HospitalInspections.org

Based on review of facility documents and staff interview (EMP), it was determined that the governing body failed to ensure that contracted services for linen and security were provided in a safe and effective manner.

Findings include:

1. Review of services provided to Ellwood City Hospital by contract revealed Linen and Security to be included.

2. Review of Ellwood City Hospital Quality Assurance/Performance Improvement (QAPI) data for 2012 revealed no documentation that the Linen or Security departments were included in the plan.

On September 5, 2012, at approximately 1:45 PM when asked if Linen and Security (Contracted services) had any QAPI data, EMP2 stated, "No. There is not." EMP2 further confirmed that the two services were not included in the QAPI plan.

Based on review of facility documents and interview with employees (EMP), it was determined that the facility failed to ensure all patients were provided with the procedure for the submission of a patient's written or verbal grievance to the hospital.
Findings include:
Review of the Administrative Manual "Bill of Rights" revealed, " ... 1. All patients being admitted to the Ellwood City Hospital will receive a copy of the Patient Rights Statement in the Admissions Office ..."
Review of "The Ellwood City Hospital Patient's Rights Statement" revealed a two page document that states, " ... you may expect the following: ... 27. The right to file a grievance. Should you disagree with any aspect of your care you or your family member should ask to speak with the nursing supervisor. If your concern is not addressed to your satisfaction you may ask the supervisor for a copy of the written grievance procedure. A copy of the procedure will be provided to you on your request."
1. On September 4, 2012, at approximately 2:50 PM, review of the Patient Handbook revealed a loose document outlining the facility's written grievance procedure.
2. On September 4, 2012, at approximately 3:00 PM, EMP2 when asked if outpatients received the patient's right booklet, which includes the the facility's grievance procedure, EMP2 stated, "No they do not."

Based on review of facility documents and staff interviews (EMP), it was determined the hospital failed to ensure the patient was provided with written notice of its decision that contained the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and/or the date of completion for four of five grievances (Grievance 1, Grievance 3, Grievance 4, and Grievance 5).
Findings include:
Review of the "Complaint Management & Grievance Procedure" revised April 2011, revealed, "Written response shall include: ... -What steps were taken on your behalf to investigate your concern -Notice of the decision result to investigate your concern -Date of completion of the process..."
1. Review of Grievance 1 revealed the grievance was filed on July 18, 2012. An initial letter dated July 23, 2012, stated, "I want to advise you that we have sent your concerns to the Medical Director of The Emergency Department for review. We will share the findings with you no later than July 30, 2012." Review of the final letter dated July 31, 2012, revealed, "In addition, the Emergency Room Nurse Manager has spoken to the nurse who cared for you at the time of the incident and has offered her apology and wants you to know that she has reinforced the importance of patient satisfaction with her ..." The letter failed to address what steps were taken and the result of the investigation, including the date the investigation was completed.
2. Review of Grievance 3 revealed the grievance was filed on July 8, 2012, (which was clarified as being submitted on July 18, 2012). An initial letter dated July 23, 2012, stated the concerns were submitted to the Medical Director of the Emergency Department for review. "We will share the findings with you no later than July 30, 2012 ..." An interim letter dated August 14, 2012, stated, "Our Emergency Department Medical Director shall provide us an update, which I will forward to you in a follow-up response no later than August 24, 2012 ..." A letter dated August 17, 2012, revealed the ED Medical Director spoke with the physician present at the time of your father's visit and spent time reviewing his medical record ... " The letter failed to include the results of the grievance investigation and the date of completion of the investigation.
3. Review of Grievance 4 and Grievance 5 revealed the final letter to the complainants failed to include the date of the completion of the investigations.
4. Interview on September 5, 2012, at 1:30 PM with EMP3 confirmed the letters failed to include all of the required information.

Based on review of facility documents and employee interview (EMP), it has been determined that the facility failed to ensure that the Patient Rights document contained the following right: The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital.

Findings include:

Review of "The Ellwood City Hospital Patient's Rights Statement" revealed, "The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital," was not included in the document.

1. On September 6, 2012, at 10:00 AM EMP2, when asked if "The Patient's Rights" contained the statement that the patient has the right to have a family member or representative of his or her choice and his or her physician notified promptly of his or her admission to the hospital," responded, "No, it is not there."

