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Based on medical record review and staff interview the hospital failed to inform the patient's family of the expense of ambulance transport prior to the family making the decision to transfer to another facility. This affected one of eleven records reviewed. ( Patient 3). The hospital census was 161.

Findings include:

The medical record for Patient #3 revealed the patient's family requested transfer to another facility. Physician J ordered the transport to another facility on 9/26/09 as an elective transfer. The detailed patient chart summary report dated 9/26/09 at 10:45 PM, revealed Nurse Q, instructed and gained a signature from the patient's family member for consent to transfer the patient and the authorization for release of health information form. The detailed patient chart summary report documented for 9/26/09 at 10:50 PM revealed the nursing supervisor, Staff B, discussed the ambulance company was requesting down payment of $192.00 and who would be accepting responsibility for the balance not covered by insurance for a total of $960.00 due to the transfer not being medically necessary. The medical record revealed the patient's family member stated " I am done, you have compromised this patient's care and you still are. I am calling my attorney."

Interview with the quality/risk manager, Staff C, on 3/12/10 at 9:45 AM, confirmed the ambulance fee was waived prior to the elective transfer. Staff C revealed the nursing supervisor was unfamiliar with the policy for requesting the ambulance fee with an elective transfer. This responsibility was typically the case manager's responsibility. Review of the education of the hospital affiliated ambulance service dated 1/28/09, revealed it was not the responsibility of this facility's employees to collect the partial payment. During the interview Staff C stated on 2/5/09, 4/2/09, and 9/4/09, meetings had occurred to discuss the problems that had arisen related to staff requesting partial payment for the ambulance transfer. Staff C presented to the surveyor a Financial Responsibility Explanation Guide to review. Staff C said the form was created to inform patients of the expense prior to transfer by the ambulance company. Staff C stated he/she was not sure if this guide was available on 9/27/09. The record lacked evidence this guide had been given to the patient's family.

This deficiency substantiates complaint number OH00051934.

Based on medical record review, restraint policy review and staff interview the hospital failed to ensure the hospital's policy and procedures relating to physician orders required every 24 hours for restraint usage, the need for the physician to personally assess and evaluated the patient before the renewal of the order for restraints, the inclusion of the initiation date and time and the order expiration date and time and the rationale for continued use of the restraint for three of three patients reviewed for whom restraints were followed. This involved Patients #9, #10 and #11. The sample was eleven patients reviewed. The hospital census was 161.

Findings include:

Per medical record review of Patient #9 completed on 03/12/10, the patient was admitted on 12/31/09 at 09:35 PM with diagnoses of urinary tract infection, severe developmental disability, Down's syndrome, tracheostomy, gastrostomy tube and chronic kidney disease. This 54 year old patient attempted to pull at tubing and a physician order was obtained at 11:00 PM on 12/31/09, for bilateral soft wrist restraints. Even though the patient was restrained from 12/31/09 through 01/03/10 until 11:00 PM and from 07:00 AM on 01/04/10 through discharge on 01/06/10 at 2:00 PM, there was no written physician order for restraint usage between 11:00 PM on 01/02/10 until 11:00 PM on 01/03/10. Per physician progress noted dates 01/04/10, no physician re-ordered the restraint due to confusion regarding which physician was responsible for the patient during the 24 hour period from 11:00 PM on 01/02/10 until 11:00 PM on 01/03/10. Bilateral wrists, mitts, soft chest, waist and an arm board were implemented at different times during Patient #9's hospitalization. Only one physician evaluation was documented which was on 01/04/10, which stated the physician attested that the restraint was consistent with the patient's needs. Dates and times for the actual restraint order, the initiation date and time, as well as, the expiration date and time of the restraint order were not consistently documented on the physician order.

Per review of the nursing assessments and progress notes, Patient #9 developed skin breakdown between admission to the hospital on 12/31/09 at 9:45 PM and 01/04/10 at 09:45 AM, when nursing implemented the use of a low air loss bed when redness was observed on 01/03/10 at 8:30 PM. On the day of discharge, 01/06/10 at 8:50 AM, a nursing note stated, "Redness, open areas to bottom and inner thighs." This was verified by Staff F on 03/12/10 at 2:30 PM.

