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.

SCRIPPS MERCY HOSPITAL 4077 5TH AVE SAN DIEGO, CA 92103 Oct. 3, 2011
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and record review, Hospital A failed to provide a safe environment for 1 patient (31) after she informed her nurse about an allegation of sexual assault by her roommate. Hospital A failed to ensure that 1 patient (31) was protected and not neglected after she related an allegation of sexual abuse by her roommate. The hospital failed to implement it's policy and procedure regarding written notice of grievance resolution to 4 complainants (15, 21, 22, 34). The Emergency Department (ED) staff at Hospital B failed to determine the existence of an Advanced Directive for 1 patient(38). Hospital B failed to obtain timely physicians orders for 3 patients (11, 12, 42) in restraints. Hospital B failed to ensure that restraint orders were not written on an as needed basis for 1 patient (11). Hospital B failed to ensure that 2 patients (12, 42) were assessed by the physician prior to the renewal of a restraint order.

Findings:

1. A safe environment was not provided for 1 patient (31) after she informed her nurse of an allegation of sexual assault by her roommate.

A Tag 144

2. One patient (31) was not protected and was neglected by the clinical staff when the patient verbalized an allegation of sexual assault.

A Tag 145

3. A written notification that provided the patient with names of the hospital's representatives involved in the grievance investigation, the actions taken, the result of the investigation, and the date the investigation was completed was not provided for 4 patients (15, 21, 22, 34).

A Tag 123 (#1, #2, #3, #4)

4. The ED staff at Hospital B did not determine the existence of an Advanced Directive for 1 patient (38).

A Tag 132

5. Timely physicians orders were not obtained for 3 patients (11, 12, 42) in restraints.

A Tag 168 (#1,#2, #3)

6. A restraint order was written as an "as needed" order for 1 patient (11).

A Tag 169

7. Two patients (12, 42) were not seen and assessed by the physician prior to the renewal of their restraint orders.

A Tag 172 (#1, #2)

The cumulative effect of these systemic practices and issues resulted in the failure of the hospital to deliver statutorily mandated compliance with the Condition of Patient Rights.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the hospital failed to implement its Patient Complaint/Grievance policy and procedure, when 4 of 6 patients (15, 21, 22, 34) were not provided with a written notification concerning the grievance investigation, results of the investigation, and the date of completion of the investigation.

Findings:

1. A review of the hospital's complaint/grievance process was conducted on 10/3/11 at 10:45 A.M., with the Director of Risk Management (DRM).

A review of the hospital's Patient Complaint/Grievance Process policy and procedure, dated 8/09, was reviewed on 10/3/11 at 10:30 A.M. Per the policy, the name of the investigation hospital representative, steps taken on behalf of the patient to investigate the grievance, results of the grievance process, and the date of completion of the grievance process was to be provided to the patient in writing.

Per the DRM, Patient Relations was informed on 5/1/11, about a complaint that Patient 15 reported on 4/30/11. A review of the patient's complaint was conducted with the DRM on 10/3/11 at 10:45 A.M. The communication between the patient and hospital representatives regarding the investigation of the complaint was well documented. However, the DRM acknowledged that a written notification that provided the patient with the names of the hospital representatives involved with the investigation, the actions taken, the result of the investigation, and the date the investigation was completed, was not provided to the patient as indicated in the hospital's policy and procedure.





2. A review of the hospital's complaint/grievance process was conducted on 10/3/11 at 8:15 A.M., with the Director of Risk Management (DRM).

A review of the hospital's Patient Complaint/Grievance Process policy and procedure, dated 8/09, was reviewed on 10/3/11 at 8:25 A.M. Per the policy, the name of the investigation hospital representative, steps taken on behalf of the patient to investigate the grievance, results of the grievance process, and the date of completion of the grievance process was to be provided to the patient in writing.

Per the DRM, Patient 21 filed a written grievance with the hospital on [DATE] concerning her care in the Emergency Department on 7/17/11.
A review of the patient's grievance and clinical record was done with the DRM on 10/3/11 at 8:40 A.M.

According to the DRM, Patient 21's grievance had been forwarded to a third party administrator on 7/26/11, for resolution since the patient requested monetary compensation. Per the DRM, the grievance was closed from the risk management/patient relations perspective. Per the DRM, no written notification concerning the steps taken by risk management/patient relations to resolve the patient's concerns, or what the next steps would be, was provided to Patient 21. The DRM acknowledged that some form of written notification should have been sent to the patient in accordance with the hospital's policy and procedure.

3. A review of the hospital's complaint/grievance process was conducted on 10/3/11 at 8:15 A.M. with the Director of Risk Management (DRM).

A review of the hospital's Patient Complaint/Grievance Process policy and procedure, dated 8/09, was reviewed on 10/3/11 at 8:25 A.M. Per the policy, the name of the investigation hospital representative, steps taken on behalf of the patient to investigate the grievance, results of the grievance process, and the date of completion of the grievance process was to be provided to the patient in writing.

Per the DRM, Patient 22 filed a grievance via electronic mail with the hospital on [DATE] concerning her care in the Emergency Department on that same date. A review of the patient's grievance and clinical record was done with the DRM on 10/3/11 at 9:00 A.M.

According to the DRM, a response from the hospital which acknowledged the grievance and requested the patient to contact the patient relations department for further discussion was sent to the patient via electronic mail on 7/5/11. Per the DRM, the patient never responded, and the grievance was closed on 7/12/11. Per the DRM, no further written notification was sent to the patient with an explanation of the hospital's intended actions to consider the grievance closed since the patient did not respond back after the first correspondence. The DRM acknowledged that some form of written notification should have been sent to the patient, in accordance with the hospital's policy and procedure.





4. A review of the hospital's complaint/grievance process was conducted on 10/3/11 at 8:15 A.M., with the Director of Risk Management (DRM).

A review of the hospital's Patient Complaint/Grievance Process policy and procedure dated 8/09, was reviewed on 10/3/11 at 8:25 A.M. Per the policy, the name of the investigation hospital representative and steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion of the grievance process, was to be provided to the patient in writing.

According to the DRM, Patient 34 arrived in person at the hospital's Risk Management office on 8/10/11, to file a complaint. She stated that she had just been treated in Hospital A's Emergency Department (ED). Her complaint was that the interpreter that was provided to her in the ED "was loud, rushing her, would interrupt her and would respond that what she was saying wasn't accurate." According to the Complaint Synopsis written by the Coordinator of Patient Relations and Risk Management, Patient 34 "took my card and said she would be back next week and would follow up with feedback at that point." There was no documentation in the Complaint Synopsis that any investigation of the complaint had occurred. The last entry, written by the Coordinator on 9/23/11, read "No further contact from Pt. (patient). Will close."

An interview was conducted with the DRM on 10/3/11 at 10:15 A.M. The DRM stated that she was concerned that this complaint was closed out before any investigation took place, such as an interview with the interpreter and the ED Manager. The DRM acknowledged that the Complaint/Grievance process was not followed. The DRM also stated that at least one more attempt should have been made to contact the patient. The DRM also acknowledged that some form of written notification should have been sent to the patient.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0172
Based on interview and record review, the facility failed to provide documented evidence that, 2 of 9 sampled patients (12,42) were seen and assessed by the physician, prior to ordering and renewing restraint orders.

Findings:

1. On 10/3/11 at 9:40 A.M., Patient 12's medical record was reviewed. Patient 12 was admitted to Hospital B on 8/27/11, per the facesheet.

A review of the Restraint Orders Non-Behavior sheet indicated that a telephone order for bilateral mittens and bilateral wrist restraints, was obtained on 8/30/11 at 6:05 P.M. The section on the order sheet that would indicate that the patient was examined by the physician was left blank. There was no documented evidence that Patient 12's physician assessed the patient prior to ordering the restraints.

A review of the hospital's policy and procedure titled, "Restraints, Non-Behavioral Management, Use in Acute Care" indicated that, "Renewal of the restraint order or a new order will be issued no less often than once each calendar day and will be based on the physician's examination of the patient."

A joint record review and interview with the Advance Practice Nurse (APN) was conducted on 10/3/11 at 10:00 A.M. The APN acknowledged that there was no documented evidence that Patient 12's physician assessed the patient prior to ordering the restraints.





2. A review of Patient 42's medical record was conducted on 10/3/11, at 8:55 A.M. Patient 42 was admitted to Hospital B on 8/10/11, per the Facesheet.

A review of Patient 42's (renewal) Restraint Orders Non-Behavior sheets indicated that a telephone order for bilateral wrist restraints, was obtained on 8/20/11 (unable to determine time listed), 8/21/11 at 10:00 A.M., and 8/22/11 at 8:00 A.M. The section on the order sheets that would indicate that the patient was examined by the physician was left blank. There was no documented evidence that Patient 42's physician assessed the patient prior to re-ordering the restraints.

