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.

RIVER PARISHES HOSPITAL 500 RUE DE SANTE LAPLACE, LA July 28, 2011
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record review and interview the hospital failed to ensure patients received a written notice of it's decision in the resolution of grievances that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for 2 of 2 grievances reviewed (R1, R2). Findings:

Review of Patient #R1's grievance dated 5/26/2011 revealed the patient complained of not having his room cleaned or his sheets changed on a regular basis. Investigation revealed there had been one day when the patient's room had not been cleaned. Further the housekeeper on duty was given a verbal warning and informed that it could never happen again.

Review of the entire Grievance folder for Patient #R1 revealed no documented evidence of a written Response Letter to include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Review of Patient #R2's grievance dated 7/06/2011 revealed the patient's daughter complained that a nurse aide had used tissue paper on #R2's pressure wound when the dressing had fallen off. Investigation revealed the Nurse Aide had placed a single 4 x 4 on the wound while awaiting wound care by the Registered Nurse.

Review of the entire Grievance folder for Patient #R2 revealed no documented evidence of a written Response Letter to include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

During a face to face interview on 7/28/2011 at 11:40 a.m., Patient Advocate S21 indicated the hospital's practice was to treat all complaints and grievances the same. S21 indicated most patients received verbal responses rather than written responses to the grievance. S21 confirmed that neither R1 nor R2 had been provided with a written response to their grievance which included the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. S21 indicated R1 and R2 had been provided with a verbal response only.

Review of the hospital policy titled, "Patient/Family/Visitor Complaints/Grievances #P-5, Submitted 5/92" revealed in part, "Patient, family, visitor complaints/concerns/grievances will be solicited and acted upon immediately. . . The staff member will report the complaint/grievance to his/her immediate Supervisor, and if the staff member and Supervisor can't resolve the issue promptly, then the Patient Advocate or Administration will be notified as soon as possible. . . The CEO (Chief Administrative Officer) will send a written response to the person filing the grievance regarding the follow up and resolution of the issue, if necessary. It is necessary to send a written response when the grievance is regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the CMS (Center Medicare Services) Hospital Conditions of Participation, or a Medicare beneficiary billing complaint. . ."
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review and interview the hospital failed to ensure a policy was in place to ensure patients were free from all forms of abuse and/or harassment. Findings:

Review of the hospital's entire policy and procedure manual revealed no documented evidence of a policy to address how the hospital would handle any allegations of abuse made by patients/visitors indicating hospital employees had abused or harassed them to include components for Prevention, Screening, Identifying, Training, Protecting, Reporting, and Responding.

This finding was confirmed by Quality Director S2 and Risk Manager S18 on 7/28/2011 at 1:30 p.m. in a face to face interview. S2 and S18 indicated the hospital had a policy for Staff on Staff abuse/harassment; however, there was no policy addressing patients with allegations or witnessed events of abuse/neglect/harassment by staff.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure Nursing Staff complete Incident/Occurrence Reports for "Near Misses" and/or falls as per hospital policy for 1 of 7 sampled patients (#4). Findings:

Review of the hospital policy titled, " Health Care Peer Review Occurrence Reporting System, # O-5, Submitted 3/98 " presented by the hospital as their current policy revealed in part, " Occurrence: That which is not consistent with routine care of a patient and/or the desired operations of the facility. The results of this event require or could have required ( " near miss " ) unexpected medical intervention, unexpected intensity of care, or causes or had the potential to cause an unexpected physical or mental impairment. . . Occurrence Reporting System: The Healthcare Peer Review Report is to be filled out to report an occurrence. This is then reviewed by the Department Manager then sent to the Risk Manager for review. . . Any hospital employee or staff member, who discovers, is directly involved in, or responds to an occurrence is to complete or direct the completion of a Healthcare Peer Review Report. This form should be referred to their manager then to the hospital Risk Manager within 72 hours of completion. "

Patient #4:
Patient #4 was admitted on [DATE] with diagnoses that included [DIAGNOSES REDACTED][DIAGNOSES REDACTED], and Gastroenteritis, resolved.

