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.

HAVEN BEHAVIORAL SENIOR CARE OF NORTH DENVER 8451 PEARL STREET SUITE 100 THORNTON, CO Oct. 5, 2011
VIOLATION: QAPI Tag No: A0263
Based on review of the facility's documents, staff interview, and the facility's policies/procedures, the facility failed to be in compliance with the Condition of Participation of Quality Assessment and Performance Improvement (QAPI). The facility failed to develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven QAPI program. Specifically, the facility failed to ensure that the QAPI program involved all hospital departments and services (including those services furnished under contract or arrangement). The facility failed to focus on indicators that related to improved health outcomes and prevented or reduced medical errors.

The findings were:

Cross Reference to A 0084 Contracted Services: for findings related to the facility's governing body's failure to institute and maintain a system to routinely evaluate the services provided to patients to ensure they were provided in a safe and effective manner. The findings created the potential for negative patient outcomes. Specifically, for findings related to the facility's failure to fully evaluate the contracted laboratory and radiology services.

Cross Reference to A 0144 Patient Rights - Care In a Safe Setting: for findings related to the facility's failure to ensure patients received care in a safe setting. Specifically, the facility had frequent patient falls and medical physicians did not routinely come see the patients thereafter as required per the Director of Nursing, neurological tests were not being conducted appropriately thereafter as per the facility's policy and procedure, and had not implemented changes, such as accessible call lights, to assist in further preventing patient falls. These failures created the potential for patient harm.

Cross Reference to A 0049 Medical Staff - Accountability: for findings related to the facility's Governing Body's failure to ensure that the medical staff was accountable to the governing body for the quality of care provided to patients. Specifically, the governing body failed to respond to the medical staff's failure to respond to nurses' calls regarding critical laboratory results for Sample Patient #2 in a timely manner. Specifically, for findings related to the facility's failure to document any corrective actions that were taken by the Medical Staff or the Quality Committee to prevent similar occurrences in the future.
VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
Based on review of personnel files and staff interview, the facility failed to ensure non-employee nursing personnel who were working in the hospital were under adequate supervision of the director of nursing service and their clinical activities were evaluated. Specifically, one of three agency files reviewed did not have proper evaluations per the facility's policy and procedure. Additionally, three of three agency files reviewed did not have evaluations conducted in accordance with the facility's Director of Nursing's expectations. This failure created the potential for a negative outcome.

The findings were:

On 10/3/11, an agency usage log list was requested for the previous three months. It revealed the following, in pertinent part:
- Staff #6 worked the following dates in the months of July, August and September: 7/12, 7/13, 7/14, 7/18, 7/19, 7/20, 7/26, 8/1, 8/20, 8/21, 8/24, 8/28, 9/3, 9/9 and 9/10.
- Staff #7 worked the following dates: 7/17, 8/18, 8/20 and 8/26.
- Staff #8 worked the following dates: 7/13, 7/14, 7/15, 7/19, 7/20 and 9/11.

An interview with the facility's Staffing Coordinator was conducted on 10/3/11 at approximately 3:25 p.m. When asked about the evaluation of agency staff, s/he stated, "The charge nurses do the evaluations and they put it in my box and then it goes in their permanent file." The Staffing Coordinator also maintained a green binder on Phase 1 and an additional white binder. S/he stated, "That [white] binder has their license and everything else in case someone needs it and can't get in the DON's office. This green binder has their 'face sheet' saying when they had their evaluations."

Review of personnel files and the facility's green binder was conducted on 10/3/11 and revealed the following:
- Staff #6's file contained four evaluations, dated 7/16, 7/19, 7/18 and 9/10. The green binder also contained dates of four evaluations. However, the agency nurse's first three shifts were 7/12, 7/13 and 7/14, as per documentation provided by the facility. There was no evidence as to why evaluations had not been done on those dates and were done later instead.
- Staff #7's file contained only one evaluation, dated 8/26, however it had been signed and "verified by" a Registered Nurse and dated 9/20. The green binder contained the date of one evaluation dated 8/26.
- Staff #8's file contained three evaluations, dated 7/15, 7/16 and 7/20. The green binder was completed with the same dates. However, the agency nurse's first three shifts were 7/13, 7/14 and 7/15. There was no evidence as to why evaluations had not been done on the nurse's first two shifts and were done later instead.

An interview with the facility's Director of Nursing (DON) was conducted on 10/4/11 at approximately 8:45 a.m. When asked about evaluations of agency staff, s/he stated, "They are expected to be done in the first shifts they work. If there is a reason [to do so], another would be done as well."

An additional interview was conducted with the Staffing Coordinator on 10/4/11 at approximately 2:25 p.m. S/he acknowledged that the CNA (sample #7) only had one evaluation completed and the face sheet stated the evaluation was 8/26, but the date of the actual evaluation was signed by a RN on 9/20, not 8/26 or 8/27. When asked further about the process of agency staff evaluations, s/he stated, "The charge nurse does the eval. When they are complete, they put it in my box. When agency come in, I put the eval in the pink Kardex for them... If the evals don't come to me, they go to the DON... They are put in the pink folder and they know that if agency staff need an eval done it will be in there... If there are none in there, it is because there were three done." The Staffing Coordinator stated that if there were issues with getting the evaluations from the charge nurses, s/he contacted the DON. It was pointed out that the CNA had worked four shifts and only had one evaluation, s/he stated, "Yeah." When asked if s/he may have kept copies of issues s/he had referred to the DON, s/he stated s/he had not.

The facility's policy titled "Agency Staff," last revised 5/11, stated the following, in pertinent part:
"PROCEDURE:
...9. An agency evaluation will be completed on all registry/agency personnel at the end of each shift worked by the supervising HBND personnel and/or Director of the department, for three work shifts...
13. An agency binder is located in the nursing station and will be maintained by the Director of Nursing. The nurse in charge of the shift will review the nursing agency file to assure that all required documents have been obtained. The nurse in charge will also review any performance evaluations to identify any potential areas of weakness."
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based upon review of facility policies and procedures, patient records and staff interviews the facility failed to meet the above standard as evidenced by the medical record orders in 3 of 20 patient records reviewed not being authenticated by the ordering practitioner within the forty eight (48) hour timeframe. The Rules and Regulations of the Medical Staff stated all orders must be signed within forty-eight (48) hours. This failure created the potential for negative outcomes.

The findings were:

The policies and procedures that were made available during the survey for review addressed only verbal orders that were written for drug prescribing and ordering.

The policy Titled: Drug Prescribing/Ordering Orders: Verbal with effective date of June, 2009 states: "Policy: Verbal orders (including telephone or other oral orders) should be minimal, and will be entered immediately on the physician's order form. These orders will include the signature of the person who received the order, the date and time and the prescriber's name. The prescribing practitioner or other authorized practitioner will countersign these orders within the facility's guidelines. The use of such orders should be minimized."

In review of the "DOCUMENTATION Clinical Pertinence Review-3 consecutive days of Progress Notes per chart," stated in pertinent part:
"Orders-from Pharmacy. Telephone orders must be dated/ timed and signed within 48 hrs "
Review of the "RULES AND REGULATIONS OF THE MEDICAL STAFF OF HAVEN BEHAVIORAL -NORTH DENVER Effective Date: June 21, 2011," stated:
"7.7 All entries to the medical record must be legibly written, dated, timed and authenticated.
7.8 Orders- stated in pertinent part: "An order shall be considered to be written if dictated by telephone to a registered nurse or, in the case of an order for medication, either to a registered nurse or a licensed pharmacist, and signed within forty-eight (48) hours (if the Physician dictating the order is the patient's Attending Physician, the order may be signed either by the Attending Physician or by any designee of the Attending Physician who is covering for the Attending Physician ...)."

Chart reviews revealed:
1) Sample Patient #11 was a [AGE] year old admitted for depression. A telephone order dated 8/30/11 taken by the registered nurse to "straight cath (catheterize) to obtain UA (urine analysis) if needed". There was a 24 hour chart check for accuracy and completeness of the patient record on 8/31/11 and documented as chart "complete." On 10/3/2011 when the survey chart review was done there was no physician signature for order authentication.
2) Sample Patient #21 was a [AGE] year old admitted for dementia, bipolar and personality disorders, CVA (cerebral vascular accident) and a h/o (history of) seizures. A telephone order dated 9/26/11, taken by the registered nurse stated: "D/C (discontinue) Naproxen-prev (?previous) allergy to ibuprofen & poss.(?possible) cross reaction. ?(change) Calcium/Vit. (vitamin) D to 600mg/200mg po (by mouth) BID (twice daily) for supplementation. 2 additional allergies noted in discharge notes- Mirtazapine & Tiagabine. OK to add to MAR." There was a 24 hour chart check for accuracy and completeness of the patient record on 9/27/11 and documented as chart "complete." On 10/3/2011 when the survey chart review was done there was no physician signature for order authentication.
3) Sample Patient #24 was an [AGE] year old admitted for anxiety, dementia, and depression. A telephone order dated 9/17/2011 added medication orders on the "Admission Orders" standard form. Zyprexa 2.5 mg.(milligrams) po(by mouth) q (every) a.m., Chloral Hydrate 500mg po q hs (at bedtime), Omeprazole 20mg. po daily, Zyprexa 5mg. po q 6? (hours) prn (as needed) for agitation/anxiety. There were 24 hour chart checks for accuracy and completeness of the patient record on 9/19/11 at 4:00 a.m. and documented 9/19/11
(?9/20/11) at 1:55 a.m., both documented as chart "complete." On 10/3/2011 when the survey chart review was done there was no physician signature for order authentication.

An interview with a registered staff nurse on the unit was conducted 10/04/11 at approximately 9:30 a.m. When asked about telephone/verbal orders requiring a signature by the ordering provider s/he stated, "I wasn't aware of that, that is good to know."
An interview was conducted 10/5/11 at approximately 7:10 a.m., with the registered staff nurses for both units who review the patient records for accuracy and completeness. When asked about the need for telephone/verbal orders requiring a signature by the ordering provider they did not have responses. When asked about policies and procedures for telephone/verbal orders s/he stated: "The policy and procedure book is out there." When asked about the 24 hour chart checks they perform and being documented as "complete" when the provider signature was missing s/he stated: the physician admission orders are not usually signed by the doctor when we check the record because he has not come in for the day to sign them. The 24 hour chart checks are reviewed by the 6:30 p.m. to 7:00 a.m. staff. When asked if they go back to check for signatures that were missing, s/he stated: "no we don't go back previous days."

