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Based on clinical record review and staff interview, it was determined the facility failed to inform the patients, or patient representatives, for two (#3,#7) of 10 patients sampled, of their patient rights before furnishing or discontinuing patient care.

Findings include:

1. Patient #3, age 45, was admitted on 01/07/2011 with diagnosis of Cerebral Vascular Accident, Hemiplegia, Dysphagia, Dysarthria, Hypercholesterolemia, Depressive disorder, Esophageal Reflux and Anemia. Review of the Interdisciplinary Assessment form, dated 01/07/2011, in the medical record, revealed there was no evidence of explanation to the patient or the patient's family of Patients Rights. The check box that indicated the patient or family was informed of their rights was not checked.

2. Patient #7, age 98, was admitted on 10/22/11 with diagnosis of Deconditioning, Failure to Thrive and Abnormal Swallowing. Review of the Interdisciplinary Assessment form, dated 10/22/2011, in the medical record revealed there was no evidence of explanation to the patient or the patient's family of Patients Rights. The check box that indicated the patient or family was informed of their rights was not checked.

3. During an interview on 11/8/11 at 2:00 p.m., the Chief Nursing Officer (CNO) indicated that Patient Rights are to be explained during the admission process and the checkbox on the interdisciplinary Assessment form to indicate the patient or family have been informed of their Patient Rights. She confirmed that the check boxes on the Interdisciplinary Assessment form were not checked.

Based on staff interview and review of medical records, it was determined the facility failed to obtain and/or offer patients the right to formulate an advance directive to four (#3, #4, #5, #7) of ten patients sampled.

Findings include:

1. Patient #3 was admitted on 01/07/2011 with a diagnosis of Cerebral Vascular Accident (CVA), Hemiplegia, Dysphagia, Dysarthria, Hypercholesterolemia, Depressive disorder, Esophageal Reflux and Anemia. Review of the Interdisciplinary Assessment form, dated 01/07/2011, in the medical record, revealed there was no documentation that indicated the patient had an Advance Directive, or wished to execute an advance directive. The Check boxes under Section I and II, that would indicate evidence of a patient having or wanting to execute an Advance Directive, were left blank. There was no evidence that any information was provided to patient.

2. Patient #4 was admitted on 01/25/11 with diagnosis of Left Extremity Cerebral Vascular Accident (CVA), Right Hemiparesis, Dysorthinia, Chronic Pain Syndrome, Neuropathy, Coronary Artery Disease (CAD), and Anxiety Disorder. Review of the Interdisciplinary Assessment form, dated 01/25/2011, in the medical record, revealed there was no documentation that indicated if the patient had an Advance Directive, or wished to execute an advance directive. The Check boxes under Section I and II that would indicate evidence of a patient having or wanting to execute an Advance Directive were left blank. There was no evidence that any information was provided to patient.

3. Patient #7 was admitted on 10/22/11 with diagnosis of Deconditioning, Failure to Thrive and Abnormal Swallowing. Review of the Interdisciplinary Assessment form, dated 10/22/2011, in the medical record, revealed there was no documentation that indicated if the patient had an Advance Directive, or wished to execute an advance directive. The Check boxes under Section I and II that would indicate evidence of a patient having or wanting to execute an Advance Directive were left blank. There was no evidence that any information was provided to patient.
During an interview on 11/8/11 at 2:00 p.m., the Chief Nursing Officer (CNO) indicated the Advance Directive information is to be explained during the admission process. The checkbox on the interdisciplinary assessment form should be checked to indicate the patient, or Medical Power of Attorney, (MPOA) has been informed of their Right to execute an Advance Directive. There is also a checkbox to indicate if the patient has an existing Advance Directive. If the Patient has no Advance Directive and would like to execute one, information should be given to the patient and the check box on the Interdisciplinary Assessment form should be checked to indicate the patient, family or MPOA has been given information on how to execute an Advance Directive. The CNO confirmed that the Interdisciplinary Assessment form did not contain the proper documentation to indicate that the patient had been informed of their Advance Directive rights.

