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.

CENTENNIAL HILLS HOSPITAL MEDICAL CENTER 6900 N DURANGO DR LAS VEGAS, NV 89149 Feb. 29, 2012
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interview, record review, and document review, the facility failed to ensure an effective governing body was legally responsible for the conduct of the hospital. The governing body failed to ensure the hospital developed and maintained an effective and comprehensive program for patient rights specifically related to training, knowledge, reporting and investigating abuse.

Refer to the following Tags:

A-0115-Patient Rights-a safe environment for the vulnerable and elderly.
A-0123-Ensure steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion of the grievance.
A-0145-Ensure that patients were free of abuse or harassment.

The cumulative effect of these systematic practices resulted in the failure of the facility to deliver statutory mandated care to patients.
VIOLATION: RESPIRATORY SERVICES Tag No: A1163
Based on record review and interview, physician orders for respiratory therapy were not followed for 1 of 38 patients (Patient #37).

Findings include:

On 2/23/12 at approximately 4:00 PM, Employee #42 confirmed that physician orders written on 2/21/12 at 11:00 AM for Patient #37 by Employee #52 were not followed. Physician orders were: "Change all NEBS to acapella," and "Acapella 10X per hour while awake." Documentation by Employee # 53 in Patient #37's Respiratory Treatment Care Activity electronic flowsheet indicated that on 2/22/12 at 7:45 PM, Employee #53 "instructed patient on acapella and patient understands." On 2/23/12 at 7:10 AM, Employee #54 noted on the flowsheet, "Reassessment done; acapella done post treatment."

On 2/23/12 at approximately 4:30 PM, Employee #42 confirmed the equipment required for the acapella therapy was not readily available for respiratory care staff, and therefore a delay in treatment ensued.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on interview and record review, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) Program included a comprehensive ongoing program that showed measurable improvement in indicators for which there was evidence that would improve health outcomes for patient rights to include identifying, training, reporting and investigating abuse, an effective operation, review and resolve to patient grievances and reporting of QAPI activities for the Occupational Health Center.

Findings include:

1. On 2/24/12 in the afternoon during review of the Quality Management Program, there was no documented evidence that the facility's Occupation Health Care Center was included in the Quality Assessment and Performance Improvement Program.

On 2/24/12 in the afternoon, the Director of Quality Management (DQM) indicated the facility conducted an ongoing program with measurable improvement indicators for which there was evidence to identify and reduce medical errors, track adverse events, and monitoring of the effectiveness and safety of services and quality of care. The DQM further indicated the Nurse Managers and Directors of the Departments were responsible to collect data and submit Performance Improvement to the Quality and Performance Improvement Department. The System Wide Quality Director (SWQD) indicated the manager of the Occupation Health Center came to one meeting over a year ago. The SWQD explained it was not necessary to attend or collect data because the health center was for employees only.

The Occupational Health Center was under the license of the facility.

The flier for the Occupation Health documented, "...In case of work related injury or illness, please do the following: Report your injury/illness to your employer immediately. Obtain authorization for treatment from your employer. Call and go directly to (address of clinic)..."
"...From injuries to wellness testing..."

The Quality Plan for the facility dated 1/01/2011 revealed:

"...This Quality Plan supports the systematic organization-wide approach to, plan design measure, assess and improve organizational performance..."

2. On 2/23/12 in the afternoon, The DQM and the Chief Nursing Officer (CNO) were unable to indicate the timelines to report abuse, unable to provide an abuse and neglect policy, or how they would carry out a comprehensive and timely investigation for abuse and neglect of a patient.

The CNO indicated, in California it was five days. The CNO was unable to answer the reporting abuse procedures in Nevada.

The DQM, indicated since the Risk Manager had left, she would be the abuse coordinator until a Risk Manager was hired. The DQM could not give timeframes for abuse reporting or produce an abuse policy for the facility.

On 2/24/12 in the afternoon, several staff members in each department throughout the facility to include administrative staff were asked how they would identify abuse, the name of the abuse coordinator and what training they had received concerning abuse and neglect.

A majority of the employees were unable to identify the person who was ultimately in charge of abuse investigations. There were discrepancies on what constituted abuse and what agency to report abuse. The staff indicated they were trained in abuse on the computer and were given three months to finish by the corporation. Several staff attempted to find the abuse policy on the facility's learning website and were unable.

3. The facility failed to ensure the hospital provided patients with written notice of the decisions that included the steps taken on behalf of the patient to investigate grievances and the results of the grievance process.

The DQM indicated on 2/23/12 in the morning, the facility was instructed by legal for the corporation that letters in response to patient grievances should not include detailed information concerning any investigation.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on interview and record review, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) Program included a comprehensive ongoing program that showed measurable improvement in indicators for which there was evidence that would improve health outcomes for patient rights to include identifying, training, reporting and investigating abuse, an effective operation, review and resolve to patient grievances and reporting of QAPI activities for the Occupational Health Center.

Findings include:

1. On 2/24/12 in the afternoon during review of the Quality Management Program, there was no documented evidence that the facility's Occupation Health Care Center was included in the Quality Assessment and Performance Improvement Program.

On 2/24/12 in the afternoon, the Director of Quality Management (DQM) indicated the facility conducted an ongoing program with measurable improvement indicators for which there was evidence to identify and reduce medical errors, track adverse events, and monitoring of the effectiveness and safety of services and quality of care. The DQM further indicated the Nurse Managers and Directors of the Departments were responsible to collect data and submit Performance Improvement to the Quality and Performance Improvement Department. The System Wide Quality Director (SWQD) indicated the manager of the Occupation Health Center came to one meeting over a year ago. The SWQD explained it was not necessary to attend or collect data because the health center was for employees only.

The Occupational Health Center was under the license of the facility.

The flier for the Occupation Health documented, "...In case of work related injury or illness, please do the following: Report your injury/illness to your employer immediately. Obtain authorization for treatment from your employer. Call and go directly to (address of clinic)..."
"...From injuries to wellness testing..."

The Quality Plan for the facility dated 1/01/2011 revealed:

"...This Quality Plan supports the systematic organization-wide approach to, plan design measure, assess and improve organizational performance..."

2. On 2/23/12 in the afternoon, The DQM and the Chief Nursing Officer (CNO) were unable to indicate the timelines to report abuse, unable to provide an abuse and neglect policy, or how they would carry out a comprehensive and timely investigation for abuse and neglect of a patient.

The CNO indicated, in California it was five days. The CNO was unable to answer the reporting abuse procedures in Nevada.

The DQM, indicated since the Risk Manager had left, she would be the abuse coordinator until a Risk Manager was hired. The DQM could not give timeframes for abuse reporting or produce an abuse policy for the facility.

On 2/24/12 in the afternoon, several staff members in each department throughout the facility to include administrative staff were asked how they would identify abuse, the name of the abuse coordinator and what training they had received concerning abuse and neglect.

A majority of the employees were unable to identify the person who was ultimately in charge of abuse investigations. There were discrepancies on what constituted abuse and what agency to report abuse. The staff indicated they were trained in abuse on the computer and were given three months to finish by the corporation. Several staff attempted to find the abuse policy on the facility's learning website and were unable.

3. The facility failed to ensure the hospital provided patients with written notice of the decisions that included the steps taken on behalf of the patient to investigate grievances and the results of the grievance process.

The DQM indicated on 2/23/12 in the morning, the facility was instructed by legal for the corporation that letters in response to patient grievances should not include detailed information concerning any investigation.
VIOLATION: POTENTIALLY INFECTIOUS BLOOD/BLOOD PRODUCTS Tag No: A0592
Based on document review and interview, the facility failed to make a provision for record maintenance in the case of cease of operation.

Findings include:

On 2/24/12 at approximately 2:30 PM, Employee #50 stated there was not a policy which referenced a fully funded plan to transfer records of all units of blood and blood components to another hospital or other entity if the facility ceased operation. Health Information Management and Record Retention policies provided by Employee #50 and Employee #51 did not make a provision for this circumstance.
VIOLATION: PATIENT RIGHTS Tag No: A0115
The facility failed to ensure the hospital protected patients' rights by:

-Failure to provide a system to give notice of the steps taken on behalf of the patient to investigate grievances (TAG A123).

-Failure to ensure care was received in accordance with patients' rights (TAG A129).

-Failure to ensure staff (including direct care staff as well as administration and upper management staff) were trained and responded appropriately to protect patients from abuse by employees (TAG A145).

The cumulative effect of these deficient practices at TAGs A123, A129, and A145 resulted in the failure of the facility to ensure patients' rights were protected.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, record review, policy review, and document review, the facility failed to ensure the patients were provided with written notice of the decisions that included the steps taken on behalf of the patient to investigate the grievance and the results of the grievance process for 2 of 38 sampled patients (Patient #18 and #38).

Findings include:

The facility's policy entitled "Grievances, Patient and Family", effective review date 5/1/2010, contained documentation which included the following:

"I. Purpose: To establish a process for reviewing and resolving patient/family grievances.
II. Policy: It is the policy of the (name of the health system) to respect a patient's or other customer's right to voice a grievance about care or service, to have that grievance reviewed and when possible, resolved."