An interview with the Director of Nursing was conducted on 10/05/2011 at approximately 11:30 a.m. When asked about the policy and procedure for authenticating telephone/verbal orders she stated that the organization had chosen to utilize the policy of signature requirements within 48 hours. When asked about the nurses who perform the 24 hour chart check and their lack of awareness regarding the policy s/he stated: "both nurses are recent nursing school graduates and this is their first job."
The facility failed to follow their policy and procedure for authentication of telephone/verbal orders.
VIOLATION: VERBAL ORDERS AUTHENTICATED BASED ON LAW Tag No: A0457
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based upon review of facility policies and procedures, patient records and staff interviews the facility failed to meet the above standard as evidenced by the medical record orders in 3 of 20 patient records reviewed not being authenticated by the ordering practitioner within the forty eight (48) hour timeframe. The Rules and Regulations of the Medical Staff stated all orders must be signed within forty-eight (48) hours. This failure created the potential for negative outcomes.

The findings were:

The policies and procedures that were made available during the survey for review addressed only verbal orders that were written for drug prescribing and ordering.
The policy Titled: Drug Prescribing/Ordering Orders: Verbal with effective date of June, 2009 stated: "Policy: Verbal orders (including telephone or other oral orders) should be minimal, and will be entered immediately on the physician's order form. These orders will include the signature of the person who received the order, the date and time and the prescriber's name. The prescribing practitioner or other authorized practitioner will countersign these orders within the facility's guidelines. The use of such orders should be minimized."

In review of the "DOCUMENTATION Clinical Pertinence Review-3 consecutive days of Progress Notes per chart" stated in pertinent part: "Orders-from Pharmacy ?Telephone orders must be dated/ timed and signed within 48 hrs."
Review of the "RULES AND REGULATIONS OF THE MEDICAL STAFF OF HAVEN BEHAVIORAL -NORTH DENVER Effective Date: June 21, 2011," stated:
"7.7 All entries to the medical record must be legibly written, dated, timed and authenticated."
7.8 Orders- stated in pertinent part: "An order shall be considered to be written if dictated by telephone to a registered nurse or, in the case of an order for medication, either to a registered nurse or a licensed pharmacist, and signed within forty-eight (48) hours (if the Physician dictating the order is the patient's Attending Physician, the order may be signed either by the Attending Physician or by any designee of the Attending Physician who is covering for the Attending Physician ...)."

Chart reviews revealed:
1) Sample Patient #11 was a [AGE] year old admitted for depression. A telephone order dated 8/30/11 taken by the registered nurse to "straight cath(catheterize) to obtain UA(urine analysis) if needed." There was a 24 hour chart check for accuracy and completeness of the patient record on 8/31/11 and documented as chart "complete." On 10/3/2011 when the survey chart review was done there was no physician signature for order authentication.

2) Sample Patient #21 was a [AGE] year old admitted for dementia, bipolar and personality disorders, CVA (cerebral vascular accident) and a h/o (history of) seizures. A telephone order dated 9/26/11 taken by the registered nurse stated: "D/C (discontinue) Naproxen-prev (?previous) allergy to ibuprofen & poss. (possible) cross reaction. ?(change) Calcium/Vit. (vitamin) D to 600mg/200mg po(by mouth) BID (twice daily) for supplementation. 2 additional allergies noted in discharge notes- Mirtazapine & Tiagabine. OK to add to MAR." There was a 24 hour chart check for accuracy and completeness of the patient record on 9/27/11 and documented as chart "complete." On 10/3/2011 when the survey chart review was done there was no physician signature for order authentication.

3) Sample Patient #24 was an [AGE] year old admitted for anxiety, dementia, and depression. A telephone order dated 9/17/2011 added medication orders on the "Admission Orders" standard form. Zyprexa 2.5 mg. (milligrams) po (by mouth) q (every) am, Chloral Hydrate 500mg po q hs (at bedtime), Omeprazole 20mg. po daily, Zyprexa 5mg. po q 6? (hours) prn (as needed) for agitation/ anxiety. There were 24 hour chart checks for accuracy and completeness of the patient record on 9/19/11 at 4:00 a.m. and documented 9/19/11
(?9/20/11) at 1:55 a.m., both documented as chart "complete." On 10/3/2011 when the survey chart review was done there was no physician signature for order authentication.

An interview with a registered staff nurse on the unit was conducted 10/04/11 at approximately 9:30 a.m. When asked about telephone/verbal orders requiring a signature by the ordering provider s/he stated, "I wasn't aware of that, that is good to know."
An interview was conducted 10/5/11 at approximately 7:10 a.m., with the registered staff nurses for both units who review the patient records for accuracy and completeness. When asked about the need for telephone/verbal orders requiring a signature by the ordering provider they did not have responses. When asked about policies and procedures for telephone/verbal orders s/he stated: "The policy and procedure book is out there." When asked about the 24 hour chart checks they perform and being documented as "complete" when the provider signature is missing s/he stated: the physician admission orders are not usually signed by the doctor when we check the record because he has not come in for the day to sign them." The 24 hour chart checks are reviewed by the 6:30 p.m. to 7:00 a.m. staff. When asked if they go back to check for signatures that were missing, s/he stated: "no we don't go back previous days."

An interview with the Director of Nursing was conducted on 10/05/2011 at approximately 11:30 a.m. When asked about the policy and procedure for authenticating telephone/verbal orders she stated that the organization had chosen to utilize the policy of signature requirements within 48 hours. When asked about the nurses who perform the 24 hour chart check and their lack of awareness regarding the policy s/he stated: "both nurses are recent nursing school graduates and this is their first job."
The facility failed to follow their policy and procedure for authentication of telephone/verbal orders.
VIOLATION: ORGAN, TISSUE, EYE PROCUREMENT Tag No: A0884
Based on the manner and degree of the deficiencies cited the hospital failed to be in compliance with the Condition of Participation of Organ, Tissue, and Eye Procurement. The hospital failed to ensure that specific organ, tissue and eye procurement requirements were met.

The facility failed to be in compliance with the following standards:

A 0885 - Written Policies and Procedures: The hospital failed to have and implement written protocols that complied with this section.

A 0887 - Tissue and Eye Bank Agreement: The hospital failed to have an agreement with at least one eye bank to cooperate in the retrieval, processing, preservation, storage, and distribution of eyes, as may be appropriate to assure that all usable eyes are obtained from potential donors, insofar as such an agreement does not interfere with organ procurement.

A 0888 - Informed Family: The hospital failed to ensure that it had policies/procedures that ensured that the family of each potential donor was informed of its options to donate organs, tissues, or eyes, or to decline to donate.

A 0889 - Designated Requestor: The hospital failed to ensure that it had policies/procedures that ensured that there was an individual designated by the hospital to initiate the request to the family or potential donors that had appropriate training.

A 0890 - Discretion and Sensitivity: The hospital failed to ensure that it had policies/procedures that encouraged discretion and sensitivity with respect to the circumstances, views, and beliefs of the families of potential donors.

A 0891 - Staff Education: The hospital failed to ensure that it had policies/procedures that ensured that staff education on donation issues were to be provided. Additionally, the facility failed to conduct staff education on donation issues.

A 0892 - Death Record Reviews: The hospital failed to ensure that it had policies/procedures that ensured that reviews of death records with the designated Organ Procurement Organization would occur to improve identification of potential donors.

A 0893 - Maintain Potential Donors: The hospital failed to ensure that it had policies/procedures that ensured that potential donors would be maintained with cooperation of the Organ Procurement Organization while necessary testing and placement of potential donated organs, tissues, and eyes took place.
VIOLATION: DESIGNATED REQUESTOR Tag No: A0889
Based on staff interview and review of the hospital's policies/procedures the facility failed to ensure that it had policies/procedures that ensured that there was an individual designated by the hospital to initiate the request to the family or potential donors that had appropriate training.

The findings were:

Cross Reference to A 0885: Written Policies and Procedures - for findings related to the facility's failure to have and implement written protocols that complied with this section.

Cross Reference to A 0887: Tissue and Eye Bank Agreement - for findings related to the facility's failure to have an agreement with at least one eye bank to cooperate in the retrieval, processing, preservation, storage, and distribution of eyes, as may be appropriate to assure that all usable eyes are obtained from potential donors, insofar as such an agreement does not interfere with organ procurement.
VIOLATION: DISCRETION AND SENSITIVITY Tag No: A0890
Based on staff interview and review of the hospital's policies/procedures the facility failed to ensure that it had policies/procedures that encouraged discretion and sensitivity with respect to the circumstances, views, and beliefs of the families of potential donors.

The findings were:

Cross Reference to A 0885: Written Policies and Procedures - for findings related to the facility's failure to have and implement written protocols that complied with this section.

Cross Reference to A 0887: Tissue and Eye Bank Agreement - for findings related to the facility's failure to have an agreement with at least one eye bank to cooperate in the retrieval, processing, preservation, storage, and distribution of eyes, as may be appropriate to assure that all usable eyes are obtained from potential donors, insofar as such an agreement does not interfere with organ procurement.
VIOLATION: STAFF EDUCATION Tag No: A0891
Based on staff interview and review of the hospital's policies/procedures the facility failed to ensure that it had policies/procedures that ensured that staff education on donation issues were to be provided. Additionally, the facility failed to conduct staff education on donation issues.

The findings were:

Cross Reference to A 0885: Written Policies and Procedures - for findings related to the facility's failure to have and implement written protocols that complied with this section.

Cross Reference to A 0887: Tissue and Eye Bank Agreement - for findings related to the facility's failure to have an agreement with at least one eye bank to cooperate in the retrieval, processing, preservation, storage, and distribution of eyes, as may be appropriate to assure that all usable eyes are obtained from potential donors, insofar as such an agreement does not interfere with organ procurement.
VIOLATION: DEATH RECORD REVIEWS Tag No: A0892
Based on staff interview and review of the hospital's policies/procedures the facility failed to ensure that it had policies/procedures that ensured that reviews of death records with the designated Organ Procurement Organization would occur to improve identification of potential donors.

The findings were:

Cross Reference to A 0885: Written Policies and Procedures - for findings related to the facility's failure to have and implement written protocols that complied with this section.