4. Patient #5 was admitted on 11/01/11 for inpatient rehabilitation of impairment secondary to abdominal pain, ground level fall, and weakness. Review of the Interdisciplinary Assessment form, dated 11/01/2011, revealed there was no documentation that indicated if the patient had an Advance Directive, or wished to execute an advance directive. The check boxes under Section I and II that would indicate evidence of a patient having or wanting to execute an Advance Directive were left blank. There was no evidence that any information was provided to patient. Interview with the Director of Quality on 11/08/11 at 11:30 a.m. confirmed the above findings.

Based on record review and staff interview, it was determined the facility failed to individualize a treatment plan for one (#2) of ten patients sampled.

Findings include:

Review of patient #2's medical record revealed the patient was admitted to the facility on 1/03/11 for comprehensive inpatient rehabilitation of impairments secondary to CVA (Cerebral Vascular Accident), left hemiparesis, and deconditioning syndrome. Review of the physician's orders, dated 1/3/11, the nursing admission and Morse fall scale assessment on 1/3/11, revealed the patient was identified as a high fall risk and was placed on standard fall precautions. Review of the record revealed on 1/7/11 at 12:01 a.m. a physicians order for a restraint was written. The patient was placed in an enclosure bed as ordered by the physician. Review of the plan of care revealed restraints were not added to the plan of care and goals were not established.

On 1/7/11 at 3:55 a.m. the patient was found on the floor outside of the enclosure bed. Review of the patient's plan of care revealed the patient's risk for falls using the Morse fall scale was not reassessed following the patient's un-witnessed fall. Review of the facility's policy, "Fall Precautions," policy #A7.5C, last revised 4/2010, stated patients will be assessed utilizing the modified Morse fall scale for their fall risk following any change of status, following a fall. Interview with the Director of Quality and the Chief Nursing Officer on 11/8/11 at 1:30 p.m. confirmed the findings.

Based on record review, review of policy and procedures and staff interview it was determined the facility failed to obtain a renewal order for a restraint as indicated by facility policy for one (#2) of ten patients sampled.

Findings include:

Review of patient #2's medical record revealed the patient was admitted to the facility on 1/03/11 for comprehensive inpatient rehabilitation of impairments secondary to CVA (Cerebral Vascular Accident), left hemiparesis, and deconditioning syndrome. Review of the record revealed on 1/7/11 at 12:01 a.m. a physician's order for a restraint was written. The patient was placed in an enclosure bed as ordered by the physician. Review of documentation revealed the patient was in the enclosure bed from 1/07/11 at 12:01 a.m. until the patient's transfer on 1/9/11 at 9:25 p.m. Review of the physician's orders did not reveal a renewal order for the restraint on 1/8/11.

Review of the facility's policy, "Use of Restraints and Seclusion", #A7.20, last revised 3/2009, requires a LIP (Licensed Independent Practitioner) to reorder the restraint every 24 hours.

Interview with the Chief Nursing Officer and Director of Quality on 11/08/11 at 1:30 p.m. confirmed the above findings.

Based on record review, staff interview, and review of policy and procedures, it was determined the Registered Nurse failed to evaluate and supervise the nursing care for 6 (#2', #3', #4', #5', #6', #7') of 10 sampled patients. This practice does not ensure that patient's goals are met, and may cause a delay in discharge.

Findings include:

1. Patient #7 was admitted on 10/22/11 with diagnosis of Deconditioning, Failure to Thrive, Abnormal Swallowing and Peg Tube.
There was Physician's order, dated 10/22/11, for nutritional assessment, which was completed 10/25/11. The patient was on Jevity bolus tube feedings. A Physician's order, dated 11/3/11, ordered daily weights. Review of medical record revealed no daily weights recorded for 11/3/11, 11/4/11, 11/6/11 and 11/7/11.

Interview with the CNO (Chief Nursing Officer) on 11/8/11 at approximately 10:00 a.m., revealed facility beds have scales used for weighing patients. She indicated patients can be weighed in their bed unless an order states differently. She confirmed there was an order for daily weights and that weights were not recorded on the above mentioned medical record for 11/3/11, 11/4/11, 11/6/11 and 11/7/11.

