The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SUMMIT HEALTHCARE REGIONAL MEDICAL CENTER 2200 EAST SHOW LOW LAKE ROAD SHOW LOW, AZ 85901 March 28, 2013
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
Based on review of hospital policies/procedures, medical records, documents, and staff interviews, it was determined the hospital failed to require patients' were restrained by the least restrictive interventions, as demonstrated by, failing to attempt alternative measures before applying restraints for 1 of 2 patients (Patient #30).

Findings include:

The hospital policy titled Guidelines for the Use of Restraint for Voluntary/Involuntary Immobilization #HW1132 Version 19.0 (last revised 01/11), requires: "...Documentation needs to reflect...Alternative measures attempted before use of restraints...Clear evidence of steps followed to protect the patient with less restrictive measures prior to application of restraints...."

Patient #30's medical record did not verify the alternative or less restrictive measures attempted before applying restraints.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policies/procedures, medical records, documents, and staff interviews, it was determined that the hospital failed to require patients' restraints were discontinued at the earliest possible time, for 1 of 2 patients when behaviors that warranted the restraints were not evident (Patient #30).

Findings include:

The hospital policy titled Guidelines for the Use of Restraint for Voluntary/Involuntary Immobilization #HW1132 Version 19.0 (last revised 01/11), requires: "...There are no PRN (as needed) orders. There are also no protocols for restraint use...Documentation needs to reflect...The patient's behavior and the intervention used...Continuing descriptions of patient behaviors necessitating restraints...The patient's response to the use of the restraint...."

The hospital policy titled The Medical Record #HIM1006 Version 1.0 (effective 08/11), requires: "...The medical record shall contain sufficient information to...justify the treatment...."

Patient #30 was admitted on [DATE] with sepsis and respiratory distress, according to the medical record. Documentation revealed the following:

03/20/13 (1600): patient intubated
03/20/13 (1800): physician ordered restraints for "potential dislodging tubes/dressing"
03/20/13 (1830): patient placed in three (3) point restraints.
03/20/13 (2000): restrained
03/20/13 (2200): restrained
03/20/13 (2300): restrained
03/21/13 (0001): restrained
03/21/13 (0200): restrained
03/21/13 (0400): restrained
03/21/13 (0713): "calm...cooperative." Restraints released for 10 minutes and reapplied.
03/21/13 (0900): "impaired safety judgement"
03/21/13 (1000): "patient agrees to call for assistance...cooperative with safety precautions." Restraints released for 10 minutes and reapplied.
03/21/13 (1138): "obeys commands"

Nurses documented Safety Restraint Criteria as "ventilator," and restraint type as "patient safety" or "soft." Nurses documented throughout the medical record the patient's status as "laying in bed...will continue to monitor." Documentation did not indicate the patient's actions that warranted the restraints that were in place from 03/20/12 at 1800, to 03/21/13 at 1138.

ICU Director RN #7 stated during an interview conducted on 03/21/13 at 1400, that the restraints remained in place per "physician's request."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policies/procedures, medical records, documents, and staff interviews, it was determined the hospital failed to require patients' were secluded according to a physicians' order for 3 of 3 patients in seclusion (Patient #'s 25, 26 and 27).

Findings include:

The hospital policy titled Guidelines for the Use of Restraint for Voluntary/Involuntary Immobilization #HW1132 Version 19.0 (last revised 01/11), requires: "...Seclusion is...confining (a patient) alone in a room or area where he/she is physically prevented from leaving...A situation where a patient is restricted to a room alone and staff are...giving the perception that threatens the patient with physical intervention if the patient leaves the room...."

Chief Quality Officer #4 and ED Director #7, identified Patients #25, 26, and 27 as secluded for behavioral concerns during their ED visits, during interviews conducted on 03/22/13, as follows:

Patient #25 (MDS) dated [DATE] at 0320 with diagnosed alcohol intoxication, according to the medical record. The patient was combative, and medicated. Security personnel were posted at the patient's bedside (according to Security documents). The patient was discharged into police custody at 0636.

The physician did not document an order for seclusion.

Patient #26 (MDS) dated [DATE] at 1420, with diagnosed drug overdose, depression, and hallucinations, according to the medical record. Security personnel were posted at the door (according to Security documents). The patient was transferred to an off campus inpatient psychiatric facility at 2328.

Chief Quality Officer #4 confirmed no physician order for seclusion, during an interview conducted on 03/22/13 at 1015.