Based on review of facility documents and medical records (MR), and staff interview (EMP), it was determined that the use of restraints was not in accordance with the order of a physician in one of three medical records (MR20).
Findings include:
Review of the Ellwood City Hospital Medical Staff Rules & Regulations reviewed and revised May 2, 2012, revealed, "Medication or treatment shall be administered only upon the written and signed orders of a physician..."
Review of the "Restraint and Seclusion" policy reviewed/revised December 2009, revealed, "H. The use of a restraint or seclusion must be in accordance with the order of a physician permitted by the State and hospital to order a restraint ..."
1. Review of MR20 revealed nursing documentation of a verbal order for soft wrist restraints in the Emergency Department (ED) on July 18, 2012. There was no verbal order written by the nurse and/or signed by the physician. There was no documentation in the ED notes between 4:00 AM and 5:38 AM that the restraints were removed. The nurse in the ICU documented that the patient was received in the ICU at 5:38 AM with "restraints off." At 6:30 AM it was documented that soft wrist restraints were applied. There was no physician order for the reapplication of the restraints.
2. Interview on September 6, 2012, at 1:50 PM with EMP21 revealed, "The ER never documented that the restraints were removed. The admission orders written by the ED physician included orders for wrist restraints but were not timed. You cannot tell what time [whether it was for the use of restraints in the ED or if it was after the patient had them reapplied in the ICU] the order for restraints was written."

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to include a policy for minimum training requirements for physicians and other licensed independent practitioners authorized to order restraint or seclusion to ensure that they have a working knowledge of the hospital policy regarding the use of restraints or seclusion.
Findings include:
Review of the "Restraint and Seclusion" policy reviewed/revised December 2009 revealed, "Staff awareness of the impact of restraint or seclusion. Staff will be educated about how the use of restraint or seclusion might be experienced by the individual and will be committed to preserving the individual's safety and dignity whenever these interventions are employed ..."
1. Further review of the policy revealed it failed to specify training requirements for physicians and other licensed independent practitioners authorized to order restraint and seclusion.
2. Interview on September 5, 2012, with EMP1 at approximately 3:00 PM confirmed the policy did not include the physician and/or licensed practitioner training requirements in regards to the hospital policy and use of restraints/seclusion.

Based on review of facility documents and employee interview (EMP), it was determined the facility failed to have written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reasons for the clinical restriction or limitation.
Findings include:
1. Review of the facility's "Patient Bill of Rights" on September 7, 2012, at approximately 9:15 AM revealed no information regarding visitation rights of patients.
2. Review of the "Patient Handbook" revealed, "Visiting Hours, General Visitation for those over the age of 14 is from Noon to 8:30 PM ..."
3. Interview of EMP2 on September 7, 2012, at 9:20 AM revealed, "There are no policies that address visitation or rationale for visitation. I will tell you that the visitation policy and what is printed is actually wrong, we follow unlimited visitation."

Based on review of facility documents and medical records (MR), and staff interviews (EMP), it was determined the facility failed to ensure that nursing staff developed specific goals and interventions, and kept current nursing care plans for each patient in two of three medical records reviewed in the ICU and Medical/Surgical unit (MR21 and MR23).
Findings include:
1. Review of facility policies/procedures on September 7, 2012, at approximately 1:00 PM failed to reveal a policy/procedure regarding nursing care plans.
2. Interview with EMP2 on September 7, 2012, at 2:45 PM confirmed the facility did not have a nursing care plan policy/procedure.
3. Review of MR21 on September 6, 2012, at approximately 3:00 PM revealed a nursing care plan indicating an intervention for the patient was "behavior management." No description of the behavior management intervention or specific goals for the patient were identified on the care plan. Interview at the time of the review with EMP21 confirmed the care plan did not specify what specific interventions were included in the "behavior" modification or what specific goal was to be achieved.
4. Review of MR23 on September 7, 2012, at approximately 10:50 AM revealed the patient was elderly, had a history of back pain and falls, was placed on Heparin, a blood thinning medication, to prevent the formation of blood clots, and had been ordered a new back brace. Review of the patient's nursing care plan included only that "fall prevention" was a goal and failed to include specific information of what type of assistance was required for the patient to ambulate safely, that the patient was at risk for blood clots and receiving heparin preventatively, and that the patient had a new back brace. Interview at the time of the review with EMP27 confirmed there was nothing specific in the nursing care plan and revealed, "We don't use that, we use the Kardex."