Review of nursing documentation for patient #7, dated 10/22/11, on the interdisciplinary plan of care revealed the patient's score was recorded as 75 from the IDA Morse Scale (patient fall risk assessment) on admission. Nursing documented interventions as side rails up X4 and enclosure bed. There was no enclosure bed ordered on 10/22/11. There were no other interventions initiated for this patient, no evidence of education to patient or family for fall precautions and no measurable goals.

Nursing documentation on 10/29/11 at 2200 revealed, "Pt. alert. Very confused and constantly pulling on clothes, trying to get up out of bed. Veil bed ordered, but will not be here until tomorrow." There was no update on care plan to indicate change in status until 11/6/11 at which time the modified Morse Scale indicated a score of 85.
Interview with the CNO on 11/8/11 at approximately 10:00 a.m., confirmed there were no fall/safety risk interventions, measurable goals and no update on care plan for change in status on 10/29/11. She also confirmed a new assessment should be completed using the Morse fall scale for any change in status following a fall and documented on the patient's care plan.

2. Patient #3 was admitted on 01/07/2011 with diagnosis of Cerebral Vascular Accident (CVA), Hemiplegia, Dysphagia, Dysarthria, Hypercholesterolemia, Depressive disorder, Esophageal Reflux and Anemia.
Medical record review of nursing documentation dated 1/24/11 at 1630 revealed the patient attempted to get up from the commode without assistance and slid to the floor between the commode and wheelchair. The patient denied any pain or any injury and was assisted to a wheelchair without difficulty. There was no documentation indicating the patient was reassessed using the Morse fall scale as per policy. There was no update found on the patient's care plan.

3. Patient #4 was admitted on 01/25/11 with diagnosis of Left Extremity Cerebral Vascular Accident (CVA), Right Hemiparesis, Dysorthinia, Chronic Pain Syndrome, Neuropathy, Coronary Artery Disease (CAD), and Anxiety Disorder.
Physician's order, dated 1/25/11, for fall precautions. Nursing assessment completed 1/25/11 with documentation of Morse fall scale score of 60. Care plan initiated on 1/25/11 for standard fall precautions.
Review of the policy, "Fall Precautions," policy #A7.5C, last revised 4/2010, revealed strict precautions for patients with a Morse Scale score of greater than 45 should include all standard precautions and to include color coded wristband on patient to alert all personnel of high risk fall. Patients will be assessed utilizing the modified Morse fall scale for their fall risk following any change of status, following a fall.
An interview with the CNO on 11/8/11 at approximately 2:00 p.m. confirmed a patient with a score of more than 45 on the Morse fall scale should be placed on High Risk Fall precautions not standard fall precautions.

4. Patient #2 was admitted on 1/03/11 for comprehensive inpatient rehabilitation of impairments secondary to CVA (Cerebral Vascular Accident), left hemiparesis, and deconditioning syndrome.

Review of the physician's orders, dated 1/3/11, and the nursing admission assessment on 1/3/11, revealed the patient was identified as a high fall risk and was placed on standard fall precautions. On 1/7/11 at 3:55 a.m., the patient was found on the floor outside of the enclosure bed. Review of the patient's record and the Morse fall scale revealed the patient was not reassessed following the patient's un-witnessed fall.

Review of the facility's policy, "Fall Precautions," policy #A7.5C, last revised 4/2010, stated patients will be assessed utilizing the modified Morse fall scale for their fall risk following any change of status, following a fall.

Review of the physician's orders for patient #2 revealed an order on 1/09/11, noted at 2:51 p.m. for 1 liter of NS (Normal Saline) IV (Intravenously) and then NS IV to run at 125 ml (milliliters) per hour. Review of the MAR and nursing documentation revealed the IV fluids were administered as ordered. Review of the nursing assessment for 1/09/11 did not reveal the IV initiation, date or time of insertion, insertion site, or size and type of IV catheter. Review of the facility policy, "Intravenous Therapy," #1:0083, last revised 2/2006, stated nursing will document IV insertion site initiation, date and time of insertion, and size and type of IV catheter.

