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.

ST TAMMANY PARISH HOSPITAL 1202 S TYLER STREET COVINGTON, LA 70433 May 11, 2011
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on record review and interview, the governing body failed to ensure the effective operation of the grievance process as evidenced by no documented evidence that the governing body had reviewed the grievance log to determine that grievances had been investigated and resolved. Findings:

Review of the grievance log presented by DON of Adult Health S4 revealed complaint codes that covered broad categories including care expectations, communication, delays, and other. Further review revealed no specific information that could be used to determine if the complaint was actually a grievance and could identify trends or problems.

In a face-to-face interview on 05/11/11 at 9:05am, Department Head of Guest Services S20 indicated the log was presented to the governing body for review and was not a part of the hospital's QAPI (quality assessment performance improvement) program.

In a face-to-face interview on 05/11/11 at 1:20pm, Legal Representative S13 indicated the Board of Commissioners reviewed the complaint log monthly. S13 further indicated the hospital did not have a Grievance Committee. S13 presented the agenda for the Board of Commissioners Open Session for 04/21/11 which revealed "Customer Service Recap". When asked for documentation of the review of the complaint/grievance log by the Board of Commissioners, S13 indicated she would get back with the surveyor.

In a face-to-face interview on 05/11/11 at 3:35pm, DON for Adult Health S4 indicated that Legal Representative S13 reported that she did not have any further documentation related to the Board of Commissioner's review of grievances.

Review of the hospital policy titled "Patient Complaint Resolution And Grievance Process:, revised 08/06 and presented by DON (director of nursing) Adult Health S4 as their current policy for the grievance process, revealed, in part, "... VII. Trending And Reporting A. Verbal and written complaints and grievances are trended and reported by Guest Services. Reports are provided to the President/CEO, Board of Commissioners, and other Hospital Committees as appropriate...".
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the hospital failed to ensure: 1) the designated health care power of attorney for a patient diagnosed with Alzheimer's dementia had been informed of her health status, was involved in care planning and treatment, and had given consent for treatment for 1 of 2 patients reviewed with a designated health care power of attorney from a total sample of 14 patients (#7); 2) patients were informed of the diagnosis or condition requiring treatment, the therapeutic alternatives to the treatment and risks associated with the alternatives, and/or the name of the physician performing the treatment for 9 of 9 patients reviewed who had consents for procedures from a total sample of 14 patients (#2, #3, #4, #5, #6, #7, #8, #9, #10); and 3) the physician followed the hospital policy for executing a DNR (do not resuscitate) order for 2 of 3 patients reviewed with an order for DNR from a total sample of 14 patients (#7, #9). Findings:

1) The designated health care power of attorney for a patient diagnosed with Alzheimer's dementia had been informed of her health status, was involved in care planning and treatment, and had given consent for treatment:
Review of Patient #7's medical record revealed she was admitted on [DATE] with a history of Alzheimer dementia (Stage VI to VII) and chief complaints of wheezing, crackles, chest congestion, shortness of breath, and hypoxic. Review of the H&P (history and physical) revealed diagnoses of nursing home-acquired pneumonia, coronary artery disease, hypertension, gastroesophageal reflux disease, and dementia with cognitive deficits. Further review revealed S25, son-in-law, was named as POA for health care decisions for Patient #7. Review of the "Authorization For Care And Services" revealed Patient #7's daughter signed the consent on 04/12/11.

Review of the "Physician Orders" revealed a telephone order was received on 04/13/11 at 12:20pm from Physician S18 to "consult LTAC B".

Review of the "Interdisciplinary Progress Notes" revealed a notation by MSW (medical social worker) S10 on 04/14/11 at 11:30am that read "rec'd (received) consult for LTAC (long term acute care) B. Referral made to Nurse Liaison with LTAC B S21 and faxed face sheet. Eval (evaluation) pending". Further review revealed an entry on 04/15/11 at 10:40am by MSW S12 of "spoke with pt (patient) regarding transfer to LTAC B. Pt dtr (daughter), who stated that she is POA, stated that she had no information regarding a ref (referral) to LTAC B nor giving the "o.k." to go... Called and spoke with Nurse Liaison with LTAC B S21 who stated that he did get family approval for LTAC B by pt other dtr Phone call made to Guest Services Assistant S19 with Guest Services to speak with pt dtr".

In a face-to-face interview on 05/10/11 at 1:55pm, MSW S10 indicated she received the referral from Physician S18 for Patient #7 to be transferred to LTAC B. S10 further indicated she knew that Physician S18 usually sent his patients to LTAC B. S10 further indicated she went into Patient #7's room, and no family member was present. S10 indicated since she had 24 hours to process a referral, she called Nurse Liaison with LTAC B S21 with the referral and faxed Patient #7's face sheet to him. S10 indicated she left a message the next day for MSW S12 to follow-up with the family regarding the LTAC referral. S10 indicated there was no documentation of a POA on Patient #7's medical record at the time she made the referral. When asked by the surveyor who had given consent for the transfer to and choice of the LTAC, MSW S10 indicated if the physician wrote an order, she could make the referral and fax the information. S10 indicated she did not have the consent of the patient or responsible party.

In a face-to-face interview on 05/10/11 at 3:10pm, RN S11 indicated she was the charge nurse at the time Patient #7's daughter became upset about the referral to LTAC B. S11 further indicated the daughter was upset her mother was going to LTAC B and expressed that she didn't know the condition of her mother, had not seen her physician, didn't know her diagnosis, and was upset with the discharge planning process. S11 indicated Patient #7's daughter at first told her (S11) that she had POA for her mother and thought the nursing home had sent a copy to the hospital. S11 indicated she received a copy of the POA from Nursing Home A and called Guest Services to come to speak with the daughter of Patient #7. RN S11 indicated she, Guest Services Assistant S19, and MSW S12 met with Patient #7's daughter and son-in-law, who was the designated power of attorney for health care decisions, to discuss what had happened. S11 further indicated the daughter was very upset about what had happened and that LTAC B had been given medical information about her mother without consent.

In a face-to-face interview on 05/11/11 at 3:55pm, MSW S12 indicated the RN told her Patient #7's daughter wanted to speak with the social worker. S12 further indicated the question she was asked by the daughter was "who gave you permission to give my mother's information to the LTAC?". S12 indicated after being told by Patient #7's daughter that she had POA and no one had approached her for consent, she called Nurse Liaison from LTAC B S21. S12 indicated S21 told her that he got consent from Patient #7's other daughter. S12 indicated no one knew Patient #7 had a POA until the day of discharge. S12 indicated after they learned of and received a copy of the POA, a meeting was conducted with herself, the charge nurse, Guest Services, the patient's nurse, Patient #7's daughter, and the son-in-law who had POA. S12 further indicated the family agreed at the time to the transfer, but they were upset with the lack of discharge planning.

In a face-to-face interview on 05/11/11 at 10:00am, Physician S18 indicated he gave the order for Patient #7 to be transferred to LTAC B. After review of the medical record, S18 confirmed there was no documentation of a discussion by him with the family regarding Patient #7's health status and subsequent referral to a LTAC. S18 further indicated often he's busy, so he doesn't always talk with patients or their families regarding transfers and such.

Review of the hospital policy titled "Patient Rights And Responsibilities", revised 01/05 and presented by DON of Adult Health S4 as their current policy for patient rights, revealed, in part, "...All patients (or family when appropriate) have the right to: ...make informed decisions about your care and any proposed procedure or treatment. This includes being informed of your health status, being involved in care planning and treatment, and being able to request or refuse treatments...".

2) Patients were informed of the diagnosis or condition requiring treatment, the therapeutic alternatives to the treatment and risks associated with the alternatives, and/or the name of the physician performing the treatment:
Patient #2
Review of the "Patient Consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information" form for Patient #2 revealed consent for insertion of a peripherally inserted central catheter (PICC). Further review revealed no documented evidence the patient was informed of the following: diagnosis or condition requiring the treatment; reasonable therapeutic alternatives and the risks associated with such alternatives including the risk of no treatment. Further review revealed Patient #2 signed the form on 05/08/11 at 2115 (9:15pm), and the physician signed the form on 05/09/11 at 0935 (9:35am).

Patient #3
Review of the "Patient Consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information" form for Patient #3 dated 05/05/11 revealed a consent for a Diagnostic Lumbar Puncture. Further review revealed no documented evidence the patient was informed of the following: diagnosis or condition requiring the treatment; reasonable therapeutic alternatives and the risks associated with such alternatives including the risk of no treatment; the time the physician signed the consent and the day and time the consent was signed by the husband of the patient.

Patient #4
Review of the "Patient Consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information" form for Patient #4 dated 03/25/11 revealed consent for CAT Scan or MRI Scan involving the administration of Intravenous Contrast material. Further review revealed no documented evidence the patient was informed of the following: diagnosis or condition requiring the treatment; reasonable therapeutic alternatives and the risks associated with such alternatives including the risk of no treatment; and the name of the authorized physician to perform the medical treatment. Further review revealed no documented evidence of the date and time Patient #4 signed the consent.

Patient #5
Review of the "Patient Consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information" form for Patient #5 dated 02/25/11 revealed consent for a thoracentesis. Further review revealed no documented evidence the patient was informed of the following: diagnosis or condition requiring the treatment; the name of the authorized physician to perform the medical treatment.

Patient #6
Review of the "Patient Consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information" form for Patient #6 dated 01/10/11 revealed consent for Transesophageal Echocardiogram. Further review revealed no documented evidence the patient was informed of the following: diagnosis or condition requiring the treatment; reasonable therapeutic alternatives and the risks associated with such alternatives including the risk of no treatment; and the name of the authorized physician to perform the medical treatment and the signature of the physician performing the procedure.

Patient #7
Review of the "Patient Consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information" form for Patient #7 revealed consent for insertion of a peripherally inserted central catheter (PICC). Further review revealed no documented evidence the patient was informed of the following: diagnosis or condition requiring the treatment; the material risks of the treatment or procedure, reasonable therapeutic alternatives and the risks associated with such alternatives including the risk of no treatment. Further review revealed Patient #7's daughter, who was not the designated POA, signed the form on 04/13/11 at 10:30am, and the physician signed the form on 04/13/11 at 1400 (2:00pm).

Patient #8
Review of the "Patient Consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information" form for Patient #8 dated 02/10/11 revealed consent for cardiac catherization/percutaneous transluminal angioplasty (PTCA) / stent placement rotational arthrectomy thrombolysis. Further review revealed no documented evidence the patient was informed of the following: diagnosis or condition requiring the treatment; reasonable therapeutic alternatives and the risks associated with such alternatives including the risk of no treatment; and the name of the authorized physician to perform the medical treatment.

Review of the "Patient Consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information" form for Patient #8 dated 02/10/11 revealed consent for Dialysis. Further review revealed no documented evidence the patient was informed of the following: diagnosis or condition requiring the treatment; reasonable therapeutic alternatives and the risks associated with such alternatives including the risk of no treatment; and the name of the authorized physician to perform the medical treatment.

Patient #9
Review of the "Patient Consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information" form for Patient #8 dated 02/28/11 revealed consent for Percutaneous Endoscopic Gastrostomy and Esophagogastroduodenoscopy. Further review revealed no documented evidence the patient was informed of the following: diagnosis or condition requiring the treatment and the name of the authorized physician to perform the medical treatment.