The facility's Policy entitled, "Grievances, Patient and Family" review date 5/1/2010, contained documentation which included the following:

Purpose: To establish a process for reviewing and resolving patient/family grievances.

Examples:
-Written complaint was always considered a grievance.
-All verbal or written complaints regarding abuse, neglect, patient harm...

The Risk Management Department will develop a written response to the patient regarding the hospital's determination. In all cases the hospital must provide a written response to each grievance. In regards to e-mail, when a patient communicates a grievance via e-mail, the hospital may provide its response via e-mail. Written responses must include the following:

-The name of a contact person at the hospital
-The steps taken to investigate the grievance
-The results of the grievance process
-The date of completion of the grievance process

Patient #18

Patient #18 was admitted to the facility on [DATE], with the complaint of shortness of breath. The patient's diagnoses included hypoxia, chronic obstructive pulmonary disease exacerbation and questionable pneumothorax. The patient used oxygen at home at 3 liters per minute and Bi-PAP intermittently (a breathing apparatus that helps patients get more air into their lungs). The patient was discharged home on 9/17/11.

Documentation in the clinical record dated 9/17/12 at 8:20 AM, indicated Patient #18 was "in her room and upset because she said she was calling because her oxygen was off." A nurse put her oxygen back on." According to the patient she was given a breathing treatment by a respiratory therapist and did not turn the oxygen back after the treatment."

Documentation received from the facility indicated Patient #18's family sent an e-mail on 9/20/11 to the facility regarding the care Patient #18 had received while at the facility from 9/12/11 through 9/17/11. The documentation indicated an investigation had begun into the concerns and a written response would be mailed to "your wife" within 60 business days with the outcome of the investigation.

A letter dated 11/29/11, from the facility documented it was a response to the "complaint" received on 9/20/11, regarding the care received at the facility. The letter documented "Your concerns were investigated by the Director of Respiratory Therapy Services, Director of Medical Surgical-Nursing, Director of Transport Services and Risk Management. It was found in our review that the above departments reviewed your concerns and have conducted meeting to discuss Service Excellence and Communication with their team members. Please be aware that our investigation of this matter was closed as of November 29, 2011."

The letter lacked documentation to indicate the steps the facility had taken to investigate the grievance and the results of the grievance.

Complaint #NV 439







Patient #38

Patient #38 was admitted on [DATE], with a diagnosis of labor.

Patient #38 was called by the Telenurse system (no date) and was asked about her care at the hospital between 10/17/11 to 10/21/11. The documentation indicated Patient #38 complained about one nurse.

The documentation revealed, "...Patient stated she was in labor for 48 hours and when she told the nurse (name) she was already to push the nurse said no. When the nurse checked her she freaked out and pulled the epidural catheter out of her back. Patient states she tried to warn the nurse that it was the epidural but the nurse insisted it was just extra tape. States the nurse waited too long to call the doctor and ended up forcing the patient on her side and told her husband to hold her legs closed. States the nurse waiting (sic) too long to call the doctor. States when the doctor came in the nurse kept pushing the oxygen mask on her face and she could not tell the doctor that the catheter had been pulled out. Also states the nurse had silenced the beeper so the doctor could not hear it. After the birth the nurse told the doctor she was pulling the catheter out then just touched the patient's back..."

Patient #38 complained that the same nurse was questioning why she had so much pain and that another patient who had a Caesarian section was not complaining as much as Patient #38

Documentation on the Patient Relations work sheet revealed, "...11/15/11: Chart reviewed on the the 16th following notification of complaint. Staff RN (Registered Nurse) mentioned in complaint interviewed..."

The conclusion of the investigation by the manager revealed, "...I think this was a mismatch of pt. (patient)/caregiver, and unfortunately this happens. The pt. did not like her nurse, but I really can find no evidence of wrong doing or deliberate malice on the nurse's part..."

A letter dated 1/4/12, to Patient #38 documented, "...Your complaint was investigated by Risk Management and the Director of Women's Health Services. The staff member in question was also interviewed by her director regarding these issues. In addition a full review of your medical record was completed. It was found that your care was appropriate and your pain was adequately addressed with supporting documentation. We regret that communication did not occur that would have put you at ease..."

On 2/23/12 in the morning, the Director of Quality indicated the telenurse was a courtesy to patients. It was a follow-up call to determine patient satisfaction. It was not necessarily considered a grievance.
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, clinical record review, and document review, the facility failed to ensure all orders were signed, dated and timed by the ordering practitioner for 2 of 38 sampled Patients (Patient #14 and #15).

Findings include:

The facility's policy entitled, Content and Timeliness of Records revised 2/09, documented, "All medical record entries should be dated, timed, and authenticated by the author."

Patient #14

Patient #14 was admitted to the facility on [DATE], with diagnoses including pneumonia and end stage renal disease.

The facility's policy entitled Drug Administration: Medication Administration Plan 13-07, revised 12/22/11, documented Medication orders must include:
-Drug name
-Dosage
-Route
-Frequency
-Date ordered
-Time ordered
-Signature of the authorized person

The clinical record contained Emergency Department physician's orders for the following medications did not contain a time or date to indicate when the orders were written:
- Xopenex 1.25 milligram (mg) x's 1
-Atrovent 0.5 mg x's 1
-Saline lock
-Zofran 4 mg Intravenous (IV) repeat times 1 as needed for nausea in 1 hours,
-Morphine 5 mg slow IV Push repeat 2 times as needed for pain every 15 minutes.
-Cefepime 2 gram IV
- Vancomycin 1 gram IV

On 2/22/12 at 11:25 AM, the Director of Critical Care and Emergency Services confirmed the Emergency Department physician's orders did not contain a time or date the orders had been written.

Patient #15

Patient #15 was admitted to the facility on [DATE], with diagnoses including altered mental status, Alzheimer's dementia and hypertension.

The clinical record contained Emergency Department physician's orders for the following orders did not contain a time or date to indicate when the orders were written for:
-Blood cultures x's 2
-Complete blood count
-Chest x-ray
-Electrocardiogram (EKG)
-Urinalysis, culture and sensitivity
-Saline lock
-Azithromycin 500 milligram (mg) IV
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interview and policy review, the facility's nurses failed to ensure physicians' orders contained initial doses for titrated intravenous medications for 2 of 38 patients (Patient #3 and #4).

Findings include:

According to the facility's policy Ordering and Prescribing: General Guidelines for Written Orders, last revised 1/6/12, "...4. All medication orders require the following elements and verifications/clarifications: ...b. All medication orders must be clear, complete, and legible and contain: ...ii. Dose of medication...xii. Orders written for titrating doses must contain qualifications for the titrations with maximum and minimum doses...e. If there is any question regarding a drug prescribed, dose, or strength (e.g., very high or low), administration frequency, or dosage interval, a nurse or pharmacist will contact the prescriber. Questionable orders shall be verified/clarified prior to dispensing of drugs. The pharmacists shall make a note of the conversation with the physician on the pharmacy copy of the prescriber's order..."

Patient #3

On 2/4/12, Patient #3 was admitted with diagnoses of [DIAGNOSES REDACTED]

On 2/4/12 at 5:48 AM, a physician ordered Levophed with drip titration for mean arterial pressure and Propofol titration for sedation. Neither order contained a starting dose/rate. The medical record did not show clarifications for the orders. The medication administration record showed the medications were administered.

Patient #4

On 2/20/12, Patient #4 was admitted with diagnoses of [DIAGNOSES REDACTED]

On 2/20/12 in the emergency department, a physician ordered Levophed drip to titrate to keep systolic blood pressure above 90. The order lacked a starting dose/rate. The medication infusion record showed a nurse initiated Levophed at 4 micrograms per minute.

On 2/23/12 at 4:30 PM: when asked about titrated medication infusion rates, Employee #4 provided Adult Guidelines for intravenous Infusion Medications, last revised March 2011. Employee #4 lacked an awareness of the facility's policy requiring starting doses/rates for orders written for titrated medications. The guidelines were issued by the pharmacy for hospital wide use and approved by the Board of Governors. Within the guidelines, the recommended initial dose for Levophed administration was 0.5 to 1 microgram per minute. The emergency department provided an undated Levophed Infusion chart, which indicated initial rates of 8-12 micrograms might be necessary to maintain desired blood pressure.

The nurse who administered Levophed to Patient #4 failed to follow the facility's guidelines and the facility's policy requiring a starting dose/rate.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review and document review, the facility failed to administer medications as ordered by the physician for 2 of 38 patients reviewed (Patient #26 and #14).

Findings include:

Patient #26

Patient #26 was admitted to the facility on [DATE] with a diagnosis of pregnancy. The patient delivered on 2/21/12 at 1:18 AM.

On 2/21/12 at 1:40 AM, the physician ordered Prenatal Vitamins one tablet to be administered daily.

On 2/22/12 at 10:40 AM, the Registered Nurse (RN), Employee #18 was observed administering Prenatal Vitamins plus Iron.

On 2/22/12 at 11:05 AM, Employee #18 explained Prenatal Vitamins plus Iron were the only kind of vitamins in the Pyxis.

On 2/22/12 at 11:15 AM, the Director of Pharmacy explained Prenatal Vitamins with Iron were the only vitamins in the hospital formulary.