Patient #27 (MDS) dated [DATE] at 1448, with diagnosed suicidal ideation and abdominal pain, according to the medical record. Co-morbidities included bipolar disorder, schizophrenia, and many previous suicide attempts. Security personnel were posted at the patient's door (according to Security documents). The patient was transferred to an off campus inpatient psychiatric facility at 1755.

The physician did not document an order for seclusion.
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of Medical Staff Rules and Regulations, hospital policies/procedures, medical records, and staff interviews, it was determined that the medical staff failed to enforce its bylaws for 4 of 4 patient records reviewed as demonstrated by;

1. failing to require a complete order for titrating Tridil (Patient #9);

2. failing to require complete orders for titrating Versed (Patient #'s 28 and 30); and

3. failing to require the hospital's social services consulted with 1 of 1 suicidal psychiatric patients (Patient #27).

Findings include:

The hospital's Medical Staff Rules and Regulations (last updated 03/12) require: "...All practitioners' orders must be written clearly, legibly and completely...."

The hospital policy titled Safe Order Writing #HW1159 Version 7.0 (last revised 01/11) requires: "...Do not add orders after completion. Once an order is signed, write any further orders as new orders. Do not modify an existing order. Discontinue the previous order and write a new one instead...All medication orders include at a minimum...the dosage, the route and frequency of administration...Open ended analgesic orders such as 'titrate to comfort' lack specific parameters, are vague, and prone to variable and unsafe interpretation...."

1. Patient #9 was admitted on [DATE] with osteoarthritis of both knees and coronary artery disease. The patient underwent bilateral total knee replacements on 02/28/13, and the next day he developed chest pain. He was transferred to the ICU on 03/01/13 at approximately 1630 hours.

A physician's order written on 03/01/13 at 1515 hours, included: "...tridil gtt (drip)--titrate to control cp (chest pain)...."

No other orders were in the record as of 03/21/13.

2. Patient #28 was admitted on [DATE], post overdose and suicide attempt, according to the medical record. The physician documented the following incomplete order:

03/21/13 (1635): "...Versed drip...."

Patient #30 was admitted on [DATE] with sepsis and respiratory distress, according to the medical record. The physician documented the following incomplete orders:

03/20/13 (1620 verbal order): "...Versed gtt (drip) while on vent (ventilator)...."

03/20/12 (2055 verbal order): "...Increase/titrate sedation to decrease spont. (spontaneous) resp (respiratory) rate to (less than) 2 of set vent (ventilator) rate...."

03/21/13 (1415): directly under and included in the 03/20/12 at 1622 order: "...Versed start at 2 mg/kg/hr increase by 3 mg every 5 min (minutes)...." This order modified the existing 03/20/12 1620 order.

ICU Director RN #7 stated during an interview conducted on 03/21/13 at 1400, that the staff often accept a vague verbal order "to get the medication from the pharmacy so it can be started." The physician will then document clarification in a separate order.

It was unclear as to why nursing felt the pharmacy needed an incomplete order to dispense medication. ICU Director RN #7 confirmed that the Versed order was incomplete and should have been clarified before nursing began administering the medication on 03/20/13 at 1654.

3. The hospital's Medical Staff Rules and Regulations require: "...Any patient known or suspected to be suicidal must have a consultation by a mental health professional within 24 hours of admission and the consultation documented...."

The hospital policy titled Suicide Prevention #HW1224 Version 3.0 (last revised 10/11) requires: "...social work staff routinely screen for suicidal ideation/behaviors...a mental status exam and a suicide risk assessment is completed by the social worker...."

Patient #27 (MDS) dated [DATE] at 1448, with diagnosed suicidal ideation according to the medical record. Co-morbidities included bipolar disorder, schizophrenia, and many previous suicide attempts. The patient was transferred to an off campus inpatient psychiatric facility at 1755.

The hospital policy titled Suicide Prevention #HW1224 Version 3.0 (last revised 10/11) requires: "...social work staff routinely screen for suicidal ideation/behaviors...a mental status exam and a suicide risk assessment is completed by the social worker...."

According to documentation provided by the hospital, a counselor from the non-hospital affiliated or contracted inpatient psychiatric facility met with the patient in the hospital ED, provided "crisis assessment," "coordinated care with the ER staff," and referred the patient to the off campus facility.

