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.

MILFORD HOSPITAL, INC 300 SEASIDE AVENUE MILFORD, CT 06460 Oct. 25, 2012
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on observation and interview, the hospital failed to ensure that the off-site center had a CLIA waiver in place. The findings include:

a. During a tour of the off-site urgent care center on 10/23/12 from 2:05 P.M. to 3:15 P.M. with the Clinical Nurse Manager and QI Coordinator #1, it was identified that the Center staff complete various laboratory examinations-including urine dipstick, urine pregnancy, blood glucose and rapid strep testing. The Center failed to have a CLIA waiver for such testing.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

1. Based on a review of clinical records, interviews and review of facility policy and procedures for ten of twenty-six patients (Patients # 15, 16, 19, 20, 21, 24, 39, 40, 43 and 44) that were provided care and services, the hospital failed to ensure that staff inquired whether the patient(s) and/or the patient representative(s) had executed advanced directives. The findings include:

a. Patients #15, 16, 19, 20, 21, 24, 39, 40, 43 and 44 were admitted to the hospital during the period of 4/21/11 to 10/23/12 for care and services. Review of the clinical records failed to reflect that the nursing staff during a pre-admission telephone call and/or that the admission staff inquired about advanced directives.
Interview with the Operating Room Nurse Manager, on 10/22/12 at 12:30 P.M., identified that the nursing staff during the pre-admission telephone call do not inquire about advance directives for the patients that are admitted to the Surgicenter and/or the outpatient center.
Interview with the Admissions Director, on 10/24/12 at 11:35 A.M., identified that admission staff do not inquire about advanced directives for patients who are admitted to the Emergency Department and outpatient care.
Interview with the Nurse Manager of the Surgicenter, on 10/24/12 at 11:55 A.M., identified that the clinical records failed to reflect that staff ascertained whether Patient #16 had advanced directives during the pre-admission telephone call.
Review of the policy and procedure, titled Advanced Directives, identified that on admission, the admitting staff asks the patient and/or representative if they have executed advanced directives. If the patient is not able to be asked on admission, the admitting nurse is responsible to obtain the information and all copies of advance directives will be made part of the medical record.
A policy and procedure, titled Preoperative Nursing Assessment, identified that prior to surgery the nurse reviews the patient's advanced directives.
Review of the information packet, titled Connecticut Advanced Directives, identified that Connecticut recognizes four types of advanced directives-living will, health care representative, conservator and/or an anatomical gift donation.

2. Based on a review of clinical records, interviews and review of facility policy and procedures for ten of twenty-six patients (#15, 16, 19, 21, 24, 40, 44, 25, 26, and 28) who presented to the hospital for care and services, the hospital failed to provide the patient and/or patient representative with information regarding formulation of advanced directives. The findings include:

a. Patients #15, 16, 19, 21, 24, 40, 43 and 44 were admitted to the hospital during the period of 4/21/11 to 10/23/12 for care and services. Review of the clinical records failed to reflect that that the hospital staff provided information regarding formulation of advanced directives.

b. During a tour of the off-site urgent care center on 10/23/12 from 2:05 P.M. to 3:15 P.M., it was identified that information packets regarding formulation of advanced directives were not available. Interview with Admission Staff #1, on 10/23/12 at 2:38 P.M., identified that if a patient asked him/her for information about formulation of advanced directives s/he would direct the patient to contact the Social Services department at the hospital.

c. Patients #25, #26, and #28 were admitted to the hospital from 10/18/12 to 10/21/12 for care and services. Review of the clinical records identified that these patients had not executed a living will. The clinical record failed to reflect that the hospital staff provided these patients with information regarding formulation of advanced directives. Interview with the Director of Quality Management on 10/24/12 at 11:30 AM identified comprehensive information regarding advanced directives was not provided to Patient #25, 26 and 28.

Review of the policy and procedure, titled Advanced Directives, identified that the hospital provides all patients written information on formulation of advanced directives and will provide the information to outpatients upon request.