On 2/24/12 at 10:50 AM, the RN relief charge in Labor and Delivery went to the Pyxis and entered prenatal vitamins. The Pyxis listed Prenatal Vitamins with Calcium. The Pyxis contained Prenatal Vitamins plus Iron.

On 2/24/12 at 11:00 AM, the Director of Woman Services checked the post partum Pyxis. Prenatal Vitamins with Calcium was listed and the Pyxis contained Prenatal Vitamins plus Iron.

On 2/24/12 at 12:00 Noon, the Director of Pharmacy acknowledged when the pharmacy technicians loaded the Pyxis with a medication, they should have entered the correct name into the Pyxis system.

Drug Administration: Medication Administration Plan 13-07 revised 12/22/11 documented:

"...III. Guideline/Procedure

7. Checking and Administration
a. At the beginning of each shift, the nurse responsible for administering medication will verify the Medication Administration Record (MAR). Any discrepancies will be checked against the physician's original order. A copy of the MAR containing the corrections will be scanned to pharmacy for reconciliation.
b. The nurse shall obtain medication from the automated dispensing unit, patient's medication bin or refrigerator and perform the following:
i. Verify the drug, dose, time, patient, and route match the medication order ..."




The facility's policy entitled, Ordering and Prescribing: General Guidelines for Written Orders current effective dated 1/6/12 documented, Medications may be dispensed only upon an order of a person authorized to prescribe by law and organizational policy.

Patient #14

Patient #14 was admitted to the facility on [DATE], with diagnoses including pneumonia and end stage renal disease.

The Medication Administration Record dated 2/20/12, documented Patient #14 had received Oxycodone 30 milligrams (mg) orally at 2:01 PM for pain.

The medication reconciliation form documented Patient #14 had been taking Oxycodone 30 mg orally at home every 8 hours for pain. The documentation on the form indicated a telephone order had been received from the attending physician for Oxycodone on 2/20/12 at 9:55 PM.

Standard physician's orders dated 2/21/12 at 12:20 AM, documented clarification: Oxycodone 30 mg orally every 8 hours as needed for severe pain.

On 2/22/12 at 11:45 AM, a Performance Improvement (PI) Analyst and the Director of Medical/Surgical and Cardiac Services confirmed the Oxycodone had been given on 2/20/12 at 2:01 PM, without a physician's order.

On 2/22/12 at 12:30 PM, the PI Analyst stated there was no physician's order for Oxycodone to be given at 2:01 PM.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a Registered Nurse (RN) supervised and evaluated upon admission and during the patients stay the nursing care for each patient in accordance with standards of nursing practice for 4 of 38 sampled patients (Patient #14, #15, #16 and #17).

Findings include:

Patient #14

Patient #14 was seen in the Emergency Department on 2/20/12 at 4:20 AM, with the complaint of shortness of breath and wheezing which started 6 hours prior to presentation to the emergency room .

The Emergency Nursing Record dated 2/20/12, documented at 7:20 AM, the patients' pain level was 8/10. Morphine 5 milligrams Intravenous push (IVP) was administered at 7:37 AM. The Emergency Nursing Record lacked documentation the patient's pain level had been reassessed after the IV Morphine had been given.

On 2/20/12 at 10:12 AM, the Emergency Nursing record documented Patient #14 had received Dilaudid 1 mg IV push. The clinical record lacked documentation regarding what the patient's pain level was prior to the administration of the IV Dilaudid and the pain level was 30 minutes after the medication had been given.

On 2/22/12 at 11:20 AM, the Director of Critical Care and Emergency Services stated there should have been documentation the patients pain level was reassessed 30 minutes after she had received the IV Morphine. The Director of Critical Care and Emergency Services was not able to locate documentation the patient had been reassessed after the IV Morphine had been given.

During the interview on 2/22/12, the Director of Critical Care and Emergency Services was not able to locate documentation Patient #14's pain level was documented prior to the administration of the IV Dilaudid or the patients pain level was reassessed 30 minutes after the medication had been given. The Director of Critical Care and Emergency Services stated the pain management policy had not been followed.

Patient #15

Patient #15 was admitted to the facility on [DATE], with diagnoses including altered mental status, Alzheimer's dementia and hypertension.

On 2/20/12, a physician's order was received for Patient #15 to have oxygen via nasal cannula at 2 liters per minute.

The clinical record documented on 2/21/12 at 5:30 PM, the patient was currently on oxygen at 2.5 liters per hour via nasal cannula.

On 2/21/12 at 7:53 PM, the clinical record documented, Patient #15 was on continuous oxygen at 3 liters per minute.

On 2/22/12 at 12:05 PM, Patient #15 was in bed with oxygen on at 2.5 liters per minute via nasal cannula.

On 2/22/12 at 2:20 PM, a Performance Improvement (PI) Analyst stated the oxygen flow rate was at 2.5 liters per hour. The PI Analyst confirmed the oxygen was not at 2 liters per minute in accordance with the physician's orders

On 2/23/12 at 7:55 AM, the Director of Medical/Surgical and Cardiac Services stated she was not able to locate a physician's order for oxygen to be on at 3 liters per minute or to titrate the patient's oxygen.

The Emergency Department Physician's order sheet (not dated) lacked documentation a physician's order was given for Patient #15 to have a Foley catheter inserted.

The clinical record documented Patient #15 arrived to the unit on 2/20/12 at 9:45 PM, via stretcher. "Urine is cloudy. Urine color is amber. Patient has indwelling catheter in place." The date of the catheter insertion was 2/21/12 at 10:20 PM. "The patient did not have a surgical procedure today."

The clinical record lacked documentation of a physician's order to insert a Foley catheter.

On 2/22/12 at 12:05 PM, Patient #15 was in bed with a Foley catheter in place.

On 2/22/12 at 2:25 PM, the Director of Critical Care and Emergency Services indicated a Foley catheter was not to be inserted without a physician's order. The Director of Critical Care and Emergency Services was not able to locate a physician's order for the Foley catheter.

On 2/23/12 at 7:55 AM, the Director of Medical/Surgical and Cardiac Services was not able to locate documentation a physician's order was received for the Foley catheter insertion.

Patient #16

Patient #16 was admitted to the facility on [DATE], for a right knee open wedge, osteotomy and left femur bone graft.

Anesthesia Orders - Pain Control dated 2/21/12 at 2:30 PM, included the following orders:
-Vital signs every 4 hours, respiratory rate, and level of consciousness every 2 hours until the PCA (patient-controlled analgesia) discontinued.
-Discontinue PCA and all orders on this page when patient was tolerating liquids and alternate analgesic ordered unless advised otherwise.

Total Knee Replacement Revision Post Operation Orders dated 2/21/12 at 3:00 PM, included the following orders:
-IV fluid to run at 100 ml (milliliters)/hour.
-Saline lock when taking fluids by mouth.
-Pain medications per Anesthesia. When anesthesia catheter removed, begin oral pain medications.
-Percocet 5-325 orally every 4 hours for moderate to severe pain

The clinical record indicated Patient #16 arrived on the Medical/Surgical unit at 6:00 PM on 2/21/12.

The Visit Record lacked documentation Patient #16's respiratory rate, and level of consciousness were assessed every 2 hours while on the PCA on 2/21/12 or 2/22/12.

The clinical record documented Patient #16 continued to have PCA on 2/22/12 at 10:00 PM.

The facility's policy entitled, Patient-Controlled Analgesia (PCA) Infuser dated revised 1/6/12, documented Patient response to medication (level of consciousness, pain relief) should be assessed and documented every 2 hours.

The Medication Administration Record (MAR) documented Patient #16 received oral medications at 8:30 AM, 10:00 AM, 12:30 PM, 5:30 PM and 10:00 PM during the period from 2/22/12 (7:01 AM) through 2/23/12 (7:00 AM). The MAR lacked documentation the IV line had been changed to saline lock when the patient was taking fluid by mouth in accordance with the physician's orders.

On 2/23/12 at 10:25 AM, a Nurse Practitioner from Orthopedics stated "an acceptable oral intake would be when a patient was taking anything by mouth."

On 2/23/12 at 10:30 AM, Patient #16 was up in a chair in his room, the PCA was still in use and IV fluids were running at to keep open. Patient #16 stated he was able to keep fluids down and had received three meals yesterday and a breakfast tray this morning.

The clinical record lacked documentation a physician's order had been received to decrease the IV rate from 100 cc/hr to a keep open rate or 20 cc/hr. The clinical record lacked documentation the physician was contacted the clarify the IV fluid orders or the physician's order to discontinue the PCA and all other anesthesia orders for pain control when the patient was tolerating liquids.

On 2/23/12 at 10:45 AM, an Registerd Nurse (RN) stated at 7:30 AM, during rounds the IV fluid was at 20 cc/hr or to keep open. The RN stated if the IV fluid rate was changed to keep open there should be a physician's order to do so. The RN verbalized according to the MAR the IV rate should be at 100 cc/hr. The employee was not able to locate a physician's order to decrease the IV rate to keep open.

Patient #17

Patient #17 was admitted to the facility on [DATE], with a diagnosis including right knee osteoarthritis. On 2/22/12, a right total knee arthroplasty was performed and the patient arrived on the Medical/Surgical unit at 11:10 AM.