Review of Patient #4's Nursing Notes revealed the following:
" 3/20/11 0720 (7:20 a.m.), pt (Patient) AAOx3 (Alert and oriented times three), C/O (complained of) weakness, pt neck area is red, denies pain (at) this time. Pt has amputations of all his toes and partial feet, pt has noted sores with drainage on socks. Pt has a sore on sacral c (with) C/O burning as stool touches sore. Pt had a large liquefied bowel movement. . . . "
" 3/20/11 1340 (1:40 p.m.) Fecal management system (FMS) inserted, balloon inflated well. Pt. tolerated well, stool noted to be draining in FMS tube. . . (review of physician ' s orders revealed an order dated 3/20/2011 at 1345 (1:45 p.m.) for " Fecal Management System " ). "
" 3/23/11 0411 (4:11 a.m.) warm compress applied to lwr (lower) back for C/O pain. Pt (#4) states ' it ' s (back) been hurting ever since I (#4) fell when I came in ' . "

Review of Patient #4 ' s Med-Surg (Medical Surgical) Flow Sheet Fall Risk Assessments (performed one time each 12 hour shift) revealed 25 points were added to the assessment indicating, " (25) History of one or more falls " on 3/23/2011 at 2000 (8:00 p.m.) and remained present for the remainder of Patient #4 ' s hospital stay from 3/23/2011 when identified through 3/30/2011. Review of all Nursing Assessments prior to the date of 3/23/2011 revealed no documented evidence of scoring Patient #4 for " (25) History of one or more falls " Review of Patient #4 ' s entire medical record; in addition to the hospital ' s incident report log, revealed no documented evidence that Patient #4 had fallen while in the hospital.

During a face to face interview on 7/27/2011 at 1320 (1:20 p.m.), Licensed Practical Nurse S15 indicated she (S15) was the nurse assigned to the care of Patient #4 on 3/20/2011 from 7:00 a.m. until 7:00 p.m. S15 indicated there was one incident on 3/20/2011 where Patient #4 had diarrhea that had " gone all over him self " . S15 indicated she (S15) had assisted Patient #4 from the bed to the chair, located at the side of the bed, in order to clean the patient (#4). S15 indicated Patient #4 had not protested being moved to the chair for incontinence care. S15 indicated she (S15) had bathed Patient #4, cleaned the floor, and changed the bed linen. S15 indicated Patient #4 had complained of being weak and unable to stand when she (S15) attempted to assist him (#4) from the chair back into the bed. S15 indicated she (S15) assisted the patient (#4) in sliding to his (#4) knees per suggestion of the patient (#4) . S15 indicated Patient #4 was placed on his (#4) knees with his (#4) head leaning across the side of the bed. S15 indicated she (S15) then called for assistance in getting Patient #4 back into bed. S15 indicated Patient #4 was 5 feet 9 inches tall and weighed 276 pounds (confirmed with record review). S15 indicated several employees (nursing staff) arrived and assisted her (S15) in getting Patient #4 back into bed. S15 indicated the team of nurses decided to assist Patient #4 from the kneeling position to lay down on his (#4) back on the floor. S15 indicated it was easier for the team of nurses to lift Patient #4 from the supine position on the floor. S15 indicated the team of nursing staff lifted Patient #4 from the floor to the bed with no difficulty. S15 confirmed that she (S15)had not documented the incident in the patient ' s medical record and had not done an incident report. S15 indicated the action taken by her in the room was to prevent the patient from falling. S15 indicated she (S15) did not see any reason to write an incident report but probably should have written something in the patient ' s (#4) chart.

During a face to face interview on 7/28/2011 at 10:15 a.m., Primary Care Physician S14 indicated there was an incident during the March admission when Patient #4 complained that no one had cleaned him (#4) after soiling himself and he (#4) had fallen. S14 further indicated Patient #4 said no one checked him (#4) after he (#4) fell . S14 indicated Patient #4 complained of generalized pain. S14 indicated he (S14) examined the patient (#4) and found nothing wrong. S14 indicated he (S14) had failed to document the examination. S14 could not recall the date of the patient reported fall or his examination of the patient.

