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Based on a review of facility documents and medical records (MR) and employee interviews (EMP), it was determined that the facility failed to inform each patient, or when appropriate, the patient's representative (as allowed under State law), of the patient's rights, in advance of discontinuing patient care for two of two inpatient Medicare beneficiaries (MR1 and MR7).

Findings include:

Review of the facility Administrative Policies and Procedures number 6.33, effective July 2007 revealed, "Subject: Important Message from Medicare ... Policy: ... These requirements include notification of Medicare, Medicare Advantage, and Medicare as a second payer (MSP) inpatients of their discharge rights as identified in the Center for Medicare and Medicaid final Rule CMS-4105-F:, 'Notification of Hospital Discharge Appeal Rights'. ... Procedure: 1. On admission, all patients receive valid written notice of their rights as a hospital Medicare patient including the discharge appeal rights. 2. The Important Message from Medicare (IM) is utilized to describe these rights. ... 11. A member of the nursing staff gives the second notice to the patient. Each unit determines which staff member is responsible for delivery of the second notice. The RN who discharges the patient is ultimately accountable to ensure the second notice has been delivered to the patient. 12. The second copy of the IM is provided to the patient as soon as possible following the physician determination of impending discharge. ... 14. All efforts are made to ensure delivery of the second notice occurs at least four hours prior to discharge."

1. Review of MR1 revealed that the patient was admitted on July 12, 2010, and discharged on July 16, 2010. Further review of MR1 revealed a (white) document titled, "An Important Message from Medicare About Your Rights (IM)," with a signature bearing the patient's name and dated July 12, 2010. A second signature line on the (white) IM form revealed, "Date/Initials Second Notice Provided ___ Time. ... Pink- Patient Copy Yellow- Follow Up Copy to Patient White- Medical Record Copy." The second signature line further failed to reveal a documented date, initials, time entry or additional evidence that the second notice of of the patient's rights under Medicare was provided prior to discharge on July 16, 2010.

On November 3, 2010, at approximately 10:10 AM EMP6 confirmed that there was no evidence on MR1 that the second notification of of the patient's rights under Medicare were provided to the patient prior to discharge within the specified time. EMP6 stated, "When they give the second (Yellow carbon) copy, they date and initial. Technically you can't see it (initial, date and time)."

2. Review of MR7 revealed that the patient was admitted on October 30, 2010, and discharged on November 5, 2010. Further review of MR7 revealed a (White and Yellow copies) document titled, "An Important Message from Medicare About Your Rights (IM)," with a signature bearing the patient's name and dated October 30, 2010. A second signature line on the IM form (White and Yellow copies) revealed, "Date/Initials Second Notice Provided ___ Time. ... Pink- Patient Copy Yellow- Follow Up Copy to Patient White- Medical Record Copy." The second signature line further failed to reveal a documented date, initials, time of entry or additional evidence that the second notice (White or Yellow copy) of of the patient's rights under Medicare were provided prior to discharge on November 5, 2010.

On November 5, 2010, at approximately 11:45 AM, EMP16 confirmed that there was no evidence identified on MR7 that the second notification (Yellow patient copy still on MR) of the patient's rights under Medicare was provided to the patient prior to discharge within the specified time. EMP6 stated, "Yes. It (Yellow copy- second notice of IM) should have been signed and gone with the patient."

Based on a review of facility documents and medical records (MR), observation and employee interviews (EMP), it was determined that the facility failed to ensure the patient's right to every consideration of privacy concerning their medical care.

Findings include:

Review of the Heritage Valley Health System Patient Guide, no date, revealed, "A Statement of the Patient's Rights. * Patients have the right to personal privacy and respectful care ... * Patient's have the right to every consideration of privacy concerning their medical care program. Case discussion, consultation, examination and treatment are considered confidential and should be conducted discretely. ..."

1. Tour of the facility Pediatric Unit on November 4, 2010, at approximately 11:20 AM revealed a telemetry monitor screen, visible from outside of the nursing station and to hallway traffic with PT1's and PT2's first and last name and monitoring information.