A review of the hospital's policy and procedure entitled, "Restraints, Non-Behavioral Management, Use in Acute Care" indicated that, "Renewal of the restraint order or a new order will be issued no less often than once each calendar day and will be based on the physician's examination of the patient."

An interview and joint record review with the Advance Practice Nurse (APN) was conducted on 10/3/11 at 9:20 A.M. The APN acknowledged that there was no documented evidence that Patient 42's physician assessed the patient prior to re-ordering the restraints.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, Hospital B failed to ensure that the Emergency Department (ED) staff determined the existence of an Advanced Directive, for 1 of 55 sampled patients (38), when the patient was treated in the ED and admitted to the hospital.

Findings:

Patient 38 (MDS) dated [DATE], for treatment of left hip pain following a fall according to the ED physician's record. A review of Patient 38's medical record was conducted on 10/3/11 at 10:40 A.M. According to the ED physician record, Patient 38's "daughter has power of attorney (a written document in which one person appoints another person to act as an agent on his or her behalf) because the patient has Alzheimer's dementia (deterioration of intellectual faculties)." However, the Advanced Directive (a written expression of a person's desire for medical treatment used in cases were the person becomes incapacitated and is no longer capable of making his or her own decisions. Examples include Living Wills and Durable Power of Attorney) section of the ED Nursing Flowsheet was blank. There was no documentation on the ED Nursing Flowsheet to indicate if Patient 38 had an Advanced Directive or if a copy was obtained, and if not, that resource formation was provided.

A review of the hospital's policy and procedure entitled "Advance Health Care Directives," indicated that "Clinical staff in outpatient settings as appropriate to patient need or request, and the Registered Nurse for hospital inpatients, are responsible for the Advance Directive Process as follows:...Ask adult patient whether he/she has a written Advance Directive. If yes, ask him/her to provide copy for their medical record. In the event a patient lacks capacity to make his or her own health care decisions, or where the patient has indicated in his or her Advance Directive that their agent's authority to make health care decisions takes effect immediately, an agent or surrogate may make all health care decisions to the same extent the patient was able to do so."

An interview was conducted with the Director of Risk Management (DRM) on 10/3/11 at 11:20 A.M. The DRM acknowledged that there was no documentation on the ED record as to whether Patient 38 had an Advance Directive. The DRM was unable to locate a copy of any Advance Directive in the patient's electronic medical record.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on interview and record review, Hospital A failed to provide a safe environment, for 1 patient (31), after she informed her nurse about an allegation of sexual assault by her roommate.

1. Patient 31 was admitted to the Behavioral Health Unit (BHU) of Hospital A on 7/11/11, for the treatment of anxiety and depression, according to the Psychiatric Admission Assessment.

An interview was conducted with the Clinical Risk Specialist (CRS) on 7/15/11 at 3:05 P.M. The CRS stated that it was reported to her that on 7/12/11, Patient 31's female roommate (Patient 32) was found on top of Patient 31 "fondling her breasts."

On 7/15/11, at 3:25 P.M., an interview was conducted with Patient 31. Patient 31 stated that she was frightened that Patient 32 was "going to get her." Patient 31 said that she really did not want to talk about what happened. Patient 31 continued to explain that the incident occurred on 7/12/11, at 3:00 A.M. Patient 31 felt that Patient 32 was not removed quickly enough. It took the clinical staff 10 hours to place Patient 32 in the BHU Intensive Care Unit (ICU). The BHU ICU is a locked unit. In the afternoon following the incident, at the lunch table, Patient 32 sat next to Patient 31 and pushed on her leg. Patient 31 stated that she "was scared." When Patient 31 saw her physician "she ran to him." Patient 32 followed her and stood a foot away. After lunch, at about 1:30 P.M., Patient 31 was on the phone when Patient 32 walked up and tried to touch her again. Patient 31 stated that she just came to the hospital to get help for stress, anxiety and depression but she was "molested by a lesbian rapist." Patient 31 felt that the clinical staff minimized what was going on. She did not feel that the staff were protecting her. The Administrator of the Behavioral Health Unit was present during the interview with Patient 31. At the end of the interview, the Administrator stated "this can't happen again to anybody."

An interview was conducted, on 9/23/11 at 7:40 A.M., with the Registered Nurse (RN 1) who was assigned to care for Patient 31 the night of 7/12/11. RN 1 stated that another RN (RN 2) came to her and told her that he had found Patient 31 and Patient 32 lying side by side in bed. RN 1 stated that she immediately went to the patient's room. Patient 32 was sitting on the edge of the bed and Patient 31 was lying in the bed. RN 1 told Patient 32 to get back in her bed. Then she went to the Charge RN and told her that she decided to move Patient 31 to another room. Patient 31 told RN 1 that Patient 32 wanted to have sex with her. RN 1 stated that "she did not believe the patient." Patient 31 also told RN 1 that Patient 32 was going to come and find her. Patient 31 said that she was afraid. RN 1 acknowledged that she did not notify Patient 31's physician, she did not provide emotional support for the alleged victim, she did not document the incident in the medical record as it was related to her by Patient 31, she did not follow hospital policy and procedure by not transferring Patient 32 to the BHU/ICU, and she did not complete an Occurrence Report.

On 9/23/11 at 8:10 A.M., an interview was conducted with the BHU Charge RN. The Charge RN stated that she was in charge of the BHU the night of the incident. She stated that at about 3:00 A.M. RN 2 reported to her that Patient 31 and Patient 32 were found in the same bed. The Charge RN stated that Patient 32 was very psychotic. After the incident Patient 32 was very restless and pacing back and forth in the hallway. Patient 32 eventually had to be medicated. The Charge RN stated that she never talked to Patient 31 or checked on her after the incident. The Charge RN acknowledged that she did not call the physician, she did not investigate the incident by interviewing both patients, she did not call the Operations Supervisor, and she did not assess the patients in the BHU/ICU to see if one could be transferred out since the BHU/ICU was full, and she did not complete an Occurrence Report.

An interview was conducted with RN 2 on 9/23/11 at 8:30 A.M. RN 2 stated that he remembers that he was assigned to do q (every) 15 minutes rounds on all the patients in the BHU the night of the incident. When RN 2 entered Patient 31 and 32's room he found them lying in Patient 31's bed. RN 2 told Patient 32 to step away from Patient 31 and she did. RN 2 stated that he asked each patient if they were okay. Neither patient answered. RN 2 then went to RN 1 and the Charge RN and reported the incident. RN 2 further stated that during the night Patient 32 was going in and out of patient's rooms and had to be re-directed. After the incident, Patient 32 became very aggressive and had to be medicated. RN 2 acknowledged that he did not stay with Patient 31 and call for help. He also, did not complete an Occurrence Report.

A review of the hospital's policy and procedure entitled "Abuse, Assault and Neglect, Patient Screening, Identification and Reporting Requirements, dated 5/11, indicated that "in all instances in which assault, abuse, neglect is suspected or alleged:...Provide a safe environment...Provide for patient comfort and emotional support."

A review of the hospital's policy and procedure entitled "Behavioral Health - Intra-Unit Transfers - Behavioral Health Inpatient, dated 1/09, indicated "The criteria for transfer to the ICU includes but is not limited to the following:...Threatening/aggressive behavior. Sexual acting-out behaviors."

A review of the hospital's policy and procedure entitled "Occurrence Reporting," dated 1/11, indicated "Discovery of an Occurrence: Immediate Actions 1. Assess patient and/or situation and implement nursing or other professional actions and clinical procedures or treatments to include notification to the physician for orders. 2. Notify by phone or in person: Supervisor, Charge Nurse or Operations Supervisor of the occurrence and report occurrence (online MIDAS or paper form during downtime) as soon as reasonably possible. Report if in doubt as to whether a report has been completed or whether the occurrence should be reported. 3. Document in the medical record: a. Statement of the incident as it relates to the patient. Only ACTUAL FACTS will be recorded. b. Clinical condition and ongoing assessment that may be needed due to the event. c. Timely notification of the patient's physician, patient, family, if appropriate and other nursing supervisory personnel as necessary."

After Patient 31 told RN 1 that Patient 32 tried to have sex with her, Patient 32 approached Patient 31 in the BHU three more times. Patient 32 was not transferred to the BHU/ICU until approximately 10 hours after the alleged incident occurred. Hospital A failed to provide a safe environment for Patient 31.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Hospital A failed to ensure that 1 patient (31) was protected and not neglected (a form of abuse) by the clinical staff, when the patient verbalized an allegation of sexual assault with resultant fear and anxiety.