Cross Reference to A 0887: Tissue and Eye Bank Agreement - for findings related to the facility's failure to have an agreement with at least one eye bank to cooperate in the retrieval, processing, preservation, storage, and distribution of eyes, as may be appropriate to assure that all usable eyes are obtained from potential donors, insofar as such an agreement does not interfere with organ procurement.
VIOLATION: MAINTAIN POTENTIAL DONORS Tag No: A0893
Based on staff interview and review of the hospital's policies/procedures the facility failed to ensure that it had policies/procedures that ensured that potential donors would be maintained with cooperation of the Organ Procurement Organization while necessary testing and placement of potential donated organs, tissues, and eyes took place.

The findings were:

Cross Reference to A 0885: Written Policies and Procedures - for findings related to the facility's failure to have and implement written protocols that complied with this section.

Cross Reference to A 0887: Tissue and Eye Bank Agreement - for findings related to the facility's failure to have an agreement with at least one eye bank to cooperate in the retrieval, processing, preservation, storage, and distribution of eyes, as may be appropriate to assure that all usable eyes are obtained from potential donors, insofar as such an agreement does not interfere with organ procurement.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on the manner and degree of deficiencies cited and review of policies/procedures and other facility documents, the hospital failed to be in compliance with the Condition of Participation of Governing Body. The governing body failed to ensure that medical staff were accountable for all care provided to patients. The governing body failed to maintain a 3-year capital budget expenditure plan and to provide oversight over the entire budget process. Additionally, the governing body failed to ensure that contracted services were detailed in a complete list that described the nature of the contracted services, as required. Finally, the governing body failed to adequately evaluate the services provided by contract to ensure that they were provided in a safe and effective manner.

The facility failed to be in compliance with the following standards under the Condition of Governing Body:

Tag A 049 Medical Staff Accountability - the governing body failed to ensure that all medical staff were accountable for all care provided to patients in the facility.

Tag A 073 Institutional Plan and Budget - the governing body failed to maintain a 3-year capital budget expenditure plan, as required.

Tag A 077 Institutional Plan and Budget - governing body failed to provide oversight over the entire budget process.

Tag A 084 Contracted Services - the governing body failed to ensure that all contracted services were provided in a safe and effective manner.

Tag A 085 Contracted Services - the governing body failed to ensure that a complete list of all contracted services, including a description of the nature of services provided.
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on medical record review, review of facility meeting minutes, and staff interview the facility's Governing Body failed to ensure that the medical staff was accountable to the governing body for the quality of care provided to patients. Specifically, the governing body failed to respond to the medical staff's failure to respond to nurses' calls regarding critical laboratory results for Sample Patient #2 in a timely manner and failed to identify the failure of physicians response to patients after falls.

The findings were:

Medical Record Review
Review on 10/3/2011 of the medical record for sample patient #2 revealed that the patient was an adult patient admitted on [DATE] with dementia and suicidal ideations. The nurse's notes on 8/26/2011 at approximately 9:00 PM stated "resident [complains of] chest pain along apical node site 5th [left intercostal space with] posterior [complaints of] pain to backside (thorax), vital signs and medication admin[istered] as [prescribed] by [physician]...vital signs are taken every 4 hours as ordered by [physician] and STAT labs for patient are pending."

A physician's order written on 8/26/2011 at approximately 9:00 PM stated for a STAT Troponin level to be drawn along with other laboratory tests and a notation on the order stated that the contracted laboratory service was notified at that time. The order was a telephone order from Physician #1.

A nurse's note on 8/27/2011 at approximately 2:30 AM stated that the contracted laboratory service had come to draw the patient.
A nurse's note on 8/27/2011 at approximately 4:30 PM stated that the "resident had STAT labs returned critical high Troponin level...called [Physician #1] at [2:10 PM] to report lab results. Call back pending..."
A nurse's note on 8/27/2011 at approximately 7:30 PM stated that "...EKG [showed] anterior septal and lateral DT wave changes [that] may be due to myocardial ischemia...call placed to [Internal Medicine Group] [Physician #2]. Returned page informed the above stated s/he would be there ASAP to evaluate the patient...doctor arrived at [8:00 PM] gave order to send patient to [nearby acute care hospital]..."
The patient was emergently transported to a nearby acute care hospital on [DATE] for myocardial ischemia which resulted in the patient needing cardiac stent placement.
The laboratory report dated and timed 8/27/2011 at 1:58 PM stated that the specimen was collected on 8/27/2011 at 1:00 AM and received into the laboratory on 8/27/2011 at 6:13 AM and reported to the facility on [DATE] at 1:57 PM.
A late entry nurse's note that was dated 9/1/11 at approximately 6:00 PM stated "Late entry for 8/27/11, 6:00 AM-7:00 PM shift. Troponin with critical high...was received by the nurse at 1:57 PM. Lab level shown to attending psychiatrist [Physician #3] at 2:30 PM, physician/psychiatrist reviewed labs acknowledged that they were high and gave it back to the nurse, no new orders were given. The nurse recalled [Physician #1] after initial call at 2:10 PM was not returned, again no answer from either calls by [Internal Medicine Group] continued to monitor vital signs while awaiting call back."

In summary, the nursing staff attempted to contact the internal medicine physician for Sample Patient #2 without a response until nearly 5 hours later.

Staff Interview
An interview with the facility's Medical Director on 10/5/2011 at approximately 11:30 AM revealed that s/he was somewhat familiar with the issues surrounding Sample Patient #2's care. S/he stated that "it was a mix-up". S/he stated that Physician #2 (the on-call internal medicine physician) had a conversation regarding this patient with Physician #3 (the patient's attending psychiatrist) and had hung up the phone on Physician #3. S/he stated that Physician #2 was no longer at the facility but stated that it was due to medical problems. S/he stated that sample patient #2 was discussed in the Medical Staff meeting.

Meeting Minutes Review
A review of the facility's Medical Staff meeting minutes and the facility's Governing Body meeting minutes and the facility's Quality Committee meeting minutes revealed that there was no documentation of discussion of sample patient #2 as well as no documentation of discussing the performance of Physician #1, #2, or #3 in regards to sample patient #2.

Physician Visits after Falls
Reference Tag A 144, part 3 for findings related to the facility's failure to ensure medical physicians were routinely seeing patients after falls.
VIOLATION: INSTITUTIONAL PLAN AND BUDGET Tag No: A0073
Based on staff interviews and review of facility documents, the hospital governing body failed to maintain an institutional budget that provided for capital expenditures for at least a 3-year period, as required. In addition, the governing body failed to ensure that the hospital had an approval process for capital purchases that ensured timely replacement of a non-functional chair scale that was necessary for monitoring patient weights. The failure created the potential for negative patient outcomes.

The findings were:

1. Governing Body Failure to Maintain a 3-Year Capital Budget Plan:

On 10/5/11 at approximately 10:30 a.m., the chief executive officer (CEO) was interviewed about the budget preparation process. The interview revealed that s/he worked with the staff to submit information for the upcoming budget year to the corporate owner entity chief financial officer (CFO), who actually develops the budget and submits the budget to the corporate entity's board of investors for approval of the budget, including the capital expenditures budget. When asked what the capital expenditures budget for the current year contained, s/he stated that they did not actually have a capital budget for the year, but that they had made approximately $30,000.00 of expenditures for the year. S/he stated that because the hospital was in a host hospital, they did need a significant capital budget, because they did not have to plan for repair and replacements related to the building. When asked what the budget was for capital expenditures for the previous year was, s/he said s/he did not know because s/he came to the facility last June (2010). When asked if s/he was aware of what was still in the capital budget, since there was still 6 more months with that budget, s/he said s/he did not have any knowledge of the capital budget for that year. When asked if the facility was preparing a capital budget for three years, s/he stated that they were not doing that, but would start to do it this year, since s/he was now aware of that requirement.

On 10/5/11 after the 10:30 a.m., interview the CEO came into the survey work room with a one page sheet that s/he stated s/he had just gotten from the corporate owner entity CFO and stated "I was mistaken...we do have a capital budget after all." Review of the "budget" provided revealed it only contained 2 personal computers ($3,000) and 2 printers ($1,000) for "new staff on new unit" for budget year 2011, for a total budgeted expenditure of $4,000. For budget year 2012, the "budget" contained 2 personal computers ($3,000) and 2 printers ($1,000) for "replacements for existing computers/printers," for a total budget expenditure of $4,000. For budget year 2012, again the "budget" contained 2 personal computers ($3,000) and 2 printers ($1,000) for "replacements for existing computers/printers," for a total budget expenditure of $4,000. The capital budget projections contained no medical or patient care equipment projections, similar to the recently purchased chair scale or other unanticipated replacements.

2. Governing Body Failure to Ensure Timely Replacement of Key Patient Care Equipment Through The Capital Budget Process:

An interview with the Director of Nursing (DON) was conducted on 10/4/11 at approximately 8:45 a.m. When asked how frequently weights were expected to be obtained on patients, s/he stated, "Weekly unless ordered more frequently due to a specific reason." When asked if they were to be conducted on a specific day, s/he stated, "I'm not sure. The chair scale has been broken. We got a new chair scale on Thursday (approximately 9/29/11)." When asked where the weights would be documented, s/he stated, "They would be on the graphic form with the I&O (intake and output) and vital signs ..." When asked if a policy existed in regards to weights, s/he stated, "I don't think we have a P&P on weights." When asked further about the chair scale, as it was evidenced to have been broken upon the last survey of the hospital in July, s/he stated, "That scale may have been in repair then."

An additional interview was conducted with the DON at approximately 11:35 a.m. When asked again about the chair scale, s/he stated, "We had some limited access to a chair scale with [the other hospital in the same building]. We couldn't find a loaner. The end of our availability [with the adjacent hospital] was in July."