3. Based on a review of clinical records, interviews and review of facility policy and procedures for three of twenty-six patients (# 39, 17, and 18) who presented to the hospital for care and services, the hospital failed to obtain a copy of the patient's living will for the clinical record in accordance with policy. The findings include:

a. Patient #39 was admitted on [DATE] for surgery. Review of the clinical record identified that the patient had executed a living will, however, a copy of the living will was not included in the medical record.
b. Patients #17 and #18, were admitted to the hospital from 2/14/12 to 9/13/12 for care and services. Review of the clinical records identified that these patients had executed a living will and the record failed to reflect that a copy of the living will was contained in the clinical record. Interview with the Director of Quality Management on 10/24/12 at 11:30 AM identified the hospital staff should have ensured that a copy of the living will was placed in the clinical record and did not know why it was not.
Review of the policy and procedure, titled Advanced Directives, identified that all copies of advance directives will be made part of the medical record.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on tour of the hospital, interviews and review of hospital policy and procedure, the hospital failed to ensure that staff members were aware of the current weapons policy and procedure. The findings include:

a. During a tour of the Emergency Department (ED), on 10/22/12 from 2:30 P.M. to 3:25 P.M., and interview with Security Officer #2, at 2:37 P.M., it was identified that s/he was not aware of the current weapons policy and procedure. The Security Supervisor immediately re-educated Security Officer #2 on 10/22/12 and began re-education of the other eight members of the security team with regards to the current weapons policy and procedure.
During a tour of the off-site urgent care center on 10/23/12 from 2:05 P.M. to 3:15 P.M., and interview with Admission Staff #1, on 10/23/12 at 2:38 P.M., identified that s/he was not aware of the current weapons policy and procedure.
Review of the hospital policy and procedure, titled Weapons Policy and dated 10/10/12, the hospital is committed to maintaining a safe, secure working environment for all hospital staff, volunteers, patients and visitors and no weapons are allowed on any property associated with the hospital.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

1. Based on a review of the clinical record, staff interviews and a review of facility policies and procedures for one sampled patient reviewed for the administration of Oxytocin in the augmentation of labor (Patient #28), the facility failed to conduct maternal fetal assessments in accordance with the hospital policy. The finding included:
a. Patient # 28 was admitted on [DATE] at 11:57 AM and was administered Oxytocin for the augmentation of labor. Oxytocin was initiated at 2 milliunits/minute at 2:14 PM and continued to be titrated per protocol until adequate uterine activity was obtained. The assessment of uterine contractions included contraction frequency, duration, quality and pattern. The fetal assessment included fetal heart rate, variability, accelerations, and decelerations. Interview and review of the clinical record with RN #17 on 10/22/12 identified on 10/18/12 from 3:51 PM until 9:11 PM uterine and fetal assessments failed to be conducted and/or documented on eleven occasions. The hospital policy for Oxytocin administration for induction or augmentation of labor directed in part that while Oxytocin is administered the fetal heart rate and uterine contraction patterns should be evaluated and documented at the start of the Oxytocin infusion, minutes after initiation, after any rate change and every fifteen minutes during maintenance.

2. Based on a review of the clinical record for one of two sampled patients (Patient #18), the facility failed failed to conduct neurological assessments in accordance with the post fall hospital policy and/or failed to have a policy and/or procedure for neurological assessments. The findings included:
a. Patient #18 was admitted on [DATE] for the treatment of pneumonia. Patient #18's diagnosis included chronic obstructive pulmonary disease, congestive heart failure, atrial fibrillation, and dementia. The patient's respiratory symptoms improved and he/she responded well to medical management. On the day of discharge Patient #18 suffered a fall with a subsequent fracture of the left femur. On 2/19/12 Patient #18 underwent a surgical fixation of the intertrochanteric hip fracture and was discharged on [DATE].
Interview and review of the clinical record with the Director of Quality on 10/24/12 at 1:30 PM identified on 2/18/12 after Patient #18 fell neurological assessments were not completed as directed in the hospital policy for post fall assessment. The hospital policy for patient fall-post assessment directed in part to conduct neurological assessments for patients with a possible head injury and un-witnessed fall.
Interview with the Director of Quality on 10/24/12 at 1:35 PM identified the hospital failed to have a policy for the implementation and procedure that directed nursing to conduct neurological assessments.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