Post-Operative orders for a total knee arthroplasty dated 2/22/12 at 9:20 AM, documented Post Operative Day (POD) #0: Vital signs with neurovascular checks every 2 hours times 2, then every 4 hours. The Post Operative orders for Intravenous (IV) fluid 0.45% Normal Saline (NS) with 20 milliequivalent (mEq) potassium chloride (kcl)/liter to run at 80 milliliters (ml) per hour. Saline lock when taking fluids by mouth.

The clinical record indicated Patient #17 had a neurovascular check performed on 2/22/12 at 11:10 AM. There was no documentation vital signs were obtained at this time. The clinical record lacked documentation Patient #17's vital signs and neurovascular checks were performed every 2 hours times 2 in accordance with the physician's orders.

Documentation in the clinical record dated 2/22/12, indicated Patient #17's vital signs were obtained at 5:06 PM and at 9:10 PM. There was no documentation in the clinical record neurovascular checks were completed when the vital signs were performed at 5:06 PM and 9:10 PM, in accordance with the physician's orders.

On 2/23/12 at 9:10 AM, the Director of Medical/Surgical and Cardiac Services was not able to locate documentation to indicate the physician's orders for vital signs with neurovascular checks every 2 hours times 2, then every 4 hours were done on POD #0.

The clinical record documented on 2/23/12 at 1:14 AM, Patient #17 had an oral intake of 240 milliliters or cubic centimeters (cc/mls).

On 2/23/12 at 9:30 AM, Patient #17 was in bed with IV fluid running at 80 cc/hour. Patient #17 stated she had "a little bit" of her dinner meal on 2/22/12 and had eaten breakfast this morning.

On 2/23/12 at 9:35 AM, the Director of Medical/Surgical and Cardiac Services confirmed the 9:30 AM, observation and interview with Patient #17. The Director of Medical/Surgical and Cardiac Services stated the Post Operative IV fluid orders had not been followed.

On 2/23/12 at 9:57 AM, a Registered Nurse (RN) stated Patient #17 was on intake and output monitoring. The RN stated he had been told on morning rounds the patient tolerated oral fluids well with no nausea or vomiting. The RN stated there was no saline lock in place because the patient was on Patient - Controlled Analgesia (PCA) pain medication. The RN verbalized the standard of practice would have been to call the physician and clarify the order or ask to change the IV rate to keep open so the patient would be be able to receive the PCA medication. The RN verbalized it should have been done this morning; a prudent nurse would have called the physician.
VIOLATION: DELIVERY OF DRUGS Tag No: A0500
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interview and policy review, the facility's pharmacy failed to ensure physicians' orders contained initial doses for titrated intravenous medications for 2 of 38 patients (Patient #3 and #4).

Findings include:

According to the facility's policy Ordering and Prescribing: General Guidelines for Written Orders, last revised 1/6/12, "...4. All medication orders require the following elements and verifications/clarifications: ...b. All medication orders must be clear, complete, and legible and contain: ...ii. Dose of medication...xii. Orders written for titrating doses must contain qualifications for the titrations with maximum and minimum doses...e. If there is any question regarding a drug prescribed, dose, or strength (e.g., very high or low), administration frequency, or dosage interval, a nurse or pharmacist will contact the prescriber. Questionable orders shall be verified/clarified prior to dispensing of drugs. The pharmacists shall make a note of the conversation with the physician on the pharmacy copy of the prescriber's order..."

Patient #3

On 2/4/12, Patient #3 was admitted with diagnoses of [DIAGNOSES REDACTED]

On 2/4/12 at 5:48 AM, a physician ordered Levophed with drip titration for mean arterial pressure and Propofol titration for sedation. Neither order contained a starting dose/rate. The medical record did not show clarifications for the orders. The medication administration record showed the medications were administered.

Patient #4

On 2/20/12, Patient #4 was admitted with diagnoses of [DIAGNOSES REDACTED]

On 2/20/12 in the emergency department, a physician ordered Levophed drip to titrate to keep systolic blood pressure above 90. The order lacked a starting dose/rate. The medication infusion record showed a nurse initiated Levophed at 4 micrograms per minute.

On 2/23/12 at 4:30 PM: when asked about titrated medication infusion rates, Employee #4 provided Adult Guidelines for intravenous Infusion Medications, last revised March 2011. Employee #4 lacked an awareness of the facility's policy requiring starting doses/rates for orders written for titrated medications. The guidelines were issued by the pharmacy for hospital wide use and approved by the Board of Governors. Within the guidelines, the recommended initial dose for Levophed administration was 0.5 to 1 microgram per minute. The emergency department provided an undated Levophed Infusion chart, which indicated initial rates of 8-12 micrograms might be necessary to maintain desired blood pressure.

The nurse who administered Levophed to Patient #4 failed to follow the facility's guidelines and the facility's policy requiring a starting dose/rate.

On 2/20/12 at 7:03 PM, a physician ordered Levophed drip to titrate systolic blood pressure to 110. The order lacked a starting dose/rate.
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review and document review, the facility failed to follow acceptable standards of infection control for 1 of 38 patients observed (Patient #28).

Findings include:

Patient #28

Patient #28 was admitted to the facility on [DATE] at 6:28 AM for an out-patient right shoulder arthroscopy with superior labral-anterior posterior repair.

On 2/23/12 at 7:30 AM, the anesthesiologist, Employee #11 was observed administering a nerve block in the pre-operative area to Patient #28. The anesthesiologist did not wash his hands prior to putting on gloves to administer the nerve block or after removing the gloves.

On 2/23/12 at 7:50 AM, the System Director of Infection Control acknowledged the anesthesiologist did not wash his hands prior to and after removing his gloves.

Hand Hygiene Guidelines, Revised November 2009 documented:

"...C. All health care workers, volunteers, and licensed independent physicians are required to perform proper hand hygiene at the following times:
1. Before and after client contact and between clients.
2. After contact with a source of microorganisms.
3. After removing gloves. Before donning gloves ..."

On 2/23/12 at 8:10 AM, the circulating Registered Nurse (RN), Employee #10 was observed applying Duraprep to Patient #28's operative site (right shoulder), down the right arm to the patient's right hand and fingers. The circulating RN then reapplied the same Duraprep applicator to the operative site.

Surgical Skin Antisepsis, effective 5/09 documented:

"...G. The antiseptic agent is to be applied to the skin over the surgical site and surrounding area in a manner to minimize contamination, preserve skin integrity, and prevent tissue damage ..."

"...G. 5. During application of the skin antiseptic the progression is to be from the incision site to the periphery of the surgical site.
a. This process prevents reintroducing microorganisms from areas into the incision site.
b. The prep sponge or applicator is to be used for a single application and discarded.
c. Subsequent applications required a fresh sponge or applicator, preventing contamination of the incision site ...."
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, clinical record review, and document review, the facility failed to ensure the medical record was complete and accurately written for 9 of 38 sampled patients (Patients #8, #9, #10, #11, #13 #14, #15, #3, and #36).

Findings include:

Patient #14

Patient #14 was admitted to the facility on [DATE], with diagnoses including pneumonia and end stage renal disease.

The Emergency Nursing Record dated 2/20/12, documented Patient #14 was 67 years of age.

The Visit Record documented Patient #14's date of birth as 6/17/74, with an age of 37.

Patient #15

Patient # 15 was admitted to the facility on [DATE], with diagnoses including altered mental status, Alzheimer's dementia and hypertension.

The clinical record contained a form entitled, Inpatient Pneumococcal and Influenza Immunization Protocol. The documentation lacked the time and date the form had been completed.

On 2/22/12 at 2:10 PM, the Director of Medical/Surgical and Cardiac Services stated the Inpatient Pneumococcal and Influenza Immunization Protocol should have been timed and dated.





Patient #3

On 2/4/12, Patient #3 was admitted with diagnoses of [DIAGNOSES REDACTED]

On 2/14/12, a physician ordered Fentanyl 50 micrograms intravenously for pain.

On 2/19/12 at 5:34 AM, Employee #55 withdrew 100 micrograms of Fentanyl from the Pyxis system. Employee #55 initialed the medication administration record. Employee #55 did not indicate the amount administered and the amount wasted with a cosigner.

On 2/20/12 at 11:48 PM, Employee #55 withdrew 100 micrograms of Fentanyl from the Pyxis system. Employee #55 initialed the medication administration record. Employee #55 did not indicate the amount administered and the amount wasted with a cosigner.

On 2/22/12 at 2:20 PM, the Pharmacy Director indicated the facility's records showed Employee #55 did not document any Fentanyl waste.

On 2/20/12 at 2:30 PM, Employee #60 documented Patient #3 received 50 micrograms of intravenous Fentanyl on the medication administration record.

On 2/22/12 in the afternoon, the Pharmacy Director provided the pharmacy's All Station Event Report for Employee #60's usage and for Patient #3's usage, returns and wastes. The reports did not show Employee #60 withdrew Fentanyl for any patient. The reports did not show Patient #3 received any Fentanyl. The reports did not show any Fentanyl was returned or wasted. Remaining activity on the reports was reconciled.

On 2/22/12 at 2:20 PM, the Pharmacy Director concluded the initialed administration on the medication administration record was an error.