On 10/5/11 at approximately 10:30 a.m., the CEO was asked about numerous months delay in replacing a non-functioning chair scale. S/he stated that the previous director of nursing (DON) had approached him/her with a "CER" (capital equipment request) to replace the chair scale. S/he stated s/he had approved the request and returned it to DON, who then should have forwarded it to the corporate entity CFO for final approval and then it should have been turned in to the hospital purchasing manager at the facility to place the order for the chair. S/he stated that only recently, after the former DON had left, did s/he become aware that the DON had "dropped the ball" and failed to process the "CER" and order the chair scale. S/he said that when the lapse was discovered, the acting DON submitted a new "CER" to him/her, which was signed again. The corporate entity CFO also approved the "CER." The chair scale was finally ordered and delivered a few days prior to the survey. The lapse with the timely ordering of the chair was identified when nurses continued to express concern about not having a chair scale and it was brought to his/her attention by the new acting director of nursing. When asked, the CEO stated that s/he did not have a copy of the original CER that was signed, or any way of knowing when that happened, because there was no system in place to track the "CER's" as they were being generated and making their way through the process. S/he stated that it was not his/her practice to log or make a copy of the "CER's" to monitor for completion of the purchase process. When asked if s/he felt it was his/her role as the CEO to forward the approved "CER" to the corporate entity CFO, s/he said that was not how the system worked and the person asking for the item was responsible for completing the process.
VIOLATION: INSTITUTIONAL PLAN AND BUDGET Tag No: A0077
Based on staff interviews and review of facility documents, the governing body failed direct and participate in the preparation of the annual and 3-year capital expenditure budgets for the facility, as required. The budgets were prepared by the corporate ownership entity's chief financial officer, with input from the facility staff, and approved by the corporate entity's board of investors. The failure to involve the governing body of the facility created the potential that the budgets did not reflect the needs, priorities and best interest of that hospital.

The findings were:

1. On 10/4/11, the meeting minutes for the facility's governing body for the current year were reviewed and revealed no evidence of board participation in the hospital's budget preparation for the upcoming year or budget performance for the current year.

2. On 10/5/11 at approximately 10:30 a.m., the chief executive officer of the hospital was interviewed about the budget process, including the capital expenditure budgets. S/he confirmed that the budget process involves providing department staff input related to budgetary needs to the chief financial officer of the corporate entity that owns the hospital. S/he stated that the budget was then presented to the corporate entity's board of investors for approval. S/he also confirmed that the board of investors monitored budget performance over the year. S/he acknowledged that the hospital's governing body did not participate in the budget preparation, approval or performance monitoring processes, as required.
VIOLATION: CONTRACTED SERVICES Tag No: A0084
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on a review of medical records, staff/physician interviews and review of facility documents, the governing body failed to institute and maintain a system to routinely evaluate the services provided to patients to ensure they were provided in a safe and effective manner. The findings created the potential for negative patient outcomes.

The findings were:

1. Failure to Evaluate All Contracted Services for Quality/Performance:

On 10/5/11 at approximately 1 p.m., the director of nursing was interviewed about contracted services evaluation, at the suggestion of the chief executive officer (CEO), who had previously stated, on 10/5/11 at 10:30 a.m., that the director of nursing maintained the list of all the contracts and had any information about contract evaluation. The director of nursing stated that the hospital had not been doing evaluation of contracts until just a few weeks ago. S/he shared an e-mail from the hospital's corporate owner, dated 9/12/11, which provided a form to use for initiating contract evaluation. The e-mail directed the facility to start with evaluation of the clinical contracts. S/he provided evidence of a preliminary implementation of the contract evaluation with evidence of evaluation of the contracted pharmacy, one of the two nursing agencies, the contractor that provided radiology, laboratory and respiratory services, the medical equipment maintenance contractor, the medical waste contractor and one of the acute care hospitals that provided services, including emergency services for their patients. Review of the evaluation sheet for the contractor that provided the radiology, laboratory and respiratory services revealed that sheet was completed on 9/21/11. The evaluation did not look at and rate each service individually. The rating also stated that there were no instances of delay in services in the past 12 month period. The rating did not reflect the delay in collecting an urgent blood sample and timely reporting critical results for sample patient #2. (Refer to additional detailed findings in this tag related to "2. Specific Failure Related to Contracted Laboratory Services"). Finally, the director of nursing confirmed that the facility had previously been relying on information provided by the contractors related to performance. The facility had not been conducting independent evaluations of the quality of the contracted services provided.

An interview with the Director of Nursing (DON) was conducted on 10/5/11 at approximately 12:30 p.m. When asked about the facility's review of contracted services, s/he stated, "I did the review of housekeeping, dietary, and linen. The (Chief Executive Officer) and I were working on utilities. The Health Information Management Coordinator evaluated (the contracted radiology, laboratory and respiratory services company) and (contracted medical credentialing service). Those evaluations go to corporate, back to (the DON) and then to Quality. No contracts went through Quality in the past year except for the quarterly observations. We are just starting the overall observation."

2. Specific Failure Related to Contracted Laboratory Services:

Medical Record Review
Sample patient #2 was an adult patient admitted on [DATE] with dementia and suicidal ideations. The nurse's notes on 8/26/2011 at approximately 9:00 PM stated "resident [complains of] chest pain along apical node site 5th [left intercostal space with] posterior [complaints of] pain to backside (thorax), vital signs and medication admin[istered] as [prescribed] by [physician]...vital signs are taken every 4 hours as ordered by [physician] and STAT labs for patient are pending."

A physician's order written on 8/26/2011 at approximately 9:00 PM stated for a STAT Troponin level to be drawn along with other laboratory tests and a notation on the order stated that the contracted laboratory service was notified at that time.

A nurse's note on 8/27/2011 at approximately 2:30 AM stated that the contracted laboratory service had come to draw the patient.
A nurse's note on 8/27/2011 at approximately 4:30 PM stated that the "resident had STAT labs returned critical high Troponin level..."
The patient was emergently transported to a nearby acute care hospital on [DATE] for myocardial ischemia which resulted in the patient needing cardiac stent placement.
The laboratory report dated and timed 8/27/2011 at 1:58 PM stated that the specimen was collected on 8/27/2011 at 1:00 AM and received into the laboratory on 8/27/2011 at 6:13 AM and reported to the facility on [DATE] at 1:57 PM.

Staff Interview
An interview with the facility's Acting Director of Nursing (DON) on 10/5/2011 at approximately 8:50 AM revealed that the contracted laboratory service was to come to the facility "within an hour" to draw the patient's blood for STAT orders. S/he confirmed that the service's contract stated that the service was to provide results within 5 hours of collection for STAT orders. The acting DON stated that s/he was not aware of the delay that occurred for sample patient #2, of 5 1/2 hours from the time of the order for collection of the STAT specimen as well as 11 1/2 hours from the time of the specimen collection until the results of the STAT order and critically high result was called to the unit.

3. Specific Failure Related to Radiological Services:

Reference Tag A 355 - Medical Staff Privileging - for findings related to the failure to ensure that the contracted radiologists that provided diagnostic readings/interpretations of the radiological examinations for their patients were credentialed and appointed and granted privileges by the hospital's medical staff.

4. Specific Failure Related to Nursing Services:

Reference Tag A 398 - Supervision of Contracted Staff - for findings related to nursing services failure to ensure non-employee nursing personnel who were working in the hospital were under adequate supervision of the director of nursing service and their clinical activities were evaluated to ensure that the nursing care provided was safe and effective.
VIOLATION: CONTRACTED SERVICES Tag No: A0085
Based on staff interview and review of facility documents the facility failed to maintain a list of all contracted services. The list the facility maintained was not complete and did not include the scope and nature of the services provided.

The findings were:

Upon entering the facility on 10/3/11, the facility was requested to provide a list of all contracted services. Subsequently, a contracts book with a list of contracts in the front of the book was provided to the surveyors on 10/3/11. The list titled "Contract Grid," was a 2-page list of the facilities contract with headings: "Contractor Name," "Description," "Effective Date" and "Expiration Date." The Administrator was contacted on 10/4/11 at approximately 11 a.m., and was confirmed that the contract book and list in front on the book were the complete contract list for the facility.

Review of the contract book and list on 10/3/11 revealed that the list did not have a description on the list for 9 of the 21 contracts listed. In addition, the description of the services provided by one contractor only described laboratory and radiology services. When the contract was reviewed, it also described respiratory services. On 10/5/11 at approximately 1 p.m., the director of nursing confirmed that the contractor did also provide respiratory services to the facility. Review of the contract book and list also revealed that it did not contain the contract with the host hospital, which the director of nursing had stated provided multiple services, including food and dietary, housekeeping and maintenance services. The facility provided a copy of the contract with the host hospital just prior to exit from the survey on 10/5/11.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on facility tour, observations, staff interviews, and review of medical records/facility documents, the facility failed to ensure patients received care in a safe setting. Specifically, the facility had frequent patient falls and medical physicians did not routinely come see the patients thereafter as required per the Director of Nursing in four of thirty sample patients (#s 3, 7, 9 & 30), neurological tests were not being conducted appropriately thereafter as per the facility's policy and procedure in five of thirty sample patients (#s 3, 7, 8, 9 & 30), and the facility had not implemented changes, such as accessible call lights, to assist in further preventing patient falls. These failures created the potential for patient harm.

The findings were:

1. Call Lights

Tour of the facility was conducted on 10/3/11 at approximately 1:15 p.m., with the Director of Nursing (DON). The facility had two separate units: Phase 1, for more acutely ill patients, and Phase 2, for more stable patients. While on tour, it was noted that each room had only one call light, wherein which the patient could push to request help, regardless if the room had one or two patient beds within. The call light was on the center of the wall in each room, approximately four feet high, and was a push button that stated "PUSH FOR HELP." Observations revealed several rooms, room 100 for example, where the call light was as many as ten feet from one of the beds in the room, rendering it unreachable for patients while in bed. When asked about call lights, the DON stated, "We have the buttons and we would also have bed alarms if they were moving and sat up... On the other side (Phase 1) we have a bell a patient can ring" because s/he can't move one side of his/her body. A patient in bed 128A was noted to be immobile and, when asked about how the patient would ask for assistance, the DON stated, "[S/he] has a bed alarm, is checked every 15 minutes, and is in the closest room to the nurse's station... We try to have a Behavioral Health Tech in each hall..." On the opposite unit (Phase 1), the patient in room 110A was unable to move one side of his/her body. When asked to see the patient's bell that the DON had stated the patient used, the DON was unable to find it. The secretary came to the room and was able to find the bell within the patient's bed. When asked if there were other bells should additional patients need them, the DON stated that s/he had some additional bells in his/her office. When asked to see those bells, the surveyor and DON entered the office, the DON was unable to find the bells, and stated s/he had them the previous weekend but that they were now gone. S/he stated, "I guess I need a sign-out sheet."

At 3:30 p.m., the DON was asked about fall preventions that the facility had implemented. S/he stated, "We do a risk assessment on admission, daily risk assessments, and then we use different types of interventions, such as no slip socks, elevated toilet seats, bed/chair alarms, assistive devices, assessment of their shoes, check the hems of pant legs, checks rooms for clutter, and only use side rails one at a time. We have red and white high risk fall magnets that go on the doors, the chart is labeled, and they have a yellow wrist band, but basically everyone is a fall risk..."