1. Based on a review of the clinical record, staff interviews and a review of the hospital policies and procedures for two of seven patients reviewed for falls (#17 and #18), the facility failed to communicate and/or document a change in the plan of care to ensure the safety of the patient and/or implement a comprehensive plan of care. The findings included:
a. Patient #17 was admitted on [DATE] for the treatment of pneumonia. Patient #17's diagnoses included [DIAGNOSES REDACTED]"up with assistance." The nursing admission assessment dated [DATE] identified neurological parameters were within normal limits. A fall risk assessment dated [DATE] identified Patient #17 was a moderate risk for falls with interventions that included a low, locked bed, to keep the room free from clutter, to place the call bell within reach of the patient, a low, frequent checks, and to keep the patient close to the nurse's station. A fall risk assessment dated [DATE] identified Patient #17 was a high fall risk for falls with an additional intervention for a personal alarm. Interview and review of the clinical record with RN #14 on 10/24/12 at 1:00 PM indicated she increased the level of fall risk to "high" as Patient #17 had oxygen extension tubing and he/she was complaining of shortness of breath. Interview with RN #14 identified Patient #17 would intermittently take the personal alarm off, therefore she sat by the patient's doorway as much as possible for close observation. Further interview with RN #14 indicated she failed to communicate and/or document that Patient #17 removed his/her personal alarm. Review of the clinical record with RN #14 identified a change in the plan of care and/or additional interventions were not put in place after it was noted that Patient #17 removed his alarm clip. The clinical record identified on 9/16/12 at 4:30 AM Patient #17 was seen by RN #15 a sleep. On 9/16/12 at 6:20 AM Patient #17 was found on the floor without a pulse, respirations and a blood pressure. Cardiopulmonary Resuscitation was administered. Patient #17 was pronounced deceased at 6:52 AM with the cause of death identified as Cardiopulmonary Arrest. Interview with RN #15 on 10/24/12 at 1:15 PM identified she was not aware Patient #17 removed his/her alarm clip and it was not sounding at the time of the event on 9/16/12. The hospital policy for care planning directed in part that the nursing care plan will address the patient's problems at the time of admission and be updated as the patient's condition changes.
b. Patient #18 was admitted on [DATE] for the treatment of pneumonia. Patient #18's diagnosis included chronic obstructive pulmonary disease, congestive heart failure, atrial fibrillation, and dementia. On 2/16/12 an activity order directed Patient #18 out of bed to a chair. A fall risk assessment dated [DATE] identified Patient #18 was a high risk for falls with interventions that included the bed locked and in a low position, nonslip footwear when out of bed, a call bell within reach, a toileting regime every two hours, out of bed with assistance, an increase in patient observation, a green arm bracelet for identification of a fall risk and a night light. On 2/17/12 Patient #18 was seen by the physical therapy department with findings that included supervision was required when standing and a contact guard assist for ambulation. Review of the nurse's notes dated 2/18/12 at 8:00 AM identified Patient #18's neurological parameters were within normal limits however he/she was forgetful. Further review of the nurse's notes dated 2/18/12 at 11:48 AM indicated Patient #18 went to the bathroom unassisted and when exiting he/she leaned against the door which swung open and Patient #18 fell to the floor. The physician was notified and imaging was completed which revealed a comminuted and displaced left hip intertrochanteric and subtrochanteric fracture. Patient #18 underwent a surgical fixation of the hip fracture on 2/19/12. Interview with PT #1 on 10/24/12 at 1:10 PM indicated she communicated the findings from 2/17/12 with the registered nurse who was caring for Patient #18. Interview with the Director of Quality on 10/24/12 at 1:15 PM identified it is the responsibility of the nurse caring for the patient to inform the nurse's aide of new recommendations from physical therapy, and to revise the plan of care accordingly. Interview with RN #9 on 10/24/12 at 1:20 PM indicated although the plan of care identified assistance was needed when the patient was out of bed, a personal alarm should have been implemented as an intervention secondary to the diagnosis of [DIAGNOSES REDACTED]

The hospital policy for care planning directed in part that a nursing care plan is developed on all patients and will address the patient's problems at the time of admission and as the patient's condition changes.