During a face to face interview on 7/27/2011 at 1420 (2:20 p.m.), Nurse Manager S20 indicated she (S20) would have expected nursing staff to document in the medical record of Patient #4 the details of the massive diarrhea followed by a " near miss (fall) " when Patient #4 had to be slid to the floor to prevent a fall on 3/20/2011. S20 further indicated when it became evident to nurses on 3/23/2011 at 4:11 a.m. that Patient #4 perceived the incident as a fall; by stating " it ' s (patient's back) been hurting ever since I (#4) fell when I (#4) came in " , the nursing staff should have further investigated the patient ' s (#4) complaint and then completed an incident report.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure a Registered Nurse supervise and evaluate the nursing care of each patient by:
1) failing to ensure an ongoing wound assessment was performed for 1 of 7 sampled patients (#4)
2) failing to ensure physician's orders were obtained and/or clarified for 2 of 7 sampled patients (#4, #5). Findings:

1)
Patient #4:
Patient #4 was admitted on [DATE] with diagnoses that included [DIAGNOSES REDACTED][DIAGNOSES REDACTED], and Gastroenteritis, resolved.

Review of Nursing Notes for Patient #4 revealed the following; "3/20/11 0720 (7:20 a.m.), pt (Patient) AAOx3 (Alert and oriented times three), C/O (complained of) weakness, pt neck area is red, denies pain (at) this time. Pt has amputations of all his toes and partial feet, pt has noted sores with drainage on socks. Pt has a sore on sacral c (with) C/O burning as stool touches sore. Pt had a large liquefied bowel movement. . . . "

Review of Patient #4's Body Audit Charts with documented Nursing Assessments revealed daily shift assessments of wounds identified as #1 (front of right lower leg), #2 (front of left lower leg), #3 (back of left arm), #4 (back of right arm), and nursing assessments of Patient #4's right foot partial amputation wound. Review of Patient #4's entire medical record revealed no documented evidence of a Nursing assessment of the "sore on sacral" documented on 3/20/2011 at 7:20 a.m. to include no description of the size, character, or depth of the wound.

During a face to face interview on 7/27/2011 at 1320 (1:20 p.m.), Licensed Practical Nurse S15 indicated she (S15) was the nurse assigned to the care of Patient #4 on the date of 3/20/2011 from 7:00 a.m. until 7:00 p.m. S15 indicated there was one incident on 3/20/2011 where Patient #4 had diarrhea that had "gone all over him self". S15 indicated she (S15) called the patient's physician and received an order for a Fecal Management System in order to protect a reddened area on the patient's (#4) buttock. S15 confirmed that she (S15) had failed to document a description of the reddened area on the patient's buttock and stated that she (S15) had no recall as to the size or character of the reddened area, sore on the patient's buttock.

During a face to face interview on 7/27/2011 at 2:10 p.m., Registered Nurse S16 indicated she (S16) had been called to the bedside of Patient #4 by Licensed Practical Nurse (LPN) S15 on 3/20/2011 when the patient (#4) had reportedly slid to the floor to prevent a fall. S16 indicated she (S16) was the nurse in charge on 3/20/2011. S16 indicated her (S16) assessment of Patient #4 after the incident was to examine his (#4's) buttocks because he (#4) "already" had a "breakdown" on his (#4) sacrum. S16 indicated she (S16) discussed the breakdown and diarrhea with LPN S15 who was assigned to the care of Patient #4 and it was decided that the patient's (#4) physician should be called to see if a Fecal Management Device should be utilized to protect the sacral area from further exposure to diarrhea. S16 further indicated she (S16) could not recall the size or character of the breakdown on Patient #4's buttocks. S16 confirmed that she (S16) had not documented her assessment of Patient #4's buttocks in the medical record. S16 indicated it would have been the LPN that would have documented an assessment of the sacral wound.

During a face to face interview on 7/28/2011 at 10:15 a.m., Primary Care Physician S14 indicated he (S14) had no recall of a wound to Patient #4's sacral region.

During a face to face interview on 7/28/2011 at 1:30 p.m., Quality Director S2 and Risk Manager S18 indicated nursing staff should have consulted Wound Care for the breakdown on Patient #4's sacrum when discovered on 3/20/2011. Further S2 and S18 indicated there should have been a complete assessment of Patient #4's sacral wound on the date of discovery as well as follow up assessments as per hospital policy.