Per medical record review of Patient #10 completed on 03/12/10, the patient was admitted on 10/23/09 and was discharged on 11/06/09 at 09:00 AM. The first order for physical restraint was obtained on 10/29/09 at 2:00 PM, for the use of a net bed due to the patient pulling at the tubes and the lines, attempting to ambulate and the patient being disoriented. The next physician order was obtained on 10/31/09 at 6:35 AM. Documentation was found in the medical record that Patient # 10 had been in the net bed between 10/30/09 at 2:00 PM and 6:35 AM on 10/31/09. The 24 hour period for the restraint usage that was ordered at 2:00 PM on 10/29/09 had ended at 2:00 PM on 10/30/09. During the time period from 10/30/09 at 2:00 PM until 10/31/09 at 6:35 AM (16 hours and 35 minutes), the patient was in a restraint without a physician's order. Additionally, there was no physician order obtained from 2:50 AM on 11/06/09 until discharge at 9:00 AM for the use of the net bed. No medical evaluation was documented on the physician orders from 10/29/09 to 11/05/09. Restraint orders lacked the initiation time and date, expiration dates and times on an ongoing basis. These findings were verified by Staff F and Staff P on 03/12/10 between 2:30 PM and 3:45 PM.

Per medical record review of Patient #11 completed on 03/12/10, the patient was admitted on 12/24/09, with diagnoses of acute right sided weakness, left frontal parietal lobe cerebral vascular accident, atrial fibrillation, hypertension, diabetes mellitus, vascular dementia and dehydration. The first physician order for a physical restraint was written on 12/24/09 at 4:30 PM, for the use of a net bed. No written physician evaluation was found on any of the physician orders for restraint usage from 12/24/09, until 12/28/09 at 7:00 PM. Per interview on 03/12/10 at 3:30 PM., with Staff P, (the nurse manager of the medical/surgical unit at the other hospital site where the patient had been hospitalized), revealed there was some confusion with staff nurses regarding the date of the current order, the initiation date and time and the date and time when the restraint order expires. For example, Patient #10's physician restraint orders reflect all of the current orders that were written on 12/25/09, even though Patient #10 was in the net bed from 12/24/09 until 12/28/09. These findings were verified by Staff P on 03/12/10 at 3:40 PM.

Per review of the hospital's restraint policy effective March, 1997, and revised as of 02/08, Restraint orders for a non-violent or a non-self-destructive patient may not exceed 24 hours. If restraints will be needed for a non-violent or a non-self-destructive patient for greater than 24 hours, the physician or licensed independent practitioner must personally assess and evaluate the patient before renewal of the order for the use of restraints. The policy further stated the restraint initiation date and time and the order expiration date and time must be in the physician order for restraints. These findings were verified by Staff F on 03/12/10 at 2:30 PM.

Based on medical record review of hospital policy related to the administration of pain medication and staff interview the facility failed to re-evaluate the patients' pain level prior to discharge. This affected 2 of 11 patients reviewed. (Patient #3 and #8). The hospital census was 161.

Findings include:

The medical record for Patient #3 was reviewed during the morning on 3/12/10. The 9 year old patient was admitted to the hospital on 9/25/09, with a diagnosis of a fractured right tibia and fibula. The pain medication, Tylenol with Codeine elixir 10 milliliters orally, was administered at 4:45 PM., as ordered every four hours as needed for pain. The patient rated his pain at level 9 at 4:45 PM. The nursing note had a second entry at 4:45 PM, which revealed the FSP rated the pain at level 10. The record lacked documentation of a reassessment of the the patient's response to the pain medication at discharge as required per the hospital's pain management policy. The patient rated the pain as a level 8 at 6:40 PM, on return arrival to the pediatric floor. During interview with Staff O on 3/12/10 at 9:00 AM, the nurse revealed Staff J had ordered intravenous Dilaudid .2 to .4 milligram every 2 hours as needed for breakthrough pain upon the patient's return to the hospital. This pain medication was held as stated by the Staff O during the interview. Staff O stated the patient's father told her he had given the patient 4 milliliters of the discharged prescription, Tylenol with Codeine elixer. The nursing notes revealed Staff J was informed the Dilaudid dose was held, however, the medication administration record (MAR), lacked an entry to indicate the Dilaudid dose was held. This finding was confirmed by Staff O and Staff F on 3/12/10 at 9:30 AM. An entry was made in the MAR by Staff O to indicate the FSP was medicated with 200 milligram orally of Ibuprofen for pain per order at 6:50 PM. The patient rated the pain as "denies pain" at 8:00 PM. The hospital's pain management policy reviewed the morning of 03/12/10, revealed reassessment will occur within 1 hour for medications given orally.