According to page 5 of the facility's Drug Administration: Medication Administration Plan Policy, last revised 12/22/11 and reviewed 1/6/12, "...vi. The Administration of dosages of controlled substance medication less than the unit dose requires: 1. A witness by a licensed person of the destruction and waste of excess drug. 2. The signature or the nurse administering the drug and a witness in the Automated Dispensing Unit or on the MAR [medication administration record]..."

Patient #36

On 2/7/12, Patient #36 was admitted with diagnoses of [DIAGNOSES REDACTED]

On 2/22/12 in the afternoon, Patient #36's medication administration record for 2/20/12 through 2/21/12 was misfiled in Patient #3's medical record.





The policy for Content and Timeliness of Records (HIM-408) (Effective date: 8/06; Revised: 2/09) revealed the following:

"...PURPOSE

Complete and accurate medical record documentation shall be maintained for the primary purpose of fostering continuity of patient care by maintaining a means of communication among the health are practitioners treating a patient now and in the future.

D. All medical records should be timed, dated, and authorized by the author.

19. LEGIBILITY & AUTHENTICITY: Entries must be legible and complete, and must be authenticated and dated promptly by the person (identified by name and discipline) who is responsible for ordering, providing or evaluating the service furnished..."

On 2/22/12 in the morning, the medical records for Patients #8; #9; #10 and #11 were reviewed and found to contain private health information from other patients.

The Director of Quality was present and notified during the chart reviews on 2/22/12.

Patient #13

Patient #13 was admitted with diagnoses including cancer of the lung, generalized weakness, abdominal pain, diarrhea, hypertension, pulmonary embolism and [DIAGNOSES REDACTED].

The policy Rapid Response Team (Effective: 06/01/2010 Revised: 09/22/2010 documented:

"...A. 4. The RRT (Rapid Response Team) leader will complete and label the RRT documentation form..."
"...The original RRT Documentation Record will be placed in the chart under Physicians Orders and signed by the physician..."

A review of the Rapid Response Protocol dated 6/21/11 for Patient #13 revealed the form was incomplete. The Assessment box contained the patient's blood pressure, heart rate and respiratory rate. The rest of the box was incomplete.
The boxes that contained Recommended Protocol/Interventions (STAT) and Results, Follow-up and Outcomes were blank.
The form was not signed, dated and timed by the Registered Nurse or the Respiratory Therapist or a Physician.

A Nursing Flow Sheet for Patient #13 dated 6/21/11 contained a signature that was illegible and no documentation of the person's discipline.

There was no documentation of the date and time the Physician's Progress Note was written for Patient #13.

Complaint #NV 832
VIOLATION: PATIENT RIGHTS: EXERCISE OF RIGHTS Tag No: A0129
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interview, record review and document review, the facility failed to ensure call lights were answered for 2 of 38 sampled patients (Patient #15 and #18), failed to ensure a patient's oxygen was reconnected after a patient returned from Radiology or after a respiratory treatment for 1 of 38 sampled patients (Patient #18), and failed to ensure linen was changed per patient request.

Findings include:

Patient #18

Patient #18 was admitted to the facility on [DATE], with the complaint of shortness of breath. The patient's diagnoses included hypoxia, chronic obstructive pulmonary disease exacerbation and questionable pneumothorax. The patient used oxygen at home at 3 liters per minute and Bi-PAP intermittently (a breathing apparatus that helps patients get more air into their lungs). The patient was discharged home on 9/17/11.

Documentation in the clinical record dated 9/17/11 at 8:20 AM, indicated Patient #18 was "in her room and upset because she said she was calling because her oxygen was off." A nurse put her oxygen back on. "According to the patient she was given a breathing treatment by a respiratory therapist and did not turn the oxygen back after the treatment."

On 2/24/12 at 10:50 AM, the Director of Medical/Surgical and Cardiac Services reviewed an event report from their reporting system. The Director of Medical/Surgical and Cardiac Services stated an oxygen saturation of 84% means the patient was oxygen compromised and "desating". The Director of Medical/Surgical and Cardiac Services stated if Performance Improvement (PI) Analyst had told staff what was going on the staff should have responded sooner than 5 minutes. The Director of Medical/Surgical and Cardiac Services stated patient care was number one priority. If the staff felt they could not leave the desk they should have called the Director, Manager or any nurse to check on the patient or watch the desk so the patient would be assessed.

The Director of Medical/Surgical and Cardiac Services stated it was not appropriate for an alarm to sound for 7 minutes without any intervention. The Director of Medical/Surgical and Cardiac Services stated it was patient safety; we were putting their lives at risk. The Director of Medical/Surgical and Cardiac Services stated it was not appropriate for the call light to be on the floor because the patient could not call for help. If they could not reach the cord, they were at risk for a fall if they tried to find it.

The facility's policy entitled, Patient Rights and Responsibilities revised 3/12/10, documented Patients have the right to:
"...1) Access to Care: Expect the hospital to respond to your requests for service, within its capacity, and to provide evaluation, service or referral by the urgency of your care needs.

2) Respect and Dignity: Considerate and respectful care that respects your psychosocial, spiritual and cultural values and beliefs. Effective management of pain as appropriate to the medical diagnosis or surgical procedure.

3) Personal Safety: to be free from all forms of abuse, harassment acts or threats of violence. To protect patients from real or perceived abuse, neglect or exploitation from anyone, including staff, students, volunteers, other patients, visitors or family members..."

The facility's policy entitled,Transport/Transfer Patients revised 5/25/10, documented, "... it was the practice of the facility to ensure the safe transport of patients throughout our facility...
Upon return to the unit, the transporter will:

-Notify the Charge Nurse or patient's primary nurse of the patient's return. If the Charge Nurse was notified, the Charge Nurse would be responsible for notifying the patient's primary nurse.
-Sign the patient back in on the "Ancillary Department Sign-Out/In Sheet".
-Indicate whether the chart was returned...

Upon return to the unit, the assigned primary nurse will:
-Assess the patient's condition
- Check status of post-op/procedure intravenous orders and equipment as appropriate
- Document patient's condition and time of return in the medical record..."

On 2/23/12 at 11:50 AM, a Registered Nurse (RN) stated the transporter should reconnect the oxygen . If the nurse and other staff assist with the transfer they need to check and make sure the oxygen was on. The RN verbalized it was ultimately the RN's responsibility.

On 2/24/12 at 10:17 AM, the Director of Medical/Surgical and Cardiac Services stated no one was to walk by a call light except in an emergency. It was a facility expectation to see what was needed, assist or get the appropriate staff. The Director of Medical/Surgical and Cardiac Services stated if the call light was answered at the desk, the staff would pick up the telephone or radio and contact the Certified Nursing Assistant, Registered Nurse or Charge Nurse based on the need of the patient. The Director of Medical/Surgical and Cardiac Services stated the call lights could be remotely turned off at the desk, but the emergency lights could not be.

On 2/24/12 at 11:30 AM, a Registered Nurse (RN) stated a Bi-PAP alarm and an oxygen saturation of 80% equaled some type of respiratory issue and a nurse was needed. The RN stated it was not appropriate for a Bi-PAP machine to alarm for 12 minutes and not be addressed. The alarm should have been answered right away. The RN stated when a patient returned from Radiology it was the nurse's responsibility to make sure the oxygen was hooked back up and the flow was correct. The transporter was not to leave the room until a ticket to ride was signed by a nurse, the bed was plugged in and the low position. The RN stated any call light that was on, you answer it as soon as you see it.

Patient #15

Patient #15 was admitted to the facility on [DATE], with diagnoses including altered mental status, Alzheimer's Disease and hypertension.

On 2/22/12 at 11:47 AM, a Surveyor heard an audible alarm sounding. At 11:56 AM, the call light was observed on above the exterior hallway door outside Patient #15's room. The call light was observed being turned off.

On 2/22/12 at 12:05 PM, Patient #15 was in bed and the Intravenous (IV) pump/machine was alarming occlusion. A family member was present at Patient #15's bedside. The family member stated she had called for assistance 10 minutes ago because of the alarm, but no staff had came in to address the alarm. The family member stated the noise was irritating/annoying to the patient due to her diagnosis. The family member stated the alarm was irritating to her also and had been alarming for a long time.

On 2/22/12 at 12:10 PM, a Registered Nurse (RN) entered the room and addressed the alarm. The RN stated the alarm was probably due to the IV fluid bag being empty.





On 2/24/12 at 2:25 PM, the transporter explained when the patient returned to the room, the transporter would switch the oxygen from the transport tank to the patient's wall oxygen. The transporter would assure the oxygen flow was the same. The patient would be given the call light, the bed lowered and the side rails put down.

Once the patient was settled, the transporter would go to the Registered Nurse to inform them the patient had returned to the room. The nurse would sign a "ticket to ride" documenting notification of return of the patient.

The transporter recalled the ticket to ride system was started sometime in the summer.





On 2/23/12 in the late afternoon, an interview was conducted with the Director of Quality Management (DQM) (who was also the interim Administrative Director of Performance Improvement) and the Risk Analyst.