2. Based on review of clinical records, review of facility policies, observations, and interview, the facility failed to ensure that the plan of care was followed for two of three patients (#34 and #35), who were identified as at risk for skin breakdown. The findings include:

a. Patient # 34 was admitted to the facility with diagnoses that included [DIAGNOSES REDACTED]#34's risk for skin breakdown with interventions that included to elevate the patient's heels when in bed. Observation on 10/23/12 at 9:15 AM identified that Patient #34 was lying in bed on his/her back without the benefit of his/her heels being elevated. The patient's bilateral heels were observed to be pink though blanchable. Interview with RN #19 at the time of the observation identified that he was aware that the patient's pressure relieving mattress did not supply pressure relief for the patient's heels.
b. Patient #35 was admitted to the facility with diagnoses that included [DIAGNOSES REDACTED]#35's risk for skin breakdown with interventions that included to elevate the patient's heels when in bed. Observation on 10/23/12 at 9:20 AM identified that Patient #35 was sitting upright in bed on his/her back without the benefit of his/her heels being elevated.
Review of facility policy directed that a Skin Risk Assessment Score be completed for every patient on admission and that an individualized plan of care be developed and implemented.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

1. Based on a review of clinical records, interviews, review of hospital policies, procedures and documentation for three of three patients (Patients #19, 20 and 21) that were admitted for a procedure, the hospital failed to ensure that insertion and/or discontinuation of an intravenous (IV) access and/or administration of IV fluids (IV) were based on a physician's order. The findings include:

a. Patient #19 was admitted on [DATE] for an IVC filter placement procedure. Review of the clinical record, with RN #11, identified that on 10/22/12 at 7:19 A.M. an intravenous access was inserted in the patient's right hand, IV Normal Saline was administered and at 8:57 A.M., the IV fluids and access were discontinued absent of physician orders. RN #11 stated it is Unit's protocol to administer Normal Saline via IV.

b. Patient #20 was admitted on [DATE] for a stereotactic biopsy of the right breast. Review of the clinical record, with RN #11, identified that an intravenous access was inserted and prior to discharge the access was discontinued absent of a physician order.

c. Patient #21 was admitted on [DATE] for a colonoscopy procedure. Review of the clinical record, with RN #11, identified that an intravenous access was inserted, intravenous fluids of Normal Saline were administered and prior to discharge the access and fluids were discontinued absent of a physician orders.

Review of the policy and procedure, titled Moderate Sedation Analgesia, identified that each patient must have intravenous access for sedation during a procedure.
A policy and procedure, titled Medication Administration, identified that medication are administered only upon the order of the Licensed Independent Practitioners who are members of the medical staff.
Review of the Medical Staff By-Laws, dated 9/27/11, identified that member of the medical staff is responsible for the timely and continuous medical care of each patient, complete and accurate medical record and all orders for treatment are in writing.


2. Based on review of clinical records, review of facility policies, and interview, the facility failed to ensure that physician orders for medications to be administered on an as needed basis to one of three patients (#36), who required intermittent pain medication, contained specific parameters for administration. The findings include:

a. Patient #36 was admitted to the facility with diagnoses that included abdominal pain and subsequently underwent a laparoscopic cholecystectomy. Physician orders dated 10/21/12 directed the administration of Morphine Sulfate, two to three milligrams intravenously (IV), every two hours as needed for pain. The physician order lacked documentation of parameters to guide the nursing staff as to which dosage of Morphine would be given based on the patient's complaints of pain.