Review of the hospital policy titled, "Wound Care, # W-2, submitted 4/92" presented by the hospital as their current policy revealed in part, " The wound care center or wound care tem (team) is consulted by a physician order and/or an initial nursing assessment using the Braden Scale. The nursing assessment will initiate a wound care consult for a Braden score of < 14. . . Inpatients will be assessed by an RN for skin integrity, using the Braden Scale system, and identify patients at risk for developing pressure sores and breakdown as part of the admit assessment and every shift throughout the patient's hospital stay. . . Conduct a total skin assessment of every patient immediately upon admission, once per shift, after any status change and upon discharge. Examine any pressure sore area thoroughly and document in the nursing notes: a. Describe exactly what you see, smell, feel b. Wound diameter c. Surrounding skin condition d. Color of wound/drainage e. Odor of wound/drainage f. Consistency of drainage g. Blanch with refill. . . If skin breakdown is noted, photograph the area. Notify the physician and document the notification. Obtain orders for treatment.

2)
Patient #4:
Review of Patient #4's physician's orders revealed an order dated 3/20/2011 at 1345 (1:45 p.m.) for "Fecal Management System." Review of Patient #4's entire medical record revealed no documented evidence of an order to discontinue Patient #4's Fecal Management System.

Review of Patient #4's nursing documentation revealed the following: "3/20/11 1340 (1:40 p.m.) Fecal management system (FMS) inserted, balloon inflated well. Pt. tolerated well, stool noted to be draining in FMS tube. . ."

Review of Patient #4's entire medical record revealed no documented evidence to indicated the date and time the patient's Fecal Management System had been removed and by whom. Further record review revealed no documented evidence of Nursing Staff clarifying with Patient #4's physician whether the Fecal Management System was to remain in place or be discontinued.

Review of Patient #4's electronically recorded Graphic "Intakes/Outputs" revealed in part, "3/21/2011 18:01 (6:01 p.m.) BM (bowel movement) 400 (400 cubic centimeters)., 3/22/2011 at 1801 (6:01 p.m.) BM 0 (zero), 3/23/2011 19:29 (7:29 p.m.) BM 1 (one) . . ." Review of Patient #4's entire medical record revealed no documented evidence to indicate when the patient's Fecal Management system had been removed. Further review revealed no physician's order to remove Patient #4's Fecal Management system.

Patient #5:
Review of Patient #5's medical record revealed the patient was admitted on [DATE] with diagnoses that included [DIAGNOSES REDACTED].m. versus p.m.) for "IV (intravenous) bolus with 500 cc (cubic centimeters) over 1 hour." Review of the entire Physician Orders revealed no documented evidence of what Intravenous Fluid the physician wanted to bolus the patient (#5) with.

During a face to face interview on 7/27/2011 at 9:30 a.m., Director of Quality S2 and Nursing Manager S20 indicated they were unable to determine when and who removed Patient #4's Fecal Management System due to a failure in documentation. S2 and S20 indicated it could be assumed that the System was removed sometime between 3/21/2011 and 3/22/2011 when the graphic sheet changed from measuring bowel movements with cubic centimeters to the number of bowel movements the patient had. S2 and S20 indicated nursing staff should have documented how the Fecal System was removed or dislodged, who participated in discovery or removal, and any order from the physician whether obtained verbally or by telephone. S2 and S20 indicated Nursing Staff should have clarified with the Patient's (#4) physician whether he wanted the Fecal Management System to remain in place or be removed.
Further S2 and S20 confirmed the absence of a complete order for an IV bolus for Patient #5. S2 and S20 indicated nursing staff should have clarified what type of IV fluid the physician intended for the IV bolus.

Review of the hospital policy titled, "Clarification of Physician Orders, #O-3, submitted 11/89" presented by the hospital as current revealed in part, "The nurse has a legal duty and moral obligation to clarify any physician order that is illegible, unclear and/or which seems to be clearly contraindicated by usual and acceptable practice before executing it. . . The nurse is to document the receipt of clarified orders in the nursing progress notes."

Review of the hospital policy titled, "Physician's verbal and phone orders, Protocol for, #V-5, Submitted 5/86" presented by the hospital as their current policy revealed in part, "Any and all orders (verbal, phone) must be written on a Physician's Order Form or on the phone order label that is placed on the chart. . Orders are to be repeated back to the physician or health care practitioner giving the orders for accuracy and clarification. . ."
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure the medical records of patients treated in the hospital were complete and accurate accounts of the patient's hospital stay for 1 of 7 sampled patients (#4). Findings:

Patient #4:
Patient #4 was admitted on [DATE] with diagnoses that included [DIAGNOSES REDACTED][DIAGNOSES REDACTED], and Gastroenteritis, resolved.