The following day, on 10/4/11 at approximately 11:15 a.m., the DON was asked if s/he was able to retrieve the bells. S/he stated, "Yes, I found them. I typed a log (to track them), but we haven't printed it yet..." The surveyor followed the DON to his/her office and asked to see the bells, however s/he was not able to obtain them. S/he stated, "They are not here so they must be in the nurse's station." The DON was again asked at approximately 11:35 a.m., if the bells had been obtained, as several patients were observed to be in wheelchairs and one in particular was wheelchair bound. S/he stated, "I'll check who has the other bell... We check on [the wheelchair bound patient] frequently. [S/he's] been here a long time." Prior to exit from the facility on 10/5/11, the DON brought a bell into the facility's conference to show the surveyor and stated it was an additional bell.

The facility's policy and procedure titled "Care of Adult Patient at Risk for Falls", last revised May, 2011, stated the following, in pertinent part: "...Assign a manual call bell to high fall risk patients. Educate patient on use of bell..."

2. Neurological Checks

On 10/4/11 at approximately 10:10 a.m., the Director of Nursing was asked about neurological assessments conducted by the nurses. S/he stated, "They have a competency they go through in orientation and they also do an observation." S/he stated they were to be done after falls. On 10/5/11 at approximately 12:30 p.m., the DON was informed that neurological checks were not being conducted after each fall, as evidenced in the medical record reviews. S/he stated, "They are supposed to use nursing judgement and start if appropriate especially if witnessed, a patient hits their head, or based on physician order."

The facility's policy titled "Neurological Checks," dated 4/14/10, stated the following, in pertinent part:
"PURPOSE:
1. To closely monitor neurological functioning.
2. To insure proper assessment of patient status.
3. To prevent neurological complications.
PROCEDURE:
1. Neurological, including vital signs are initiated upon physician's order or after Nursing Assessment of possible need.
2. The following areas are assessed and recorded: a. Vital signs, i.e. blood pressure, temperature, pulse, and respiration. b. State of consciousness, i.e. oriented, awake, restless, drowsy, combative, disoriented, unconscious. c. Speech: clear, rambling, garbled, none. d. Responds to name shaking, light pain, strong pain. e. Non-verbal reaction to pain; appropriate, inappropriate, none. f. Pupils; size (eye) right, size (eye) left, reacts to light, right reacts to light, left. g. Extremities; right arm (grasp), right leg (push), left arm (grasp), left leg (push). h. Drainage; small/ moderate/ large, i.e. eyes, ears, nose, mouth.
3. Nursing shall notify the physician of any abnormalities or abrupt changes in condition or whenever blood pressure is greater either diastolic or systolic of 160/90.
4. Unless otherwise ordered, Neurological Vital signs will be taken and recorded every 30 minutes for 2 hours... every 2 hours times 2, and... every 4 hours until discontinued.
5. Monitoring is documented in the Neurological Check Form and summary in the Progress note."

Sample patient #3 was an adult patient admitted to the facility on [DATE] for dementia. On 7/18/11, the nurse's note stated, in pertinent part: "CNA heard a thud while passing snack. Pt found on floor of peers room next to the bed. Pt had scant amount of blood on forehead... Pt confused, disoriented unable to explain what had happened... Neuro & Vs started & WNL (within normal limits)...Continue [with] neuros... Contact [contracted medical physician's group] with pt's BP @ 0130." The next nurse's note stated that the contracted medical group was contacted at 1:50 a.m., with the patient's blood pressure and stated the MD "said to continue neuros..." The "Neurological Assessment" form contained documentation including vital signs, pupil and extremity checks, consciousness level, speech level, and patient response on 7/18 at 7:55 p.m., 8:25 p.m., 8:55 p.m., 9:25 p.m., 11:25 p.m., 1:25 a.m., and 5:25 a.m. At 9:25 a.m., only the patient's vital signs were documented. No further documentation existed on the form. The nurse's note dated 7/19/11 and timed 12:55 p.m., stated the following, in pertinent part: "Pt in geri chair this AM, not ambulatory. Pt took meds crushed in pudding. By mid morning, Pt remained sleepy and difficult to rouse. MD notified..." Two physician notes were timed earlier than the nurse's notes. The medical physician's note was timed 10:40 a.m. and stated, in pertinent part: "Patient is obtunded..." The psychiatrist's note was timed 11:00 a.m. and stated, in pertinent part: The patient is "very obtunded now and may well need transfer to general hospital for intensive care." There was no evidence that a neurological check had been conducted by nursing staff since 5:25 a.m., when the exam was reported unchanged with the patient being awake, with clear speech, and responsive to name, however, the patient was obtunded upon physician assessment at 10:40 a.m.

Sample patient #7 was an adult patient admitted to the facility on [DATE] for dementia. Review of the nurse's note revealed the patient had at least three falls during the hospitalization . The first was documented on 8/27/11 at 5:30 p.m. It stated, in pertinent part: "Pt walking down hallway and lost balance, fell . Unwitnessed fall, pt reported head hit floor. Assessed for injury... Mental status remains the same as admission." The second was documented to have occurred on 8/28/11 at 1:30 a.m. It stated, in pertinent part: "Pt had unwitnessed fall. Pt found laying on floor of bathroom... Continue [with] neuros..." The third was documented on 9/8/11 at 11:58 a.m. It stated, in pertinent part: "Pt witnessed ambulating in Dayroom and tripped over peers walker, falling to buttocks then rolling to [left] side..." The "Neurological Assessment" forms in the chart were complete according to the facility's policy after the patient's first fall on 8/27, however, after the patient's second fall on 8/28, neuro checks were done at 4:30 a.m., 8:30 a.m. and 12:30 p.m., not every 30 minutes for two hours, then every two hours for two hours, then every four hours, etc. The nurse continued on the schedule that had been set for the patient's first fall. After the 12:30 p.m., neuro check, no further checks were conducted and only vital signs were documented, which were done so without a nurse's signature until 8/31/11 at 4:30 a.m., when the form stated, "complete." On two occasions (8/29 at 12:30 a.m. and 4:30 a.m.) the documentation stated "ref," indicating that the patient refused the exams and vital signs. No neurological assessment documentation was in the chart for the third fall.

Sample patient #8 was an adult patient admitted to the facility on [DATE] for paranoid dementia. The patient fell on the day of admission and the nurse's note stated, in pertinent part: "...pt collapsed when [s/he] attempted to stand in dayroom. CNA's eased [him/her] to the floor. Pt non-responsive for approx 30 seconds then pt became agitated & combative [with] attempts to obtain VS... [Contracted physician medical group] notified & new [sliding scale] orders obtained. Pt assisted to bed once calm..." The "Neurological Assessment" form contained documentation including vital signs, pupil and extremity checks, consciousness level, speech level, and patient response on 8/22 at 11:00 a.m., 11:15 a.m. and 11:30 a.m. At 11:45 a.m., 12:15 p.m., 12:45 p.m. and 1:45 p.m., only the patient's vital signs were documented. No further documentation existed on the form ensuring that the neuro assessments were completed per policy.

Sample patient #9 was an adult patient admitted to the facility on [DATE] for depression. The patient fell on ,d+[DATE] and 9/5. On 8/28, the nurse's note stated the following, in pertinent part: "Patient is sent out for fall on left side of body. No signs of bruising but patient complains of pain. Patient stated [s/he] hit [his/her] head on right side of head... Patient is alert and oriented x3... Patient family notified as well as DON, physician... Patient was not assessed by physician and sent out patient per nurses report..." The note was documented at 6:30 p.m., however the "Neurological Assessment" form contained documentation beginning at 3:15 p.m., thus inferring 3:15 p.m., was the actual time of the patient's fall. The form contained documentation including vital signs, pupil and extremity checks, consciousness level, speech level, and patient response on 8/28 at 3:15 p.m., 3:30 p.m., 3:45 p.m., 4:00 p.m. and 5:00 p.m. From 6:00 p.m. to 9:00 p.m., there was documentation that the patient was at the hospital. Thereafter, the form contained documentation on 8/29 at 1:00 a.m. of only vital signs, no documentation at 5:00 a.m., only vital signs at 9:00 a.m., and no documentation at 1:00 p.m. or 5:00 p.m. At 9:00 p.m., the form again contained all required information such as vital signs, pupil and extremity checks, consciousness level, speech level, and patient response as did the next two sets of checks at 1:00 a.m. and 5:00 a.m. The nurse's note in regards to the patient's second fall on 9/5 stated the following, in pertinent part: "Pt put call light on, CNA went into bathroom, found pt on bathroom floor... Pt said [s/he] hit the [right] side of [his/her] face, chin and [right] elbow... Notified charge nurse, DON, family member and practitioner. Continue to do neuros, assist pt [with] toileting. Fall occurred at [4:25 p.m.]." The "neurological assessment" form contained documentation including vital signs, pupil and extremity checks, consciousness level, and speech level on 9/5 at 4:50 p.m. However, the documentation for 5:00 p.m., 5:30 p.m. and 6:00 p.m., contained only vital signs. The documentation for 7:00 p.m., contained vital signs, consciousness level, speech level, and patient response. The next four checks at 7:30 p.m., 8:00 p.m., 8:30 p.m. and 10:30 p.m., contained vital signs, pupil and extremity checks, consciousness level, and speech level, as well as a nurse's signature. On 9/6 at 12:30 a.m., 4:30 a.m. and 8:30 a.m., only vital signs were documented. There was no documentation for 12:30 p.m. and 4:30 p.m. At 8:30 p.m. and 12:30 a.m., only vitals signs were again documented. No documentation existed thereafter.

Sample patient #30 was an adult patient admitted to the facility on [DATE] for agitation. The patient had a history of a stroke. On 8/2/11 at approximately 5:50 PM a nurse's note stated that the patient "...fell this evening, has a swelling (bump) on right forehead. Neuro[logical checks] started..." The form titled "Neurological Assessment" had documentation of neurological checks including vital signs, pupil and extremity checks, as well as consciousness level documented on 8/2/11 at "5:45, 6:00, and 6:15". The remaining entries for "6:30, 7:00, 19:30, 20:00, 21:00, 21:30, 22:30, 23:30, 8/3/11 00:30, 1:30, 5:30, 9:30, 13:30, 17:30, 21:30" contained vital signs, but no other data. The checks did not include any notation of the patient's consciousness, speech patterns, or responsiveness. Entries after 1:30 AM on 8/3/11 did not have an RN/LPN signature.