EMP14, present at the time of the Pediatric Unit tour stated, "We don't have to actually use the first and last name on the (telemetry) monitor. We put (first and last name) it in at admission so the telemetry strips print with the full name. At 12:05 PM on November 4, 2010, when asked if it was standard to include both first and last name on other telemetry monitors, EMP5 stated, "I just spoke to CCU (Critical Care Unit) and they also use first and last name."

2. Tour of the facility Level Two medical area on November 5, 2010, at approximately 11:35 AM revealed a Wallaroo (Fold down MR storage and writing surface) for Room# 252. The full names for PT3 and PT4 (Room# 252W and 252D) were observed to be visible to hallway traffic. EMP4, present for the tour stated, "Oh yes. They should be closed." At 11:40 AM on November 5, 2010, When asked to confirm the open Wallaroo exposing the patient occupants of Room 252W and 252D, EMP19 stated, "I am sorry but they get stuck (open)."

3. Tour of the facility Level Two medical area November 5, 2010, at approximately 11:25 AM revealed a Wallaroo for room 267. The charts for the patients in 267W and 267D were exposed allowing access to the full names of the patients. EMP40, who was present in the hallway stated, "They (physicians) always leave them open. Some of them do not close properly. They should not be open." Continuing the tour of the unit, a chart was noted sticking out of a Wallaroo with the patient's full name exposed. EMP39, who was in the hallway stated, "The doctors put them like that so the nurse knows there are orders that need to be taken off."

4. Tour of the facility outpatient services area on November 4, 2010, at approximately 2:50 PM revealed four of four occupied patient bays, with the privacy curtains not drawn. Two of the four bays revealed patients receiving treatment/care by facility staff. The patients, receiving care or waiting for care, were visible from the interior hallway and were further visible from outside the registration area through the glass walls. EMP17, present at the time of the tour stated, "The thought is that if someone needed help, you would be able to see them."

Based on review of the facility policy, and review of medical records (MR) and staff interview (EMP) it was determined that the facility failed to ensure the evaluation of patients' pain levels for eight of 47 medical records reviewed (MR1, MR22, MR23, MR24, MR30, MR31, MR34 and MR35).

Findings include:

Review of "Pain Assessment and Care-Policy # 400.00," revised in July 2010, revealed, "...1. Assessment:...When pain is assessed, the assessment will include the existence, nature, location, onset, duration, effects, history of pain, interventions, level of pain utilizing the age appropriate pain scale and level of sedation...4. Evaluation - Reassessment of the patient's pain will occur within 30 minutes after IV medication is administered, 60 minutes after oral medication is administered, and every four hours or more often as indicated by the patient's diagnosis and plan of care. .."


1) Review of MR1 revealed that the patient was administered oral pain medication on July 15, 2010. Further review of MR1 revealed that the pain follow up was not completed within the policy indicated time frame.

On November 3, 2010, at approximately 1:05 PM EMP1 confirmed the pain follow up for MR1 was not completed within the policy indicated time frame. "It was just a couple Tylenol."

2) Review of MR23, MR24, and MR31 revealed that the patients were administered oral or transdermal pain medication between November 2, 2010, and November 3, 2010. Further review of MR23, MR24 and MR31 revealed that the pain follow up was either not completed, incomplete, or not completed within the policy indicated time frame.

3) Review of MR22 and MR30 revealed that the patients were administered intravenous pain medication on between October 30, 2010, and November 3, 2010. Further review of MR22 and MR30 revealed that the pain follow up was either not completed, incomplete, or not completed within the policy indicated time frame.

Interview with EMP34 on November 4, 2010, at approximately 2:00 PM confirmed the above findings and revealed, "Yes, I see. There is nothing charted related specifically to the pain follow up."

4) Review of MR34 revealed that the patient was administered intravenous anti-nausea, PRN medication on November 2, 2010. Further review of MR34 failed to reveal a follow-up assessment for the effectiveness of this intervention.

During an interview on November 3, 2010, at approximately 3:00 PM, EMP48 stated "I did not chart that, but normally I would."

5) Review of MR35 revealed that the patient was administered a PRN dose of an oral anti-anxiety medication on November 1, 2010. Further review of MR35 failed to reveal a follow-up assessment for the effectiveness of this intervention.