Based on review of facility documents and staff interviews (EMP), it was determined the facility failed to ensure that medical records were promptly completed for 233 of 678 medical records.
Findings include:
Review of the Ellwood City Hospital Medical Staff Rules & Regulations reviewed and revised May 2, 2012, revealed, "16. The patient's medical record shall be complete at time of discharge, including progress notes, final diagnosis and/or (dictated) clinical resume'... If the record still remains incomplete thirty (30) days after all essential reports have been received and placed on the chart, the Executive Committee or their designee shall notify the practitioner by certified, receipted mail that his privileges to admit patients shall be suspended until the records have been completed. The admitting office shall be notified of this actions Three such suspensions of admitting privileges within any twelve (12) month period shall be sufficient cause for permanent suspension of the privileges of the hospital for that practitioner. (Refer to policy and procedure on Delinquent Medical Records). Attachment #1... Completion of Medical Records [attached] revealed, "A. In accordance with the Rules and Regulations of the Medical Staff, medical records of discharged patients are to be completed within 30 days unless there are extenuating circumstances. B. Any member of the active Medical Staff having any outstanding delinquent records is suspended. A physician suspended for delinquent records will be permitted to care for patients presently inhouse but will not be permitted to admit or perform elective surgery on any patient... Action ... 3. After 20 days sends a letter on pink paper that is considered a warning letter that they will be fined $1.00 per day per chart for any charts not completed within 30 days..."
1. Review of a list of delinquent medical records revealed that there were 233 medical records that were not complete 30 days or longer after the patients were discharged. The list included 41 physicians that had from 1-53 delinquent records and also included four records by four nursing staff that had incomplete documentation.
2. Interview on September 6, 2012, at 3:50 PM with EMP25 revealed, "The oldest delinquency is from the end of June or the first of July, except for one physician that has not signed off from the first part of the year [2012]." When asked what the policy was for staff that were delinquent in completing medical records, EMP25 stated, "The By-Laws say to suspend." There was no reference to what happened when nursing staff had incomplete documentation. When asked how many physicians were suspended, EMP25 said, "None."