3. Physician Visits after Patient Falls

On 10/4/11 at approximately 10:10 a.m., the Director of Nursing was asked if a member from the contracted medical service was expected to come by and see the patients after a fall. The DON stated they were and continued, "They have to document. They come and document to get paid." When asked what is to be done if one of the practitioners does not come after a patient falls, s/he stated, "The nurse is to call the DON." At approximately 11:30 a.m., when asked the exact process that occurs after a fall, the DON stated, "Nurses call and give their assessment. [A practitioner from the contracted physician group] will come over... We had one that used to not come over. We met with them and they agreed they should be coming over. That is taken care of now. It is expected that they come over." The DON reiterated this information on 10/5 at approximately 12:30 p.m. and stated, "Most of our falls happen at night... If [a practitioner from the contracted physician group] does not respond immediately, they go to the Emergency Department. They are to let me know if [the contracted physician group] does not come by... A physician is supposed to come by with falls."

However, a "MEMO" to staff, dated 3/21/11 from the previous Director of Nursing, contradicted the new DON's statements and stated the following, in pertinent part: "...Falls: The Psychiatrist needs to be notified of all falls. Routine or non injury falls should be reported to the psychiatrists and not [the contracted medical physician service]. The request for [the contracted medical physician service] to see the patient after a fall needs to come directly from the psychiatrist..."

Sample patient #3 was an adult patient admitted to the facility on [DATE] for dementia. The patient fell on ,d+[DATE] and, although there was evidence that the nurse called the contacted medical group twice, there was no documentation that the physician or mid-level for the group came to assess the patient until the following day.

Sample patient #7 was an adult patient admitted to the facility on [DATE] for dementia. Review of the nurse's note revealed the patient had at least three falls during the hospitalization . The falls from 8/27 and 8/28 did not evidence that a physician was called by nursing staff. However, the fall on 9/8 contained documentation that a "MD" was called, but no evidence that a physician came to see the patient.

Sample patient #9 was an adult patient admitted to the facility on [DATE] for depression. The patient fell on ,d+[DATE] and 9/5. The nurse's documentation after the first fall stated that a physician did not come to see the patient and instead consulted with the nurse via telephone and then transferred the patient. After the second fall, the nurse documented that a "practitioner" was notified, however, there was no evidence that the patient was seen and assessed by a mid-level practitioner or physician.

Sample patient #30 was an adult patient admitted to the facility on [DATE] for agitation. The patient fell on ,d+[DATE] and there was no evidence that the contracted medical physician's group was notified of the fall that evening. On 8/3/11, a medical Nurse Practitioner documented a note regarding the patient's fall.

4. Summary

Although the DON stated manual call bells were readily available to patients, such was not evidenced on survey. The facility had evidence of tracking large numbers of patient falls, observations revealed inaccessible call lights, however the facility failed to follow its own policy by having manual call bells as another means of fall prevention.

Patient neurological checks were not consistently implemented after falls, not thoroughly conducted, and not routinely signed with the practitioner's (RN/LPN) signature after documented in accordance with the facility's policy.

After falls, physicians or mid-levels did not consistently come to assess patients. Additionally, the medical records did not contain evidence that the providers were constantly notified of the falls by nursing staff. Finally, nursing meeting minutes/education evidenced conflicting instructions to the staff regarding physician notification after falls than what the current DON stated in interviews. However, there was no other evidenced written nursing meeting minutes/education that may have informed staff of the new DON's expectation, thus leaving guidance to staff regarding patient safety unclear.
VIOLATION: MEDICAL STAFF PRIVILEGING Tag No: A0355
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on staff interview and review of facility documents, the hospital failed to ensure that the contracted radiologists that provided diagnostic readings/interpretations of the radiological examinations for their patients were credentialed and appointed and granted privileges by the hospital's medical staff. Additionally, the hospital failed to ensure that privileges were delineated for each member of the medical staff in three of four files reviewed. These failures created the potential for a negative outcome.

The findings were:

1. Radiologist Files

On 10/3/11 at approximately 11:05 a.m., the staff member responsible for medical staff credentialing was asked if any of the radiologists that were affiliated with the contracted radiological services were credentialed as part of the medical staff. S/he stated that they were contract, therefore, the contractor had their files and they were not a part of the hospital's medical staff. S/he confirmed that the list of medical staff and allied health staff was complete and did not include the contracted radiologists.

On 10/3/11 at approximately 11:15 a.m., the administrator was interviewed to determine if the contracted radiologists were members of the hospitals medical staff. S/he confirmed that they were not part of the medical staff. S/he stated that the issue had come up in a recent accreditation survey and they had contacted the contractor for radiological services, who was also accredited by the same entity. S/he stated the contractor had provided a letter to the hospital stating that they maintained credential files on all of the radiologists. The administrator stated that information satisfied the accreditation surveyor and the issue was resolved.

On 10/5/11 at approximately 1 p.m., the corporate director of nursing provide a package of information provided by the contracted radiology service. It contained an e-mail from the contractor, which also provided contracted laboratory services to the facility. The e-mail, dated 10/5/11 at 12:40 p.m., stated the following, in pertinent parts:
"...Attached are our radiologist credentials. There may be more here than you need but I wanted you to have anything I had. (The name of the contractor) is Certified with CMS and (the name of the accreditation entity)."

Review of the information provided with the e-mail were faxed copies of information about 26 radiologists. The packet contained a Colorado medical license (2 of which were expired as of 5/31/11) for each physician. For only 4 of the physicians was additional information, such as a resume, validation of current malpractice insurance coverage and board certification provided.





2. Other Physician Files

Credential files were reviewed on 10/4/11 and revealed the following:
- Sample #1 contained a form titled "DELINEATION OF PRIVILEGES." The form had check-marks in the section titled "Requested" however neither sections titled "Approved" or "Denied" contained any check-marks. The form was signed by the requesting physician as well as by the other physician that worked at the hospital on [DATE]. Governing Board Meeting Minutes were reviewed from the meeting dated 10/13/10 and stated that this physician had "accepted the position of Medical Director," however no other meeting minutes provided by the facility evidenced the specific approval or denial of the physician's requested privileges.

- Sample #3 contained a form titled "DELINEATION OF PRIVILEGES." The form had a check-mark in the section titled "Requested" however neither sections titled "Approved" or "Denied" contained a check-mark. The form was signed by the requesting physician as well as the Medical Director. A second form identified that the physician was granted temporary privileges.

- Sample #4 contained a form titled "DELINEATION OF PRIVILEGES." The form had a check-mark in the section titled "Requested" however neither sections titled "Approved" or "Denied" contained a check-mark. The form was signed by the requesting practitioner, but no signature was present in the "Approved by" signature line. A second form identified that the practitioner was granted temporary privileges. However, the temporary privileges were dated 7/14/11 and stated the following, in pertinent part: "Temporary privileges are granted for a period not to exceed sixty (60) days, subject to extension for no more that a total of one hundred twenty (120) days during the application process and care of no more than five (5) specific patients per year per applicant." A review of the Medical Executive Committee Meeting Minutes, dated 7/21/11, stated "Credentialing process continues to give Full Privileges within the next 120 days" to the practitioner.

An interview with the Health Information Management Coordinator (HIMC) was conducted on 10/4/11 at approximately 2:20 p.m.
- When asked about sample #1, s/he stated, "The privileges were approved. They should be in the meeting minutes." However, the meeting minutes only stated approval of position of Medical Director, not privileges and the latter was not evidenced within the credential file.

- When asked about the lack of privilege approval check-marked for sample #3, s/he stated, "[S/he] is still in the temporary status so the delineation of privileges should not be signed yet."

- When asked about sample #4 and the expiration of temporary privileges, s/he stated, "They did extend to 120 days in the meeting minutes." However, such was not evidenced within the credential file. When asked about delineation of privileges form and lack of signature, s/he stated, "It would be signed once they are appointed to regular staff... They don't get an appointment letter until they are on official staff."

An interview with the Corporate Director of Nursing was conducted on 10/4/11 at approximately 3:20 p.m. When asked about the delineation of privileges, s/he stated, "The official approval is through Med Exec and Governing Body." When asked why the "Approval" section was not check-marked in three of the four files, s/he stated that they should have been. "I would expect it should be approved on the forms, but I steer away from that. That is a good [Corporate Vice President of Clinical Services] question." However, the Corporate VP of Clinical Services was not onsite during the survey and was not responsible for the privileging forms.

The "BYLAWS OF THE MEDICAL STAFF," with an effective date of 6/22/11, were reviewed and stated the following, in pertinent part:
"...ARTICLE VII.
CLINICAL PRIVILEGES...
7.2 Delineation of Clinical Privileges
7.2.1 Application
Clinical Privileges may be granted only on written request on forms provided by the Hospital followed by processing and approval. Every Application for Medical Staff or AHP Staff reappointment must contain a request for the specific Clinical Privileges desired by the Applicant...
7.3.2 Authority to Grant Temporary Privileges...
In all cases, Temporary Privileges shall be granted for a specific initial period up to ninety (90) days, subject to extension in the manner provided in this Section 7.3.2. After the initial period of time, the Practitioner may request a renewal of Temporary Privileges for an additional time period not to exceed one hundred and twenty (120) day total, but the decision as to whether to grant such extension is solely within the discretion of the Chief Executive Officer, with the concurrence of the President of the Medical Staff and is subject to the maximum periods of time set forth in this Section 7.3.2. Temporary Privileges shall expire automatically at the end of the specific period for which they were granted without any otherwise applicable Hearing and appeal rights set forth in these Bylaws, except to the extent required by State law..."
VIOLATION: NURSING SERVICES Tag No: A0385
Based on the manner and degree of deficiencies cited and review of policies/procedures and other facility documents, the hospital failed to be in compliance with the Condition of Participation of Nursing Services. The nursing services failed to ensure that monitored patients appropriately related to weight, neurological checks and timely reporting of critical laboratory results to the patient's physician. In addition, the nurses failed to modify patient care plans related to skin/wound care, fall prevention and other special patient needs. Finally, the nursing services department failed to ensure that nursing staff operating as contract employees were monitored and evaluated to ensure safe and effective nursing care was provided.