Findings:

Patient 31 was admitted to the Behavioral Health Unit (BHU) of Hospital A on 7/11/11, for the treatment of anxiety and depression, according to the Psychiatric Admission Assessment.

An interview was conducted with the Clinical Risk Specialist (CRS) on 7/15/11 at 3:05 P.M. The CRS stated that it was reported to her that on 7/12/11, Patient 31's female roommate (Patient 32) was found on top of Patient 31 "fondling her breasts."

On 7/15/11 at 3:25 P.M., an interview was conducted with Patient 31. Patient 31 stated that she was frightened that Patient 32 was "going to get her." Patient 31 said that she really did not want to talk about what happened. Patient 31 continued to explain that the incident occurred on 7/12/11 at 3:00 A.M. Patient 31 felt that Patient 32 was not removed quickly enough. It took the clinical staff 10 hours to place Patient 32 in the BHU Intensive Care Unit (ICU). The BHU ICU is a locked unit. In the afternoon following the incident, at the lunch table, Patient 32 sat next to Patient 31 and pushed on her leg. Patient 31 stated that she "was scared." When Patient 31 saw her physician "she ran to him." Patient 32 followed her and stood a foot away. After lunch, at about 1:30 P.M., Patient 31 was on the phone when Patient 32 walked up and tried to touch her again. Patient 31 stated that she just came to the hospital to get help for stress, anxiety and depression, but she was "molested by a lesbian rapist." Patient 31 felt that the clinical staff minimized what was going on. She did not feel that the staff were protecting her. The Administrator of the Behavioral Health Unit was present during the interview with Patient 31. At the end of the interview, the Administrator stated "this can't happen again to anybody."

An interview was conducted, on 9/23/11 at 7:40 A.M., with the Registered Nurse (RN 1) who was assigned to care for Patient 31 the night of 7/12/11. RN 1 stated that another RN (RN 2) came to her and told her that he had found Patient 31 and Patient 32 lying side by side in bed. RN 1 stated that she immediately went to the patient's room. Patient 32 was sitting on the edge of the bed and Patient 31 was lying in the bed. RN 2 told Patient 32 to get back in her bed. Then she went to the Charge RN and told her that she decided to move Patient 31 to another room. Patient 31 told RN 1 that Patient 32 wanted to have sex with her. RN 1 stated that "she did not believe the patient." Patient 31 also told RN 1 that Patient 32 was going to come and find her. Patient 31 said that she was afraid. RN 1 acknowledged that she did not provide any emotional support to Patient 31 and that she did not follow hospital policy by not transferring Patient 32 to The BHU/ICU.

On 9/23/11 at 8:10 A.M., an interview was conducted with the BHU Charge RN. The Charge RN stated that she was in charge of the BHU the night of the incident. She stated that at about 3:00 A.M. RN 2 reported to her that Patient 31 and Patient 32 were found in the same bed. The Charge RN stated that Patient 32 was very psychotic. After the incident Patient 32 was very restless and pacing back and forth in the hallway. Patient 32 eventually had to be medicated. The Charge RN stated that she never talked to Patient 31 or checked on her after the incident. The Charge RN acknowledged that she did not investigate the incident by interviewing both patients. She also acknowledged that she did not assess the patients in the BHU/ICU to see if one could be transferred out since the BHU/ICU was full.

An interview was conducted with RN 2 on 9/23/11 at 8:30 A.M. RN 2 stated that he remembers that he was assigned to do q (every) 15 minutes rounds on all the patients in the BHU the night of the incident. When RN 2 entered Patient 31 and 32's room he found them lying in Patient 31's bed. RN 2 told Patient 32 to step away from Patient 31 and she did. RN 2 stated that he asked each patient if they were okay. Neither patient answered. RN 2 then went to RN 1 and the Charge RN and reported the incident. RN 2 further stated that during the night, Patient 32 was going in and out of patient's rooms and had to be re-directed. After the incident, Patient 32 became very aggressive and had to be medicated. RN 2 acknowledged that he did not stay with Patient 31 and call for help.

A review of the hospital's policy and procedure entitled "Abuse, Assault and Neglect, Patient Screening, Identification and Reporting Requirements, dated 5/11, indicated that "in all instances in which assault, abuse, neglect is suspected or alleged:...Provide a safe environment...Provide for patient comfort and emotional support."

A review of the hospital's policy and procedure entitled "Behavioral Health - Intra-Unit Transfers - Behavioral Health Inpatient, dated 1/09 indicated "The criteria for transfer to the ICU includes but is not limited to the following:...Threatening/aggressive behavior. Sexual acting-out behaviors."

A review of the hospital's policy and procedure entitled "Occurrence Reporting", dated 1/11, indicated "Discovery of an Occurrence: Immediate Actions 1. Assess patient and/or situation and implement nursing or other professional actions and clinical procedures or treatments to include notification to the physician for orders. 2. Notify by phone or in person: Supervisor, Charge Nurse or Operations Supervisor of the occurrence and report occurrence (online MIDAS or paper form during downtime) as soon as reasonably possible. Report if in doubt as to whether a report has been completed or whether the occurrence should be reported. 3. Document in the medical record: a. Statement of the incident as it relates to the patient. Only ACTUAL FACTS will be recorded. b. Clinical condition and ongoing assessment that may be needed due to the event. c. Timely notification of the patient's physician, patient, family, if appropriate and other nursing supervisory personnel as necessary."

Hospital A neglected to protect Patient 31 from the possibility of further abuse by Patient 32, until 10 hours after the alleged incident occurred, when Patient 32 was transferred to the locked BHU/ICU unit. Hospital A neglected to conduct an investigation, in a timely manner, of the alleged sexual assault in accordance with their abuse policy and procedure.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on interview and record review, the facility failed to ensure that timely physician's orders were obtained, for 3 of 9 sampled patients (11, 12, 42) in restraints.

Findings:

1. On 9/28/11 at 2:40 P.M., Patient 11's medical record was reviewed. Patient 11 was admitted to Hospital B on 8/29/11, per the facesheet. According to the History and Physical dated, 8/30/11, the patient had increased confusion and agitation.

According to the "Restraint Orders Non-Behavior" sheet, dated 8/29/11, at 5:30 P.M., Patient 11 was ordered to have bilateral wrist and ankle restraints due to the patient's "attempts to disrupt medical equipment or lines and attempts to stand or ambulate without assistance."

A review of the Restraint Summary Report, dated 8/29/11 at 11:00 P.M., indicated that Patient 11 continued to pull on her urinary catheter and would kick her legs when restraints were removed. Further review of the Restraint Summary Report, dated 8/30/11 at 12:00 P.M., indicated that the patient's restraints were off and that the patient remained calm while off of restraints. Following the documentation on 8/30/11 at 12:00 P.M., there was no further documentation regarding the use of restraints for Patient 11 on the Restraint Summary Report until 8/30/11 at 10:30 P.M., 10 hours and 30 minutes later. Based on the documents reviewed, the patient was off of restraints for more than 10 hours. According to the Restraint Summary Report, dated 8/30/11 at 10:30 P.M., the patient had bilateral mittens, bilateral wrist restraints and a roll belt.

A review of the Nursing Narrative, dated 8/30/11 at 8:55 P.M., indicated that Patient 11 was found on the floor on 8/30/11 at 8:48 P.M. Per the same report, dated 8/30/11 at 10:00 P.M., the patient was confused and restless and was pulling on the intravenous lines and urinary catheter. The report also indicated that Patient 11 was placed on bilateral wrist restraints, bilateral mittens and a roll belt. However, a review of the Restraint Orders Non-Behavior sheet, dated 8/31/11, indicated that orders for the 3 restraints applied to the patient on 8/30/11 at 10:00 P.M. were not obtained until 8/31/11 at 10:20 A.M., 10 hours and 20 minutes after the restraints were applied to the patient.

On 9/28/11 at 3:30 P.M., the hospital's policy and procedure titled "Restraints, Non-Behavioral Management, Use in Acute Care" was reviewed. According to the hospital's policy, "1. A physician order is required prior to the application of restraint (except in an emergency) for all restraint use." This policy was not followed when Patient 11 was placed on bilateral wrist, bilateral mittens and a roll belt without an order from the patient's physician.

A joint record review and interview with the Advance Practice Nurse (APN) was conducted on 10/3/11 at 9:00 A.M. The APN stated that orders should have been obtained before the restraints were applied to Patient 11.

2. On 10/3/11 at 9:40 A.M., Patient 12's medical record was reviewed. Patient 12 was admitted to Hospital B on 8/27/11 per the facesheet.

A review of the Restraint Summary Report, dated 8/29/11 at 5:30 P.M., indicated that bilateral mittens and bilateral wrist restraints were applied to Patient 12. However, a review of the Restraint Orders Non-Behavior sheet indicated that the order for the restraints was not obtained until 8/30/11 at 6:05 P.M., almost 25 hours later.