Patient #10
Review of the "Patient Consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information" form for Patient #10 dated 04/14/11 revealed consent for insertion of a Central Venous Catheter. Further review revealed no documented evidence the patient was informed of the following: diagnosis or condition requiring the treatment; reasonable therapeutic alternatives and the risks associated with such alternatives including the risk of no treatment; and the name of the authorized physician to perform the medical treatment.

In a face-to-face interview on 05/09/11 at 11:35am, RN (registered nurse) Manager S3 indicated the staff nurse knows they are only witnessing the signature of the patient. She further indicated the nurse asked the patient if the procedure had been explained to them, and if the patient said no, the nurse would stop and call for the physician. S3 indicated it was the physician's responsibility to assure the informed consent was completed accurately.

Review of the hospital policy titled "Consent For Treatment", revised 01/10 and submitted by DON (director of nursing) for Adult Health S4 as their current policy for consents, revealed, in part, "...All competent patients (or their legal representative) presenting for treatment shall sign a general authorization for medical/surgical treatment upon admission to St. Tammany Parish Hospital. In addition, informed consent is obtained by the doctor or licensed healthcare provider performing a medical treatment, surgical or special procedure when indicated. ... Guidelines A. All competent patients presenting to the Hospital will sign a general authorization for medical/surgical treatment upon admission to the Hospital. The patient's signature on this authorization form is to be obtained by the Admitting Clerk registering the patient. ... B. In addition to the authorization discussed in (A), patients who will undergo surgery and invasive procedures will sign: 1. Patient Consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information (consent form); and 2. All risk attachments or documented risks specific to and associated with the proposed procedure. ... D. A physician has a duty to inform his/her patient about proposed medical or surgical treatment and to obtain informed consent when performing a medical treatment, surgical or special procedure. E. It is the responsibility of the patient's physician... to explain and disclose the following information to patients: 1. The nature of the pertinent ailment or condition and the general nature of the proposed treatment or procedure; 2. The material risks involved in the proposed treatment or procedure; 3. The risks associated with failing to undergo any treatment at all; and 4. The alternative methods of treatment including the associated risks and potential complications. The physician will provide an opportunity for the patient or the person authorized to give consent to ask any questions and acknowledge in writing that he answered such questions and explained the requisite information by signing the appropriate space on the consent form. Note: The physician, by written order, may delegate the responsibility to approach the patient (or his/her legal representative) with a consent form prepared by the physician or prepared with information provided per his/her orders and to obtain and witness the patient's signature. Any unresolved questions about the procedure shall be referred to the physician and satisfied prior to accepting a signature. The statement of consent and applicable attachment pages shall contain the certification of the physician or healthcare provider that he/she discussed the contents and obtained the informed consent...".

3) The physician followed the hospital policy for executing a DNR order:
Patient #7
Review of Patient #7's medical record revealed she was admitted on [DATE] with a history of Alzheimer dementia (Stage VI to VII) and chief complaints of wheezing, crackles, chest congestion, shortness of breath, and hypoxic.
Review of Patient #7's "Physician Orders" revealed an order on 04/13/11 at 12:20am by Physician S18 for DNR. Review of the entire medical record revealed no documented evidence of a discussion by Physician S18 with S25, Patient #7's son-in-law who had been designated as the power of attorney for health care decisions, regarding Patient #7 being declared a DNR or that Patient #7 was examined by her attending physician and another physician indicating her condition is terminal and irreversible or profoundly comatose.

In a face-to-face interview on 05/11/11 at 10:00am, Physician S18 indicated he wrote the order for Patient #7 to be a DNR. After review of the medical record, S18 confirmed there was no documentation of a discussion by him with Patient #7's power of attorney S25 regarding his wishes for Patient #7 to be made a DNR. S18 further indicated he usually writes the order based on a nurse telling him that a patient was a DNR at another facility. S18 indicated he was not aware that he had to have a discussion with the family/POA before writing an order for DNR.

Review of the policy titled "Withholding/Withdrawing of Life-Sustaining Procedures" last revised 12/07 and submitted by the hospital as the one currently in use revealed..... E. In the event a patient is near the end of life and the Physician and Hospital staff are notified of a declaration, the patient must be examined and if so indicated, certified in writing by two physicians. These Physicians must confirm that in their best medical judgement: (1) the patient's condition is terminal and irreversible or profoundly comatose, and (2) death will occur whether or not life-sustaining procedures are utilized, as they would only serve to prolong the dying process. One of the two certifying physicians must be the attending physician, and both Physicians must examine the patient before life-sustaining procedures may be withdrawn or withheld".

Physician's responsibility A. An attending Physician who has been notified of the existence of a declaration must examine, certify, and obtain confirmation from a second physician of the patient's terminal and irreversible condition. This is to be documented in the patient's medical record before ordering the withdrawal or withholding of life-sustaining procedures".

Patient #9
Review of the medical record for Patient #9 revealed a [AGE] year old chronically ill female living in an apartment and being cared for by family and hospice. #9's condition began to deteriorate five days prior to admission on 02/27/11 at which time the family rescinded the hospice care and brought her to the hospital. Patient #9 was admitted for lethargy, PEG tube re-insertion and a rapid response to her chronic Atrial fibrillation.

Review of the H&P (History & Physical) for Patient #9 dated 02/27/11 revealed.... "Plan:......Advanced care plan was discussed with the patient's daughter who has the medical Power of Attorney. She and her family are not ready for the patient to die and do not feel that this is the end of life situation for the patient. There wish is for their mother to have palliative care in hopes of restoring her to her baseline level of quality of life as of 2 to 3 weeks prior to this admission".

Review of the Physician's Admit Orders for Patient #9 dated/timed 02/27/11 at 2300 (11:00pm) revealed.... "12. Advanced Directive/Living Will: DNR - discussed with Family".

In a face to face interview on 05/10/11 at 4:30pm Hospital Attorney S13 reviewed Patient #9's medical record agreed the physician documented the patient's daughter who had medical power of attorney rescinded the hospice and that she and her family felt their mother (#9) was not at the end of her life.

Review of the policy titled "Withholding/Withdrawing of Life-Sustaining Procedures" last revised 12/07 and submitted by the hospital as the one currently in use revealed.... VI. Revocation of Declaration A. A declaration may be revoked without regard to mental state or capacity by: (1) written revocation, (2) the cancellation or destruction of a prior declaration, or (3) an oral or non-verbal expression by the Declarant of the intent to revoke the declaration".
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure physician orders were obtained for the application of restraints for 4 of 5 patients reviewed with restraints from a total sample of 14 patients (#5, #12, #13, #14). Findings:

Patient #5
Review of the H&P (History and Physical) for Patient #5 revealed he was [AGE] year old male admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of the "MED/SURG Restraint: Physician's Order and Documentation Record" for Patient #5 revealed he was pulling at lines, tubes, and dressings, interfering with caregivers, and refusing/unable to maintain safety. Further review revealed the following interventions were attempted: reorient; quiet environment; keep comfortable; increase observation; maintain conversation; listen; evaluate medication; explain procedures before assessment/treatment; conceal/dc (discontinue) tubes/lines; rollbelt; mittens. Further review revealed an order was received to apply restraints on 03/01/11 at 2115 (9:15pm). Further review revealed the restraints were removed at 2300 (11:00pm) and reapplied at 1:00am on 03/02/11 with no documented evidence of an order for the restraints to be applied.

Patient #12
Review of Patient #12's H&P revealed she was a [AGE] year old female who had a normal full-term vaginal delivery 2 weeks ago following an uncomplicated pregnancy. Further review revealed she was found on the floor having a seizure and was brought to the emergency department for evaluation.

Review of the "MED/SURG Restraint: Physician's Order and Documentation Record" for Patient #12 revealed she was pulling at lines, tubes, and dressings, had a risk of self-extubation, interfering with care givers, and refusing/unable to maintain safety. Further review revealed the following interventions were attempted: reorient; quiet environment; keep comfortable; increase observation; explain procedures before assessment/treatment; conceal/dc tubes/lines; secure catheter. Further review revealed restraints were applied on 03/14/11 at 3:00am with no documented evidence of an order from the physician.

Patient #13
Review of the H&P for Patient #13 date of admit 04/17/11 revealed a [AGE] year old female who was found at home, unresponsive with empty prescription bottles. She was transferred to St. Tammany Parish Hospital with intravascular volume depletion, acute renal failure, elevated CK and CKMB, and leukocytosis.

Review of the MED/SURG Restraint: Physician's Order and Documentation Record for Patient #13 revealed she began pulling at her urinary catheter, telemetry leads and IV and attempted to punch and bite staff. Further review revealed the following interventions were attempted: reorientation, quiet environment, keep comfortable, increase observation, maintain conversation, listen, sitter at bedside, evaluate medication, conceal lines, roll-belt, secure catheter and mittens. According to the restraint form, no verbal or written order was written by the physician for the restraints.

Patient #14
Review of the H&P for Patient #14 revealed a [AGE] year old female admitted to the hospital with bilateral effusions and CHF (Congestive Heart Failure), shortness of breath and lower extremity edema.

Review of the MED/SURG Restraint: Physician's Order and Documentation Record for Patient #14 revealed she began pulling at her triple lumen catheter. Further review revealed the following interventions were attempted: securing the catheter, mittens, re-orientation, quiet environment and explaining procedures before assessment. According to the restraint form, bilateral soft wrist restraints were applied to Patient #14 at 8:00am and removed at 9:00am. Further review revealed the bilateral wrist restraints were applied again at 9:00am; however there is no documented evidence the physician was notified and a new order obtained.

In a face-to-face interview on 05/11/11 at 7:25am with RN (registered nurse) Clinical Coordinator S14, RN S15, RN S16, and Director of Critical Care S9 present, RN S16 confirmed Patient #5 was released from restraints and the restraints reapplied two hours later without contacting the physician for a new order. RN Clinical Coordinator S14 indicated as long as the the patient's behavior was the same as that which caused the initial application of restraints, the restraints could be reapplied without another physician's order. Review of the hospital policy revealed this information was not correct, as a new order was needed for the restraints to be reapplied.

Review of the hospital policy titled "Restraint Protocol", revised 06/10 and submitted by DON (director of nursing) for Adult Health S4 as the current restraint policy, revealed, in part, "...Physician Order: If the attending physician is not available, a registered nurse (Nurse Manager or Nursing Supervisor) may initiate restraint in advance of a physician's order. If the restraint was necessary due to a significant change in the patient's condition the physician shall be contacted immediately for an order. If the need for restraint is not due to a significant change in the patient's condition, the attending physician must be notified and a restraint order obtained within 12 hours of restraint initiation... If at any time restraints need to be reapplied, a new order for restraints shall be obtained...".
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the hospital failed to follow its policy and procedures for the use of restraints when less restrictive interventions have been determined to be ineffective as evidenced by failure to have an evaluation performed by the nursing supervisor prior to the application of restraints for 3 of 5 patients reviewed with restraints from a total sample of 14 patients (#5, #11, #14). Findings:

Patient #5
Review of the H&P (History and Physical) for Patient #5 revealed he was [AGE] year old male admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of the "MED/SURG Restraint: Physician's Order and Documentation Record" for Patient #5 revealed he was pulling at lines, tubes, and dressings, interfering with caregivers, and refusing/unable to maintain safety. Further review revealed the following interventions were attempted: reorient; quiet environment; keep comfortable; increase observation; maintain conversation; listen; evaluate medication; explain procedures before assessment/treatment; conceal/dc (discontinue) tubes/lines; rollbelt; mittens. Further review revealed restraints were applied at 9:15pm on 03/01/11 with no documented evidence of an assessment of Patient #5 by the Nurse Manager or Nursing Supervisor prior to the application of restraints as required by hospital policy.