The Chief Compliance Officer (CCO) confirmed during an interview conducted on 03/21/13, that the hospital has no contract or agreement with the off campus organization/facility to perform in-hospital crisis assessments.

The hospital confirmed on 03/22/13, that the off campus facility visited the patient to obtain "medical clearance," that the hospital social worker "wasn't involved" per Medical Staff Rules and Regulations requirements, and that the physician did not document an order for the facility to contact/consult with the patient.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on review of medical records, policies/procedures, and interviews with staff, it was determined the hospital failed to ensure nursing services were supervised and evaluated, as demonstrated by failing to:

Tag 0395 482.23(b)(3) reassess and intervene for Pt #2's oxygen (O2) saturation of 84% at 0624 on 03/16/13, and labored, tachypneic, and grunting respirations at 0930 on 03/16/13; assess and reassess Pt #15's condition and pain, and notify the physician of elevated enzymes; and directly supervise and evaluate the nursing care provided by LPN #37 to ED Pt #29 related to the patient's initial assessment, nursing treatment, patient education, and application/monitoring of restraints on 01/09/13;

Tag 0396 482.23(b)(4) require Care Plans were developed specific to the needs of pediatric patients; and

Tag 0406 482.23(c)(2) require complete Tridil titration orders for 1 of 1 patients (Patient #9); and require complete Versed titration orders for 2 of 2 patients (Patient #'s 28 and 30).

The cumulative effect of these deficient practices resulted in the hospital not being compliant with the Nursing Services Condition of Participation.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, policies/procedures, and interviews with staff, it was determined the nurse executive failed to require a registered nurse supervised and evaluated care provided to (3 of 3) patients (Pt #'s 2, 9, and 29) as demonstrated by failing to:

1. reassess and intervene for Pt #2's oxygen (O2) saturation of 84% at 0624 on 03/16/13, and labored, tachypneic, and grunting respirations at 0930 on 03/16/13;

2. assess and reassess Pt #9's condition and pain, and notify the physician of elevated enzymes; and

3. directly supervise and evaluate the nursing care provided by LPN #37 to ED Pt #29 related to the patient's initial assessment, nursing treatment, patient education, and application/monitoring of restraints on 01/09/13.

Findings include:

The hospital's policy titled Initial Admission and Reassessments required: "...Reassessments are performed by the RN. Patients are reassessed each 24 hours or more often as pertinent to the patient's course of treatment; To determine the patient's response to treatment; When a significant change occurs in the patient's condition...Documentation of the reassessment of all patients is noted in the patient's medical record...."

The hospital's policy titled Assessments of Patients required: "...Patient assessment is the basis of recognizing patient problems and needs, and identifying and planning specific, individual intervention and course of treatment...."

1. Patient #2 was admitted on [DATE] at 18:15 hours with the following diagnoses: Nausea, vomiting, diarrhea, diabetes mellitus, hypertension, and coronary artery disease.

On 03/16/13 at 0230 documentation included: oxygen (O2) saturation (sat) of 94% on 5 liters (L) of O2, respiratory rate (RR) 16;

0630 hours: O2 sat 84% on 5 L of O2, RR 22;

0730 hours: Nursing indicated breath sounds were clear all fields;

0923 hours: respiratory therapy entered room and family requested continuous positive airway pressure (CPAP) machine and the registered nurse (RN) entered the room at the same time. Respiratory therapy documented labored, tachypneic and grunting respirations, (no O2 sat is documented);

1527 hours: O2 sats 87%, on 6 L of O2, RR 28;

1540 hours: Respiratory therapy noted breath sounds coarse all fields and an initial small volume nebulizer (SVN) with Xopenex given;

1627: Nursing documented calling the attending physician regarding: "...pts respiratory status, pt is de-sating to 83% on c-pap at 6 lpm (liters per minute). New order obtained for pt to have xopenex SVN now and q (every) 4 hours...."

1640 hours: Patient is transferred to intensive care unit (ICU).

Nursing and Respiratory Therapy did not document a reassessment of the patient's O2 sat level of 84% at 0630 until nine hours later at 1527 when the O2 sat level was 87% on 6 L. The physician was notified at 1627 hours and orders were received and the patient was transferred unexpectedly to the ICU.