The facility failed to be in compliance with the following standards under the Condition of Nursing Services:

Tag A 386 Organization of Nursing Services - for findings related to nursing services failure to ensure that patients were weighed weekly, as required, that neurological checks were instituted to monitor a patient after a fall and ensure that critical laboratory results were provided to the patient's physician timely.

Tag A 396 Nursing Care Plan - for findings related to nursing services failure to modify patient care plans related to skin/wound care and fall prevention.

Tag A 398 Supervision of Contracted Staff - for findings related to nursing services failure to ensure non-employee nursing personnel who were working in the hospital were under adequate supervision of the director of nursing service and their clinical activities were evaluated to ensure that the nursing care provided was safe and effective.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of medical records and facility policies/procedures and staff interviews, the hospital's nursing service failed to ensure that patient weights were monitored as required by their policy/procedure in 4 of 30 sample patients (#4, #18, #21 and #22). The nursing service failed to ensure that a patient needing STAT laboratory services was treated with the urgency expected by the facility as well as failed to ensure that once critical laboratory results were received, that such results were communicated to the appropriate physician for follow-up. In addition, the nursing service failed to ensure neurological checks were done appropriately on patients after falls. These failures created the potential for a delay in care and a negative patient outcome.

The findings were:

Failure to assess for weight loss:
Review on 10/4/11 of the medical record for sample patient #4 revealed that the patient was an elderly adult with the diagnosis of Alzheimer's dementia with agitation and a history of assaultive behavior at his/her prior supervised senior living situation. The patient was admitted on [DATE] and was transferred out to an acute care hospital emergency department for evaluation/treatment of hypotension and altered mental status on 8/5/11. Further review of sample record #4, on 10/4/11 revealed that the patient was weighed at the time of admission and had a weight of 136 lbs.

Review on 10/3/11 of the Dietary Consult completed on 7/28/11 revealed the following findings, in pertinent parts:
"...Reason for Consult: Assessment and Evaluation ...Consult findings: Patient with poor p.o. (oral) intake - both food and beverage - has difficulty sitting in chair for eating at risk for continuing adult failure to thrive - per history.
1) Patient may benefit from close aide observation of food preferences since patient unable to provide preference information.
2) Patient may benefit from appropriate appetite stimulant to improve intake.
3) Dietary to provide supplements of Health Shakes each meal in addition to Ensure already ordered.
Recommendations:
1) Physician/pharmacist to determine and order appropriate appetite stimulant e.g., Remeron.
2) Dietary to be notified to provide vanilla or other flavored Health Shake per observed patient preference for lunch and dinner ..."

Despite the dietary consult findings, and the fact that the patient was described on 7/26/11 by the medical nurse practitioner as a "Patient with obvious weight loss ...On Ensure for anorexia," the patient was not weighed again during his/her hospitalization .

The medical record of sample patient #4 was reviewed by the director of nursing for additional evidence of weights. S/he stated on 10/3/11 at approximately 3 p.m., that the nurses should be charting subsequent weights during the hospitalization . She was unable to find additional evidence of subsequent weights.

The corporate and hospital directors of nursing were interviewed on 10/4/11 at approximately 11:40 a.m., and asked about expectations for charting weights. They stated that they were not sure of a policy, but would check. They stated the expectation was for a weight on admission and weekly weights for all patients, with more frequent weights for patients with anorexia, poor intake, etc. They stated that the weights should be documented on the graphics sheets in the medical record. They were also asked to confirm reports that the chair scale was broken. They confirmed that the chair scale had been broken for a number of months. They stated they had continued to have access to a chair scale by borrowing the chair scale of the host hospital. They stated that they were still able to use the host hospital's chair scale or their own stand-up scale in July when #4 was in the facility. They stated that soon after that time, the host hospital refused to let them borrow the chair scale, so they were without a chair scale until just a few days ago when their new chair scale was delivered.

Review of the facility policy/procedure "Vital Signs" on 10/5/11 revealed the following, in pertinent parts: "...2. Weights will be taken upon admission and then weekly unless ordered more frequently ..."

Additional review of the 30 sample records revealed that sample patients #18, #21 and #22 had all been in the facility for at least a week and the record contained no evidence of the patients having been weighed after a week, as was required in the "Vitals Signs" policy/procedure.

Failure to follow-up on critical laboratory results
Review on 10/3/2011 of the medical record for sample patient #2 revealed that the patient was an adult patient admitted on [DATE] with dementia and suicidal ideations. The nurse's notes on 8/26/2011 at approximately 9:00 PM stated "resident [complains of] chest pain along apical node site 5th [left intercostal space with] posterior [complaints of] pain to backside (thorax), vital signs and medication admin[istered] as [prescribed] by [physician]...vital signs are taken every 4 hours as ordered by [physician] and STAT labs for patient are pending."

A physician's order written on 8/26/2011 at approximately 9:00 PM stated for a STAT Troponin level to be drawn along with other laboratory tests and a notation on the order stated that the contracted laboratory service was notified at that time.

A nurse's note on 8/27/2011 at approximately 2:30 AM stated that the contracted laboratory service had come to draw the patient.
There were not any additional nurse's notes that documented any additional attempts to contact the contracted laboratory service to respond sooner than the 5 1/2 hours.
A nurse's note on 8/27/2011 at approximately 4:30 PM stated that the "resident had STAT labs returned critical high Troponin level...called [Physician #1] at [2:10 PM] to report lab results. Call back pending..."
A nurse's note on 8/27/2011 at approximately 7:30 PM stated that "...EKG [showed] anterior septal and lateral T wave changes [that] may be due to myocardial ischemia...call placed to [Internal Medicine Group] [Physician #2]. Returned page informed the above stated s/he would be there ASAP to evaluate the patient...doctor arrived at [8:00 PM] gave order to send patient to [nearby acute care hospital]..."
The patient was emergently transported to a nearby acute care hospital on [DATE] for myocardial ischemia which resulted in the patient needing cardiac stent placement.
The laboratory report dated and timed 8/27/2011 at 1:58 PM stated that the specimen was collected on 8/27/2011 at 1:00 AM and received into the laboratory on 8/27/2011 at 6:13 AM and reported to the facility on [DATE] at 1:57 PM.
A late entry nurse's note that was dated 9/1/11 at approximately 6:00 PM stated "Late entry for 8/27/11, 6:00 AM-7:00 PM shift. Troponin with critical high...was received by the nurse at 1:57 PM. Lab level shown to attending psychiatrist [Physician #3] at 2:30 PM, physician/psychiatrist reviewed labs acknowledged that they were high and gave it back to the nurse, no new orders were given. The nurse recalled [Physician #1] after initial call at 2:10 PM was not returned, again no answer from either calls by [Internal Medicine Group] continued to monitor vital signs while awaiting call back."
There were no additional nurse's notes documenting any further efforts by the nursing staff to contact the internal medicine physician other than the two calls between 1:57 PM and 2:10 PM until after 7:30 PM.

An interview with the facility's Acting Director of Nursing (DON) on 10/5/2011 at approximately 8:50 AM revealed that the contracted laboratory service was to come to the facility "within an hour" to draw the patient's blood for STAT orders. S/he confirmed that the service's contract stated that the service was to provide results to the facility within 5 hours of collection for STAT orders. The acting DON stated that s/he was not aware of the delay that occurred for sample patient #2, of 5 1/2 hours from the time of the order for collection of the STAT specimen as well as 11 1/2 hours from the time of the specimen collection until the results of the STAT order and critically high result was called to the unit.
S/he stated that there was a lack of "follow-up by the nurse" and that the nurse's were expected to "take responsibility and more accountability" and that follow-up with each of the nurses involved in the patient's care between the onset of chest pain on 8/26/2011 at approximately 9:00 PM, through her emergent transfer on 8/27/2011 at approximately 8:30 PM was conducted to ensure that they were aware of the expectations of them and that their care did not meet the expectations of the facility.

Failure to institute neurological checks after falls:
Reference Tag A 144, part 2 for findings related to nursing failure to institute neurological checks after patient falls as per the facility's policy and procedure.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on a review of medical records, policies/procedures and facility documents, the nurses failed to modify patient care plans related to skin/wound care, fall prevention and other special patient needs, in 3 of 30 sample records (#4, #16 and #18) reviewed. The failures created the potential for negative patient outcomes.

The findings were:

Sample Patient #4:
Review on 10/4/11 of the medical record for sample patient #4 revealed that the patient was an elderly adult with the diagnosis of [DIAGNOSES REDACTED]. The patient was admitted to the acute care hospital and did not return to the facility. Upon admission the patient was assessed for fall risk and determined to be a significant fall risk. A "Fall Precautions Treatment Plan" was completed for the patient on 7/25/11, which specified the following interventions: "Yellow fall precaution armband," "Fall precautions sticker placed on chart/Kardex," "Non skid footwear on patient," "Assist with toileting/bathing/dressing/transfer," and "Daily fall assessment." Daily fall assessments were completed on 7/26 through 8/5/11. On 7/31/11, the patient fell in the hallway and had a left facial/head laceration. The patient was transferred to an acute care hospital emergency department by ambulance for evaluation/treatment of the injury. The patient was evaluated and the head wound was closed with staples. The patient returned to the facility later that day. Further review of the record revealed that there were no modifications to the initial fall care plan or the multidisciplinary care plan after the patient's fall with injury on 7/31/11. On 8/1/11 the medical nurse practitioner ordered "Standby assist to ambulate" and "Bed and chair alarm: falls." There was no evidence of modification of care plans to incorporate these changes and there was no documentation that the new orders, which were intended to prevent further falls, were instituted by nursing staff.

On 10/3/11 at approximately 3:30 p.m., the director of nursing for the facility stated that s/he was unable to find documentation in sample patient #4's medical record to confirm the use of the chair and bed alarms for the patient. S/he also stated, when asked, that if a patient had a history of falls or fell in the hospital, then the care plan should have a goal related to fall prevention. The surveyor confirmed with the director of nursing that the patient's medical record had not been modified to address fall risks, even though s/he was at risk on admission. The patient subsequently had a serious fall with a head laceration requiring an emergency department visit and staples several days after admission (7/31/11).

Further review of the medical record (#4) on 10/4/11 revealed that the care plans and care plan updates contained no content related to food and fluid intake problems, hypotension/dehydration problems, and EPS(extrapyramidal syndrome)/other movement disorder issues, despite the fact that all of these findings were documented in the nursing and progress notes, consults and on the medical record coding summary signed by the psychiatrist.