Patient #11
Review of the H&P for Patient #11 revealed he was a [AGE] year old male with multiple medical problems including diabetes, coronary artery disease, peripheral arterial disease, and end-stage renal disease requiring hemodialysis who was sent from the dialysis unit upon completion of therapy for complaints of shortness of breath and abdominal distention.

Review of the "MED/SURG Restraint: Physician's Order and Documentation Record" for Patient #11 revealed he was placed in restraints on 04/10/11 at 11:45pm due to pulling off oxygen. Further review revealed the Nursing Supervisor's visit to Patient #11 was on 04/11/11 at 6:00am, more than 6 hours after the restraints had been applied, rather than prior to the application of restraints as required by hospital policy.

Patient #14
Review of the H&P for Patient #14 revealed a [AGE] year old female admitted on [DATE] with bilateral effusions and CHF (Congestive Heart Failure), shortness of breath and lower extremity edema.

Review of the MED/SURG Restraint: Physician's Order and Documentation Record for Patient #14 revealed she began pulling at her triple lumen catheter. Further review revealed the following interventions were attempted: securing the catheter, mittens, re-orientation, quiet environment and explaining procedures before assessment. According to the restraint form, there was no documented evidence the house manager assessed Patient #14 before the bilateral soft restraints were applied.

In a face-to-face interview on 05/11/11 at 7:25am, Director of Critical Care S9 confirmed the hospital policy required the nursing manager or nursing supervisor to evaluate the patient prior to restraints being applied.

Review of the hospital policy titled "Restraint Protocol", revised 06/10 and submitted by DON (director of nursing) for Adult Health S4 as the current restraint policy, revealed, in part, "...Orders For Restraint Use: 10. The Charge Nurse assesses the patient, the alternative interventions attempted by the assigned nurse, and the patient's response. If restraints are indicated the Charge Nurse notifies the Nurse Manager or Nursing Supervisor of need for restraint. Upon arrival, the Nurse Manager or Nursing Supervisor evaluates patient for clinical justification for restraints. If restraints are indicated, the least restrictive method of restraint shall be chosen...".
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the hospital failed to ensure the patient and/or their representative was afforded the right to participate in the development and implementation of the patient's care as evidenced by making a referral for long term acute care (LTAC) for a patient diagnosed with [DIAGNOSES REDACTED]#7) and for a patient with a diagnosis of [DIAGNOSES REDACTED]#3) from a total sample of 14 patients. Findings:

Patient #3
Review of Patient #3's medical record revealed a [AGE] year old female admitted on [DATE] with the diagnosis of [DIAGNOSES REDACTED]#3 was unable to consent for herself due to her condition; therefore the Consent for Treatment was signed by her husband.

Review of the Interdisciplinary Progress Notes dated 05/06/11 at 2:10pm by the Social Service Department revealed Patient #3 was assessed by the Physical Therapy Department at the hospital and may be appropriate for in-patient therapy. Further review revealed no documented evidence the social worker had spoken with Patient #3's husband since admit.

In a face to face interview on 05/09/11 at 9:05am the husband of Patient #3 indicated his wife has been in the hospital 10 days. Further he indicated he knows his wife (#3) will need more care after discharge from the hospital but no one has come to talk to him about it. The husband of Patient #3 indicated he has not left his wife side since she was transferred out of ICU and no Social Worker has come to talk to him.

Review of the medical record for Patient #3 could not find documented evidence case management or social services had spoken with the husband of Patient #3.

Patient #7
Review of Patient #7's medical record revealed she was admitted on [DATE] with a history of Alzheimer's dementia (Stage VI to VII) and chief complaints of wheezing, crackles, chest congestion, shortness of breath, and hypoxic. Review of the H&P (history and physical) revealed diagnoses of [DIAGNOSES REDACTED]"General Power of Attorney" (POA), which included health care, had been faxed to the hospital from Nursing Home A on 04/15/11 at 11:00am. Further review revealed S25, son-in-law, was named as POA for health care decisions for Patient #7.

Review of the "Physician Orders" revealed a telephone order was received on 04/13/11 at 12:20pm from Physician S18 to "consult LTAC B".

Review of the "Interdisciplinary Progress Notes" revealed a notation by MSW (medical social worker) S10 on 04/14/11 at 11:30am that read "rec'd (received) consult for LTAC (long term acute care) B. Referral made to Nurse Liaison with LTAC B S21 and faxed face sheet. Eval (evaluation) pending". Further review revealed an entry on 04/15/11 at 10:40am by MSW S12 of "spoke with pt (patient) regarding transfer to LTAC B. Pt dtr (daughter), who stated that she is POA, stated that she had no information regarding a ref (referral) to LTAC B nor giving the "o.k." to go... Called and spoke with Nurse Liaison with LTAC B S21 who stated that he did get family approval for LTAC B by pt other dtr Phone call made to Guest Services Assistant S19 with Guest Services to speak with pt dtr". Further review revealed an entry by MSW S12 at 2:00pm on 04/15/11 of "had a meeting between Guest Services Assistant S19, SW (social worker), CN (charge nurse), and pt nurse with pt dtr and son-in-law (POA). Pt dtr was concerned regarding not being notified as above...".

In a face-to-face interview on 05/10/11 at 1:55pm, MSW S10 indicated she received the referral from Physician S18 for Patient #7 to be transferred to LTAC B. S10 further indicated she knew that Physician S18 usually sent his patients to LTAC B. S10 further indicated she went into Patient #7's room, and no family member was present. S10 indicated since she had 24 hours to process a referral, she called Nurse Liaison with LTAC B S21 with the referral and faxed Patient #7's face sheet to him. S10 indicated she left a message the next day for MSW S12 to follow-up with the family regarding the LTAC referral. S10 indicated there was no documentation of a POA on Patient #7's medical record at the time she made the referral. When asked by the surveyor who had given consent for the transfer to and choice of the LTAC, MSW S10 indicated if the physician wrote an order, she could make the referral and fax the information. When asked again who had given consent, S10 answered "the doctor". After being reminded by the surveyor of patients' rights and being asked again about consent, S10 indicated she did not have the consent of the patient or responsible party. S10 confirmed there was no family present when she entered Patient #7's room, and she had no communication with any family member of Patient #7.

In a face-to-face interview on 05/10/11 at 3:10pm, RN S11 indicated she was the charge nurse at the time Patient #7's daughter became upset about the referral to LTAC B. S11 further indicated the daughter was upset her mother was going to LTAC B and expressed that she didn't know the condition of her mother, had not seen her physician, didn't know her diagnosis, and was upset with the discharge planning process. S11 indicated Patient #7's daughter at first told her (S11) that she had POA for her mother and thought the nursing home had sent a copy to the hospital. S11 indicated she received a copy of the POA from Nursing Home A and called Guest Services to come to speak with the daughter of Patient #7. RN S11 indicated she, Guest Services Assistant S19, and MSW S12 met with Patient #7's daughter and son-in-law (POA) to discuss what had happened. S11 further indicated the daughter was very upset about what had happened and that LTAC B had been given medical information about her mother without consent.

In a face-to-face interview on 05/11/11 at 3:55pm, MSW S12 indicated the RN told her Patient #7's daughter wanted to speak with the social worker. S12 further indicated the question she was asked by the daughter was "who gave you permission to give my mother's information to the LTAC". S12 indicated after being told by Patient #7's daughter that she had POA and no one had approached her for consent, she called Nurse Liaison from LTAC B S21. S12 indicated S21 told her that he got consent from Patient #7's other daughter. S12 indicated no one knew Patient #7 had a POA until the day of discharge. S12 indicated after they learned of and received a copy of the POA, a meeting was conducted with herself, the charge nurse, Guest Services, the patient's nurse, Patient #7's daughter, and the son-in-law who had POA. S12 further indicated the family agreed at the time to the transfer, but they were upset with the lack of discharge planning.

In a face-to-face interview on 05/11/11 at 10:00am, Physician S18 indicated he gave the order for Patient #7 to be transferred to LTAC B. After review of the medical record, S18 confirmed there was no documentation of a discussion by him with the family regarding the referral to a LTAC. S18 indicated he usually writes the order, and the social worker checked with the patient for choice. When informed by the surveyor that his order was specifically for LTAC B, S18 indicated if he just writes refer to LTAC, a lot of times the social worker chooses to which LTAC the patient will go. S18 further indicated often he's busy, so he doesn't always talk with patients or their families regarding transfers and such.

In a face-to-face interview on 05/11/11 at 10:40am, Nurse Liaison with LTAC B S21 indicated he came to the hospital to evaluate Patient #7 for LTAC placement. S21 further indicated he got a call from MSW S10 who sent him Patient #7's face sheet that included the patient's address, contact information, and insurance coverage. S21 indicated when he got to the hospital, he reviewed Patient #7's medical record, visited the patient, and talked with the patient's daughter (not the daughter whose spouse had POA). S21 indicated the consent for release of medical information was supposed to be done by the hospital before he came to the hospital. S21 indicated the daughter present during his visit tried unsuccessfully to call her sister three times. S21 indicated he spoke with Patient #7's daughter the next day who informed him that her husband had POA, and they had no objection to her mother's transfer to LTAC B, but they were dissatisfied with discharge planning process.

Review of the hospital policy titled "Interdisciplinary Care Management", revised 06/10 and presented by DON (director of nursing) for Adult Health S4 as their current policy for care planning, revealed, in part, "... All patients admitted to St. Tammany Parish Hospital for acute care services will have access to Interdisciplinary Care Management, Continuity of care requires thoughtful preparation, and thorough interdisciplinary care management, Hospital staff is to assure that all patients and their families receive appropriate physical, social, emotional, spiritual and/or financial care and referrals during hospitalization and prior to discharge. ...Social Worker Case Manager: ... 5. Obtain facility acceptance for nursing home placements, psychiatric facility transfers and home health referrals. ... Nurse Case Manager: ... 6. Obtain facility acceptance for transfer to rehabilitation facilities, long term acute facilities or to other acute care facilities...". Further review of the procedure revealed no documented evidence that the staff was required to discuss the plan for care with the patient and/or family.

Review of the hospital policy titled "Patient Rights And Responsibilities", revised 01/05 and presented by DON of Adult Health S4 as their current policy for patient rights, revealed, in part, "...All patients (or family when appropriate) have the right to: ...make informed decisions about your care and any proposed procedure or treatment. This includes being informed of your health status, being involved in care planning and treatment, and being able to request or refuse treatments...".
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure all patients were given the opportunity to formulate Advanced Directives as evidenced by failing to ask patients if he/she had an Advanced Directive or a Durable Power of Attorney at the time of admit for 5 of 14 sampled patients (#2, #3, #5, #6, #7). Findings:

Review of the Consent for Treatment form used by the hospital revealed no documented evidence the hospital required information concerning a Durable Power of Attorney.