On 10/3/11 at 9:55 A.M., the hospital's policy and procedure titled "Restraints, Non-Behavioral Management, Use in Acute Care" was reviewed. According to the hospital's policy, "1. A physician order is required prior to the application of restraint (except in an emergency) for all restraint use." This policy and procedure was not followed when bilateral mittens and bilateral wrist restraints were applied to Patient 12 without an order from the patient's physician.

A joint record review and interview with the Advance Practice Nurse (APN) was conducted on 10/3/11 at 10:00 A.M. The APN acknowledged that Patient 12 was applied restraints without a physician's order. The APN acknowledged that the restraint orders were obtained almost 25 hours after the restraints were applied to the patient.




3. A review of Patient 42's medical record was conducted on 10/3/11 at 8:55 A.M. Patient 42 was admitted to Hospital B on 8/10/11 per the Facesheet.

A renewal Restraint Orders Non-Behavior sheet dated 8/19/11 at 8:00 A.M., indicated that Patient 42 was to have bilateral wrist restraints applied, due to the patient's attempts to disrupt medical equipment or lines based on the boxes that were marked. However, there was no documented evidence to show that the nursing staff obtained a verbal or telephone order nor was there a physician's signature, date and time on the renewal order sheet, for the application of Patient 42's wrist restraints.

According to Patient 42's Restraint Summary Report, bilateral wrist restraints were applied due to the patient's attempts to disrupt needed equipment or lines, on 8/19/11 at 1:00 A.M. to 8/19/11 at 11:55 P.M.

A review of the facility's policy and procedure entitled "Restraints, Non-Behavioral Management, Use in Acute Care" was reviewed on 10/3/11. The policy indicated that , "1. A physician order is required prior to the application of restraint (except in an emergency) for all restraint use."

An interview and joint record review with the Advanced Practice Nurse (APN) was conducted on 10/3/11 at 9:20 A.M. The APN stated that Patient 42's renewal restraint order sheet did not have a licensed nurse's signature nor a physician's signature with a date and time, in accordance with the facility's policy. He acknowledged that a renewal restraint order was not obtained for the continual use of bilateral wrist restraints applied to Patient 42's wrists on 8/19/11.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0169
Based on interview and record review, the facility failed to ensure that a restraint order was not written as a "standing order" or on an "as needed" basis, for 1 of 9 sampled patients (11) in restraints.

Findings:

On 9/28/11 at 2:40 P.M., Patient 11's medical record was reviewed. Patient 11 was admitted to Hospital B on 8/29/11, per the facesheet. According to the History and Physical, dated 8/30/11, the patient had increased confusion and agitation.

According to the Restraint Orders Non-Behavior sheet, dated 8/29/11 at 5:30 P.M., Patient 11 was ordered to have bilateral wrist and ankle restraints due to the patient's attempts to disrupt medical equipment or lines, and attempts to stand or ambulate without assistance. Further review of the Restraint Orders Non-Behavior sheet, dated 8/30/11 at 10:00 A.M., indicated that the bilateral wrists and ankle restraints were renewed with the addition of bilateral mittens. However, there was no documentation in the physician's progress notes nor in the nurse's notes, to support the need for an order for bilateral mittens.

According to the Restraint Summary Report, dated 8/30/11 at 12:00 P.M., Patient 11's restraints were off and the patient was calm.

A joint record review and interview with the Advance Practice Nurse (APN) was conducted on 10/3/11 at 9:00 A.M. The APN acknowledged that there was no documentation to support the need to order bilateral mittens. The APN stated that the only explanation he could think of was that, the nurse may have asked for an order for mittens in the anticipation of decreasing the use of restraints to something less restrictive, if and when Patient 11 was ready. However, it was explained to the APN that by obtaining the order for bilateral mittens before the nurse had knowledge of whether or not the patient would need it or use it, made the bilateral mittens order an "as needed" order.

On 10/3/11 at 9:30 A.M., the hospital's policy and procedure titled "Restraints, Non-Behavioral Management, Use in Acute Care" was reviewed. The policy indicated that, "Standing or PRN (as needed) orders for restraint are not acceptable." The policy also indicated that, "Restraint may be removed before the end of the designated timeframe to attempt alternatives to restraint, considered a trial release. If the alternatives are ineffective and restraints must be reapplied, the original order will remain in effect for remainder of designated time frame." The APN acknowledged that this section of the hospital's policy and procedure was not written in accordance to the regulations.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on interview and record review, Hospital A failed to ensure that the nursing staff supervised and evaluated 1 patient's (31) needs, after the patient reported an allegation of sexual assault by her roommate. In addition, Registered Nurses (RNs) in the Emergency Department (ED) failed to perform a focused assessment for 2 patient's (21, 33) chief complaint, in accordance with hospital policy and procedure. There was no documented evidence that RNs in the ED reassessed 1 patient's (21) level of pain and response to a procedural intervention, in an effort to ensure effective pain management, per hospital policy and procedure. And, there was no documented evidence in 1 patient's (34) ED record that a language and communication assessment was performed or that interpreter services were provided.

Findings:

1. Hospital A failed to ensure that nursing staff supervised and evaluated the needs of 1 patient (31), after she reported an allegation of sexual assault by her roommate.

A Tag 395 (#1)

2. RNs in the ED of Hospital A failed to perform a focused assessment for 2 patient's (21, 33), chief complaint.

A Tag 395 (#2, #4)

3. RNs in the ED of Hospital A failed to reassess 1 patient's (21), level of pain and response to a procedural intervention.

A Tag 395 (#4)

4. There was no documentation in 1 patient's (34) ED record at Hospital A, that a language and communication assessment was performed or that interpreter services were used.

A Tag 395 (#3)

The cumulative effect of these systemic practices and issues resulted in the failure of the hospital to deliver statutorily mandated compliance with the Condition of Nursing Services.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on interview and record review, Hospital A failed to ensure that the nursing staff supervised and evaluated 1 patient's (31) needs, after the patient reported an allegation of sexual assault by her roommate. In addition, Registered Nurses (RNs) in the Emergency Department (ED) failed to perform a focused assessment, for 2 of 55 sampled patients (21, 33) chief complaint, in accordance with hospital policy and procedure. There was no documented evidence that RNs in the ED reassessed Patient 21's level of pain and response to a procedural intervention, in an effort to ensure effective pain management, per hospital policy and procedure. And, there was no documented evidence in 1 patient's (34) ED record, that a language and communication assessment was performed or that interpreter services were used.

Findings:

1. Patient 31 was admitted to the Behavioral Health Unit (BHU) of Hospital A on 7/11/11, for the treatment of anxiety and depression, according to the Psychiatric Admission Assessment.

An interview was conducted with the Clinical Risk Specialist (CRS) on 7/15/11 at 3:05 P.M. The CRS stated that it was reported to her that on 7/12/11, Patient 31's female roommate (Patient 32) was found on top of Patient 31 "fondling her breasts."

On 7/15/11 at 3:25 P.M., an interview was conducted with Patient 31. Patient 31 stated that she was frightened that Patient 32 was "going to get her." Patient 31 said that she really did not want to talk about what happened. Patient 31 continued to explain that the incident occurred on 7/12/11 at 3:00 A.M. Patient 31 felt that Patient 32 was not removed quickly enough. It took the clinical staff 10 hours to place Patient 32 in the BHU Intensive Care Unit (ICU). The BHU ICU is a locked unit. In the afternoon following the incident, at the lunch table, Patient 32 sat next to Patient 31 and pushed on her leg. Patient 31 stated that she "was scared." When Patient 31 saw her physician "she ran to him." Patient 32 followed her and stood a foot away. After lunch, at about 1:30 P.M., Patient 31 was on the phone when Patient 32 walked up and tried to touch her again. Patient 31 stated that she just came to the hospital to get help for stress, anxiety and depression but she was "molested by a lesbian rapist." Patient 31 felt that the clinical staff minimized what was going on. She did not feel that the staff were protecting her. The Administrator of the Behavioral Health Unit was present during the interview with Patient 31. At the end of the interview, the Administrator stated "this can't happen again to anybody."

An interview was conducted, on 9/23/11 at 7:40 A.M., with the Registered Nurse (RN 1) who was assigned to care for Patient 31 the night of 7/12/11. RN 1 stated that another RN (RN 2) came to her and told her that he had found Patient 31 and Patient 32 lying side by side in bed. RN 1 stated that she immediately went to the patient's room. Patient 32 was sitting on the edge of the bed and Patient 31 was lying in the bed. RN 1 told Patient 32 to get back in her bed. Then she went to the Charge RN and told her that she decided to move Patient 31 to another room. Patient 31 told RN 1 that Patient 32 wanted to have sex with her. RN 1 stated that "she did not believe the patient." Patient 31 also told RN 1 that Patient 32 was going to come and find her. Patient 31 said that she was afraid. RN 1 acknowledged that she did not notify Patient 31's physician, she did not provide emotional support for the alleged victim, she did not document the incident in the medical record as it was related to her by Patient 31, she did not follow hospital policy and procedure by not transferring Patient 32 to the BHU/ICU, and she did not complete an Occurrence Report.