The Risk Analyst indicated the following:
-There was a complaint by Patient #18 and a family member about the nurses not responding to the oxygen alarm.
-The grievance was submitted on 9/19/11 by the Performance Improvement (PI) Analyst, who had the duties of performing "Ambassador Rounds" (Patient Satisfaction rounds) every Friday. On Friday, 9/16/11, the PI Analyst was doing the ambassador rounds and noticed Patient #18's oxygen alarm was going off and the call light had fallen on the floor. The PI Analyst then called for help, and the Respiratory Therapist (RT) came in and scolded Patient #18 for not having the nasal cannula on.
-The family later wrote a thank you note via email (electronic mail) dated 9/20/11 to the PI Analyst reiterating the incident.
-The facility treated the above communication by the family as a grievance.
-The facility wrote a response letter dated 9/23/11 and a final response on 11/29/11.

The DQM indicated she was the interim Director of Performance Improvement, and she was ultimately the responsible person for monitoring, tracking, and responding to grievances. The DQM further indicated she was the responsible person to communicate information to the Quality Assurance Performance Improvement (QAPI) Committee.







On 2/22/12 at 9:00 AM, an unsampled patient (Patient #39) complained he had soiled sheets on his bed for 3 days and he had requested several times for a change of linen. The patient's draw sheet contained several stained areas distributed in several places on the sheet. The patient indicated he had turned the sheet over so he or his visitors did not have to look at the soiled sheet.

The policy title: Linen Changes (revised 1/06/2012) documented the following:

"...POLICY:
A. As a routine, linen will be changed when soiled, or by request of the patient..."

Complaint #NV 439
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, and document review, the facility failed to ensure 2 of 38 sampled patients were protected from abuse (Employee #18 and #38) and failed to maintain a systematic process regarding abuse to train staff, identify, report, investigate, and protect patients from abuse.

Findings include:

The facility's policy ("Patient Rights and Responsibilities", effective 9/1/2007, revised 3/12/2010) indicated the following:

"I. Purpose: To define the Rights and Responsibilities for all patients and parents or guardians of patients in the hospital."

"...Considerate and respectful care that respects your psychosocial, spiritual and cultural values and beliefs...
Personal Safety:
*Be cared for by staff that has been educated about patient rights and their role in supporting these rights....
*To receive care in a safe setting.
*To be free from all forms of abuse, harassments, acts or threats of violence.
*To protect patients from real or perceived abuse, neglect, or exploitation from anyone, including staff, students, volunteers, other patients, visitors or family members...

Grievances:
*File a grievance. If you want to file a grievance with this hospital, you may do so by writing ...The grievance process consists of a review of each grievance by the appropriate personnel and a written response within 60 business days. The written response will contain the steps taken to investigate the grievance, the results of the grievance process, and the date of completion of the grievance process. A quarterly review of the grievances and responses will take place by the Grievance Committee with further action taken if necessary. You may also refer concerns regarding quality of care or premature discharge to the Nevada Peer Review Organization, which is the name of the Peer Review Organization (PRO) authorized by Medicare patients. All senior HMO (Health Maintenance Organization) and medicare patients receive the "Notice of Discharge & Medicare Appeal Rights" form during their hospital stay. Refer to this form for reporting information."

The following employees were interviewed about their knowledge and training in regard to identifying and reporting abuse by an employee toward a patient, and what to do in the event they witnessed or were told about another employee abusing a patient:

2/24/12: Interviews in the Emergency Department (ED) from 12:50 PM - 1:20 PM:

*Interview with the Director of Case Management, who stated she had been employed at the facility for 3 years, revealed the following statements:
"If I was a direct witness of abuse, I would separate the employee from the patient and protect the patient.
I would let the Risk Manager know if she was available.
At certain times I would call the police, but I am not sure exactly in what case I would call them.
I would call the administrator in charge if they are not already involved.
Yes, we had abuse training on orientation. The education piece is done by (name of the Education Coordinator). She taught us about all kinds of abuse. No, there are no refresher courses."

*Interview with a registered nurse (RN) III in the ED revealed the following statements:
"No, I did not really have any specific training about employee abuse toward a patient. I can not really remember though, it was so long ago.
I was not told specifically the definitions of physical abuse and verbal abuse. I know I have to report things to my supervisor up the chain of command, but there is no special training about if an employee is abusing a patient.
In a hypothetical case if I saw an employee verbally abusing or physically abusing a patient, I would call my charge nurse. I would do it immediately. I would not wait.
I would go to (name of charge nurse).
No there is no phone number or anything that I could call if I wanted to anonymously report it. I can not make a decision on whether the employee has abused someone or not; I would just report it and hope that the employee is taken care of by the supervisor."

*Interview with the ED Charge Nurse, revealed the following statements:
"There was a week long orientation for all new employees. There may have been something in the training about patient abuse, but I do not remember any specific training about what verbal abuse, physical abuse, or intimidation toward a patient really is.
I would go talk to the patient and see if I can figure out why something like this happened (in response to a hypothetical case of verbal or physical abuse by an employee toward a patient reported to me). I would make sure everything is okay.
It is not up to me to prove that an employee has abused a patient. I just report it in the MIDAS (internal event reporting system).
They stress chain of command here. I would just forward it to my supervisor. I am not aware of any time frame.
Yes, I would talk to the nurse, and if she denies it, I will forward it to (name of the ED Manager). I would not be the one who would take the nurse off the floor or reprimand a nurse or employee though.
I would have to look into it and see if it really happened before the nurse would be suspended or any action taken.
In the case of the badge intimidation (in answer to the hypothetical case about a staff member shoving a badge in an elderly female patient's face and saying, 'Here's my name. Can't you read?') "I would not really consider that abuse."

*Interview with the Admitting Registrar revealed the following statements:
"Yes we had some training, something in the (name of online class) about abuse. Mostly it was about what to do if a patient was abused by their spouse, or if a child was abused by their family member or something. They did not tell us any definitions or any specific examples about abuse by an employee.
If an elderly patient told me she was roughly handled or verbally abused or physically abused, I would go to the employee's supervisor, and then I would go to my supervisor. I do not know about any way to report it anonymously. I would just tell my supervisor.
If I saw a nurse hurting or verbally abusing a patient I would just report it to my supervisor. At least by the end of my shift."

*Interview with a RN in the ED revealed the following statements:
"Yes, they trained me at (name of online class). There was initial training for one day.
They went over what to do if a patient was abused on arrival to the hospital, but not specifically on what to do if a patient was abused here by an employee.
We would go to the patient and get the whole story.
No, I was not specifically trained on what verbal and physical abuse is. I do not know that I would think of rough handling as physical abuse, it would depend on whether I saw it or not. I would definitely report it to my supervisor though."

*Interview with an ED Triage Nurse revealed the following statements:
"If I saw it (in response to a hypothetical case of another nurse shoving an elderly patient into a wheelchair roughly), I would report it to my charge nurse immediately. She would tell (name of the ED Manager) immediately. I would tell the charge nurse. She would enter it into the MIDAS system.
(In response to the question of how much time do you have to report possible abuse?) I do not know. I would have to look into it. Yes, I think we can report it anonymously, but I do not know how or what phone number to call. Maybe Elder Protective Services or Metro? I am not sure."

On 2/24/12, the following interviews were conducted:

*Interview with the Director of Education revealed the following statements:
"I do the orientations, but I do not train the employees about the definitions of abuse or anything. I just tell them to tell their supervisors. The supervisors will know what to do.
They get some training in the (name of the online course), but I am not sure what they tell them about abuse of patients."

*Interview with the Director of Respiratory Services revealed the following statements:
"I do not know if I am a mandatory reporter. I am not sure how much time I have to report possible abuse. I would hope it would not take a long time.
I had some modular training when I was hired, but nothing specific to abuse.
I am sure there was training, but I can not recall.
(In response to the question 'According to policy, what should have been done after the Director of Respiratory Services became aware of the 2 incidents of employee abuse toward Patient #18) "I do not know the policy. I would have to read it. I can not speak to the policy." (In response to the question 'Did you take any steps to protect the patient or any other patients from further abuse by the 2 respiratory staff members?') "No, I did not."

*Interview with the Chief Nursing Officer (CNO) revealed the following statements:
"I have been working here at the hospital as the CNO since last November.
I have been licensed as a registered nurse in Nevada for 3 years.
I do not know what a mandatory reporter is. I just know it would have to be reported if someone actually abused a patient.
I do not know how much time I would have to report a case of patient abuse. I do not know how much time you have in Nevada, but in California it is 5 days.
I do not know who I would report a case of patient abuse to. To the health department?
There was some training about abuse in the orientation I took before I was hired in November. I do not remember it though. I do not think they told me anything about any definitions or examples of abuse. I do not really remember.
(In response to the question whether there is anything specific about patient abuse in the learning materials provided in the orientation) It is generic.
In my role here, I would expect each employee to refer to the policy and procedure on abuse.
No, I do not know what the policy and procedure on abuse is. I have never seen it.
I would expect them to go through the chain of command, and for the supervisor to know what the policy and procedure is. They would just go through the chain of command to protect the patients.
(In response to the question 'How would the supervisors know when to suspend an employee in a suspected case of abuse?') I would just expect them to know the policy."