Patient #2
Review of Patient #2's medical record revealed she was a [AGE] year old alert and oriented female admitted on [DATE] with the diagnosis of [DIAGNOSES REDACTED]"Authorization For Care And Services" for Patient #2 revealed no documented evidence Advance Directives were discussed with the patient as evidenced by a blank in the boxes indicating "Yes or No" for the statement "I have executed an Advanced Directive".

Patient #3
Review of the medical record for Patient #2 revealed a [AGE] year old female admitted on [DATE] via the Emergency Department with focal seizures, nausea and vomiting.
Review of the "Authorization For Care And Services" for Patient #3 revealed no documented evidence Advance Directives were discussed with the patient as evidenced by a blank in the boxes indicating "Yes or No" for the statement "I have executed an Advanced Directive".

Patient #5
Review of Patient #5's H&P dated 02/24/11 revealed he was a [AGE] year old male who was alert, oriented, and admitted with right lower lobe pneumonia and lower extremity edema. Review of the "Authorization For Care And Services" for Patient #5 revealed no documented evidence Advance Directives were discussed with the patient as evidenced by a blank in the boxes indicating "Yes or No" for the statement "I have executed an Advanced Directive".

Patient #6
Review of the H&P dated 01/06/11 for Patient #6 revealed a [AGE] year old female admitted for temperature spikes and a chronic non-productive cough. Further review revealed #6 has a history of COPD (Chronic Obstructive Pulmonary Disease), recurrent pneumonia, DM (Diabetes Mellitus) Chronic Kidney Disease, and Schizophrenia.

Review of the Consent for Treatment form for Patient #6 dated 01/06/11 and signed by #6 revealed no documented evidence Advanced Directives were discussed with the patient as evidenced by a blank in the boxes indicating "Yes or No" for the statement "I have executed an Advanced Directive".

Patient #7
Review of Patient #7's H&P dated 04/12/11 revealed she was an [AGE] year old female with Alzheimer dementia. Review of the "Authorization For Care And Services" for Patient #7 revealed the box "Yes" was checked indicating "I have executed an Advance Directive", and the box "Yes" was checked for "Copy on chart". Review of the medical record revealed a form titled "Resident/Family Consent For Cardiopulmonary Resuscitation" signed on 08/07/09 and sent with Patient #7 from Nursing Home A. Further review revealed Patient #7's "General Power Of Attorney", which included directions on health care matters, was not received by the hospital until 04/15/11 at 11:00am by fax from Nursing Home A. There was no documented evidence in the medical record that any family member had been asked by hospital staff if Patient #7 had a designated power of attorney.

In a face-to-face interview on 05/09/11 at 11:45am, S4 Director of Nursing (DON) of Adult Health indicated the Admissions Department is responsible for asking the patient about Advanced Directors. Further she indicated if the patient requests additional information, his/her name is given to the chaplain of the hospital who has the responsibility of giving the patient information on Advanced Directives.

In a face-to-face interview on 05/11/11 at 4:15pm, Registration Manager S7 indicated her registration staff asked patients about advance directives, but it was not in their script to ask about power of attorney. S7 further indicated if someone other than the patient signed the consent, her staff would ask what relation the person was to the patient, but they do not ask if anyone has been designated as power of attorney for health care decisions.

Review of the hospital policy titled "Advance Directives", revised 06/09 and submitted by DON of Adult Health S4 as their current policy for Advance Directives, revealed, in part, "...A. During registration, adult patients will receive written information about advance directives via the Patient Rights and Responsibilities handout. In addition, patients will be asked if they have executed an advance directive prior to registration. ... B. Members of the Hospital's nursing staff will use reasonable efforts to inquire about the existence of an advance directive upon initial assessment. The nurse completing the assessment form or documenting the initial patient contact will also document whether or not an individual has executed an advance directive. C. If a patient is unable to provide information concerning the existence of an advance directive, Hospital personnel will make reasonable efforts to obtain that information from the patient's family or legal representative. D. A copy of a patient's executed advance directive(s) will be placed on the chart and become part of the patient's medical record...".
VIOLATION: PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS Tag No: A0147
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the hospital failed to ensure patients had a right to the confidentiality of their medical records as evidenced by releasing a patient's medical information to LTAC (long term acute care) B without the consent of the designated power of attorney for health care decisions for 1 of 5 patients reviewed who were referred to a LTAC from a total sample of 14 patients (#7). Findings:

Review of Patient #7's medical record revealed she was admitted on [DATE] with a history of Alzheimer dementia (Stage VI to VII) and chief complaints of wheezing, crackles, chest congestion, shortness of breath, and hypoxic. Review of the H&P (history and physical) revealed diagnoses of nursing home-acquired pneumonia, coronary artery disease, hypertension, gastroesophageal reflux disease, and dementia with cognitive deficits. Further review revealed S25, Patient #7's son-in-law, was named as POA (power of attorney) for health care decisions for Patient #7.

Review of the "Physician Orders" revealed a telephone order was received on 04/13/11 at 12:20pm from Physician S18 to "consult LTAC B".

Review of the "Interdisciplinary Progress Notes" revealed a notation by MSW (medical social worker) S10 on 04/14/11 at 11:30am that read "rec'd (received) consult for LTAC (long term acute care) B. Referral made to Nurse Liaison with LTAC B S21 and faxed face sheet. Eval (evaluation) pending". Further review revealed an entry on 04/15/11 at 10:40am by MSW S12 of "spoke with pt (patient) regarding transfer to LTAC B. Pt dtr (daughter), who stated that she is POA, stated that she had no information regarding a ref (referral) to LTAC B nor giving the "o.k." to go... Called and spoke with Nurse Liaison with LTAC B S21 who stated that he did get family approval for LTAC B by pt other dtr Phone call made to Guest Services Assistant S19 with Guest Services to speak with pt dtr".

In a face-to-face interview on 05/10/11 at 1:55pm, MSW S10 indicated she received the referral from Physician S18 for Patient #7 to be transferred to LTAC B. S10 further indicated she knew that Physician S18 usually sent his patients to LTAC B. S10 further indicated she went into Patient #7's room, and no family member was present. S10 indicated since she had 24 hours to process a referral, she called Nurse Liaison with LTAC B S21 with the referral and faxed Patient #7's face sheet to him. S10 indicated she left a message the next day for MSW S12 to follow-up with the family regarding the LTAC referral. S10 indicated there was no documentation of a POA on Patient #7's medical record at the time she made the referral. When asked by the surveyor who had given consent for the transfer to and choice of the LTAC, MSW S10 indicated if the physician wrote an order, she could make the referral and fax the information. S10 indicated she did not have the consent of the patient or responsible party to make the referral. S10 confirmed there was no family present when she entered Patient #7's room, and she had no communication with any family member of Patient #7.

In a face-to-face interview on 05/10/11 at 3:10pm, RN S11 indicated she was the charge nurse at the time Patient #7's daughter became upset about the referral to LTAC B. S11 further indicated the daughter was upset her mother was going to LTAC B and expressed that she didn't know the condition of her mother, had not seen her physician, didn't know her diagnosis, and was upset with the discharge planning process. S11 indicated Patient #7's daughter at first told her (S11) that she had POA for her mother and thought the nursing home had sent a copy to the hospital. S11 indicated she received a copy of the POA from Nursing Home A. RN S11 indicated the daughter was very upset about what had happened and that LTAC B had been given medical information about her mother without consent.

In a face-to-face interview on 05/11/11 at 3:55pm, MSW S12 indicated the RN told her Patient #7's daughter wanted to speak with the social worker. S12 further indicated the question she was asked by the daughter was "who gave you permission to give my mother's information to the LTAC?". S12 indicated after being told by Patient #7's daughter that she had POA and no one had approached her for consent, she called Nurse Liaison from LTAC B S21. S12 indicated S21 told her that he got consent from Patient #7's other daughter. S12 indicated no one knew Patient #7 had a POA until the day of discharge.

In a face-to-face interview on 05/11/11 at 10:00am, Physician S18 indicated he gave the order for Patient #7 to be transferred to LTAC B. After review of the medical record, S18 confirmed there was no documentation of a discussion by him with the family regarding the referral to a LTAC. S18 indicated he usually writes the order, and the social worker checked with the patient for choice. S18 further indicated often he's busy, so he doesn't always talk with patients or their families regarding transfers and such.

In a face-to-face interview on 05/11/11 at 10:40am, Nurse Liaison with LTAC B S21 indicated he came to the hospital to evaluate Patient #7 for LTAC placement. S21 further indicated he got a call from MSW S10 who sent him Patient #7's face sheet that included the patient's address, contact information, and insurance coverage. S21 indicated when he got to the hospital, he reviewed Patient #7's medical record. S21 indicated the consent for release of medical information was supposed to be done by the hospital before he came to the hospital.

Review of the hospital policy titled "Patient Rights And Responsibilities", revised 01/05 and presented by DON of Adult Health S4 as their current policy for patient rights, revealed, in part, "...All patients (or family when appropriate) have the right to: ...expect confidentiality of health information and clinical records; have that information provided only to those involved in your care, to those monitoring its quality, or to those legally authorized to receive such information...".
VIOLATION: LIST OF HOME HEALTH AGENCIES Tag No: A0823
Based on record review and interview the hospital failed to ensure the list of available facilities such as LTACs (Long Term Acute Care), Skilled Nursing, Nursing Home and Hospice, were documented in the patient's medical record as being given to the patient in need of the service for 5 of 5 patients with an order for transfer to an LTAC (#6, #7, #8, #9, #10) and 1 of 1 patient with an order for Hospice (#5) out of a total of 14 sampled patients. Findings:

Review of the Case Management Initial Assessment/Final Screen form, Interdisciplinary Progress Notes and Interdisciplinary Plan of Care for Patients #5, #6, #7, #8, #9, and #10 revealed no documented evidence the patient had been provided a list of available Long Term Acute Care facilities or Hospice Agencies.

In a face to face interview on 05/11/11 at 1:55pm, MSW (medical social worker) S10, the staff member responsible for discharge planning, indicated patients are given the lists; however she was not aware this information had to be documented in the patient's chart.

Review of the policy titled "Discharge Planning/Case Management", last revised 06/06 and submitted by the hospital as the one currently in use, revealed no documented evidence the presentation of the the list(s) of available facilities was required to be documented in the patient's medical record.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on record review and interview, the hospital failed to inform patients or their representative of their rights in advance of discontinuing patient care as evidenced by failure to provide patients with "An Important Message from Medicare" within two days of discharge for 5 of 5 discharged Medicare patients reviewed from a total sample of 14 patients (#5, #7, #8, #9, #10). Findings:

Review of the medical records of Patients #5, #7, #8, #9, and #10 revealed no documented evidence each patient or their representative had received "An Important Message from Medicare" within two days of discharge.