The Director of the Medical/Surgical Unit, and Employee #15, reviewed the documentation for Patient #2. They confirmed the above findings. They also thought the Respiratory Therapist might have documented on the wrong patient, as the patient next door to Pt #2 also was having respiratory problems (Pt #31). However, review of Pt #31 revealed the patient was not on CPAP and his O2 sat levels were 90% or higher on 03/16/13.

2. Patient #9 was admitted on [DATE] with osteoarthritis of both knees and coronary artery disease. The patient underwent bilateral total knee replacements on 02/28/13 and the next day he developed chest pain.

Documentation in the medical record for 03/01/13 included:

0811 hours: (Medical/Surgical Unit #2) Chest pain, diaphoretic and pain level is 10/10 (pain level 0-10, with 10 the worst pain ever).

0820 hours: A physician's order included: "...NTG (nitroglycerin) 0.4 mg (milligrams) SL (sublingual) Q (every) 5 minutes prn (as needed) for pain...ECASA (enteric coated aspirin) 325 mg PO (orally) now...move to tele...Trop-I (troponin)/ ck (creatine kinase)/ mb (myocardial band) Q 6 hours X (times) 3-call if elevated...."

0840 hours: Patient #9 is transferred to the telemetry unit (Medical/Surgical #1), RN #32 is assigned to the patient;

0900 hours: The Medication Administration Record (MAR) documentation included oxycodone 10 milligrams (mg) orally;

0900 hours: MAR documentation included Nitroglycerin 0.4 mg sublingual;

1023 hours: The Patient Care Tech (PCT) documented orienting the patient to the room;

1100 hours: MAR documentation included Nitro Dur 0.2 mg patch;

1105 hours: MAR documentation included Nitroglycerin 0.4 mg sublingual;

1237 hours: MAR documentation included Percocet 1 tablet orally;

1414 hours: Case Management RN visits patient for discharge planning;

1419 hours: MAR documentation included Morphine 4 mg intravenous (IV) push;

1500 hours: Physical Therapy noted nursing placed a hold on therapy due to cardiac status;

1628 hours: Intensive Care RN documentation begins.

On 03/21/13, the Director of Medical/Surgical Services and the Chief Nursing Officer (CNO) confirmed:

a. RN #15 caring for Patient #9 on the telemetry floor did not document any assessments of the patient as required by policy;

b. RN #15 did not document an assessment of the patient's pain prior to administering pain medication and evaluate the patient's pain after pain medication was administered; and

c. RN #15 did not notify the physician of an elevated Troponin/CK and CKmb, according to the physician's order.

3. The hospital policy titled Nursing Leadership Authority and Roles #NU1099 Version 9.0 (last revised 03/11), requires: "...The nursing management group has the responsibility and authority to provide leadership and direction for nursing care...."

The hospital policy titled Nursing Scope of Practice, Arizona State Board of Nursing #NU1039 Version 3.0 (last revised 02/11), requires: "...A licensed practical nurse may provide nursing care only under the supervision of a professional nurse or licensed physician...The scope of practice for a professional nurse includes...Providing the nursing supervision in the planning for and provision of nursing care to patients and the directing and evaluating of nursing care provided by other licensed nurses...A professional nurse is responsible both for the nursing care directly provided by the nurse and the care provided by others who are under the professional nurse's supervision...."

Patient #29 (MDS) dated [DATE] at 1535, with suicidal ideation, according to the medical record. The RN triaged the patient at 1536, and administered medication at 1551. LPN #37 performed the initial assessment at 1600, documented vital signs, initiated an intravenous line, and infused fluids and medication, performed an electrocardiogram (EKG), inserted a urinary catheter, initiated and discontinued restraints, and discharged the patient.

ED Director RN #40 reviewed Patient #29's medical record during an interview conducted on 03/21/13 at 1400, and confirmed that the RN conducted the triage at 1536, but also confirmed the triage was not the patient's assessment. The ED Director stated that RN signed her name indicating agreement with the LPN's documentation at 1551. The patient's initial assessment was documented by the LPN at 1600, which was 9 minutes after the RN made her entry.

Documentation did not demonstrate that the RN supervised the LPN in the care of patient #29.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policies/procedures, medical records, and staff interviews, it was determined that the hospital failed to require Care Plans were developed specific to the needs of pediatric patients.

Findings include:

The hospital policy titled Pediatric Patient Care Standards #NU1083 Version 9.0 (last revised 03/11), requires: "...The plan for nursing care...is individualized and based upon the nursing assessment...includes therapeutic interventions...The plan for care is updated and revised as indicated by changes in the patient's condition and response to intervention...."