On 9/23/11 at 8:10 A.M., an interview was conducted with the BHU Charge RN. The Charge RN stated that she was in charge of the BHU the night of the incident. She stated that at about 3:00 A.M. RN 2 reported to her that Patient 31 and Patient 32 were found in the same bed. The Charge RN stated that Patient 32 was very psychotic. After the incident Patient 32 was very restless and pacing back and forth in the hallway. Patient 32 eventually had to be medicated. The Charge RN stated that she never talked to Patient 31 or checked on her after the incident. The Charge RN acknowledged that she did not call the physician, she did not investigate the incident by interviewing both patients, she did not call the Operations Supervisor, she did not assess the patients in the BHU/ICU to see if one could be transferred out since the BHU/ICU was full, and she did not complete an Occurrence Report.

An interview was conducted with RN 2 on 9/23/11 at 8:30 A.M. RN 2 stated that he remembers that he was assigned to do q (every) 15 minutes rounds on all the patients in the BHU the night of the incident. When RN 2 entered Patient 31 and 32's room he found them lying in Patient 31's bed. RN 2 told Patient 32 to step away from Patient 31 and she did. RN 2 stated that he asked each patient if they were okay. Neither patient answered. RN 2 then went to RN 1 and the Charge RN and reported the incident. RN 2 further stated that during the night Patient 32 was going in and out of patient's rooms and had to be re-directed. After the incident, Patient 32 became very aggressive and had to be medicated. RN 2 acknowledged that he did not stay with Patient 31 and call for help. He, also, did not complete an Occurrence Report.

A review of the hospital's policy and procedure entitled "Abuse, Assault and Neglect, Patient Screening, Identification and Reporting Requirements, dated 5/11, indicated that "in all instances in which assault, abuse, neglect is suspected or alleged:...Provide a safe environment...Provide for patient comfort and emotional support."

A review of the hospital's policy and procedure entitled "Behavioral Health - Intra-Unit Transfers - Behavioral Health Inpatient, dated 1/09, indicated "The criteria for transfer to the ICU includes but is not limited to the following:...Threatening/aggressive behavior. Sexual acting-out behaviors."

A review of the hospital's policy and procedure entitled "Occurrence Reporting", dated 1/11, indicated "Discovery of an Occurrence: Immediate Actions 1. Assess patient and/or situation and implement nursing or other professional actions and clinical procedures or treatments to include notification to the physician for orders. 2. Notify by phone or in person: Supervisor, Charge Nurse or Operations Supervisor of the occurrence and report occurrence (online MIDAS or paper form during downtime) as soon as reasonably possible. Report if in doubt as to whether a report has been completed or whether the occurrence should be reported. 3. Document in the medical record: a. Statement of the incident as it relates to the patient. Only ACTUAL FACTS will be recorded. b. Clinical condition and ongoing assessment that may be needed due to the event. c. Timely notification of the patient's physician, patient, family, if appropriate and other nursing supervisory personnel as necessary."

Registered nurses int the BHU of Hospital A failed to assess Patient 31 and provide emotional support after she related an allegation of sexual assault. The physician was not notified. There was no timely documentation of the allegation in Patient 31's medical record. There was no timely investigation of the allegation. The Operations Supervisor was not notified. An Occurrence Report was not completed in a timely manner. And, Patient 31 was not provided protection from the alleged perpetrator (Patient 32) until 10 hours after the allegation was reported to RN 1.

2. Patient 33 presented to the Emergency Department (ED) of Hospital A on 8/6/10, with a chief complaint of a migraine headache according to the ED Physician Record. A review on Patient 33's medical record was conducted on 9/29/11 at 11:30 A.M. According to the ED Physician Record "The patient has a severe migraine headache. She states that she has had similar severe migraine headaches to this, left sided, severe, throbbing, with associated nausea, photosensitivity, non-radiating, without associated trauma, fever, chills, blurriness of vision, or double vision." A review of the ED Nursing Flowsheet revealed that the neurological (pertaining to the nervous system) assessment section of the Nursing Flowsheet was blank. There was no documentation on the ED Nursing Flowsheet that Patient 33 had been assessed for headache, photophobia (sensitivity to or intolerance to light), numbness, blurred vision, dizziness, neck/back pain, or double vision.

According to the hospital's policy and procedure entitled "Assessment and Reassessment Requirements for the Emergency Department," dated 5/10, a focused assessment of the patient's chief complaint would occur during the intake process.

An interview was conducted with the Director of Risk Management (DRM) on 9/29/11 at 11:55 A.M. The DRM acknowledged that there was no documentation in Patient 33's medical record that the ED Registered Nurse (RN) had adequately assessed Patient 33 regarding her chief complaint of a severe migraine headache. The DRM also acknowledged that the neurological portion of the ED Nursing Flowsheet was blank.

3. A review of Hospital A's Complaint and Grievance Log was conducted with the Director of Risk Management (DRM) on 9/28/11 at 1:45 P.M. Patient 34 was selected for review of her complaint and the Emergency Department (ED) record. According to the Complaint Log, Patient 34 "was seen in the ED on 8/14/11, following a forehead laceration. Pt (patient) is Spanish speaking and when the MD (medical doctor) came into the room, she mentioned that she could understand English but wanted an interpreter who could assist." The synopsis of Patient 34's complaint was that the "interpreter...was loud, rushing her, would interrupt her and would respond that what she was saying was not accurate."

A review of Patient 34's medical record was conducted with the Clinical Risk Specialist (CRS) on 9/29/11 at 3:15 P.M. Learning/Special Consideration Assessment of the ED Nursing Flowsheet was blank. There was no documentation of Patient 34's primary language, communication preferences or use of an interpreter.

On 9/2911 at 3:25 P.M. an interview was conducted with the CRS. The CRS stated that Patient 34's ED record lacked documentation of an assessment of Patient 34's language and communication needs. The CRS also acknowledged that the ED Registered Nurse (RN) did not document that an interpreter was used nor identify the interpreter.

An interview was conducted with the Administrative Director of the Emergency Department (ADED) on 9/29/11 at 3:30 P.M. The ADED stated that there was a Technical Partner in the ED that was also an interpreter. If his interpreter services were used it was to be documented on the ED record.





4. A record review was initiated on 10/3/11 at 8:30 A.M. with the Director of Risk Management (DRM). According to the DRM, Patient 21 filed a grievance with the hospital concerning her care and treatment in the ED on 7/17/11. Patient 21's documented grievance, and the hospital's synopsis of that grievance, was also reviewed with the DRM on 10/3/11 at 8:30 A.M.

Per the Emergency Record, dated 7/17/11 and dictated by Medical Doctor (MD) 21, Patient 21 walked into the ED with a chief complaint of a "lump on her private parts." Per the report, Patient 21 had a large "abscess Bartholin cyst" (an infected blocked gland near the vagina). The abscess was opened with a scalpel blade and drained in the ED, by a resident physician (not MD 21). Per MD 21's report, the area to be drained was anesthestized with 1 percent lidocaine prior to the procedure.

According to Patient 21's documented grievance (no date), during the ED procedure, on 7/17/11, she yelled out with pain "10" rate, "get it out." Patient 21 documented that she yelled out in pain with a rate of "10" two more times during the procedure to open and drain the infected Bartholin's Cyst. Patient 21 documented that she said "stop I can't take no more."

A review of the Emergency Department Nursing Flowsheet, dated 7/17/11, revealed that at 7:03 P.M., RN 22 documented that Patient 21 had no complaints concerning her genitourinary system; however, in the nursing notes, RN 22 documented that the patient complained of redness, swelling, and pain to her labia (external female genitalia). There was no documented initial pain score or further assessment of Patient 21's pain or chief complaint by RN 22, upon admission to the ED. At 7:30 P.M., RN 23 documented that the MD was at the bedside to evaluate Patient 21 for a possible incision and drainage of the patient's labia. There was no documentation by either RN concerning the actual procedure, how the patient tolerated the procedure, what the patient's pain level was, or if her pain was managed. No pain score was ever documented by nursing staff. There was no documentation by nursing staff that the 1 percent lidocaine was administered to Patient 21 for pain control.

According to the hospital's Pain Management Policy, dated 3/09, "all patients have the right to systematic, individualized pain assessment and effective pain management." Per the policy, to achieve effective pain management, RNs were responsible for pain screening and reassessments.