b. Further review of Patient #36's clinical record identified a physician orders dated 10/22/12 that directed the administration of Percocet, one to two tablets, every three hours for pain as needed. The physician order lacked documentation of parameters to guide the nursing staff as to which dosage of Percocet would be given based on the patient's complaints of pain. Review of the clinical record and the physician orders with Unit Manager #10 on 10/23/12 at 10:30 AM identified that facility policy directed physician orders be written with specific parameters for administration of all medications and that the range orders for Patient #36's Morphine and Percocet should have been clarified with the physician at the time the order was written and/or before the order was transcribed.
VIOLATION: VERBAL ORDERS Tag No: A0408
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of clinical records and interviews, for two of three patients (#24 and 39) reviewed for medication administration, the hospital failed to ensure that verbal orders were documented in the clinical record. The findings include:

a. Patient #24 arrived at the Emergency Department (ED) on 10/22/12 at 8:29 A.M. via ambulance. Review of the clinical record identified that RN #12 administered Normal Saline intravenously (IV) wide open at 3:55 P.M. and 5:10 P.M. absent physician orders. Interview with RN #12, on 10/23/12 at 9:20 A.M., identified that s/he received verbal orders for administration of the identified intravenous fluids and had forgotten to write the orders.

b. Patient #39 was admitted on [DATE] for abdominal aortic aneurysm repair surgery. Review of the clinical record identified physician orders, dated 10/18/12 that directed the staff to administer two medications, Fentanyl and Versed, for sedation. Review of the clinical record, with the Nurse Manager of the unit, failed to reflect that the Fentanyl was administered as ordered. Interview with RN #13, on 10/23/12 at 9:40 A.M., identified that s/he called the ordering physician and received a verbal order to not administer Fentanyl although he/she did not write the order.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of clinical records, interviews and review of hospital policy, procedure and documentation for six of twenty-three patients (Patients #20, 43, 44, 15, 40, and 19) that had care and services provided, the hospital failed to ensure that the clinical records were complete and/or accurate. The findings include:

a. Patient #20 was admitted on [DATE] for a stereotactic biopsy of the right breast. Review of the clinical record, with RN #11 on 10/22/12, identified a verbal order, dated 10/19/12 at 11:40 A.M. and was not signed by the ordering physician. Review of the hospital policy and procedure, titled Physician Orders: Written, Telephone and Verbal, identified that the ordering physician is required to authenticate all orders as soon as possible.

b. Patient #43 arrived at the off-site urgent care center on 10/23/12 at 10:33 A.M. with the complaints of lower back muscle spasms, cough and a rash. Review of the clinical record identified that the patient was brought to a room and triaged at 11:07 A.M. although review of the provider's electronic note identified that the physician saw the patient was 10:33 A.M. Interview with the Clinical Nurse Manager and review of Patient #43's record, on 10/23/12 at 2:05 P.M. identified that the time documented on the provider electronic note that the patient was seen by the physician was inaccurate.

c. Patient #44 arrived at the off-site urgent care center on 10/23/12 at 10:05 A.M. with the complaints of pain upon urination. Review of the clinical record identified that the patient was brought to a room and triaged at 10:49 A.M. Review of the provider electronic note identified that the physician saw the patient was 10:06 A.M. Interview with the Clinical Nurse Manager and review of Patient #44's record, on 10/23/12 at 2:05 P.M. identified that the time documented on the provider electronic note that the patient was seen by the physician was inaccurate.

d. Patient #15 was admitted on [DATE] for a mediastinoscopy with biopsy. Interview and review of the clinical record with the Nurse manager of the unit, on 10/24/12 at 11:55 A.M., identified that the discharge instruction sheet was not signed by Patient #15 and/or there was no documentation that the nurse explained the discharge instructions to the patient. Reviews of the policy and procedure titled Discharge order Instruction Sheet, identified that the nurse will review the discharge orders with the patient and/or family and have them sign the form.

e. Patient #40 arrived at the Emergency Department (ED) on 10/23/12 at 6:05 A.M. via ambulance from a long-term care facility, unresponsive with hypoxia. Review of the clinical record identified that at the time of arrival, Patient #40 was unable to sign the consent to treat although the admission staff documented that the patient had not executed a living will. Interview with Admission Staff #1, on 10/23/12 at 9:42 A.M., identified that the admission staff could not have asked Patient #40 if s/he had executed a living will upon arrival to the ED due to the patient's medical condition.

f. Patient #19 was admitted on [DATE] for an IVC filter placement procedure. Review of the clinical record, with RN #11, failed to reflect that comprehensive history and physical was contained in the record. subsequent to inquiry, the hospital submitted a comprehensive history and physical of Patient #19, dated 10/19/12 and a fax date of 10/23/12. Staff identified that the document should have been included in Patient #19's clinical record.