During an interview on November 3, 2010, at approximately 3:15 PM, EMP29 confirmed the above findings and stated, "We expect to see a follow-up assessment for all PRN medications, not just pain meds."

Based on a review of facility policy and medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure staff documented pertinent and complete information for two of 31 medical records (MR1 and MR30).

Findings include:

Review of policy "Beacon (Bridging Electronics and Clinicians Online) Documentation for Patient Care" revised July 2010 revealed, "Viewing/Printing/Placement in the Chart...3. Vital Signs / Intake and Output is available in CAP under Clinical Documents. This information is also available to physicians on the IPAQ/Handheld Devices using M-CAP...).

1) Review of MR1 revealed a July 15, 2010, physician order for Pro-biotic liquid to be administered daily. Further review of MR1 failed to reveal evidence that the patient had received the Pro-biotic liquid as ordered or documentation of any amount consumed.

On November 3, 2010, at approximately 1:00 PM when asked where on MR1 evidence related to the provision and consumption of the Pro-biotic would be documented, EMP1 stated, "It wouldn't be in the record unless they (patient) are being followed by dietary." At 3:20 PM, on November 3, 2010, EMP1 further confirmed that there was not a designated place on the medical record for dietary supplements and stated, "The order would be the documentation."

2) Review of MR30 Vital Signs record dated November, 2010, revealed a dietary progress note dated October 29, 2010, for the patient to be provided Health Shakes and Ensure with meals. Further review revealed that the resident completed 100% of the breakfast and 100% of lunch on November 4, 2010.

Review of MR30, November 4, 2010, at approximately 3:00 PM, EMP21 confirmed that the nutritional shake was included as part of the meal consumption documentation.

During an interview on November 4, 2010, at approximately 3:15 PM the patient of MR30 indicated, "No, I do not drink the Ensure all of the time and I think I only drank 1/2 of the can today. They just are not my cup of tea."

Interview on November 4, 2010, at approximately 3:20 PM with EMP31 confirmed, "The Ensure for [MR30] was not opened and was not documented.

3) Interview with EMP22, November 5, 2010, at approximately 10:00 AM, "When a physician orders a probiotic we send up yogurt on the patient's tray. If the physician wanted a probiotic in a pill form, he would order the medication by name and that would be sent to the pharmacy. When a probiotic (yogurt) is ordered, the call center is notified and it is listed as a "must select" item. I don't think there is a place in the chart to verify that a probiotic is being taken."

Based on review of facility policy and medical records (MR) and staff interview (EMP), it was determined that the facility failed to ensure compliance with the Medical Staff Rules and Regulations related to the completion of medical records by ensuring all entries into the medical record were completed as required for five of 47 medical records (MR32, MR33, MR37, MR38 and MR43).

Findings include:

Review of the Rules & Regulations of The Medical Staff, reviewed on January 28, 2010 revealed, "II. Medical Records. A. ...All entries in the medical record shall be legible, dated, timed and signed by the practitioner making the entry. ...C. 11. b. Pharmacists are permitted to document therapeutic substitutions...in the progress notes. The pharmacist's entry must be dated and signed. ...13. A practitioner's routine orders, when applicable to given patient, shall be reproduced in detail on the order sheet of the patient's record, dated, and signed by the practitioner."

Review of facility policy Therapeutic Alternatives/Interchange, revised July 2010 revealed, "...2. When a medication is prescribed for a product considered to have a Therapeutic Alternative, the pharmacy will notify nursing and/or the physician that an alternative is being dispensed."

1) Review of MR32 revealed a Progress Note written by social services that did not include a time that the entry was made on the medical record. Further review of MR32 revealed a Psychiatric Progress Note that failed to include the date and time the entry was placed into the medical record..

2) Review of MR33 revealed physician orders, a medication reconciliation form, and progress notes that failed to include the date and/or time the entry was placed into the medical record.

During an interview on November 3, 2010 at approximately 11:00 AM, EMP4 confirmed the above findings and stated, "These are not complete."

3) Review of MR37 revealed physician orders that failed to include the time of entry into the medical record.

During an interview on November 4, 2010 at approximately 9:30 AM, EMP4 confirmed the above findings.