The medical record of Patient #4 was reviewed. Review revealed Patient #4 arrived at the hospital's Emergency Department per private vehicle on 3/19/2011 at 1035 (10:35 a.m.) and was triaged a level 3 (1 = Minor, 2 = Non-Urgent, 3 = Urgent, 4 = Emergent, 5 = Critical) with chief complaint of "Pt (patient) reports N/V/D (nausea, vomiting, diarrhea) since this morning. Pt's (Patient's) clothes soiled c (with) feces " Further review of Patient #4 ' s Emergency Department Record revealed nursing documentation dated 3/19/2011 at 1515 (3:15 p.m./4 hours and 45 minutes after admission to the Emergency Department) indicating, "pt (patient) to room. Pt. had another bowel movement x4 (four times) PTA (prior to arrival) to floor " . Review of Patient #4's entire Emergency Department Record revealed no documented evidence that Patient #4 had ever received Hygiene Care during his entire Emergency Department Stay from 10:35 a.m. until transferred to the floor at 3:15 p.m.)

During a telephone interview on 7/27/2011 at 9:05 a.m., Registered Nurse S8 indicated he (S8) was the nurse assigned to the care of Patient #4 on 3/19/2011 in the Emergency Department. S8 indicated Patient #4 had been seen repeatedly in the Emergency Department and was a patient known to him (S8) although his (S8) recollection about specific details might be " vaguely remembered " . S8 indicated that he (S8) did recall cleaning/bathing Patient #4 and placing him (#4) in a gown while in the Emergency Department on 3/19/2011. S8 described Patient #4 ' s diarrhea as being such that "as soon as we (Emergency Department Staff) cleaned him (#4) up, he (#4) would go again." S8 indicated he (S8) had never known of an instance where a patient had been denied incontinence care in the Emergency Department. S8 confirmed that he (S8) had not documented any hygiene care provided to Patient #4 and maybe could chart better.

Review of Patient #4's In-patient Nursing Notes revealed the following:
"3/20/11 0720 (7:20 a.m.), pt (Patient) AAOx3 (Alert and oriented times three), C/O (complained of) weakness, pt neck area is red, denies pain (at) this time. Pt has amputations of all his toes and partial feet, pt has noted sores with drainage on socks. Pt has a sore on sacral c (with) C/O burning as stool touches sore. Pt had a large liquefied bowel movement. . . . "
"3/20/11 1340 (1:40 p.m.) Fecal management system (FMS) inserted, balloon inflated well. Pt. tolerated well, stool noted to be draining in FMS tube. . . (review of physician's orders revealed an order dated 3/20/2011 at 1345 (1:45 p.m.) for "Fecal Management System" )."
"3/23/11 0411 (4:11 a.m.) warm compress applied to lwr (lower) back for C/O pain. Pt (#4) states 'it's (back) been hurting ever since I (#4) fell when I came in'."

During a face to face interview on 7/27/2011 at 1320 (1:20 p.m.), Licensed Practical Nurse S15 indicated she (S15) was the nurse assigned to the care of Patient #4 on 3/20/2011 from 7:00 a.m. until 7:00 p.m. S15 indicated there was one incident on 3/20/2011 where Patient #4 had diarrhea that had " gone all over him self " . S15 indicated she (S15) had assisted Patient #4 from the bed to the chair, located at the side of the bed, in order to clean the patient (#4). S15 indicated Patient #4 had not protested being moved to the chair for incontinence care. S15 indicated she (S15) had bathed Patient #4, cleaned the floor, and changed the bed linen. S15 indicated Patient #4 had complained of being weak and unable to stand when she (S15) attempted to assist him (#4) from the chair back into the bed. S15 indicated she (S15) assisted the patient (#4) in sliding to his (#4) knees per suggestion of the patient (#4) . S15 indicated Patient #4 was placed on his (#4) knees with his (#4) head leaning across the side of the bed. S15 indicated she (S15) then called for assistance in getting Patient #4 back into bed. S15 indicated Patient #4 was 5 feet 9 inches tall and weighed 276 pounds (confirmed with record review). S15 indicated several employees (nursing staff) arrived and assisted her (S15) in getting Patient #4 back into bed. S15 indicated the team of nurses decided to assist Patient #4 from the kneeling position to lay down on his (#4) back on the floor. S15 indicated it was easier for the team of nurses to lift Patient #4 from the supine position on the floor. S15 indicated the team of nursing staff lifted Patient #4 from the floor to the bed with no difficulty. S15 confirmed that she (S15)had not documented the incident in the patient's medical record. S15 indicated she (S15) probably should have written something in the patient's (#4) chart.