In a face-to-face interview on 05/10/11 at 11:40am, Director of Case Management S8 indicated it was the responsibility of the case management staff to present the form, "An Important Message from Medicare", to patients within two days of discharge. S8 further indicated she was informed last week by the Medical Records Department that the form was not being completed prior to discharge. S8 could provide no documentation of a corrective action plan and/or actions taken to ensure Medicare patients would be provided notification of their rights before discontinuing care.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the hospital failed to follow its policies and procedures for the prompt resolution of patient grievances as evidenced by failure of the supervisor to investigate patient/caregiver complaints/grievances when notified by staff of patient/caregiver complaints and to complete a "Patient Complaint Resolution Form" to be forwarded to Guest Services for tracking, trending, and provision of a written response to the patient/caregiver for 2 of 2 patients reviewed with grievances from a total sample of 14 patients (#5, #7). Findings:

Patient #5
Review of Patient #5's medical record revealed he was admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #5's "Discharge Assessment" revealed he was discharged from ICU (intensive care unit) on 03/03/11 at 2100 (9:00pm) via a cab.

Review of "Patient/Family Concerns", reported by RN (registered nurse) House Supervisor S6 and dated 03/04/11 at 4:53pm, revealed "(name of wife of Patient #5), wife of Patient #5, who was discharged to hospice from ICU yesterday upset. she was at home waiting for husband to come home by ambulance and he was sent home by cab. When researching, found that multiple attempts were made to the numbers we had for the wife without any answers. The number that (name of wife of Patient #5) gave me for call back had no answer. she mentioned that she would be calling administration".

Review of an e-mail sent by Guest Services Assistant S19 to Executive Assistant (to Vice-President Chief Compliance Officer) S24 on 04/12/11 at 4:12pm revealed, in part, "...Just wanted to follow-up regarding Patient #5 and his daughter's inquiry about him being discharged in a cab. After speaking with (first name with no identification of last name or title of employee), I found out that an ambulance did come; however, Patient #5 did not meet criteria to be transported home via ambulance therefore arrangements were made by his nurse for him to go home in a cab. I also remember reading on the nursing report from RN House Supervisor S6 on March 4th that several attempts had been made to call (name of Patient #5's wife) prior to him being discharged but no one answered at the number ... I called (name of Patient #5's daughter) this afternoon and provider her with this explanation. She said she and her mother were at home when he arrived and he appeared to be weak and out of breath and couldn't believe he didn't get sent home on oxygen...".

No one in Administration or Guest Services could provide any documentation of an investigation, a completed "Patient Complaint Resolution Form", and a written response to Patient #5's wife or daughter regarding this grievance.

Review of the grievance log revealed the grievance was reported on 03/14/11 by Patient #5's wife, Guest Services Assistant S19 spoke with Patient #5's wife and daughter, "issues were discussed, CEO (chief executive officer) S1 and Director of Case Management S8 made aware, and no additional follow-up required at this time 04/13/11".

In a face-to-face interview on 05/10/11 at 10:45am, RN House Supervisor S6 indicated she was working as the House Supervisor on 03/04/11 when she received a telephone call from Patient #5's wife. S6 further indicated Patient #5's wife was upset, because her husband had been sent home in a cab. S6 further indicated since it was late Friday afternoon and her resources were gone, she took the information from Patient #5's wife and told her she'd follow-up. S6 indicated she handed the complaint off to ICU/CCU (intensive care unit/critical care unit) RN Clinical Coordinator S14 to handle. When asked by the surveyor if she knew the difference of between a complaint and a grievance, RN House Supervisor S6 indicated she could not quote the hospital policy, but a grievance would have "substantial evidence". S6 further indicated in her role as House Supervisor, she was the administrative representative for the hospital.

In a face-to-face interview on 05/10/11 at 11:40am, Director of Case Management S8 indicated she reviewed Patient #5's chart after she received a report from Guest Services. S8 further indicated her review revealed an ambulance came and found Patient #5 sitting in a chair. S8 further indicated the ambulance refused to transport the patient, because the patient could sit up. S8 further indicated the discharging nurse did not document why Patient #5 went home by cab. S8 indicated she called Patient #5's wife and left a message on her voice mail to call S8. S8 indicated she never received a return call from Patient #5's wife.

In a face-to-face interview on 05/10/11 at 1:25pm, Director of Critical Care S9 indicated the nurse tried to call Patient #5's wife throughout the day and evening. S9 further indicated Patient #5 was asked what he wanted to do when he was informed that he did not meet criteria to be transported by ambulance, and Patient #5 said to call a cab. S9 indicated she discussed this complaint with the nursing staff involved and was in touch with Guest Services. S9 further indicated RN Clinical Coordinator for ICU S14 initiated the investigation and attempted to call Patient #5's wife. S9 further indicated she had no documentation of her discussion with the nursing staff, because it was done informally. When asked by the surveyor what determined the difference between a complaint and a grievance, S9 indicated a grievance was something that could not be resolved immediately, and this complaint from Patient #5's wife should have been handled as a grievance.

In a face-to-face interview on 05/11/11 at 7:25am, RN S15 indicated she was assigned to Patient #5 the evening of his discharge from ICU. S15 further indicated she called for the ambulance, but they never came, because it was determined during the phone call that he didn't meet criteria since he was ambulatory. S15 further indicated the hospice nurse called her and informed her that she (hospice nurse) was at Patient #5's home with his wife.

In the same interview on 05/11/11 at 7:25am, RN Clinical Coordinator S14 indicated House Supervisor S6 spoke with her to find out what had happened regarding Patient #5's transport home in a cab. S14 indicated she agreed to contact Patient #5's wife to explain, but she was unable to reach her after several attempts. S14 further indicated she did not perform any investigation related to this occurrence.

In a face-to-face interview on 05/11/11 at 9:05am, Guest Services Assistant S19 indicated she saw the report regarding Patient #5 on a nursing report. S19 further indicated Patient #5's wife was an employee of the hospital and stopped S19 in the hall and asked to speak with Department Head of Guest Services S20. In the same interview, Department Head of Guest Services S20 indicated Patient #5's wife approached her in the cafeteria, and S20 told Patient #5's wife to come see her, but Patient #5's wife never came to meet with her. S20 further indicated she later learned Patient #5's wife went to Administration, and her daughter called Administration. Department head of Guest Services S20 confirmed this complaint was actually a grievance, and it was not processed according to hospital policy. S20 further indicated there was no investigation and provision of a written response to Patient #5's wife.

Patient #7
Review of Patient #7's medical record revealed she was admitted on [DATE] with a history of Alzheimer dementia and chief complaints of wheezing, crackles, chest congestion, shortness of breath, and hypoxic. Review of the H&P (history and physical) revealed diagnoses of [DIAGNOSES REDACTED]"General Power of Attorney" (POA), which included health care, had been faxed to the hospital from Nursing Home A on 04/15/11 at 11:00am. Further review revealed S25, son-in-law, was named as POA for health care decisions for Patient #7.

Review of the "Physician Orders" revealed a telephone order was received on 04/13/11 at 12:20pm from Physician S18 to "consult LTAC B".

Review of the "Interdisciplinary Progress Notes" revealed a notation by MSW (medical social worker) S10 on 04/14/11 at 11:30am that read "rec'd (received) consult for LTAC (long term acute care) B. Referral made to Nurse Liaison with LTAC B S21 and faxed face sheet. Eval (evaluation) pending". Further review revealed an entry on 04/15/11 at 10:40am by MSW S12 of "spoke with pt (patient) regarding transfer to LTAC B. Pt dtr (daughter), who stated that she is POA, stated that she had no information regarding a ref (referral) to LTAC B nor giving the "o.k." to go... Called and spoke with Nurse Liaison with LTAC B S21 who stated that he did get family approval for LTAC B by pt other dtr Phone call made to Guest Services Assistant S19 with Guest Services to speak with pt dtr". Further review revealed an entry by MSW S12 at 2:00pm on 04/15/11 of "had a meeting between Guest Services Assistant S19, SW (social worker), CN (charge nurse), and pt nurse with pt dtr and son-in-law (POA). Pt dtr was concerned regarding not being notified as above...".

Review of the hospital grievance log presented by Guest Services Assistant S19 revealed no documented evidence of a grievance reported by Patient #7's daughter.

In a face-to-face interview on 05/10/11 at 1:55pm, MSW S10 indicated she received the referral from Physician S18 for Patient #7 to be transferred to LTAC B. S10 further indicated she knew that Physician S18 usually sent his patients to LTAC B. S10 further indicated she went into Patient #7's room, and no family member was present. S10 indicated since she had 24 hours to process a referral, she called Nurse Liaison with LTAC B S21 with the referral and faxed Patient #7's face sheet to him. S10 indicated she left a message the next day for MSW S12 to follow-up with the family regarding the LTAC referral. S10 indicated there was no documentation of a POA on Patient #7's medical record at the time she made the referral. When asked by the surveyor who had given consent for the transfer to and choice of the LTAC, MSW S10 indicated if the physician wrote an order, she could make the referral and fax the information. When asked again who had given consent, S10 answered "the doctor". After being reminded by the surveyor of patients' rights and being asked again about consent, S10 indicated she did not have the consent of the patient or responsible party. S10 confirmed there was no family present when she entered Patient #7's room, and she had no communication with any family member of Patient #7.

In a face-to-face interview on 05/10/11 at 3:10pm, RN S11 indicated she was the charge nurse at the time Patient #7's daughter became upset about the referral to LTAC B. S11 further indicated the daughter was upset her mother was going to LTAC B and expressed that she didn't know the condition of her mother, had not seen her physician, didn't know her diagnosis, and was upset with the discharge planning process. S11 indicated Patient #7's daughter at first told her (S11) that she had POA for her mother and thought the nursing home had sent a copy to the hospital. S11 indicated she received a copy of the POA from Nursing Home A and called Guest Services to come to speak with the daughter of Patient #7. RN S11 indicated she, Guest Services Assistant S19, and MSW S12 met with Patient #7's daughter and son-in-law (POA) to discuss what had happened. S11 further indicated the daughter was very upset about what had happened and that LTAC B had been given medical information about her mother without consent. At the conclusion of the interview, RN S11 was asked by the surveyor if she knew the difference between a complaint and a grievance, and S11 indicated she could not explain the difference.

In a face-to-face interview on 05/11/11 at 3:55pm, MSW S12 indicated the RN told her Patient #7's daughter wanted to speak with the social worker. S12 further indicated the question she was asked by the daughter was "who gave you permission to give my mother's information to the LTAC?". S12 indicated after being told by Patient #7's daughter that she had POA and no one had approached her for consent, she called Nurse Liaison from LTAC B S21. S12 indicated S21 told her that he got consent from Patient #7's other daughter. S12 indicated no one knew Patient #7 had a POA until the day of discharge. S12 indicated after they learned of and received a copy of the POA, a meeting was conducted with herself, the charge nurse, Guest Services, the patient's nurse, Patient #7's daughter, and the son-in-law who had POA. S12 further indicated the family agreed at the time to the transfer, but they were upset with the lack of discharge planning. At the conclusion of the interview, MSW 12 was asked by the surveyor if she knew the difference between a complaint and a grievance, and S12 indicated "I don't know what a grievance is, a complaint is when a patient is not satisfied about something".