Interview with the Director of Quality and the Chief Nursing Officer on 11/8/11 at 1:30 p.m. confirmed the findings.

5. Patient #5 was admitted on 11/01/11 for inpatient rehabilitation of impairment secondary to abdominal pain, ground level fall and, weakness.

Review of the patient's MAR (Medication Administration Record) revealed the patient was medicated with Percocet for pain on 11/3/11 at 8:45 a.m. Review of the nursing assessment for that date, did not indicate the location or severity of the patient's pain. There was no indication if the pain medication was effective.

Review of the patient's MAR revealed the patient was medicated with Percocet for pain on 11/4/11 at 9:20 p.m. Review of the nursing assessment, for that date, did not indicate the location or severity of the patient's pain. There was no indication if the pain medication was effective.

Review of the patient's MAR revealed the patient was medicated with Percocet for pain on 11/5/11 at 10:00 p.m. Review of the nursing assessment, for that date, did not indicate the location or severity of the patient's pain. There was no indication if the pain medication was effective.

Interview with the Director of Quality on 11/8/11 at 11:30 a.m. confirmed the above findings.

6. Patient #6 was admitted on 11/01/11 for inpatient rehabilitation of impairments secondary to subarachnoid hemorrhage and deconditioning syndrome.

Review of patient's MAR (Medication Administration Record) revealed the patient was medicated with Vicodin for pain on 11/3/11 at 5:10 p.m. Review of the nursing assessment, for that date, did not indicate the location or severity of the patient's pain. There was no indication if the pain medication was effective.

Review of the patient's MAR revealed the patient was medicated with Vicodin for pain on 11/3/11 at 9:40 p.m. Review of the nursing assessment, for that date, did not indicate the location or severity of the patient's pain. There was no indication if the pain medication was effective.

Interview with the Director of Quality on 11/8/11 at 11:55 a.m. confirmed the above findings.

Based on record review and staff interview it was determined the facility failed to keep current an individualized nursing care plan for two (#2, #3) of ten patients sampled.

Findings include:

1. Review of patient #2's medical record revealed the patient was admitted to the facility on 1/03/11 for comprehensive inpatient rehabilitation of impairments secondary to CVA (Cerebral Vascular Accident), left hemiparesis, and deconditioning syndrome. Review of the physician's orders, dated 1/3/11, the nursing admission and Morse fall scale assessment on 1/3/11, revealed the patient was identified as a high fall risk and was placed on standard fall precautions. Review of the record revealed on 1/7/11 at 12:01 a.m. a physicians order for a restraint was written. The patient was placed in an enclosure bed as ordered by the physician. Review of the plan of care revealed restraints was not added to the plan of care and goals were not established.

On 1/7/11 at 3:55 a.m. the patient was found on the floor outside of the enclosure bed. Review of the patient's plan of care revealed the patient's risk for falls using the Morse fall scale was not reassessed following the patient's un-witnessed fall. Review of the facility's policy, "Fall Precautions," policy #A7.5C, last revised 4/2010, states patients will be assessed utilizing the modified Morse fall scale for their fall risk following any change of status, following a fall. Interview with the Director of Quality and the Chief Nursing Officer on 11/8/11 at 1:30 p.m. confirmed the findings.

2. Patient #3 was admitted on 01/07/2011 with diagnosis of Cerebral Vascular Accident (CVA), Hemiplegia, Dysphagia, Dysarthria, Hypercholesterolemia, Depressive disorder, Esophageal Reflux and Anemia.
Medical record review of nursing documentation, dated 1/24/11, at 1630 revealed the patient attempted to get up from the commode without assistance and slid to the floor between the commode and wheelchair. The patient denied any pain or any injury and was assisted to a wheelchair without difficulty. There was no documentation indicating the patient was reassessed using the Morse fall scale as per policy. There was no update found on the patient's care plan.