The hospital policy titled Interdisciplinary Care Planning Process #HW1154 Version 10.0 (last revised 04/12), requires: "...The plan of care reflects the patient's unique needs and is consistent with the medical diagnosis and physician orders...The problem list, goals, and treatment plan are customized to reflect the patient's status and goals...The plan of care and associated goals are reviewed periodically and are updated according to the patient's status and progress. Changes in the care plan are based upon a reassessment and the patient's ongoing needs...."

Patient #5, an infant, was admitted on [DATE] for treatment of hyberbilirubinemia and urinary tract infection, according to the medical record. The Care Plan initiated on 03/15/13, revealed two (2) entries: Impaired Elimination, and High Fall Risk.

Interventions for High Fall Risk included: "...re-orient confused patient, referral to Physical Therapy services for evaluation, and monitor the patient during toileting...." There were no amendments to the Care Plan as of 03/19/13 at 1300 (4 days post patient admission).

The Chief Quality Officer RN #4, the Med/Surg 2 Director RN #12, and the Med/Surg Charge RN #18, all confirmed during interviews conducted on 03/19/13 at 1300, that Care Plan interventions are selected (electronically) from a "drop down" list specific for adult patients. All interviewees confirmed that the hospital does not have Care Plans specific to pediatric patients.
VIOLATION: WRITTEN MEDICAL ODERS FOR DRUGS Tag No: A0406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policies/procedures, medical records, and staff interviews, it was determined that administrator failed to require medications were administered according to complete physicians' orders, as demonstrated by:

1. failing to require complete Tridil titration orders for 1 of 1 patients (Patient #9); and

2. failing to require complete Versed titration orders for 2 of 2 patients (Patient #'s 28 and 30).

Findings include:

The hospital policy titled Safe Order Writing #HW1159 Version 7.0 (last revised 01/11), requires: "...Do not add orders after completion. Once an order is signed, write any further orders as new orders. Do not modify an existing order. Discontinue the previous order and write a new one instead...All medication orders include at a minimum...the dosage, the route and frequency of administration...Open ended analgesic orders such as 'titrate to comfort' lack specific parameters, are vague, and prone to variable and unsafe interpretation...."

1. Patient #9 was admitted on [DATE] with osteoarthritis of both knees and coronary artery disease. The patient underwent bilateral total knee replacements on 02/28/13, and the next day he developed chest pain. He was transferred to the ICU on 03/01/13 at approximately 1630 hours.

A physician's order written on 03/01/13 at 1515 hours included: "... tridil gtt (drip)--titrate to control cp (chest pain)...."

No other orders were in the record as of 03/21/13.

2. Patient #28 was admitted on [DATE] at 1631 after a drug overdose suicide attempt.

On 03/21/13 at 1735 hours, the ED physician ordered "...versed drip...." The ED nurse started the Versed drip at 1615 hours at 0.2 mg/kg (kilogram)/hour, without a complete order.

Nurses documented administering the Versed drip as follows:
03/21/13 1815 hours: 0.2 mg/kg/hr;
03/21/13 1845 hours: 0.15 mg/kg/hr;
03/21/13 1930 hours: 0.1 mg/kg/hr; and
03/21/13 2000 hours: 0.05 mg/kg/hr.

On 03/21/13 at 1740 hours, a physician ordered "...Midazolam (Versed) 3 mg IVP (intravenous push) every 1 hr. PRN anxiety...."

Nursing administered a Versed drip without a complete order and without obtaining a clarifying order for the Versed drip and prn IVP Versed.

Patient #30 was admitted on [DATE] with sepsis and respiratory distress, according to the medical record. Physicians' orders included the following:

03/20/13 (1620 verbal order): "...Versed gtt (drip) while on vent (ventilator)...." The Unit Secretary faxed the order to the pharmacy on 03/20/13 at 1622.

03/20/12 (2055 verbal order): "...Increase/titrate sedation to decrease spont. (spontaneous) resp (respiratory) rate to (less than) 2 of set vent (ventilator) rate...."

03/21/13 (1415): the physician added to the 03/20/13 1620 order: "...Versed start at 2 mg/kg/hr increase by 3 mg every 5 min (minutes) to meet goal Ramsey at 3...."