Another policy entitled "Assessment and Reassessment Requirements for the Emergency Department," dated 5/10, documented that a focused assessment of the patient's chief complaint would occur during the intake process. The required focused assessment included the determination of the patient's level of pain.

On 10/3/11 at 9:30 A.M., an interview was conducted with the Emergency Services Director (ESD). The ESD acknowledged that the nursing staff in the ED had not implemented the hospital's policies concerning focused assessments/reassessments and pain management with regards to Patient 21's care and treatment.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on interview and record review, the facility failed to ensure that pain medications were given as ordered, for 1 of 55 sampled patients (13).

Findings:

On 9/28/11 at 1:00 P.M., Patient 13's medical record was reviewed. Patient 13 was admitted to Hospital B on 9/7/11, with diagnoses that included gangrenous left foot, per the History and Physical.

A review of Patient 13's pain assessment record indicated that on 9/12/11 at 6:07 A.M., the patient complained of left foot pain at a rate of 8 using a scale of 1 to 10 (1 being the least and 10 being the most pain). Per the same record, the patient was given 1 tablet (tab) of oxycodone hydrochloride/acetaminophen (Percocet - pain medication) 5/325 milligrams (mg) at 6:08 A.M. Further review of the patient's pain assessment record indicated that on 9/12/11 at 9:50 A.M., the patient complained of having moderate pain on her left foot. Per the same record, the patient was given hydromorphone hydrochloride (Dilaudid - pain medication) 0.5 mg. intravenously (IV) at 9:48 A.M.

A review of the physician's order sheet, dated 9/10/11 at 1:30 A.M., indicated that an order was written for Dilaudid 0.5 mg IV every 2 hours PRN (as needed), for severe pain. Further review of the physician's order sheet indicated that an order was written on 9/11/11 at 2:25 P.M., for Percocet 5/325 mg 1-2 tablets q (every) 6 hours as needed for pain. The physician's order did not give the nurses a clear order as to when to give 1 tablet versus 2 tablets. However, a review of the hospital's policy and procedure titled "Medication Use: Order Clarifications" indicated that, "1. The use of range orders is discouraged. 2. An indication for use is required for all PRN orders. In order to provide timely care to patients and establish a standard for medication order entry, automatic clarification of orders will be instituted for all applicable PRN orders written without an indication, when the intent is clear. 3. For pain medications, pain levels of Mild, Moderate, and Severe refer to pain scales of 1-3, 4-6, and 7-10, respectively. 4. In order to provide timely care to patients and establish a standard for medication order entry, the following automatic substitution of orders will be instituted for all applicable range orders when received by the pharmacy. Actions performed by the pharmacist within the scope of this policy will not require a new physician order or physician countersignature." Following this policy, the order for Percocet was automatically clarified by a pharmacist. The clarification of the Percocet orders were reflected on the Medication Administration Record. The order for Percocet was documented as, "oxycodone hydrochloride/acetaminophen 5-325 mg 1 tab q 6hrs PRN for mild pain and oxycodone hydrochloride/acetaminophen 5-325 mg 2 tabs q 6hrs PRN for moderate pain."

Based on the clarified orders for Percocet and the physician's order for Dilaudid, the nurse who administered the pain medications on 9/12/11 at 6:08 A.M. and 9:48 A.M., did not follow the physician's orders. On 9/12/11 at 6:08 A.M., the nurse gave 1 tablet of Percocet for a pain level of 8, which was severe pain according to the hospital's policy. The order for severe pain was to give Dilaudid. On 9/12/11 at 9:48 A.M., Patient 13 complained of moderate pain and was given Dilaudid. The order for moderate pain was to give 2 tablets of Percocet.

A joint record review and interview with the Director of Patient Care (DPC) was conducted on 9/28/11 at 1:30 P.M. The DPC acknowledged that the physician's orders related to the administration of pain medications was not followed as ordered.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the hospital failed to ensure that the medical records of 3 of 55 sampled patients (32, 38, 41) were completed, dated, timed and authenticated per hospital policy. Hospital B failed to ensure that the nursing care plan was documented in the medical record.

Findings:

1. Patient 32 was admitted on [DATE], to the Behavioral Health Unit (BHU) of Hospital A for treatment of a manic episode, according to the Admission Facesheet. A review of Patient 32's medical record was conducted on 9/28/11 at 10:30 A.M. According to a Multidisciplinary Record of Care, dated 7/12/11, Patient 32 was "transferred to the locked unit due to inappropriate sexual bx (behavior)..." In addition, there was a physician's order present, also dated 7/12/11, "Transfer to ICU (intensive care unit) as soon as bed's available..." However, there was no documentation by her attending physician found in Patient 32's medical record, that he had been made aware of an alleged incident of sexual assault involving Patient 32 as the alleged perpetrator.

An interview was conducted with Patient 32's attending physician (MD 32) on 9/28/11, at 3:00 P.M. MD 32 stated that he received a call from the Registered Nurse Manager of the BHU the afternoon following the occurrence of the alleged incident involving Patient 32. MD 32 stated that he did not document any information in Patient 32's medical record, regarding the allegation of her sexually assaulting her roommate on 7/12/11.

The hospital's policy and procedure entitled "Occurrence Reporting," dated 1/11, was reviewed. The policy indicated that upon the discovery of an incident, the immediate actions to be taken included to "assess the patient and/or situation and implement nursing or other professional actions...Document in the medical record."

MD 32 further stated looking back he realized that he should have documented the allegation as it was reported to him between 1:00 P.M. and 2:00 P.M., on 7/12/11. MD 32 also stated that he should have documented in Patient 32's medical record the fact that he was informed of the sexual assault allegation about 12 hours after it supposedly occurred.

2. Patient 38 presented to Hospital B's Emergency Department (ED) on 6/17/11, at 8:00 P.M. after sustaining a fall. Patient 38's chief complaint was the inability to bear any weight on her left hip, according to the ED physician's record. The ED physician's record also indicated that Patient 38 was admitted to Hospital B.

A review of Patient 38's medical record was conducted on 10/3/11 at 10:40 A.M. The Admission/ Discharge section of the ED Nursing Flowsheet was completely blank. There was no date and time of admission, pain level, vital signs, or condition at the time of Patient 38's transfer to a hospital room. Also, there was no documentation of what hospital bed Patient 38 was admitted to, who or how she was transported, or documentation of a hand-off report to the receiving care giver. In addition, there was no documentation of the disposition of Patient 38's personal belongings.

An interview was conducted with the Director of Risk Management (DRM) on 10/3/11 at 11:25 A.M. The DRM acknowledged that it is the expectation that the ED Registered Nurse (RN) complete the Admission/Discharge section of the ED record, once the disposition of the patient is determined. The DRM acknowledged that there was no documentation in Patient 38's ED Record that she was admitted to the hospital, her condition at the time of admission, nor the disposition of her belongings.





3. A review of Patient 41's medical record was conducted on 9/28/11 at 11:00 A.M. Patient 41 was admitted to the facility on [DATE] per the Facesheet. A microbiology report dated 9/27/11, indicated that a final result was obtained and Patient 41 was positive for Methicillin Resistant Staphylococcus (MRSA- an infection caused by a strain of staph bacteria that's become resistant to the antibiotics commonly used to treat ordinary staph infections) in the nares. There was no documented evidence found in the medical record to show that the nursing care plan had been initiated, reviewed or revised to reflect the patient's infection control status. A section of the Critical Care Flowsheet, dated 9/27/11 at 7:00 A.M., that read "infection control precautions" was blank. Per the same flowsheet, the nursing narrative had no documented evidence of the nursing plan of care or interventions that were initiated due to the positive MRSA test result.

On 9/28/11 at 11:20 A.M., general observations were conducted. Before entering Patient 41's room, a sign with stop signs in English and Spanish read "Contact Precautions (in addition to standard precautions)" was posted. Contract Precautions are guidelines recommended by the Centers for Disease Control for reducing the risk of transmission of microorganisms by direct or indirect contact .

An interview and joint record review with the registered nurse (RN 41) was conducted on 9/29/11 at 1:18 P.M. RN 41 stated that she received the call from the lab informing her of Patient 41's positive MRSA in the nares test result. RN 41 stated that she did not document in the patient's medical record the nursing care plan she initiated and all the interventions that were implemented related to Patient 41's positive MRSA test result.

An interview with the Manager of the Intensive Care Unit (MICU) was conducted on 9/29/11 at 1:58 P.M. The MICU acknowledged that the nursing staff should have documented in the patient's medical record the infection control practices and interventions that were implemented for Patient 41's nasal MRSA infection in accordance with the facility's policy.