In a face-to-face interview on 05/11/11 at 9:05am, Guest Services Assistant S19 indicated MSW S12 called her to speak with Patient #7's daughter about the level of communication about the LTAC referral and her (daughter) not knowing what was going on with the patient. S19 indicated MSW S12, the charge nurse, the patient's nurse, and herself sat with Patient #7's daughter and son-in-law (who had POA) to discuss the matter. S19 indicated the daughter said she didn't know if she was comfortable with Physician S18's affiliation with LTAC B. S19 indicated the family finally agreed to the transfer, and since the daughter agreed to the transfer, S19 felt it was resolved to the daughter's satisfaction and thus a complaint and not a grievance. S19 could offer no explanation for a complaint regarding a patient's privacy rights not being considered and handled as a grievance.

In a face-to-face interview on 05/11/11 at 10:00am, Physician S18 indicated he gave the order for Patient #7 to be transferred to LTAC B. After review of the medical record, S18 confirmed there was no documentation of a discussion with the family regarding the referral to a LTAC. S18 indicated he usually writes the order, and the social worker checked with the patient for choice. When informed by the surveyor that his order was specifically for LTAC B, S18 indicated if he just writes refer to LTAC, a lot of times the social worker chooses to which LTAC the patient will go. S18 further indicated often he's busy, so he doesn't always talk with patients or their families regarding transfers and such.

In a face-to-face interview on 05/11/11 at 10:40am, Nurse Liaison with LTAC B S21 indicated he came to the hospital to evaluate Patient #7 for LTAC placement. S21 further indicated he got a call from MSW S10 who sent him Patient #7's face sheet that included the patient's address, contact information, and insurance coverage. S21 indicated when he got to the hospital, he reviewed Patient #7's medical record, visited the patient, and talked with the patient's daughter (not the daughter whose spouse had POA). S21 indicated the consent for release of medical information was supposed to be done by the hospital before he came to the hospital. S21 indicated the daughter present during his visit tried unsuccessfully to call her sister three times. S21 indicated he spoke with Patient #7's daughter the next day who informed him that her husband had POA, and they had no objection to her mother's transfer to LTAC B, but they were dissatisfied with discharge planning process.

Review of the hospital policy titled "Patient Complaint Resolution And Grievance Process:, revised 08/06 and presented by DON (director of nursing) Adult Health S4 as their current policy for the grievance process, revealed, in part, "..A complaint arises out of patient care and can be handled by Hospital staff present at the time of the complaint. ... A grievance is a written complaint or a verbal complaint that cannot be resolved at the time it is presented. ... A grievance requires a written response as further set forth in this policy and procedure. ... B. Each employee is expected to address and resolve patient complaints. If an employee is unable to resolve a patient or family complaint, it is to be referred to the next level of supervision. If a complaint cannot be addressed timely within the department, Guest Services is to be notified. A complaint regarding a patient's privacy rights or any issue related to HIPAA (health insurance portability and accountability act) is to be reported to Guest Services immediately upon receipt. C. Guest Services coordinates the patient complaint resolution and grievance process including any concerns about the privacy of health information or issues related to HIPAA. ... Note: If a patient wants to file a grievance after hours or when Guest Services is unavailable, the Hospital employee receiving the request will document the information received on a Patient Complaint Resolution Form, will advise the person rendering the complaint that the matter will be reviewed, and will promptly route the form to Guest Services for review and coordination of the process. ... Grievances are to be documented on a Patient Complaint Resolution Form and are to be routed to Guest Services for tracking and coordination of follow-up. ... D. The Hospital will conduct a review of grievances and provide a written response to the patient within thirty (30) days after receiving notice of the grievance. The written notice is to include a summary of the steps taken to investigate the grievance, the results of the grievance process and any pertinent decisions, the date of completion, and the name of a Hospital contact person. If a grievance cannot be resolved within thirty (30) days, the Hospital will inform the patient in writing that the matter continues under review and will provide the patient a written response within ten (10) days of completing the review and follow up. ... VII. Trending And Reporting A. Verbal and written complaints and grievances are trended and reported by Guest Services. Reports are provided to the President/CEO, Board of Commissioners, and other Hospital Committees as appropriate...".
VIOLATION: TIMELY DISCHARGE PLANNING EVALUATIONS Tag No: A0810
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to implement their process for discharge planning in a timely manner as evidenced by the failure of the case management/social service department, designated as responsible for discharge planning by the hospital, to evaluate all patients assessed upon admit by the nursing staff as "acute" and of need of further evaluation within 48 hours of admit (#1, #5, #6, #7, #10) for 5 of 10 patients reviewed for initial discharges out of a total of 14 sampled medical records. Findings:

Patient #1
Review of Patient #1's H&P (history and physical) revealed she was a [AGE] year old female admitted on [DATE] with a history of hypertension, chronic [DIAGNOSES REDACTED]and chronic back pain who fell over the past weekend and was seen in the emergency department 4 days ago. Further review revealed she had a mild compression fracture at T9 (thoracic) and was discharged on Flexeril and Percocet. Further review revealed Patient #1, since being on Flexeril and Percocet, the patient had been confused and hallucinating. Review of the "Case Management Initial Screen/Final Disposition" and the "Interdisciplinary Progress Notes" revealed the social worker screened the medical record on 05/09/11 at 2:30pm, 63 hours after admission.

In a face-to-face interview on 05/10/11 at 9:10am, S5, daughter of Patient #1, indicated she had been staying with her mother a lot since her admission. S5 further indicated her mother lived alone and had been at S5's home since her emergency visit due to a fall and subsequent fracture. S5 indicated her mother was very confused and had begun hallucinating, since she had been prescribed the Flexeril and Percocet. S5 indicated no one had come to meet with her to discuss discharge planning, and she was not aware of a discharge evaluation available to her and her mother.

In a face-to-face interview on 05/10/11 at 11:40am, Director of Case Management S8 indicated that since Patient #1 hallucinating while in the emergency department, Patient #1 would have met the criteria as high-risk and should have had an evaluation by the social worker within 48 hours of admission.

Patient #5
Review of Patient #5's medical record revealed he was admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]"Interdisciplinary Progress Notes" revealed no documented evidence the social worker had evaluated Patient #5 for post-discharge needs until 03/02/11 when a consult for hospice had been ordered, 6 days after admission (more than 48 hours as required by hospital policy).

Patient #6
Review of the medical record for Patient #6 revealed 1 sixty-eight year old female admitted on [DATE] from a long term psychiatric care facility. Further review revealed #6 was admitted with temperature spikes and a chronic non-productive cough. Past medical history included COPD (Chronic Obstructive Pulmonary Disease), recurrent pneumonia, DM (Diabetes Mellitus) Chronic Kidney Disease, and Schizophrenia. According to the Discharge Planning/Case Management Policy Patient #6 met the criteria for a discharge evaluation due to living in a long term psychiatric facility and her history of mental illness and should have been evaluated by a medical social worker within 48 hours of admit.

Review of the Case Management Initial Screen/Final Disposition form used to document discharge evaluations dated 01/13/11 (7 days after admit) revealed the patient lived in a long term psychiatric facility, ambulatory, needed assistance with ADLs (Activities of Daily Living) Awake, Alert. Final D/C (Discharge) Plan/Disposition/Comments: "01/13/11 Patient is a long time patient at long term psychiatric hospital. May need LTAC (Long -Term Acute Care) for IVABX (Intravenous antibiotics). Will follow.

Review of the Interdisciplinary Progress Notes for Patient #6 revealed only one entry by the Social Service Department as follows: 01/31/11 at 5:00pm Spoke with S21 from LTAC "B" regarding the patient's (#6) acceptance to their facility. I also spoke with her long term psychiatric facility as the patient lives there to update them. I faxed S21 the paperwork".

Patient #7
Review of Patient #7's medical record revealed she was admitted on [DATE] with a history of Alzheimer dementia and chief complaints of wheezing, crackles, chest congestion, shortness of breath, and hypoxic. Review of the H&P (history and physical) revealed diagnoses of [DIAGNOSES REDACTED]#7.

Review of the "Interdisciplinary Progress Notes" for Patient #7 revealed an entry by Medical Social Worker (MSW) S10 on 04/14/11 at 11:30am of "Rec'd (received) consult for LTAC B. Referral made to Nurse Liaison with LTAC B S21 and faxed face sheet...". Further review revealed an entry by MSW S12 on 04/15/11 at 10:40am, 60 hours after admission, of "spoke with pt regarding transfer to LTAC B. Pt (patient ) dtr (daughter), who stated that she is POA (power of attorney), stated that she had no information regarding a ref (referral) to LTAC B nor giving the "o.k." to go...".

In a face-to-face interview on 05/10/11 at 1:55pm, MSW S10 indicated she received the referral from Physician S18 for Patient #7 to be transferred to LTAC B. S10 further indicated she knew that Physician S18 usually sent his patients to LTAC B. S10 further indicated she went into Patient #7's room, and no family member was present. S10 indicated since she had 24 hours to process a referral, she called Nurse Liaison with LTAC B S21 with the referral and faxed Patient #7's face sheet to him. S10 indicated she left a message the next day for MSW S12 to follow-up with the family regarding the LTAC referral. S10 confirmed there was no family present when she entered Patient #7's room, and she had no communication with any family member of Patient #7 regarding post-hospital discharge needs.

In a face-to-face interview on 05/10/11 at 3:10pm, RN S11 indicated she was the charge nurse at the time Patient #7's daughter became upset about the referral to LTAC B. S11 further indicated the daughter was upset her mother was going to LTAC B and expressed that she didn't know the condition of her mother, had not seen her physician, didn't know her diagnosis, and was upset with the discharge planning process.

Patient #10
Review of the medical record for Patient #10 revealed a ninety-two year old female admitted on [DATE] for constipation, anorexia and dehydration with a past history of hypertension and osteoarthritis. Further review of the medical record revealed #10 lived alone and was independent prior to admit. According to the Discharge Planning/Case Management Policy Patient #10 met the criteria for a discharge evaluation due to her age and the fact that she lived alone and should have been evaluated by a medical social worker within 48 hours of admit.

Review of the Discharge Planning Screen performed by the nursing staff on 04/14/11 at 1648 (4:48pm) three days after Patient #10 was admitted revealed Patient #10 was assessed as "Required Discharge Planning Intervention 5 = Severe Disability; bedridden, incontinent and requiring constant nursing care and attention".

Review of the Interdisciplinary Progress Notes used by all disciplines revealed the only entry made by Social Services was dated 04/18/11 at 12:15 (am/pm not documented) which was nine days after Patient #10 was admitted and contained the following information, "Chart reviewed and screened. Received consult for LTAC (Long-Term Acute Care). Referral made to LTAC "B" and LTAC "C". Met with patient at this time. Patient does not care which LTAC however LTAC "C" maybe closer for family to visit".

In a face to face interview on 05/11/11 at 11:30am S23 Dept. Head of Decision Support indicated communication problems with discharge planning were identified due to back-ups in the Emergency Department. Further S23 indicated lack of documented communication between the disciplines would be trying out the use of a new form on which all disciplines could document. When asked if the hospital presently used both an Interdisciplinary Plan of Care form and an Interdisciplinary Progress note for communication S23 indicated the hospital did; however the new form was a starting point to try to improve communication.