4) Review of MR38 revealed pharmacist entries for therapeutic substitution of medications which failed to include signature, date and/or time of the person making the entry on the record. Further review of MR38 revealed a Surveillance Screening Physician Order form which failed to include a time the entry was placed on the record.

During an interview on November 4, 2010 at 11:55 AM, EMP44 confirmed the above entries for MR38 were incomplete.

During an interview on November 5, 2010 at 11:00 AM, when asked what the expectation was for completion of the therapeutic substitution stickers, EMP45 stated "We do expect everything to be filled out including the doctor it is being addressed to, the medication order, date, time and pharmacist signature. These are not complete."

5) Review of MR43 revealed a physician order that failed to include the time of entry into the medical record.

During an interview on November 5, 2010 at 12:15 PM, EMP21 stated, "That is not complete."

Based on a review of facility documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure Medical Staff compliance with Medical Staff Rules and Regulations relative to the authentication of verbal orders within 24 hours for 12 of 47 medical records (MR1, MR8, MR10, MR11, MR12, MR13, MR15, MR19, MR20, MR33, MR38 and MR43).

Findings include:

Review of the Rules & Regulations of The Medical Staff, reviewed January 28, 2010 revealed, "...13. Orders for treatment...b. ...Verbal orders shall be taken only by a registered nurse, graduate nurse, CRNP, or physician assistant who shall transcribe the orders in the proper place in the medical record of the patient. The order shall include the name of the ordering practitioner, the date, time and full signature of the person taking the order and shall be countersigned, dated and timed within 24 hours by the ordering practitioner or another practitioner who is responsible for the care of the patient and authorized to write orders by hospital policy."

1. Review of MR1, MR8, MR10, MR11, MR12, MR13, MR15, MR19, MR20, MR33, MR38 and MR43 revealed verbal orders that were not authenticated by either signature, date and/or time.

During review of MR10 and MR11, November 3, 2010, at approximately 2:00 PM, EMP21 verified the medical records had verbal orders that had not been authenticated within 24 hours.

During review of MR6, November 4, 2010, at approximately 2:00 PM, EMP16 verified that the medical record had verbal orders authenticated three to five days after the order was received. "Yes. They were not done (within 24 hours). I wonder if it was a weekend."

During review of MR12, November 5, 2010, at approximately 11:30 AM, EMP39 verified that the medical record had verbal orders that had not been authenticated within 24 hours.

During review of MR 19, November 5, 2010, at approximately 11:00 AM, EMP 31 verified that the medical record had verbal orders that had not been authenticated within 24 hours.

During review of MR 20, November 2, 2010, at approximately 11:00 AM, EMP34 verified that the medical record had verbal orders that had not been authenticated within 24 hours.

During review of MR33, November 3, 2010, at approximately 11:00 AM, EMP4 verified the medical record had verbal orders that had not been authenticated within 24 hours.

During review of MR38, November 4, 2010, at 11:55 AM, EMP44 verified the medical record had verbal orders that had not been authenticated within 24 hours.

During review of MR43, November 5, 2010, at 12:15 PM, EMP21 verified the medical record had verbal orders that had not been authenticated within 24 hours.

During review of MR8, November 5, 2010, at 12:15 PM, EMP16 verified the medical record had verbal orders that had not been authenticated within 24 hours. "Yes. Nursing puts a sticker on them (Verbal orders). What more can they do?"

Based on observation and staff interviews (EMP), it was determined that the facility failed to ensure safe use of medication-related devices.

Findings include:

1) A tour of the Rehabilitation Unit, room 466, on November 4, 2010, at approximately 1:50 PM revealed an unlocked drawer containing needles and syringes.

2) Interview with EMP34 on November 4, 2010, at approximately 1:50 PM revealed, "Yes, it is unlocked [the drawer in room 466, which contained needles and syringes] but the drawers are always locked."

3) During a telephone interview on November 15, 2010, at 1:30 PM, when asked for the policy for securing needles and syringes, EMP4 indicated, "While the practice is to lock syringes and needles at all times, there is no written policy regarding this practice."

Based on Life Safety Code federal monitoring survey, the Condition for Physical Environment is not met based on the results of Department of Safety Inspection survey completed on November 4, 2010. See Life Safety Code 2567 for deficiencies.