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.

SAINT THOMAS RUTHERFORD HOSPITAL 1700 MEDICAL CENTER PARKWAY MURFREESBORO, TN 37129 June 28, 2012
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, facility policy review, and interview, the Registered Nurse failed to document the home medications of a patient for one (# 8) of ten patients reviewed.

The findings included:

Medical record review revealed patient #8 was admitted to the facility on on [DATE], with complaints of worsening tremors and inability to ambulate. Continued record review of the patient's stay in the Emergency Department while undergoing several tests, revealed an abdominal CT which showed a "...massively distended bladder..." for which a foley catheter was inserted and 2500 ml (milliliters) of urine was removed.

Continued medical record review revealed a past history of Parkinson's Disease, Orthostatic Hypotension, and Partial Pneumonectomy (removal of part of lung). Continued review revealed the patient had a BUN of 45 (normal 0 - 17) and creatinine of 3.8 (normal 0.1 - 1) (indicative of kidney function) and the physician determined the patient was suffering from acute renal failure.

Review of the nursing admission assessment completed on February 4, 2011, at 1:20 a.m., revealed the reason for admission was "...He couldn't walk...". Continued review of the nursing admission assessment revealed the patient had "...new onset confusion, new onset loss of balance/coordination...". Further review of the nursing admission assessment revealed the patient was "...anxious, cooperative, intermittent confusion, restless..." and the patient's movement was ..."shaking, spontaneous, symmetrical, thrashing...".

Continued review of the nursing admission assessment revealed no reconciliation of the patient's home medications. Further review revealed the section on medications was blank. Continued reivew of the assessment form revealed allergies were listed as none.

Interview with the Pharmacist on June 8, 2012, at 10:20 a.m., in the administrative conference room, revealed the patient and/or family are asked about home medications while in the ED. Further interview revealed this list of medications is entered into the computer as a Home Medication Reconciliation form by the admitting nurse on the floor. Continued interview revealed the medications to be continued in hospital are marked with "yes"; the form is signed by the physician; and the form is scanned to pharmacy. Further interview revealed pharmacy is unable to fill the medications without a physician's signature. Continued interview revealed "...the staff should call the physician for orders if the medications are needed before the physician signs the form...".

Review of the facility policy entitled Medication Reconciliation Process,#808.015, revealed "...When a patient presents for admission/treatment the attending nurse will take a medication history with the patient and/or representative as soon as possible. The nurse or clerk will print the Admission Medication Reconciliation form and place in the physician order section of the chart. The attending physician will review the home medication information within 24 hours. A physician signature is required on the Medication Reconciliation Form. A telephone order may be used following the Medical Staff Regulations...".

During interview on May 22, 2012, at 12:15 p.m., in the administrative conference room, the QI/Risk Manager confirmed there was not a reconciliation of home medications on the nursing admission assessment and also confirmed there were no medications listed on the nursing admission assessment.

COMPLAINT #
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, facility call systems logs, observation, and interview, the facility failed to ensure patient call lights were answered by the technicians in a timely manner so appropriate care could be provided to the patient for one (#2) of ten patients reviewed.

The findings included:

Medical record review revealed patient #2 was admitted to the facility on on [DATE], with current complaint of mental status change for several days and past medical history to include Deep Vein Thrombosis, Bipolar Disorder, Gastroesophageal Reflux Disease, Parkinson's Disease, Severe Dementia, and Urinary Tract Infection.

Review of the Nurse Call Systems log for the patient dated March 4, 2012, revealed a routine call was made from the patient's room at 10:59:11 a.m. and the call was forwarded to the technician. Continued review revealed repeat notification of the technician at 10:59:14, 11:02:17; 11:05:20; and 11:08:24 before the light was canceled in the patient's room at 11:10:06 a.m. Further review revealed the time elapsed between the light being activated and the light being turned off in the room was 10 minutes and 55 seconds.

Continued review of the log dated March 7, 2012, revealed a routine call was placed from the resident's room at 11:05:40 a.m. and forwarded to the technician. Further review revealed repeat notification of the technician at 11:05:43, 11:08:46, 11:11:49, 11:14:52, and 11:17:56 before the light was turned off in the patient's room at 11:18:21 a.m. Further review revealed the time elapsed between the light being activated and the light being turned off in the patient's room was 12 minutes and 41 seconds.

Continued review of the log dated March 7, 2012, revealed a routine call was placed from the resident's room at 17:33:05 (5:33 p.m.) and forwarded to the technician. Further review revealed repeat notification of the technician at 17:33:07, 17:36:11; 17:39:14, 17:42:17; 17:45:21, 17:48:24, 17:51:27; 17:54:30; 17:57:34; 18:00:37; 18:03:40; 18:06:43; 18:09:47;18:12:50; and 18:15:36. Further review revealed the time elapsed between the light being activated and the light being turned off in the patient's room was 44 minutes and 10 seconds.

Observation of the call system on May 22, 2012, at 8:30 a.m., revealed four white lights flashing on arrival to 4 East. Interview with the Nurse Manager at this time revealed the white flashing lights indicated the patient had orders which had been transcribed by the Unit Secretary. Continued interview revealed each patient has a pillow pad with a green button with a frowning face on it to push when needing pain medication; a yellow button with a bedpan on it to push when needing to use the bedpan; and a red button with a cross and nurse's head for routine calls. Further interview revealed when the button is pushed, the corresponding color will light up on the dome outside the patient's room, and the type of call will be reflected on the monitor screen at the nurses' station. Continued interview revealed the technician can cancel the call on the telephone but it will keep on recalling the technician until the light is canceled in the patient's room.