*Interview with the Director of Quality Management (DQM), who was also the Interim Director of Performance Improvement:
"No, the hospital does not have a designated abuse coordinator. I am ultimately responsible for the grievances and all action taken.
I have been licensed here as a registered nurse in Nevada for 1 year.
I do not know what the reporting time is for a mandatory reporter.
I do not know who to report to.
I was not trained about abuse."
(In response to the question, 'How would the supervisors and staff know what to do if they saw or became aware of a possible physical or verbal abuse?') If there is no training, we can not expect them to know.
The MIDAS system is a community system. The staff know they have to report all incidents by the end of the shift.
(In response to the question, 'Is there any monitoring to oversee and track any incidents of abuse?') No. Because we have not had any cases of abuse in this hospital.
-There might be a policy that says we have to report abuse to authorities in 3 days. I do not know. I have not reviewed the policy."

On 2/24/12, at approximately 4:30 PM, the Performance Improvement (PI) Analyst who had reportedly witnessed and been advised by the patient of verbal abuse and intimidation of Patient #18, was interviewed.

The PI Analyst indicated the following:

"I have been employed at the facility as the PI Analyst since May, 2011.
Part of the duties of my position included going on 'Ambassador Rounds' (patient satisfaction rounds) on Friday afternoons.
I have been a licensed registered nurse in Nevada off and on for the past 40 years.
I got the orientation training before I started working last May. I received the training about abuse in the (name of online course). No, there is no specific training on how to identify abuse of patients by employees."

The PI Analyst verified she did not make a verbal report to the authorities, Elder Protective Services, or State of Nevada Aging Disabilities Services Department (ADSD), after the incident with Patient #18. The PI Analyst stated, "I did not think it was abuse. I did not consider the scolding abuse. I have seen so much worse. The situation with the employee shoving a badge in front of the patient's face was hearsay. I did not think it was abuse."

The PI Analyst further indicated, "I called (name of the Risk Analyst) on the following day, even though it was my day off. I called him because I knew I had to enter it into the MIDAS system, but that was the first time I had ever done that and I did not know how. He said I had to enter it into the MIDAS system. I also went to the (name of previous CNO), but he was not there in his office, so I gave him a letter. "

(In answer to the question of why the employee did not report the incident(s) of verbal abuse and intimidation to the authorities, Elder Protective Services, or the State of Nevada Aging Disabilities Services Department (ADSD), "I did not think I had to. That is why I called their supervisor and my supervisor. I felt like they should know what to do."

In answer to the question 'Did you take any steps to protect Patient #18 from further abuse or intimidation?' the PI Analyst stated, "No. I did not. To tell you the truth, I was more worried about her O2 sats (oxygen saturation level) being so low. No, I did not do anything to make sure the respiratory therapists did not abuse her any more. I really did not think it was abuse."






Patient #18

Patient #18 was admitted to the facility on [DATE], with the complaint of shortness of breath. The patient's diagnoses included hypoxia, chronic obstructive pulmonary disease exacerbation and questionable pneumothorax. The patient used oxygen at home at 3 liters per minute and Bi-PAP intermittently (a breathing apparatus that helps patients get more air into their lungs). The patient was discharged home on 9/17/11.

Patient #18 had physician's orders for Albuterol sulfate 2.5 milligrams (mg) every 4 hours, Atrovent 0.02 solution 0.5 mg every 4 hours. The medication administration record (MAR) documented these medications were to be given by Respiratory Therapy (RT).

Documentation received from the facility indicated on 9/16/12, Performance Improvement (PI) Analyst "was conducting Ambassador rounds when she heard an extremely loud sounding alarm in a near by room." After about 7 minutes she decided to investigate the alarm. A Bi-PAP machine was alarming and Patient #18's oxygen (02) saturation was at 80%. The PI Analyst "went into the hallway and found a Respiratory Therapist. She came in and scolded the patient for having the Bi-PAP on instead of the Nasal Cannula on." After an additional 5 minutes the PI Analyst went into the hallway to find a nurse. The alarm continued to sound and the patient's oxygen saturation was now 84%. The PI Analyst "summoned a respiratory therapist who was approaching (name of patient) room to perform an arterial blood gas draw. She turned off the alarm and proceeded to scold (name of patient) for having the Bi-PAP machine on instead of the 02 cannula... She said a male respiratory therapist has been very rude to her during the night and treats her like she is stupid".... and indicated "she asked him what his name was and he pulled his badge away from his shirt and shoved it close to her face and said "Can't you read? Its (name of RT). The patient cried when she told me this."

On 2/24/12 at 10:50 AM, the Director of Medical/Surgical and Cardiac Services verbalized it was not okay to shove a name badge close to a patient's face. "Absolutely not. It is disrespectful and rude making the patient feel intimidated." The Director of Medical/Surgical and Cardiac Services verbalized it was "absolutely not, not okay to scold anybody in an environment like that." Because it is "degrading, you do not know the whole situation. Patients are never at fault. The Director of Medical/Surgical and Cardiac Services usually patients were assisted with Bi-PAP. When staff scold a patient it would increase anxiety which "compromises patient safety."

On 2/24/12 at 1:00 PM, a Registered Nurse (RN) on the 6th floor stated she started working at the facility 2/11. The RN was asked who the abuse coordinator was at the facility. The RN stated "I would talk to Case Management/Social Services. The RN stated she had received abuse training during orientation and during extra new graduate classes that had a section dedicated to abuse. The RN stated if she witnessed abuse she would follow the chain of command with the Charge Nurse, Security and call Social Services. The RN indicated she would fill out the Midas form. When asked if she would report it to anyone else she stated yes, at shift change."

On 2/24/12 at 1:18 PM, a Unit Manager had worked at the facility since 11/11. The Unit Manager stated she was not sure who the abuse coordinator was at the facility. The Unit Manager stated she would refer to the phone directory on line and Human Resources would assist as well. The Unit Manager stated she had "a quick orientation, no training specifically on abuse. The Unit Manager stated the facility had a class called Handle with Care, but she had not been able to take the class yet. The Unit Manager was asked what the facility's policy was on abuse. the Unit Manager stated she would have to go to the facility intranet to get the proper policy and procedure. The Unit Manager indicated if she witnessed a staff member scolding a patient she would reassure the patient and let them know she would be right back, and pull the staff member aside and tell them we do not treat our patients that way. We treat them with respect and dignity. The Unit Manager stated she would follow up to see how the patient was doing.







The following interviews were conducted on 2/24/2011 between 12:50 PM and 1:20 PM concerning the facility abuse prevention:

The Director of Quality Improvement(DQM) indicated, if an employee was accused of abuse such as intimidation the employee was referred to the person's manager. The manager would then take care of the issue. The DQM was unable to indicate the time frame to report abuse or to what agency to report the abuse.

An RN (registered nurse) indicated she did not know who the abuse coordinator was, however the RN indicated she would report to her manager. The RN indicated she did not know what the policy said, however she indicated it was on the intranet education line. The RN indicated if she saw or heard a staff member verbally or physically abusing a patient, she would take the staff member into the hall and speak to the person. The RN indicated she would inform the manager.

An RN indicated the Risk Manager was the abuse coordinator, however the RN indicated the Risk Manager had recently retired. The RN indicated she would go to the Social Worker or the Director of Quality.
The RN indicated, she did not know the abuse policy, however the RN indicated she would look up the policy on line.
The RN attempted to find the abuse policy on line and was unable. The RN indicated she did not know where to find the policy. The RN indicated she thought she took an abuse class on line.
The RN indicated she would go to the staff person's manager if she heard a staff member verbally abuse a patient. The RN described verbal abuse as a spouse of a patient shouting or intimidating to him/her.
The RN indicated, she thought the spouse should be reported to the police or Adult Protective Services.

A Unit Coordinator (UC) indicated she took a course on line called, "Handle with Care" that dealt with abuse. The UC indicated she would tell the charge nurse if a patient was being abused.
When asked for examples of abuse the UC indicated, when a patient became aggressive with staff or a family member of a patient yelled or cursed at the patient.

The Director of Education indicated, "Handle with Care" dealt with the aggressive or abusive patient and how the staff would handle the patient without getting injured.

Patient #38

Patient #38 was admitted on [DATE], with a diagnosis of labor.

Patient #38 was called by the Telenurse system (no date) and was asked about her care at the hospital between 10/17/11 to 10/21/11. The documentation indicated Patient #38 complained about one nurse.
The documentation revealed, "...Patient stated she was in labor for 48 hours and when she told the nurse (name) she was already to push the nurse said no. When the nurse checked her she freaked out and pulled the epidural catheter out of her back. Patient states she tried to warn the nurse that it was the epidural but the nurse insisted it was just extra tape. States the nurse waited too long to call the doctor and ended up forcing the patient on her side and told her husband to hold her legs closed. States the nurse waiting (sic) too long to call the doctor. States when the doctor came in the nurse kept pushing the oxygen mask on her face and she could not tell the doctor that the catheter had been pulled out. Also states the nurse had silenced the beeper so the doctor could not hear it. After the birth the nurse told the doctor she was pulling the catheter out then just touched the patient's back..."
Patient #38 complained that the same nurse was questioning why she had so much pain and that another patient who had a Caesarian section was not complaining as much as Patient #38.