Review of the Medical Staff By-Laws, dated 9/27/11, identified that members of the medical staff are responsible for the timely and continuous medical care of each patient, complete and accurate medical record and all orders for treatment are in writing.
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of the clinical record, staff interviews and a review of the facilities policies and procedures for one of two sampled patients reviewed for falls (Patient #18) the facility failed to obtain an admitting physician's order that directed an activity level. The finding included:
Patient #18 was admitted on [DATE] for the treatment of pneumonia. Patient #18's diagnosis included chronic obstructive pulmonary disease, congestive heart failure, atrial fibrillation, and dementia. The patient's respiratory symptoms improved and s/he responded well to medical management. On the day of discharge Patient #18 suffered a fall with a subsequent fracture of the left femur. On 2/19/12 Patient #18 underwent a surgical fixation of the intertrochanteric hip fracture and was discharged on [DATE]. Interview and review of the clinical record with the Director of Quality on 10/24/12 at 1:40 PM failed to identify admission orders dated 2/14/12 that included an activity level for Patient #18. Further interview with the Director of Quality indicated the physician was responsible to include an activity level in the admission orders.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on tour, interviews and policy reviews the Hospital did not ensure that the buildings, equipment and surroundings were kept clean and in good repair at all times. 10/22/12 at 1:15 PM the surveyors accompanied by the Safety Director and the contracted FNS Director during a tour of the Dietary Department the following was observed:
a. There was a build-up of grease, grime and dust on exposed overhead mechanical piping and ductwork above the preparation areas, cooking equipment, pot wash sinks; walk-in coolers and freezers. Dietary Department policy indicates that the exposed overhead mechanical piping and ductwork above the preparation areas, cooking equipment, pot wash sinks; walk-in coolers and freezers shall be cleaned every three months with a schedule of March, June, September and December; documentation provided indicated that the September cleaning was not conducted and the exposed piping and ductwork had not been cleaned as of 10/23/12.
b. There was a build-up of grime and food debris under and behind the cooking equipment.
VIOLATION: LIFE SAFETY FROM FIRE Tag No: A0710
Based on tours of the Hospital, staff interviews, and documentation review. The hospital did not ensure that applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA 101, 2000 edition) were met.

See K tags K 017, K 018, K 021, K 029, K 076, and K 077 from the Life Safety Code Survey conducted 10/09/12 through 11/09/12.
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the clinical record, interview and review of hospital policy and procedure for one patient (Patient #15) that was discharged home after surgery, the facility failed to ensure that the nursing staff educated the patient and/or ensured that the patient understood the discharge plan. The finding includes:

a. Patient #15 was admitted on [DATE] for a mediastinoscopy with biopsy. Interview and review of the clinical record with the Nurse manager of the unit, on 10/24/12 at 11:55 A.M., identified that the discharge instruction sheet was not signed by Patient #15 and/or there was no documentation that the nurse explained the discharge instructions to the patient.
Review of the policy and procedure titled Discharge Order Instruction Sheet, identified that the nurse will review the discharge orders with the patient and/or family and have them sign the form.
VIOLATION: HISTORY AND PHYSICAL Tag No: A0952
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of clinical records, interviews and review of hospital documentation for one of five patients (#22) that had surgery, the hospital failed to ensure that the history and physical was complete. The finding includes:

a. Patient #22 was admitted on [DATE] for removal of left upper eye lid cyst surgery. Review of the clinical record, with RN #16, identified that the history & physical was incomplete (page 2 of 3 was missing) although review of the pre-operative checklist, dated 10/22/12 at 8:46 A.M., identified that the physician history & physical was in the chart and met criteria.

Review of the Medical Staff By-Laws, dated 9/27/11, identified that a member of the medical staff performs a history and physical for each patient admitted to the hospital and/or undergoing an invasive procedure which is recorded prior to the procedure.