablet from the ADM. At 14:22 (2:22PM), that same day, the medication was returned and witnessed. However, there is documentation of administration recorded on the MAR that oxycodone 5mg was administered on April 11, 2010 at 14:19 (2:19PM).

There is documentation of administration recorded on the MAR that oxycodone 5mg was administered on April 12, 2010 at 5:48AM. There is no documentation of a withdrawal from the ADM machine that corresponds to the time recorded on the patient ' s MAR.

There is documentation of administration recorded on the MAR that oxycodone 5mg was administered on April 12, 2010 at 10:00AM. There is no documentation of a withdrawal from the ADM machine that corresponds to the time recorded on the patient ' s MAR.

There is documentation of administration recorded on the MAR that oxycodone 5mg was administered on April 12, 2010 at 18:15 (6:15PM). The ADM report indicates that the medication was withdrawn at 19:08 (7:08PM).

There is documentation of administration recorded on the MAR that oxycodone 5mg was administered on April 13, 2010 at 6:08AM. There is no documentation of a withdrawal from the ADM machine that corresponds to the time recorded on the patient ' s MAR.

C. Patient #36 was admitted on March 6, 2010. On March 29, 2010 at 10:55AM, the physician wrote an order, " Methadone 2.5mg, by mouth, peg, two times daily " .

On April 11, 2010 at 20:24 (8:24PM), the nurse withdrew one methadone 5mg tablet from the ADM. There was no documentation available at the time of survey to indicate that 2.5mg of methadone was wasted.

On April 12, 2010 at 8:27AM, the nurse withdrew one methadone 5mg tablet from the ADM. There was no documentation available at the time of survey to indicate that 2.5mg of methadone was wasted.

D. Patient #37 was admitted on March 27, 2010. On April 12, 2010 at 5:44AM and April 13, 2010 at 5:45AM, the nurse withdrew one oxycodone 5mg tablet from the ADM. There was no documentation available at the time of survey that this patient was prescribed oxycodone 5mg.

E. Patient #38 was admitted on March 30, 2010. On March 30, 2010 at 1705 (5:05AM), the physician telephoned in an order for Oxy IR 5mg. The order states, " Dose- 1 or 2 tablets. Route- by mouth. Frequency- every 3 hours as needed. Other instructions- Give one tablet for pain less than 5 out of 10. Give 2 tablets for pain equal to or greater than 5 out of 10. Discontinue Percocet " .On April 13, 2010 at 2:42AM, the nurse withdrew two oxycodone 5mg tablets from the ADM. On the MAR, the nurse indicated that she administered one tablet at 2:49AM.There was no documentation available at the time of survey that 2 tablets of oxycodone 5mg were administered on this date on or around the time that the 2 tablets were withdrawn from the ADM.

The nurse documented on the patient ' s MAR, that one tablet of Oxycodone 10mg extended release and oxycodone 10mg (Oxy IR) were administered on April 13, 2010 at 2233 (10:33PM). There is no corresponding documentation for that day and time that oxycodone extended release was taken from the ADM.

F. Patient #39 was admitted on March 31, 2010. On March 31, 2010 at 6:45PM, the physician wrote an order, " Oxycodone 5mg, one tablet, by mouth, every 4 hours, as needed for pain " .

The nurse documented on the patient ' s MAR, that one tablet of Oxycodone 5mg was administered on April 13, 2010 at 2225 (10:25PM). There is no corresponding documentation for that day and time that oxycodone 5mg was taken from the ADM.

G. Patient #40 was admitted on March 3, 2010. On April 2, 2010 at 2:45PM, the physician wrote an order, " Please decrease Fentanyl patch to 100mcg. Start new dose when change patch " .

On April 13, 2010 at 8:43AM the nurse withdrew one Fentanyl 100mcg and one 25mcg patch for the ADM. The nurse documented that on April 13, 2010 at 8:53AM, they applied one 100mcg and one 25mcg patch.

H. Patient #41 was admitted on April 2, 2010.On April 2, 2010 at 6:15PM, the physician wrote, " Oxycodone 15mg, by mouth, every 6 hours as needed " .

The nurse documented on the patient ' s MAR, that Oxycodone 15mg was administered on April 12, 2010 at 1900 (7:00PM). There is no corresponding documentation for that day and time that oxycodone was taken from the ADM.