During a face to face interview on 7/28/2011 at 10:15 a.m., Primary Care Physician S14 indicated there was an incident during the March admission when Patient #4 complained that no one had cleaned him (#4) after soiling himself and he (#4) had fallen. S14 further indicated Patient #4 said no one checked him (#4) after he (#4) fell . S14 indicated Patient #4 complained of generalized pain. S14 indicated he (S14) examined the patient (#4) and found nothing wrong. S14 indicated he (S14) had failed to document the examination. S14 could not recall the date of the patient reported fall or his examination of the patient.

During a face to face interview on 7/27/2011 at 1420 (2:20 p.m.), Nurse Manager S20 indicated she (S20) would have expected nursing staff to document in the medical record of Patient #4 the details of the massive diarrhea followed by a "near miss (fall)" when Patient #4 had to be slid to the floor to prevent a fall on 3/20/2011.

Review of Patient #4's electronically recorded Graphic "Intakes/Outputs" revealed in part, "3/21/2011 18:01 (6:01 p.m.) BM (bowel movement) 400 (400 cubic centimeters)., 3/22/2011 at 1801 (6:01 p.m.) BM 0 (zero), 3/23/2011 19:29 (7:29 p.m.) BM 1 (one) . . ." Review of Patient #4's entire medical record revealed no documented evidence to indicate when the patient's Fecal Management system had been removed. Further review revealed no physician's order to remove Patient #4's Fecal Management system.

The following employees were interviewed: Registered Nurse S7 on 7/27/2011 at 8:40 a.m., Licensed Practical Nurse S12 on 7/27/2011 at 9:50 a.m., Registered Nurse S10 on 7/27/2011 at 10:30 a.m., Registered Nurse S9 on 7/27/2011 at 11:00 a.m., Registered Nurse S15 on 7/27/2011 at 1:20 p.m., and Registered Nurse S16 on 7/27/2011 at 2:10 p.m. All interviewed reviewed the medical record of Patient #4. All confirmed there was no order to discontinue the Fecal Management System for Patient #4. All indicated there was no documentation as to when Patient #4's Fecal Management System; that had been inserted on 3/20/2011 at 1340 (1:40 p.m.), had been removed. All indicated they had not removed the Fecal Management System.

During a face to face interview on 7/27/2011 at 9:30 a.m., Director of Quality S2 and Nursing Manager S20 indicated they were unable to determine when and who removed Patient #4's Fecal Management System due to a failure in documentation. S2 and S20 indicated it could be assumed that the System was removed sometime between 3/21/2011 and 3/22/2011 when the graphic sheet changed from measuring bowel movements with cubic centimeters to the number of bowel movements the patient had. S2 and S20 indicated nursing staff should have documented how the Fecal System was removed or dislodged, who participated in discovery or removal, and any order from the physician whether obtained verbally or by telephone.

Review of the hospital policy titled, "Nursing Services. Documentation. # D-9, Submitted 6/82" presented by the hospital as their current policy revealed in part, "Documentation in the medical record (electronic or in writing) shall be pertinent, concise, legible, and reflect nursing interventions to meet the patient's nursing care needs, the patient's response to those interventions and patient status. . . All nursing care provided, including age specific care, shall be documented in the medical record. . . Nursing care data related to patient assessments, the nursing diagnosis, and/or patient needs, nursing interventions, and patient outcomes are a permanent part of the medical record. . . The day, including the ear, and times are recorded on each entry. . . The Registered Nurse, in reviewing data which has been delegated to be collected by other members of the health care team, shall sign the patient record as "Above noted" and sign his/her name. This signature shall reflect that all data and assessments, so delegated, has been reviewed and that the registered nurse will, as appropriate, initiate further action according to the needs of the patient. . ."