Review of the policy titled "Discharge Planning/Case Management last revised 06/06 and submitted as the one currently in use revealed......Criteria used to assess and coordinate identified discharge planning needs may include: admitting diagnosis that may affect the ability to function at the same level prior to admission, e.g., CVA; patients 75 years and older; those who live alone; residents of Assisted Living, Nursing Home, Skilled/Long-Term Acute/Rehab;
physical/mental disability, mental illness, substance abuse or chronic illness; surgical procedures or a medical plan which may necessitate post-hospital care; unexpected continuing needs; residence outside the geographic area of the hospital; patients readmitted within 30 days; primary caregiver for others in the home; victim/possible victim of abuse or neglect.... B.... medical social workers will screen all acute patients within forty-eight (48) hours of hospital admission".
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure an initial discharge plan was implemented for each patient as evidenced by failure to follow hospital policy for the evaluation of all acute patients by the social worker within 48 hours of admission to identify discharge planning needs which resulted in 5 of 10 patients reviewed for discharged planning from a total sample of 14 patients not having discharge planning needs identified as a patient problem on the Interdisciplinary Plan of Care (#1, #5, #7, #9, #10). Findings:

Patient #1
Review of Patient #1's H&P (history and physical) revealed she was a [AGE] year old female admitted on [DATE] with a history of hypertension, chronic [DIAGNOSES REDACTED]and chronic back pain who fell over the past weekend and was seen in the emergency department 4 days ago. Further review revealed she had a mild compression fracture at T9 (thoracic) and was discharged on Flexeril and Percocet. Further review revealed Patient #1, since being on Flexeril and Percocet, had been confused and hallucinating.

Review of the "Interdisciplinary Plan of Care" for Patient #1 dated 05/06/11 through 05/08/11 revealed no documented evidence "discharge planning needs" had been identified as a patient problem.

In a face-to-face interview on 05/10/11 at 9:10am, S5, daughter of Patient #1, indicated she had been staying with her mother a lot since her admission. S5 indicated no one had come to meet with her to discuss discharge planning, and she was not aware of a discharge evaluation available to her and her mother.

Patient #5
Review of Patient #5's medical record revealed he was admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of the "Interdisciplinary Plan Of Care" for Patient #5 dated 02/24/11 through 03/02/11 revealed "discharge planning needs" was identified as a patient problem as priority #5, and the status was active on 03/02/11, 6 days after admission. There was no documented evidence of what discharge planning needs had been identified. Review of the "Interdisciplinary Progress Notes" revealed the first documented meeting with the family to discuss discharge planning to hospice was on 03/02/11, the day prior to discharge.

Patient #7
Review of Patient #7's medical record revealed she was admitted on [DATE] with a history of Alzheimer dementia and chief complaints of wheezing, crackles, chest congestion, shortness of breath, and hypoxic. Review of the H&P (history and physical) revealed diagnoses of [DIAGNOSES REDACTED]

Review of Patient #7's medical record revealed no documented evidence of a "Interdisciplinary Plan Of Care".

In a face-to-face interview on 05/10/11 at 3:10pm, RN S11 indicated she was the charge nurse at the time Patient #7's daughter became upset about the referral to LTAC B. S11 further indicated the daughter was upset her mother was going to LTAC B and expressed that she didn't know the condition of her mother, had not seen her physician, didn't know her diagnosis, and was upset with the discharge planning process.

Patient #9
Review of the medical record for Patient #9 revealed a seventy-six year old female admitted on [DATE] for lethargy and PEG tube replacement. Further review revealed #9 lived in an apartment and was cared for by her children and grandchildren. Past medical history included frequent hospitalization s, aspiration pneumonia, hypertension, Atrial fibrillation, COPD (Chronic Obstructive Pulmonary Disease), [DIAGNOSES REDACTED], and anemia.

Review of the Interdisciplinary Plan of Care section titled "discharged Planning Needs" for Patient #9 dated 02/28/11 revealed, "chart was reviewed and screened and a consult to LTAC (Long-Term Acute Care ) "A" was received and sent and evaluation pending. Possible discharge once patient is approved". Further review revealed no documented evidence the plan was discussed with Patient #9 or her family who was previously in charge of her care at home.

Review of the Interdisciplinary Plan of Care section titled "discharged Planning Needs" for Patient #9 dated 02/27/11 through 03/03/11 revealed no documented evidence a discharge plan had been implemented.

Patient #10
Review of the medical record for Patient #10 revealed a ninety-two year old female admitted on [DATE] for constipation, anorexia and dehydration with a past history of hypertension and osteoarthritis. Patient #10 was treated conservatively with a rectal tube and observation for an obstruction which resolved; however she was then found to have a urinary infection, severe disability and failure to thrive. Further review revealed due to Patient #10's lack of motivation and poor nutrition, it was felt to be appropriate to move her to a long-term acute care facility.

Review of the Discharge Planning Screen dated 04/14/11 at 1648 (4:48pm) revealed Patient #10 lived in her own home and was independent prior to admit with home health for wound care and physical therapy. Further #10 had a Primary Care Physician and Hematologist and appointments would need to be scheduled prior to discharge. Patient #10 "Requires Discharge Planning Intervention 5 = Severe Disability; bedridden, incontinent and requiring constant nursing care and attention.

Review of the Interdisciplinary Plan of Care section titled "discharged Planning Needs" for Patient #10 dated 04/07/11 through 04/17/11 revealed no documented evidence a discharge plan had been implemented. On 04/18/11 Discharge Planning was identified on the Interdisciplinary Plan of Care and listed as a "4" in priority. Patient #10 was discharged on [DATE] to LTAC "A".

Review of the Interdisciplinary Progress Notes used by all disciplines revealed the only entry made by Social Services was dated 04/18/11 at 12:15 (am/pm not documented) and contained the following information, "Chart reviewed and screened. Received consult for LTAC (Long-Term Acute Care). Referral made to LTAC "B" and LTAC "C". Met with patient at this time. Patient does not care which LTAC however LTAC "C" maybe closer for family to visit". Further review revealed no documented evidence by Social Services whether or not #10 qualified for long-term acute care, the name of the accepting facility, alternative plans if needed or communication with the physician, patient, family and nursing staff concerning the final disposition for Patient #10.

Review of the Case Management Initial Screen/Final Disposition form for Patient #10 dated 04/18/11 revealed, "Final D/C (Discharge) Plan/Disposition/Comments: 04/18/11 Pt. (Patient) was home prior to admit and will possible benefit from HH (Home Health) upon discharge".

In a face to face interview on 05/09/11 at 11:45am RN S3 RN Manager of 2 South indicated interdisciplinary meetings take place twice a week; however the team did not use the form to document decisions made about the patient related to discharge planning.

Review of the policy titled "Discharge Planning/Case Management last revised 06/06 and submitted as the one currently in use revealed......Criteria used to assess and coordinate identified discharge planning needs may include: admitting diagnosis that may affect the ability to function at the same level prior to admission, e.g., CVA; patients 75 years and older; those who live alone; residents of Assisted Living, Nursing Home, Skilled/Long-Term Acute/Rehab;
physical/mental disability, mental illness, substance abuse or chronic illness; surgical procedures or a medical plan which may necessitate post-hospital care; unexpected continuing needs; residence outside the geographic area of the hospital; patients readmitted within 30 days; primary caregiver for others in the home; victim/possible victim of abuse or neglect.... B.... medical social workers will screen all acute patients within forty-eight (48) hours of hospital admission".

Review of the hospital policy titled "Interdisciplinary Care Management", revised 06/10 and submitted by DON (director of nursing) of Adult Health S4 as their current policy for care management, revealed, in part, "...The Interdisciplinary Care Management process is implemented at the time of admission, with a complete assessment by the patient's admitting nurse. The process is to include: ... identification of a patient's family/significant others that will be able to assist with the patient's care after discharge; Determination of a patient's living arrangements prior to admission and anticipated needs at discharge... Identification of medical equipment in the patient's home as well as possible equipment needs at discharge; Determination of a patient's ability to manage care needs upon discharge... social worker case manager will screen acute inpatient admissions ... This screen will include an evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services. The screen will also include an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being care for in the environment from which he/she entered the Hospital. This screening and interdisciplinary care management is documented by the social worker case manager and becomes part of the patient's medical record. ... All patients, who fall into high-risk, Level I, categories will be provided face to face/telephone conferences with the patient/caregiver/significant other and the Social Worker Case Manager. The Charge Nurse is to notify the Social Worker Case Manager promptly upon identification of the Level I high-risk patients. ... High Risk Guidelines: Level I: Exacerbation of mental disability/mental illness; Inability to care for oneself, especially those who live alone or are homeless; admitted for possible suicide; Victim/possible victim of abuse, neglect or violent crimes...".
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the hospital failed to inform all patients and/or a person acting on behalf of a patient that he/she could request a discharge planning evaluation for 2 of 2 patients whose family was interviewed regarding discharge planning resulting in the surveyors having to report to the RN Manager of 2 South and the Director of Case Management/Social Services in order to obtain the services for the patients from a total of 14 sampled patients (#1, #3). Findings:

Patient #1
Review of Patient #1's H&P (history and physical) revealed she was a [AGE] year old female admitted on [DATE] with a history of hypertension, chronic [DIAGNOSES REDACTED]and chronic back pain who fell over the past weekend and was seen in the emergency department 4 days ago. Further review revealed she had a mild compression fracture at T9 (thoracic) and was discharged on Flexeril and Percocet. Further review revealed Patient #1 lived with her daughter, and since being on Flexeril and Percocet, the patient had been confused and hallucinating.

Review of the "Interdisciplinary Progress Notes" for Patient #1 revealed an entry on 05/09/11 at 2:30pm by the case manager of "pt (patient) to d/c (discharge) home tomorrow and will resume ...HH (home health)...". Further review revealed no documented evidence of a visit with the family of Patient #1 to discuss discharge planning by the RN (registered nurse) case manager or social worker.

In a face-to-face interview on 05/10/11 at 9:10am, S5, daughter of Patient #1, indicated she had been staying with her mother a lot since her admission. S5 further indicated her mother lived alone and been at S5's home since her emergency visit due to a fall and subsequent fracture. S5 indicated her mother was very confused and had begun hallucinating, since she had been prescribed the Flexeril and Percocet. S5 indicated the physician spoke with her briefly the previous day about home health and physical therapy after discharge from the hospital. S5 indicated she had asked a hospital staff person downstairs if they had a skilled nursing facility and was told no. She expressed concern that her mother would not be able to care for herself as she did previous to the fracture and this hospitalization . S5 indicated no one had come to meet with her to discuss discharge planning, and she was not aware of a discharge evaluation available to her and her mother.

Patient #3
In a face to face interview on 05/10/11 at 9:05am the husband of Patient # 3 indicated his wife had become ill at home and was brought to the hospital. Further Patient #3's spouse indicated he had not left her side since admission. When the surveyor asked if anyone had talked with him about his wife's discharge, Patient #3's spouse indicated they had been in the hospital for nine days, and no one had discussed discharge plans. Further he indicated he knew his wife was going to need a lot of help, because her recovery was going to be slow, and it would be a long time before she could do the things she once did. Patient #3's spouse indicated he was not aware of a discharge evaluation.