Documentation on the Patient Relations work sheet revealed, "...11/15/11: Chart reviewed on the the 16th following notification of complaint. Staff RN (Registered Nurse) mentioned in complaint interviewed..."

The conclusion of the investigation by the manager revealed, "...I think this was a mismatch of pt. (patient)/caregiver, and unfortunately this happens. The pt. did not like her nurse, but I really can find no evidence of wrong doing or deliberate malice on the nurse's part..."

A letter dated 1/4/12, to Patient #38 documented, "...Your complaint was investigated by Risk Management and the Director of Women's Health Services. The staff member in question was also interviewed by her director regarding these issues. In addition a full review of your medical record was completed.
It was found that your care was appropriate and your pain was adequately addressed with supporting documentation. We regret that communication did not occur that would have put you at ease..."

On 2/23/12 in the morning, the Director of Quality indicated the telenurse was a courtesy to patients. It was a follow-up call to determine patient satisfaction. It was not necessarily considered a grievance.





On 2/24/12 at 1:00 PM, a laboratorian indicated she had not heard of an abuse coordinator. This employee did not go through a specific orientation. The employee attended a general orientation given by the facility, which included: "policies and procedures and the Health Information Portability and Accountability Act; always know your surroundings, who belongs there and who doesn't, look for badges, etc.; notify security or pbx if you see anything suspicious, inside or outside of the hospital. This includes patients, coworkers, and visitors. Remember the codes: what you are supposed to do per the code." When asked about the facility policy regarding abuse, the laboratorian asked the question, "Other than reporting it?," and asked about pulling up the policy. If the laboratorian witnessed abuse, the laboratorian's response would depend on the type of abuse. If it was verbal abuse, the action taken would be to ask the abuser to leave, and then to call security. If the abuse was violent, the laboratorian would not get in the middle, but would call security. This employee would abide by "Don't put yourself in danger," and would use common sense, taking each incident on a case-by-case basis; i.e., if one felt that he or she could control the situation, that person could step in, but if the perpetrator had a 2-by-4 in hand this would be too dangerous. The laboratorian conducted a hospital intranet search of the word "abuse" and several policies came up.

On 2/24/12 at 1:10 PM, a second laboratorian indicated she was not so sure about having heard the title, Abuse Coordinator. This laboratorian did not know who that would be; "Human Resources or Employee Health?" When asked about the training or orientation regarding abuse received upon hire, the employee spoke of having attended the facility orientation, which included how to recognize abuse in patients and employees, for example, in the reaction of the person. The employee was taught to report abuse using the anonymous hotline. The employee did not remember it all because it was two years ago. When asked about the policy of the facility regarding abuse, the laboratorian said that they did not tolerate it, and employees had an obligation to report it: physical or mental; employee or patient. When asked what the employee would do upon witnessing abuse, the employee said the response would be different depending on the situation. For example, if the laboratorian saw patient bruising, this would be mentioned to an RN, her supervisor, and maybe security. If the employee witnessed an actual act of abuse, the employee would contact security, and then the employee's supervisor.





On 2/24/12 at 12:55 PM, a telemetry monitor technician could not identify an individual in charge of abuse investigations, the abuse policy, or abuse training at hire. The employee mentioned a "Handle with care" class detailing how employees were to handle difficult/aggressive patients.

On 2/24/12 at 1:00 PM, a Registered Nurse III did not know if there was an individual in charge of abuse investigations, indicated there was no specific abuse training, received no regular updates about abuse training, and was unaware of an abuse policy. The employee verbalized removing an abuser from a situation and calling the house supervisor. The employee mentioned contacting the patient advocate and the "Handle with care" program.

On 2/24/12 at 1:10 PM, a health unit clerk indicated to report abuse to a social worker or up the chain of command, did not know an individual in charge of abuse investigations, and did not remember abuse training.

On 2/24/12 at 1:15 PM, three dietary aides distributing lunch trays indicated they did not know an individual in charge of abuse investigations, did not remember abuse training, and did not receive updated training. They indicated they would call security for abuse problems.

Each of the dietary employees failed to indicate whether there was an abuse policy or how the facility's employees were supposed to handle a situation where a patient was abused.





On 2/24/12 at 2:40 PM, the General Manager of Environmental Services/Transport explained when there was a concern entered into the Midas system and no employee was identified, the General Manager of Environmental Services/transport would give all employees a "note to file".

The General Manager of Environmental Services/Transport acknowledged he did not investigate the allegation of the transporter not replacing the oxygen on the patient and not notifying the RN upon return to the medical floor.

The General Manager of Environmental Services/Transport acknowledged he could not identify the facility abuse coordinator.

The General Manager of Environmental Services/Transport was not sure what constituted neglect. The employee acknowledged he had not had training in abuse and neglect, but thought there were policies in the Intranet.





On 2/24/12, a Registered nurse (RN) stated in the event of witnessed verbal abuse, the employee would call the abusing employee out of the situation and report it to the manager. The employee would then interview the patient and start an investigation and if the patient was a senior, the employee would report the incident to a social worker. The employee also said that they had an in-service about abuse but could not remember when.
Another RN stated abuse was not tolerated, and if abuse was witnessed, it would be grounds for immediate termination. The RN could not remember having specific abuse and neglect training regarding what should be done if an employee abused a patient. The RN also stated that if a nurse was involved, it would be reported to the State Board of Nursing. The RN then stated the facility had a policy on suspected abuse, but could not remember if the policy addressed how to manage incidents regarding employees who abused patients.
A certified nurse assistant (CNA) stated that they had training about abuse and neglect and if an incident of abuse was witnessed, it would be reported to the house supervisor. The CNA stated she had training which was in her personnel training file. The CNA stated if the house supervisor or charge nurse did not do anything about an abuse incident involving a senior, she would call elder abuse. The CNA stated she had never witnessed any abuse.




2/24/12 at 1:30 PM with maintenance personnel.

Three members of the Plant Operations team were interviewed and asked questions pertaining to the facility's Abuse Policy. Employment longevity varied from 16 months to 4 years. All three acknowledged receiving some training in the facility's Abuse Policy. One employee said he had the training by way of an on-line learning system. When asked what situations would warrant them to report abuse, all three identified verbal (elevated vocalization and arguing) abuse, and two of three employees identified physical (striking) abuse. All of the interviewees said that they would report these incidents through their chain of command.

Complaint #NV 439
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on interview and document review, the facility failed to ensure data was collected and was monitored for the effectiveness, safety of service and quality of care for the Occupational Health Center.

Findings include:

On 2/24/12 in the afternoon during review of the Quality Management Program, there was no documented evidence that the facility's Occupation Health Care Center was included in the Quality Assessment and Performance Improvement Program.

On 2/24/12, the Director of Quality Management (DQM) indicated the facility conducted an ongoing program with measurable improvement indicators for which there was evidence to identify and reduce medical errors, track adverse events, and monitoring of the effectiveness and safety of services and quality of care. The DQM indicated the Nurse Managers and Directors of the Departments were responsible to collect data and submit Performance Improvement to the Quality and Performance Improvement Department. The System Wide Quality Director (SWQD) indicated, the manager of the Occupation Health Center came to one meeting over a year ago. The SWQD indicated, it was not necessary to attend or collect data because the health center was for employees only.

The Occupational Health Center was under the license of the facility.

The flier for the Occupation Health documented, "...In case of work related injury or illness, please do the following: Report your injury/illness to your employer immediately. Obtain authorization for treatment from your employer. Call and go directly to (address of clinic)..."
"...From injuries to wellness testing..."

The Quality Plan for the facility dated 01/01/2011 revealed:

"...This Quality Plan supports the systematic organization-wide approach to, plan design measure, assess and improve organizational performance..."
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview with the Medical Staff Services Manager, review of the Medical Staff bylaws (Rules and Regulations), and the clinical record the facility failed to ensure an attending practitioner (Employee #41) conducted a comprehensive assessment and justification for the admission of a patient (Patient #13).

Findings include:

The following documentation was contained in the Medical Staff Bylaws (approved by the Board of Governors September 26, 2007).

"...A practitioner who admits an emergency room case shall be prepared to justify to the Medical Executive Committee (MEC) of the Medical Staff and the Administration of the Hospital that such emergency admission was indicated. The history and physical examination must clearly justify the emergency admission and these findings must be recorded on the patient's chart as soon as possible..."

"...Emergency Admissions. Within twenty four (24) hours following an emergency admission, the attending practitioner shall furnish a signed, sufficiently complete documentation of need for such an admission, based on the definition of "emergency." Failure to furnish this documentation, or evidence of willful or continued misuse of this category of admission, shall be brought to the attention of the MEC for appropriate action...."

Patient #13

Patient #13 was admitted on [DATE] with diagnoses including cancer of the lung, generalized weakness, abdominal pain, diarrhea, hypertension, pulmonary embolism, [DIAGNOSES REDACTED] and clostridium difficile.

The Nurses Notes for Patient #13 dated from 6/21/11 at 7:10 AM until 6/21/11 at 7:46 PM when Patient #13 expired, indicated the patient's attending physician was kept informed of the patient's condition.

The attending physician for Patient #13 did not write a history and physical or a progress note until after the patient expired on [DATE].

Complaint #NV 832