A review of the facility's policy entitled "Patient Care Process: Assessment, Planning, Intervention and Evaluation", effective date of 3/09, was conducted on 9/29/11. The policy's definition of interdisciplinary plan of care was "... based on patient assessment by a registered nurse which identifies and documents the patient's care issues/problems, treatment goals, interventions and evaluation of the patient's progress in meeting identified goals." Per the same policy, it stipulated the responsibilities of the interdisciplinary team members which included "Documenting patient information/data collected and care provided in the medical record."
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, Hospital A failed to ensure that all orders written by physicians contained a signature, date and time written by the ordering physician, per hospital policy and procedure for 1 patient (36).

Findings:

Patient 36 was admitted to Hospital A on 9/18/11, with a diagnosis of [DIAGNOSES REDACTED].M. In the physician's orders section of Patient 36's medical record, it was noted that the following written physician's orders, lacked authentication by the ordering physician's signature, date, and time:

9/19/11 Please give vanco (vancomycin, an antibiotic) dose @ 11:00 A.M...
9/19/11 Potassium Electrolyte Replacement Adult Order Set
9/19/11 Magnesium electrolyte Replacement Adult Order Set
9/19/11 Atorvastatin (cholesterol lowering drug) 80 mg. (milligrams) po (by mouth) q (every) day
9/28/11 Heparin (anti coagulant) flush 100 units per cc (cubic centimeter)...

A review of the hospital's policy and procedure entitled "Orders, Licensed Independent Practitioners, Physician and Allied Health Professionals, for Hospital Services", dated 4/10, indicated that "Orders must be written on a hospital approved order form and would be considered complete when a signature, a blocked printed or stamped name, date, and time are included.

An interview was conducted with the Director of Risk Management (DRM) on 9/29/11 at 1:55 P.M. The DRM acknowledged that the five handwritten physician orders on Patient 36's medical record lacked authentication in accordance with the hospital's policy and procedure and were considered incomplete.
VIOLATION: VERBAL ORDERS AUTHENTICATED BASED ON LAW Tag No: A0457
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, Hospital A and Hospital B failed to ensure that verbal orders were authenticated by the ordering physician in accordance with hospital policy and procedure for 2 of 55 sampled patients (36, 42).

Findings:

1. Patient 36 was admitted to Hospital A on 9/18/11, with a diagnosis of [DIAGNOSES REDACTED].M. In the physician's orders section of Patient 36's medical record, it was noted that the following physician's verbal and/or telephone orders lacked authentication with the ordering physician's signature, date, and time:

9/19/11 Change IVF (intravenous fluids) to D5 (5% Dextrose) NS (normal saline)
9/19/11 Hold PO (by mouth) meds at this time
9/19/11 Start Heparin (anti-coagulant) drip @ (at) 12 units/kg (kilogram/hr (hour)...
9/19/11 Morphine (narcotic analgesic) 1 mg (milligram) IVP (intravenous push) x 1 now...
9/20/11 Zofran (anti nausea medication) 4 mg. IV (intravenous) q (every) 6 hours PRN (as needed)...
9/21/11 per Heparin protocol For PTT (used to assess coagulation) : 49, increase rate by 4 units/kg/hr
9/22/11 Increase PS (pressure support of ventilator) to 14
9/23/11 NS (normal saline) 10 ml (milliliters)/hr (hour)
9/25/11 DC (discontinue) NGT (naso-gastric tube)

A review of the hospital's policy and procedure entitled, "Orders, Licensed Independent Practitioners, Physician and Allied Health Professionals, for Hospital Services," dated 4/10, indicated that "The LIP (licensed independent practitioner) must sign, date and time the telephone order within forty eight (48) hours of giving the orders."

An interview was conducted with the Director of Risk Management (DRM) on 9/29/11 at 1:55 P.M. The DRM acknowledged that the nine verbal/telephone orders on Patient 36's medical record, lacked authentication in accordance with the hospital's policy and procedure.





2. A review of Patient 42's medical record was conducted on 10/3/11 at 8:55 A.M. Patient 42 was admitted to Hospital B on 8/10/11 per the Facesheet. The physician's orders section of Patient 42's medical record contained the following verbal and/or telephone orders, that were not authenticated with the ordering physician's signature, date and time:

Restraint Orders Non-Behavior sheet, dated 8/20/11 (unable to read the time), Patient 42 was ordered to have bilateral wrist restraints due to patient's attempts to disrupt medical equipment or lines.

Restraint Orders Non-Behavior sheet, dated 8/21/11 at 10:00 A.M., Patient 42 was ordered to have bilateral wrist restraints due to patient's attempts to disrupt medical equipment or lines.
Restraint Orders Non-Behavior sheet, dated 8/22/11 at 8:00 A.M., Patient 42 was ordered to have bilateral wrist restraints due to patient's attempts to disrupt medical equipment or lines.

According to Patient 42's Restraint Summary Report, bilateral wrist restraints were applied due to patient's attempts to disrupt needed equipment or lines on 8/20/11, 8/21/11 and 8/22/11.

An interview and joint record review with the Advance Practice Nurse (APN) was conducted on 10/3/11, at 9:20 A.M. The APN stated that the all telephone and verbal orders should have the ordering physician's signature, time and date. He acknowledged that Patient 42's Restraint Orders Non-Behavior sheets were not authenticated by the ordering physician in accordance with the facility's policy.

A review of the hospital's policy and procedure entitled "Orders, Licensed Independent Practitioners, Physician and Allied Health Professionals, for Hospital Services", dated 4/10, indicated that "The LIP (licensed independent practitioner) must sign, date and time the telephone order within forty eight (48) hours of giving the orders."
VIOLATION: DELIVERY OF DRUGS Tag No: A0500
Based on interview and record review, the facility failed to ensure that the hospital's policy and procedure related to clarification of medication orders, was implemented by the pharmacy, for 1 of 55 sampled patients (14).

Findings:

On 9/29/11 at 11:15 A.M., Patient 14's medical record was reviewed. Patient 14 was admitted to Hospital B on 9/21/11, per the facesheet.

A review of the physician's order sheet, dated 9/22/11 at 10:00 A.M., indicated that an order was written for Morphine 2 mg (milligrams) q (every) 4 hours PRN (as needed) for pain. There was no clear indication as to the level of pain when Morphine should be given.

A review of the hospital's policy and procedure titled "Medication Use: Order Clarifications," dated 6/11, indicated that, "1. The use of range orders is discouraged. 2. An indication for use is required for all PRN orders. In order to provide timely care to patients and establish a standard for medication order entry, automatic clarification of orders will be instituted for all applicable PRN orders written without an indication, when the intent is clear. 3. For pain medications, pain levels of Mild, Moderate, and Severe refer to pain scales of 1-3, 4-6, and 7-10, respectively. 4. In order to provide timely care to patients and establish a standard for medication order entry, the following automatic substitution of orders will be instituted for all applicable range orders when received by the pharmacy. Actions performed by the pharmacist within the scope of this policy will not require a new physician order or physician countersignature."

There was no documented evidence that the Morphine order was clarified by a pharmacist.

A joint record review and interview with the Director Patient Care (DPC) was conducted on 9/29/11 at 11:20 A.M. The DPC acknowledged that there was no documented evidence that the Morphine order, which was written without a clear indication, was clarified by a pharmacist. The DPC acknowledged that the hospital's policy and procedure related to clarifying medication orders was not followed as written.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, Hospital B failed to ensure that hospital staff implemented their policy and procedure related to infection control practices, for 1 of 2 patients reviewed (Patient 41) who was on contact isolation. In addition, Hospital B failed to implement their Active Surveillance For Methicillin Resistant Staphylococcus (MRSA- an infection caused by a strain of staph bacteria that's become resistant to the antibiotics commonly used to treat ordinary staph infections), policy and procedure. There was no documented evidence to show that the nursing staff notified the physician of the positive MRSA test result, nor was there documentation to show that the attending physician notified the patient or patient's representative of the positive MRSA test result.

Findings:

1. A review of Patient 41's medical record was conducted on 9/28/11 at 11:00 A.M. Patient 41 was admitted to Hospital B on 9/23/11 per the Facesheet. A microbiology report, dated 9/27/11, indicated that a final result was obtained and Patient 41 was positive for MRSA in the nares. According to Patient 41's Nursing assessment dated [DATE], contact precautions were implemented for MRSA in the nares.

On 9/28/11 at 11:20 A.M., general observations were conducted. Hospital Staff (HS 1) entered Patient 41's room with a document on a clipboard. She put a on a yellow disposable gown, spoke to Patient 41, reviewed a document, obtained a signature from the patient, removed her yellow gown and walked out of the room without washing her hands or using the alcohol hand gel. Before entering Patient 41's room, a sign with stop signs in English and Spanish read "Contact Precautions (in addition to standard precautions)" was posted. The sign listed instructions for visitors to do the following:

Report to nurse before entering.
Gloves must be worn by everyone entering patient room.
A gown must be worn by everyone entering the room.
Remove gown and wash hands before leaving patient room.
Wash hands with soap and water before leaving patient room or use the alcohol hand gel.