In a face-to-face interview on 05/10/11 at 11:40am, Director of Case Management S8 indicated the social workers were the main discharge planners and should look for a safe discharge plan. S8 further indicated patients should be screened once they were in the hospital for 5 days or if they meet criteria as high-risk, they should be seen by the social worker within 24 to 48 hours. She further indicated any type of change in activities of daily living from what the patient could do prior to hospitalization would be considered high risk. S8 indicated only one social worker worked on the weekend, one RN (registered nurse) worked on Saturday and was on-call on Sunday, so some patients admitted on Friday would not be seen until Monday. S8 indicated if Patient #1 was hallucinating in the emergency department, the social worker should have been notified to perform an evaluation for needs. She could offer no explanation as to why the hospital policy was not being implemented.

Review of the policy titled "Patient Rights and Responsibilities", last revised 01/05 and submitted by the hospital as the one currently in use, revealed no documented evidence that the right of a patient to request a discharge evaluation was included.

Review of the hospital policy titled "Interdisciplinary Care Management", revised 06/10 and submitted by DON (director of nursing) of Adult Health S4 as their current policy for care management, revealed, in part, "...The Interdisciplinary Care Management process is implemented at the time of admission, with a complete assessment by the patient's admitting nurse. The process is to include: ... identification of a patient's family/significant others that will be able to assist with the patient's care after discharge; Determination of a patient's living arrangements prior to admission and anticipated needs at discharge... Identification of medical equipment in the patient's home as well as possible equipment needs at discharge; Determination of a patient's ability to manage care needs upon discharge... social worker case manager will screen acute inpatient admissions ... This screen will include an evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services. The screen will also include an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being care for in the environment from which he/she entered the Hospital. This screening and interdisciplinary care management is documented by the social worker case manager and becomes part of the patient's medical record. ... All patients, who fall into high-risk, Level I, categories will be provided face to face/telephone conferences with the patient/caregiver/significant other and the Social Worker Case Manager. The Charge Nurse is to notify the Social Worker Case Manager promptly upon identification of the Level I high-risk patients. ... High Risk Guidelines: Level I: Exacerbation of mental disability/mental illness; Inability to care for oneself, especially those who live alone or are homeless; admitted for possible suicide; Victim/possible victim of abuse, neglect or violent crimes...".
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
Based on record review and interview the hospital failed to ensure discharge planning was re-assessed for continuing care needs or the appropriateness of the discharge plan as evidenced by no documentation in the medical record that the Interdisciplinary Plan of Care for Discharge Planning was implemented and/or updated for 7 of 10 patient records reviewed for discharge planning (#1, #4, #5, #7, #8, #9, #10) out of a total of 14 sampled medical records. Findings:

Review of the Interdisciplinary Plan of Care, Patient Problem: Discharge Planning Needs revealed the expected outcome - Patient will return to baseline or appropriate resources arranged. Further review revealed the status of (A) Active or (R) Resolved is addressed daily; however the need or the interventions implemented are not documented. The form is then initialed by the appropriate discipline.

Review of the Interdisciplinary Plan of Care for Patient #1, #4, #5, #7, #8, #9, and #10 revealed no documented evidence discharge planning needs were resolved before discharge.

In a face to face interview on 05/09/10 at 11:45am RN S3 Manager of 2 South indicated interdisciplinary meetings are held twice a week in the conference area on the second floor. Further S3 indicated most of the disciplines are in attendance and discharge planning is discussed at this time; however there was no documentation of the meetings that could be submitted. S3 confirmed notes are not taken and entries are not made in the medical records.
VIOLATION: DOCUMENTATION OF EVALUATIONS Tag No: A0811
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure a discharge planning evaluation was conducted within 48 hours of hospital admission as required by hospital policy and/or the results of the discharge evaluation was discussed with the patient or the individual acting on his/her behalf which resulted in a [AGE] year old alert and oriented male discharged on hospice being transported home alone in a cab (#5), an [AGE] year old female's (with Alzheimer's dementia) health information being released to a LTAC (long term acute care) without the consent of the designated health care power of attorney (#7) for, and families with patients who are cognitively impaired not being informed of plans for after-care (#1, #3) for 4 of 10 patients reviewed for discharge planning from a total of 14 sampled medical records (#1, #3, #5, #7). Findings:

Patient #1
Review of Patient #1's H&P (history and physical) revealed she was a [AGE] year old female admitted on [DATE] with a history of hypertension, chronic [DIAGNOSES REDACTED]and chronic back pain who fell over the past weekend and was seen in the emergency department 4 days ago. Further review revealed she had a mild compression fracture at T9 (thoracic) and was discharged on Flexeril and Percocet. Further review revealed Patient #1, since being on Flexeril and Percocet, the patient had been confused and hallucinating. Review of the "Case Management Initial Screen/Final Disposition" and the "Interdisciplinary Progress Notes" revealed the social worker screened the medical record on 05/09/11 at 2:30pm, 63 hours after admission.

In a face-to-face interview on 05/10/11 at 9:10am, S5, daughter of Patient #1, indicated she had been staying with her mother a lot since her admission. S5 further indicated her mother lived alone and had been at S5's home since her emergency visit due to a fall and subsequent fracture. S5 indicated her mother was very confused and had begun hallucinating, since she had been prescribed the Flexeril and Percocet. S5 indicated no one had come to meet with her to discuss discharge planning, and she was not aware of a discharge evaluation available to her and her mother.

Patient #3
Review of Patient #3's medical record revealed a [AGE] year old female admitted on [DATE] with the diagnosis of [DIAGNOSES REDACTED]#3 was unable to consent for herself due to her condition; therefore the Consent for Treatment was signed by her husband.

Review of the Interdisciplinary Progress Notes dated 05/06/11 at 2:10pm by the Social Service Department revealed, "Pt (Patient) possible Rehab candidate". Further review of Patient #3's medical record revealed no documented evidence case management or social services had spoken to the patient's husband concerning her possible discharge plans.

In a face to face interview on 05/09/11 at 9:05am the husband of Patient #3 indicated his wife has been in the hospital 10 days. Further he indicated he knows his wife (#3) will need more care after discharge from the hospital but no one has come to talk to him about it. The husband of Patient #3 indicated he has not left his wife side since she was transferred out of ICU and no Social Worker has come to talk to him.


Patient #5
Review of Patient #5's medical record revealed he was admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]"Interdisciplinary Progress Notes" revealed no documented evidence the social worker had evaluated Patient #5 for post-discharge needs until 03/02/11 when a consult for hospice had been ordered, 6 days after admission. Review of the "Discharge Assessment" documented by RN (registered nurse) S15 revealed Patient #5 was discharged from ICU (intensive care unit) on 03/03/11 at 2100 (9:00pm) via a cab.

In a face-to-face interview on 05/10/11 at 1:25pm, Director of Critical Care S9 confirmed, after review of Patient #5's medical record, there was no documentation regarding an evaluation of Patient #5's mode of transport at discharge. She indicated case management rounding was done each morning in ICU at 10:00am with both the social worker and case management nurse present, and the mode of transport and the next level of care was discussed, but this discussion was not documented in the patients' records.

In a face-to-face interview on 05/11/11 at 7:25am, RN S15 indicated she was assigned to Patient #5 the evening of his discharge from ICU. S15 further indicated she called for the ambulance, but they never came, because it was determined during the phone call that he didn't meet criteria since he was ambulatory. S15 could offer no explanation for Patient #5 not meeting criteria for discharge by ambulance not being identified prior to his discharge at 9:00pm.

Patient #7
Review of Patient #7's medical record revealed she was admitted on [DATE] with a history of Alzheimer dementia and chief complaints of wheezing, crackles, chest congestion, shortness of breath, and hypoxic. Review of the H&P (history and physical) revealed diagnoses of [DIAGNOSES REDACTED]#7.

Review of the "Interdisciplinary Progress Notes" for Patient #7 revealed an entry by Medical Social Worker (MSW) S10 on 04/14/11 at 11:30am of "Rec'd (received) consult for LTAC B. Referral made to Nurse Liaison with LTAC B S21 and faxed face sheet...". Further review revealed an entry by MSW S12 on 04/15/11 at 10:40am, 60 hours after admission, of "spoke with pt regarding transfer to LTAC B. Pt (patient ) dtr (daughter), who stated that she is POA (power of attorney), stated that she had no information regarding a ref (referral) to LTAC B nor giving the "o.k." to go...".

Review of the policy titled "Discharge Planning/Case Management" last revised 06/06 and submitted by the hospital as the one currently in use revealed..... III. Procedure B. ....medical social workers will screen all acute patients within forty-eight (48) hours of hospital admission. This screen will include an evaluation of the likelihood of a patient needing post-hospital services and of the availability of the services. The screen will also include an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he/she entered the hospital. This screening process and discharge plan is documented by the patient's medical social worker and becomes part of the patient's medical record. C. If hospital personnel determine that further discharge planning evaluation is required (or if a discharge planning evaluation is requested as set forth in the policy statement above), one of the hospital's medical social workers will interview the patient or family/significant other in person (or by telephone as appropriate for a particular situation) and will arrange, coordinate, and document implementation of the patient's discharge plan".

Review of the documentation of the medical social worker used to assess those patients assessed by hospital personnel as "acute" and in need of a discharge evaluation includes the following information: relevant history; insurance info; living arrangements; mobility; ADL (Activities of Daily Living); Mental Status, Community Resources Used Prior to Admit; Post Acute Needs; and Final Discharge Plan/Disposition/Comment.

In a face-to-face interview on 05/10/11 at 11:55am S8 Director of Case Management indicated the nursing staff performs an initial assessment and if the patient meets the criteria, the nurse will communicate to the Case Management/Social Service Department the need for further assessment. S 8 indicated a social worker will assess the patient and enter the information into a computerized charting system which is separate from nursing.

In a face-to-face interview on 05/10/11 at 1:25pm, Director of Critical Care S9 indicated daily multidisciplinary rounds are made in the ICU at the bedside and twice a week on the other units which take place in the unit conference rooms. Further S9 indicated each patient's needs are discussed by all disciplines in attendance; however no notes are taken and nothing is documented in the individual patient's chart.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on observation and interview, the hospital failed to ensure medical records were properly filed and stored to be protected from water damage as evidenced by having medical records stored on open metal shelving in the medical record department and having 71 cardboard boxes of medical records stored on the floor in the medical record department. Findings:

Observation on 05/11/11 at 11:35am of the medical record department revealed the medical records were stored on open metal shelves that did not have a means of securing them from the possibility of water damage that could occur in the event the sprinkler system was activated. Further observation revealed 62 cardboard boxes of patient medical records were stacked on the floor adjacent to the file shelves, and 9 cardboard boxes of patient medical records were stacked on the floor in the front area of the medical record room where staff were working on patient medical record filing. Further observation revealed this area was also accessible to the sprinkler system.

In a face-to-face interview on 05/11/11 at 11:35am, Department Head of Health Information Management S26, RHIA, (Registered Health Information Administrator), confirmed the medical records were accessible to water damage in the event the sprinkler system was activated.