Per medical record review of Patient #8 on 03/12/10, during the morning hours, the 13 year old patient was admitted to the hospital on 10/01/09 at 7:00 PM, with a diagnosis of fractured right tibia and fibula. Seen initially in the emergency department, the patient was admitted to the pediatric floor for surgical intervention on 10/02/09 at 5:00 PM. Per review of physician orders written on 10/01/09 at 11:00 PM, Morphine Sulfate (M.S.) 2 to 4 milligrams intravenously every two hours as necessary was ordered to manage Patient #8's pain. Per review of the initial nursing assessment on 10/01/09 at 8:40 PM, Patient #8 stated his/her pain in the right lower leg was 3 to 4 of 10. After the nurse elevated the right leg on two pillows and applied ice to the lower leg, the patient stated the pain was less after the elevation and ice. Morphine sulfate(MS) 2 milligrams was given at 10:55 PM for pain rated by the patient at 5 of 10 and at 01:24 AM, for pain rated at 5 of 10 with reassessment of pain within 45 minutes with an acceptable level of relief achieved. At 04:25 AM, Patient #8 complained of pain at 8 of 10 and was medicated with MS 2 milligrams. No reassessment of the response to the pain medication was found in the nurses notes. The next nursing note was written at 07:15 AM, when the level of pain was not documented but MS 2 milligrams was administered with a reassessment of the patient's response made at 07:50 AM which reflected an acceptable level of comfort had been achieved. At 09:20 AM, Patient #8 stated her/his pain was 5-6 of 10. MS 2 milligrams was given with no documented reassessment of the patient's response. At 11:00 AM on 10/02/09, Patient #8's pain level was reported as 3 of 10 and MS 3 milligrams was given with a reassessment documented as the patient was sleeping 33 minutes later. At 12:15 PM, a nursing entry described the patient with pain in the left lower extremity (the fracture was in the right lower leg) at a level of 5 of 10 with no intervention documented. An entry on 10/02/09 at 1:40 PM, stated Patient 8's pain was at 3 of 10 and MS 3 milligrams was administered. No route was documented for the medication. Thirty minutes later, at 02:10 PM, the patient rated his/her pain at 2 of 10. Per interview with Staff F at 10:45 AM on 03/12/10, these findings were verified.

This deficiency substantiates Complaint Number OH00051934.

Based on medical record review and staff interview, nursing staff failed to develop a nursing care plan for 1 of 11 patients reviewed who developed skin breakdown after admission to the hospital. This affected Patient #9. The hospital census was 161.

Findings include:

Per medical record review completed on 03/12/10, Patient #9 a 54 year old patient was admitted to the hospital on 12/31/09 at 9:45 PM, with diagnoses including urinary tract infection, severe developmental disability, Down's syndrome, tracheostomy, gastrostomy and chronic kidney disease. The initial nursing assessment lacked a skin risk assessment. The first assessment was completed at 7:00 AM on 01/01/10, when the patient's assessment score was determined to be 13, which placed Patient 9 at moderate risk for skin breakdown. Per medical record review, the patient was initially placed in bilateral wrist restraints on 12/31/09 at 11:00 PM, and continued with this restraint intervention until discharge on 01/06/10 at 2:27 PM. Per a nursing note written on 12/31/09 at 10:00 PM, the patient's buttocks were pink but the skin was intact. On 01/03/10 at 8:30 PM, a nursing entry stated the patient's gluteal folds and buttocks were red. A reference to the initiation of the use of a low air loss mattress on 01/04/10, was made at 09:45 AM. At 10:20 AM on 01/04/10, the skin care nurse saw Patient #9 and wrote, " Noted several superficial areas, red, moist to bilateral buttocks. Also two areas of partial thickness loss to sacral area and in between buttocks less than .5 centimeters by 0.1 centimeter. Pump equalizer ordered." Per physician order review it was noted on 01/04/10, at 7:30 PM, a topical dressing to the buttocks every 8 hours was ordered. This physician order was obtained after a nursing note was written describing the following: "bottom and inner thighs have abraised areas that bleed when cleaned. Two small open areas to gluteal crease. Equalizer pump applied to air mattress for patient comfort." Patient #9 was described as being non-verbal and restless in bed, even when restrained. The skin risk assessments beginning on 01/04/10, placed Patient #9 at high risk for skin breakdown. Documentation contained in the medical record related to turning, lacked information related to what position the patient was placed in to ensure the patient did not stay in one position longer than two hours. No further measurements of the open areas were documented in the medical record after the 01/04/10 entry by the skin care nurse at 10:20 AM. Review of Patient #9's nursing plan of care, revealed the first entry related to skin breakdown prevention was on 01/02/10 and no skin breakdown intervention was recorded in the nursing intervention plan on 01/03/10. These findings were verified by Staff F on 03/12/10 at 2:30 PM.