An interview and joint document review with HS 1 was conducted on 9/28/11 at 11:25 A.M. HS 1 stated that she reviewed a document with Patient 41 and obtained her signature. She acknowledged that she did not wash her hands before or after entering Patient 41's room. She stated that prior to entering Patient 41's room, she saw the posted contact precaution sign but did not know all the visitor instructions that were listed. She stated that she did not know that she was supposed to wear gloves and wash her hands before leaving patient's room.

An interview with the Access Manager was conducted on 12:45 P.M. The Access Manager stated that HS 1 should have observed and implemented the facility's infection control practices for patients in isolation, which included using gloves, washing hands or using the alcohol hand gel (if indicated), before leaving a patient's room.

A review of the facility's policy entitled "Standard Precautions and Transmission Based Precautions" effective date of 1/08, was conducted on 9/29/11. The policy indicated that "In addition, to Standard Precautions, use Contact Precautions for patients known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the patient (hand or skin-to-skin contact that occurs when performing patient care activities that require touching the patient's dry skin), or indirect contact (touching environmental surfaces or patient care items in the patient's environment)." Per the same policy, under the gloves and hand disinfection section, it instructed all staff to wear gloves when entering a patient's room, remove gloves before leaving the patient's room and wash thier hands immediately with an antimicrobial agent or disinfect hands with an alcohol based hand rub.

2. A review of Patient 41's medical record was conducted on 9/28/11 at 11:00 A.M. Patient 41 was admitted to Hospital B on 9/23/11 per the Facesheet. A microbiology report, dated 9/27/11, indicated that a final result was obtained and Patient 41 was positive for MRSA in the nares. There was no documented evidence found in the medical record to show that the physician was notified of the positive MRSA test result.

An interview and joint record review with the registered nurse (RN 41) was conducted on 9/29/11 at 1:18 P.M. RN 41 stated that she notified the physician of Patient 41's positive MRSA test result. However, she acknowledged that there was no documented evidence in Patient 41's medical record that the physician was notified of the positive MRSA test result.

A review of the facility's policy and procedure entitled "Standard Precautions and Transmission Based Precautions", effective date of 1/08, was conducted on 9/29/11. The policy indicated that "The nurse is responsible for initiating the appropriate precaution as indicated by laboratory results or physician diagnosis and for notifying the primary physician if not already informed."

An interview and joint record review with the Manager of the Intensive Care Unit (MICU) was conducted on 9/29/11 at 1:58 P.M. The MICU stated that Patient 41's medical record should have had documented evidence to show that the physician was notified of the positive MRSA test result in accordance with the facility's policy.

3. A review of Patient 41's medical record was conducted on 9/28/11 at 11:00 A.M. Patient 41 was admitted to Hospital B on 9/23/11 per the Facesheet. A microbiology report, dated 9/27/11, indicated that a final result was obtained and Patient 41 was positive for MRSA in the nares. There was no documented evidence found in the medical record to show that the attending physician notified Patient 41 or her representative of the positive MRSA test result.

An interview and joint record review with the registered nurse (RN 41) was conducted on 9/29/11 at 1:18 P.M. RN 41 stated that Patient 41's medical record did not have documented evidence to show that the attending physician notified the patient or the patient's representative of the positive MRSA test result identified on 9/27/11.

An interview with the manager of the intensive care unit (MICU) was conducted on 9/29/11 at 1:58 P.M. The MICU stated that when patient's tested positive for MRSA, it was the responsibility of the attending physician to notify the patient or the patient's representative of the positive test result. She stated that Patient 41's medical record should have had documented evidence to show that the attending physician notified the patient of the positive MRSA test result in accordance with the facility's policy.

A review of the facility's policy and procedure entitled "Active Surveillance For Methicillin Resistant Staphylococcus Aureus (MRSA)," effective date of 9/09, was conducted on 9/29/11. The policy indicated that under the attending physician's response section, "If the result is positive, the attending physician is responsible to inform the patient of the results."
VIOLATION: INTEGRATION OF EMERGENCY SERVICES Tag No: A1103
Based on observation, interview and record review, the hospital failed to ensure that the pediatric crash carts in the Emergency Department (ED) and Post-Anesthesia Care Unit (PACU) at Hospital B, did not contain expired supplies, in accordance with the facility's policy and procedure. Multiple expired emergency supplies were found in the pediatric crash carts in the ED and PACU at Hospital B.

Findings:

1. On 9/28/11 at 8:15 A.M., a tour of the ED was conducted with the Assistant Administrator (AA) and the ED Manager (EDM).

On 9/28/11 at 8:38 A.M., an audit of the ED's pediatric crash cart was conducted with the EDM. The following expired supplies were found:

Two 18 gauge intravenous catheters with an expiration date of 2/2011.
Two syringes of 0.9% Sodium Chloride (normal saline- sterile solution of salt water) with an expiration of 3/2011.
Two syringes of 0.9% Sodium Chloride with an expiration date of 4/2011.
Two 18 gauge x 1 1/4 inch intravenous catheters with an expiration date of 6/2011.
Two 22 gauge x 1 inch intravenous catheter with an expiration date of 5/2011.

An interview with the EDM was conducted on 9/28/11 at 8:52 A.M. The EDM stated that the charge nurse on the night shift checked all the ED crash carts for expired medications and supplies. She stated that the expired supplies in the pediatric crash cart was missed. She stated that proper disposal and replacement of expired supplies should have been performed in accordance with the facility's policy.

A review of the facility's policy entitled "Emergency Drugs And Crash Cart" approval date of 9/09 was conducted on 9/28/11. The policy indicated that code carts were checked daily by the charge nurse, lead registered nurse (RN) or the designated RN/LVN (licensed vocational nurse). Per the same policy, it stipulated that "During any inspection/check, if any equipment is in non-working order, missing any items, items not specified on the check list are present, or if any item has expired, complete a Code Blue Discrepancy Report and return the code cart to central services."

2. On 9/28/11 at 1:15 P.M., during a tour of the Post-Anesthesia Care Unit (PACU), the pediatric crash cart was inspected with the Surgery Services Manager (SSM). The following emergency supplies were found: Two purple top microtainers (blood collection tubes) with an expiration date of 7/2011.

An interview with the SSM was conducted on 9/28/11 at 1:30 P.M. The SSM stated that the purple top microtainers were replaced but the expired on es were not removed. She stated that the charge nurse was responsible for checking the crash carts daily and removing any expired items in accordance with the facility's policy.

A review of the facility's policy entitled "Emergency Drugs And Crash Cart" approval date of 9/09 was conducted on 9/28/11. The policy indicated that code carts were checked daily by the charge nurse, lead registered nurse (RN) or the designated RN/LVN (licensed vocational nurse). Per the same policy, it stipulated that "During any inspection/check, if any equipment is in non-working order, missing any items, items not specified on the check list are present, or if any item has expired, complete a Code Blue Discrepancy Report and return the code cart to central services."
VIOLATION: ORGANIZATION OF RESPIRATORY CARE SERVICES Tag No: A1152
Based on observation, interview and record review, the hospital failed to ensure that a tracheostomy (surgical formation of an opening in to the trachea through the neck to allow for the passage of air) tray was readily accessible in the Intensive Care Unit (ICU) at Hospital B.

Findings:

On 9/28/11 at 9:28 A.M., a tour of the ICU was conducted with the Assistant Administrator (AA) and the Manager of the ICU (MICU). After an audit of the emergency drugs and crash cart was performed, the MICU was asked if the unit had a tracheostomy tray. The MICU went to the ICU's Equipment Supply Room and checked the all the cabinets. There was no tracheostomy tray found in the unit.

On 9/28/11 at 10:00 A.M., the MICU asked the Charge Registered Nurse (RN 42) if she knew where the unit's tracheostomy tray was located. RN 42 went to the same Equipment Supply Room and checked all the cabinets. RN 42 stated that the ICU's tracheostomy tray was missing.

An interview and joint observation with the MICU was conducted on 9/28/11 at 10:05 A.M. The MICU stated that the unit's emergency supply included the tracheostomy tray. She stated that a tracheostomy tray was always readily accessible in cases of an emergency in the intensive care unit. However, she stated that the facility did not have a policy to support this practice. RN 42 walked in the unit with a tracheostomy tray from the facility's sterile processing department. The MICU acknowledged that it took 10 minutes for the ICU to obtain a tracheostomy tray.