Interview with the Quality/Risk Manager on May 22, 2012, at 9:00 a.m., at the 4 East nurses' station, revealed at the beginning of each shift the phones were programmed with the room numbers each nurse and technician had for the shift so the call from the room rings directly to the telephone of the appropriate staff member. Continued interview revealed calls for pain medication go directly to the nurse while calls for potty and routine calls go directly to the technician.

Interview with the Quality/Risk Manager on May 22, 2012, at 1:30 p.m., in the Administrative conference room, confirmed it was unacceptable for a patient to wait forty-four minutes to have a light answered by the technician and confirmed the technician should have called a buddy to respond to the light.

Interview with two Nurse Managers on June 6, 2012, at 11:50 a.m., in the administrative conference room, revealed an acceptable time frame for staff to respond to a call light is five to ten minutes. Continued interview revealed some technicians may go into the room and assist the patient before turning off the light.

COMPLAINT #
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, facility policy review, and interview, the facility failed to ensure a patient received medications after admission and failed to obtain a physician's order to administer the medications for one (#5) of ten patients reviewed.

The findings included:

Medical record review revealed patient #5 was admitted to the facility on on [DATE], at 6:00 p.m., after a fall in which the patient sustained a right ankle strain and left scalp abrasion. Past medical history included Cerebrovascular Accident, Hypertension, [DIAGNOSES REDACTED], Gastroesophageal Reflux Disease, and Fracture to Right Knee.

Review of the Emergency Department (ED) Medication List revealed the patient's home medication list was entered into the computer system on March 12, 2012, at 18:54 (6:54 p.m.) by the nurse. Continued review revealed the patient took Seroquel (antipsychotic) XR 150 mg (milligrams) extended release at bedtime; Exelon (treatment of dementia) 9.5 mg/24 hours transdermal film, extended release daily; Zocor (anti-cholesterol) 20 mg at bedtime.

Review of the Admit Medication Reconciliation form which listed all the patient's medications as well as times administered, revealed the physician signed the orders on May 13, 2012, at 9:10 a.m. Continued reivew of the form revealed all home medications were to be continued in the hospital.

Review of the Medication Administration Record (MAR) revealed the only medication the patient received on March 12, 2012, was Norco (pain medication) 5/325 mg (milligrams) at 1930 (7:30 p.m.) . Continued review of the record revealed no documentation of any other medications being administered to the patient on March 12, 2012. Further review of the MAR revealed all home medications with doses and times of administration were listed and the start date of the medications was March 13, 2012.

Review of physician's orders dated March 12, 2012, revealed no orders for the evening medications. Continued review revealed the medication orders were signed by the physician on March 13, 2012.

Review of nursing notes revealed no documentation of notification of the physician the patient had not received the daily medications prescribed for the patient nor a request for orders to administer the evening medications.

Review of the facility policy entitled Medication Reconciliation Process, #808.015, revealed "...When a patient presents for admission/treatment the attending nurse will take a medication history with the patient and/or representative as soon as possible. The nurse or clerk will print the Admission Medication Reconciliation form and place in the physician order section of the chart. The attending physician will review the home medication information within 24 hours. A physician signature is required on the Medication Reconciliation Form. A telephone order may be used following the Medical Staff Regulations...".

Interview with the Quality/Risk Manager on May 22, 2012, at 1:30 p.m., in the administrative conference room, confirmed the physician had not ordered any evening medications for March 12, 2012; the nurse had not notified the physician of the patient's twice daily medications; and the nurse had not contacted the physician to obtain orders to administer the evening medications. Continued interview revealed it was an expectation medications would be administered to patients upon admission if they had not taken the medications before admission.

Interivew with the Pharmacist on June 8, 2012, at 10:20 a.m., in the administrative conference room, revealed the patient and/or family are asked about home medications while in the ED. Further interivew revealed this list of medications is entered into the computer as a Home Medication Reconciliation form by the admitting nurse on the floor. Continued interivew revealed the medications to be continued in hospital are marked with "yes"; the form is signed by the physician; and the form is scanned to pharmacy. Further interivew revealed pharmacy is unable to fill the medications without a physician's signature. Continued interivew revealed "...the staff should call the physician for orders if the medications are needed before the physician signs the form...".

COMPLAINT #
VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY Tag No: A0468
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, Medical Staff By-Laws review, and interview, the facility failed to ensure a discharge summary was completed for one (#2) of ten patients reviewed.

The findings included:

Medical record review revealed patient #2 was admitted to the facility on on [DATE], with current complaint of mental status change for several days and past medical history to include Deep Vein Thrombosis, Bipolar Disorder, Gastroesophageal Reflux Disease, Parkinson's Disease, Severe Dementia, and Urinary Tract Infection.

Medical record review revealed this patient was discharged on [DATE]. Continued review revealed there was no discharge summary in the record.

Review of the Medical Staff Bylaws Article Ten: Medical Records, section 10.2 Necessary Information revealed "...The patient's medical record shall include the following: (n) Discharge summary...". Continued review of Article Ten, section 10.3 Time Limits revealed "...If the physician does not dictate the discharge summary at the time of discharge, the diagnosis must be included in the final progress note. Within fourteen days of discharge a discharge summary shall be written or dictated or dictated on all medical records...".

Interview with the Quality/Risk Manager on May 22, 2012, at 1:30 p.m., in the administrative conference room, confirmed there was no discharge summary in the record nor was there any documentation of the patient's discharge or final diagnosis in the physicians' progress notes.

COMPLAINT #