Nurses administered Versed, as follows:

03/20/13:

1654: Initiated at .05 mg/kg/hr
1705: increased to "1" mg/kg/hr
1900: 0.1 mg/kg/hr
2030: increased to 0.15 mg/kg/hr

03/21/13:

0001: increased to 0.2 mg/kg/hr
0700: 0.2 mg/kg/hr
0900: 0.2 mg/kg/hr
1324: decreased to 0.18 mg/kg/hr
1400: 0.18 mg/kg/hr

ICU Director RN #7 confirmed during an interview conducted on 03/22/13 at 1615, that the physician's 03/21/13 1620 order was incomplete, and that the nursing staff did not administer the Versed at the rate ordered on [DATE] at 1415, because the order was added to the order sheet after it was faxed to the pharmacy. The Medication Administration Record (MAR) did not reflect the late order written on 03/21/13 at 1415.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, observations during electronic record reviews in patient care areas, and interviews with staff, it was determined the hospital failed to ensure staff were trained and competent in accessing the electronic medical record to retrieve information regarding their assigned patients.

Findings include:

The hospital policy titled The Medical Record #HIM1006 required: "...all information regarding an individual patient is retrievable and accessible for continuing care...."

On 03/19/13, a tour of the ICU unit was conducted. Patient # 2 was selected for a chart review by the surveyor.

Patient #2 was admitted on [DATE] at 18:15 hours with the following diagnoses: Nausea, vomiting, diarrhea, diabetes mellitus, hypertension, and coronary artery disease.

The surveyor inquired about the following entry in the medical record:

03/16/13 (0923 hours): respiratory therapy entered room and family requested continuous positive airway pressure (CPAP) machine and the registered nurse (RN) entered the room at the same time. Respiratory therapy documented labored, tachypneic and grunting respirations, (no O2 sat is documented);

The staff were asked what interventions were taken when the patient's respirations were noted to be "labored, tachypneic, and grunting" and what was the patient's O2 saturation level.

The Director of ICU could not navigate the record and the nurse caring for the patient was summoned to help. This nurse could not determine what happened and suggested the Telemetry nurse could help since the patient was in the telemetry unit for this entry. The Telemetry Charge Nurse came over and could not determine what happened with the patient. A Respiratory Therapist in the ICU unit also attempted to retrieve information. At this time the Director of ICU suggested we call medical records to print this portion of the record for review.

The next day 03/20/13, the nurse who cared for Patient #2 was interviewed. She also could not navigate the medical record for clarity of what happened to Pt #2. Patient #2 was transferred emergently to the ICU unit on 03/16/13 at approximately 1640 hours. The Director of the Medical/Surgical Unit, and Employee #15, reviewed the documentation for Patient #2. They suggested the Respiratory Therapist might have documented on the wrong patient, as the patient next door to Pt #2 also was having respiratory problems (Pt #31). However, review of Pt #31 revealed the patient was not on CPAP and his O2 sat levels were 90% or higher on 03/16/13.

Time spent attempting to ascertain what happened to Pt #2 on 03/16/13 from 0930 hours until 1640 took staff approximately a total 4 hours on 2 different days.

Review of Patient # 9 was conducted on 03/21/13 with the CNO and Quality Team member.

Patient #9 was admitted on [DATE] with osteoarthritis of both knees and coronary artery disease. The patient underwent bilateral total knee replacements on 02/28/13 and the next day he developed chest pain.

Documentation in the medical record for 03/01/13 included:

0811 hours: (Medical/Surgical Unit #2) Chest pain, diaphoretic and pain level is 10/10 (pain level 0-10, with 10 the worst pain ever).

0840 hours: Patient #9 is transferred to the telemetry unit (Medical/Surgical #1), RN #32 is assigned to the patient; and

1628 hours: Intensive Care RN documentation begins.

The surveyor asked what care and assessments were obtained by the telemetry nurse for the 9 hours the patient was on the telemetry unit.

The Director of the Medical/Surgical Services and CNO both attempted to gather the information from the medical record, approximately 2 hours were spent attempting to retrieve information.

The next day, on 03/22/13, the Director of Medical/Surgical Services confirmed they could not find nursing notes by the Registered Nurse (RN) during the telemetry unit stay. The patient was emergently transferred to the ICU unit at an unknown time. Intensive Care Unit documentation began at 1628 hours.

The Quality Specialist confirmed on 03/19/13, that the staff could not navigate the medical record to obtain information from past assessments.


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