Sample Patient #16:
The medical record of Sample patient #16 was reviewed on 10/3/2011. The patient was admitted on [DATE] and revealed that the patient was an elderly adult with the diagnoses of [DIAGNOSES REDACTED]

Review of the medical record revealed that the "Interdisciplinary Treatment Plan" (care plan) identified 5 problems with goals and interventions. None of the problems in the care plan addressed the urinary tract infection or the Foley catheter and its care. On 9/29/2011, one nursing progress note stated "Foley care completed".

The facility Policy and Procedure "Treatment Plan-Interdisciplinary" stated in pertinent part: "Activated Problems: for each problem to be addressed during treatment, a treatment plan will be completed. The problem statement will be in behavioral, observable terminology ...Only medical problems should be stated in diagnostic terms (i.e., hypertension), but should also include a statement of current status of condition". The hospital failed to ensure that nursing staff developed, and kept current, a nursing care plan. None of the entries addressed status of condition "effectiveness of intervention" and "progress toward goals" as required by the facility Policy and Procedure "Treatment Plan-Interdisciplinary".

Sample Patient #18:
The medical record of Sample patient #18 was reviewed on 10/3/2011. The patient was admitted on [DATE] was an elderly adult with the diagnoses including Suicide Ideations, Psychosis with Delusions/Paranoia, and Dementia. Past medical history included [DIAGNOSES REDACTED], Diabetes type 2, and Hyperthyroidism. Patient had hip surgery approximately 2 weeks prior to admission and a prostatectomy in the past.

The nursing assessment documented urinary incontinence and pressure sores. Under heading of "Skin", the drawings for the locations of skin conditions included: right hip "stage 2 pressure ulcer", "between buttocks reddened area", right inguinal fold "dry, scabbed area", "dry scaly feet-bloody right great toe".

Prior to admission the history noted a fall occurred on 9/6/11. The patient was placed on Fall Prevention because s/he "needs to balance/re-balance self (i.e. hold on to rail, touch chairs)". The patient was at high risk for falls and refused to use walker and was placed on the "Fall Precautions Treatment Plan" (FPTP) implemented on 9/20/2011. Upon review of the "Daily Fall Precautions Assessment" that was required by the (FPTP), it was determined that assessments for 9/30/11 and 10/1/11 were missing from the record.

The interdisciplinary Treatment Plan (Care Plan) of 9/20/2011 documented "Incontinence following Prostatectomy (Problem #4) ...Nurse Practitioner (N.P.) to assess patient's skin conditions, nursing to comply with orders when written". On 9/23/11, the N.P. documented "New buttock Open area ...New skin tear ...Use Calmoseptine, BID (twice daily) to improve". The Nursing progress note dated 9/27/2011 stated: "Ischium area of buttocks is quite reddened. Also of note is that patient had diarrhea stool with much mucus in it, barrier cream applied to reddened areas"...and on 9/28/2011 the N.P. documented "bilateral feet eczema. Patient has extremely dry feet with some superficial opening and cracking. Will start Eucerene Cream BID (twice daily) to improve dryness; will re-evaluate". On 10/1/2011 the nursing progress note documented "Provided treatment to patient feet as ordered".

Review of the medical record revealed that there were no modifications or additions made to the goals and interventions of care plan problem #4, implemented on 9/20/2011 as it related to the N.P. note of 9/23/2011: "New buttock Open area". Nursing flow sheets reflected assessment 9/27/2011 of skin condition and 10/1/2011 addressed treatment provided. No other evidence was found of treatment to "stage 2 pressure ulcer", "between buttocks reddened area", right inguinal fold "dry, scabbed area", "dry scaly feet-bloody right great toe" (noted on admission nursing assessment and 9/28/2011 by the NP.

There was no documentation in the nursing notes that the patient's urinary tract infection diagnosed and treated after admission had resolved the urinary incontinence and the impact on the patient's skin condition. None of the entries addressed the "effectiveness of intervention" and the "progress toward goals" as required by the facility Policy and Procedure, titled "Treatment Plan-Interdisciplinary". Two out of 13 days of daily fall assessments were missing from the medical record. The new skin buttock open area, the skin and wound care was not documented in the care plan nor goals set to meet this patient's medical needs.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
An unannounced onsite recertification survey was conducted (see event ID #OF4B21) October 26, 2011 by one (1) Life Safety Code Inspector and included an inspection for compliance with the fire safety requirements of NFPA (National Fire Protection Association) 101, Life Safety Code, (2000 edition) and NFPA 99 Health Care Facilities (1999 Edition). The facility failed to comply with the regulations set forth. Deficiencies were cited under Life Safety Code tags K0018, K0050, K0062, K0074, and K0130
See survey event ID #OFB421 for full details of the cited deficiencies.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on staff interview and review of the facility's equipment list, the facility failed to have a comprehensive and legible list of the medical equipment owned by the facility. Furthermore, there was not a formalized schedule that documented a regular preventive maintenance program. This failure created the potential for a lack of equipment safety and quality.

The findings were:

A list of medical equipment was provided on 10/4/11. The list included seven items that were typed and the rest of the list was hand written and for the most part, undecipherable. There was no way to determine if previous maintenance had been performed on the equipment or if and when preventive maintenance was done.

An interview was conducted with the interim DON (Director of Nursing) on 10/4/11 at approximately 1:00 p.m. The DON stated that s/he had recently been given the task of creating an inventory list of the facility's medical equipment and a preventive maintenance schedule. To have a starting point, the facility had preventive maintenance performed on all the equipment in June 2011.

In summary, although the facility stated preventive maintenance was performed, a complete list of the equipment that had been serviced was not provided. Furthermore, going forward, there was not a clearly defined plan of maintaining a scheduled preventive maintenance program.
VIOLATION: WRITTEN POLICIES AND PROCEDURES Tag No: A0885
Based on staff interviews and review of the hospital's policies/procedures the hospital failed to have and implement written protocols that complied with this section.

The findings were:

During an entrance conference with the hospital's CEO on 10/3/2011 at approximately 10:20 AM a request was made for "Policies and Procedures for...Organ Tissue and Eye Procurement..." as well as for "Meeting minutes for the past year for...Organ Procurement."

An interview with the facility's Acting Director of Nursing (DON) on 10/3/2011 at approximately 2:45 PM revealed that the facility's policy/procedure that addressed organ donation was not in the book provided and that the policy was being revised because the contract with the federally designated Organ & Tissue Procurement Organization was just renewed. A request was made to review any policy that was currently in place.

An interview with the facility's Acting DON on 10/4/2011 at approximately 8:45 AM revealed that the facility was in the process of updating the policies due to the contract being renewed and that s/he would retrieve the policy for review by the surveyors.

A subsequent request for the requested documents from the entrance conference that would demonstrate the facility's compliance with the Condition of Participation of Organ, Tissue, and Eye Procurement was made of the Corporate DON on 10/4/2011 at approximately 11:30 AM.

On 10/4/2011 at approximately 3:15 PM a request for the originally requested documents was made to the Acting DON. S/he stated that s/he thought that the Corporate DON was "supposed to be looking for it."

An interview with the Corporate DON on 10/4/2011 at approximately 3:30 PM revealed that the facility did not have a policy/procedure to address this requirement. S/he stated that a letter was received by the federally designated Organ & Tissue Procurement Organization by another one of their facilities that stated that they didn't need to have a contract with the federally designated Organ & Tissue Procurement Organization. The letter was provided to the surveyors.

The letter, dated 12/27/2007, stated the following in pertinent part:
"...Psychiatric units within an acute care hospital are not required under CMS to have a separate agreement..."

The corporate DON and CEO confirmed that the hospital was not a psychiatric unit within an acute care hospital. The corporate DON stated that once the facility had received the letter, they had "stopped making a policy and doing a contract because we weren't required to do so." S/he stated that the facility did not have a policy/procedure in the event of a patient death. S/he stated that the facility did not have a tissue bank agreement with the designated eye bank. S/he stated that there was not staff education regarding death or donation of organs or other tissues.
VIOLATION: TISSUE AND EYE BANK AGREEMENTS Tag No: A0887
Based on review of the facility's contracts, policies/procedures, and staff interview the facility failed to have an agreement with at least one eye bank to cooperate in the retrieval, processing, preservation, storage, and distribution of eyes, as may be appropriate to assure that all usable eyes are obtained from potential donors, insofar as such an agreement does not interfere with organ procurement.

The findings were:

A review of the facility's contracts revealed that the facility had a contract with the federally designated Organ & Tissue Procurement Organization, but did not have a contract with any eye banks.

A review of the contract with the federally designated Organ & Tissue Procurement Organization that was signed by the hospital's CEO on 9/30/2011 stated, in pertinent parts:
"...C. Hospital
Hospital agrees to the following:
1. Implement and maintain current policies and procedures to provide for organ donation after cardiac death and donation after brain death, and tissue referral and donation (including, without limitation, criteria for the determination of death). Hospital will provide [name of designated Organ & Tissue Procurement Organization] with copies of its policies and procedures and any amendments thereto. All of these policies and procedures will meet the requirements of applicable federal and state law and accepted medical practice...
3. In accordance with the Conditions of Participation (CoP), identify and refer all hospital deaths or imminent deaths in a timely manner to [name of designated Organ & Tissue Procurement Organization] via the Donor Information Line...
13. Cooperate in routine review of medical records conducted by [name of the designated Organ & Tissue Procurement Organization] personnel, to assist in identifying Hospital's potential organ and tissue donor pool and educational needs. [Name of the designated Organ & Tissue Procurement Organization] personnel will have access to and maintain the confidentiality of medical information in accordance with applicable law..."

Cross Reference to A 0885: Written Policies and Procedures - for findings related to the facility's failure to have and implement written protocols that complied with this section.
VIOLATION: INFORMED FAMILY Tag No: A0888
Based on staff interview and review of the hospital's policies/procedures the facility failed to ensure that it had policies/procedures that ensured that the family of each potential donor was informed of its options to donate organs, tissues, or eyes, or to decline to donate.

The findings were:

Cross Reference to A 0885: Written Policies and Procedures - for findings related to the facility's failure to have and implement written protocols that complied with this section.

Cross Reference to A 0887: Tissue and Eye Bank Agreement - for findings related to the facility's failure to have an agreement with at least one eye bank to cooperate in the retrieval, processing, preservation, storage, and distribution of eyes, as may be appropriate to assure that all usable eyes are obtained from potential donors, insofar as such an agreement does not interfere with organ procurement.