Based on review of facility documents, review of medical records (MR), and staff interview (EMP), it was determined that all orders, including verbal orders were dated, timed, and authenticated by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures in four of 30 medical records (MR18,MR19, MR20, MR23).
Findings include:
Review of the Ellwood City Hospital Medical Staff Rules & Regulations reviewed and revised May 2, 2012, revealed, "7. All clinical entries int he patient's medical record shall be accurately dated, and authenticated. All entries made by allied health professional must be countersigned by the attending practitioner. Authentication means to establish authorship by written signature, identifiable initials or computer key..."
Review of "Administering Medications " policy, no date provided, revealed, " 1. Any medication administered to a patient is based on a written order by a physician ... 2. A Complete medication order includes the name of the patient, the name of the drug, dosage, route, frequency of administration, date and time of order and physician's signature ... Verbal orders and telephone orders are to be countersigned by the physician within 24 hours."
Review of "General Orders Dosing Guidelines for Dosing for Sedation and Analgesia" revealed, "Propofol (Patient must be mechanically ventilated with an artificial airway to order Propofol.) -10-20 mg IV every 2-5 minutes to obtain sedation goal. Maximum 40 mg -Titrate continuous infusion by 10 mcg/kg/min every 5 minutes until sedation goal is achieved to a maximum of 50 mcg/kg/min ... Propofol ... Initial dose___ mg IV [to be filled in by the physician], may repeat in 5 minutes x 1 if needed to obtain sedation goal ... Infusion rate to begin at ____ mcg/kg/min [to be completed by the physician]. Titrate infusion to increments of ____ mcg/kg/min [to be completed by the physician]; dosage may be increased every 15 minutes ... Richmond Agitation-Sedation Scale (RASS level) _____ [to be completed by the physician] (A goal Richmond Agitation-Sedation Scale level must be selected for the guidelines to be utilized ..." There was a line for the signature of the person ordering the protocol and the date and time the order was written.
1. Review of MR18 on September 6, 2012, at 11:10 AM revealed admission orders on January 14, 2012, that were written without noting a time the orders were written including orders for medications, treatments, bloodwork, etc. Interview at the time of the review with EMP21 confirmed the orders should have been timed when they were written and revealed, "They didn't mark the time it was written."
Further review of the medical record revealed an order for Diprivan PRN for sedation. There was no level of the sedation the physician wanted to maintain.
Interview with EMP21 at the time of the review confirmed the order did not include information to guide the nurse administering the medication to obtain the level of sedation the physician wanted to obtain. EMP21 stated, "We don't normally get an order [for the titration level] when the patient comes from the ED. If we initiate the order [in ICU] we ask for the protocol which includes those orders."
2. Review of MR19 on September 6, 2012, at approximately 11:50 AM revealed a telephone order, "Wean off of sedation wean vent to T. tube and when able to breath [sic] on own D/C." Further review of the record revealed an additional order written by the physician that included orders for treatments and procedures written on February 4, 2012 with no time the order was written.
Interview on September 6, 2012, at 12:10 PM with EMP21 confirmed the missing date.
3. Review of MR20 on September 6, 2012, at approximately 1:15 PM revealed an order for the patient to have Diprivan titrated PRN not to exceed 50 [mcg] but did not include the level of sedation the patient was to be maintained at in the physician order.
Interview on September 6, 2012, at 1:45 PM with EMP21 confirmed there was no level of sedation specified, and revealed, "The order doesn't say but the physician likes the level around negative 2."
4. Review of MR21 on September 6, 2012, at approximately 3:00 PM revealed physician orders on September, 2012, September 3, 2012, x 2, September 4, 2012, September 5, 2012, and September 6, 2012, including orders written by the physician and telephone orders written by the nurse, signed and dated by the physician were not timed.
Interview at the time of the review with EMP22 confirmed the above findings.
5. Review of MR23 on September 7, 2012, at approximately 10:45 AM revealed telephone orders dated September 3, 2012 that were co-signed by the physician without a time they were co-signed, two orders written by the Physician Assistant without a time on September 4, 2012, an order written by the Physician Assistant on September 5, 2012, that did not contain a time when the physician co-signed it, and an order written by the Physician Assistant on September 6, 2012, that did not contain a time when the order was written.

Based on review of facility documentation, and staff interview (EMP), it was determined that the facility failed ensure that drug storage in the Pharmacy Department was administered with accepted professional principals.

Findings include:

Review of the Ellwood City Hospital Department of Pharmacy Policy and Procedure Quality Control- Medication Storage Areas- Monthly Inspections, revised December 2011 revealed, "Intent: The Pharmacy department is responsible for assuring medications are properly stored and accounted for throughout the hospital. ... Policy: 1. Medications shall be stored under the proper conditions of light, temperature, moisture, ventilation, segregation, and security. ... 3. Medications stocked in a particular area shall have a corresponding list posted identifying the medications stocked and the quantity stocked."

1. Tour of the Pharmacy Department on September 7, 2012, at approximately 10:20 AM revealed an unmonitored break room with three boxes of expired/distressed medications. When asked for a list of the inventory of the medications, EMP13 stated that there was no list and the medications were not reconciled. When asked if there was any way to account for medications after they are placed in the box, EMP13 stated, "No."

Based on review of facility documents and staff interviews (EMP), it was determined the facility failed to develop and maintain the environment in such a manner to ensure the safety and well-being of patients as evidenced by the lack of fire drills at two satellite locations.
Findings include:
1. Review of documentation of hospital fire drills failed to reveal any documentation of fire drills at any satellite locations.
2. Interview on September 7, 2012, at 11:45 AM with EMP30 revealed there were no satellite locations under the hospital provider number that he/she was aware of.
3. Interview on September 7, 2012, at 12:05 PM with EMP2 revealed the hospital had two satellite locations.
4. An additional interview on September 7, 2012, at 12:10 PM with EMP30 confirmed there were no fire drills completed at those aforementioned satellite locations.

Based on review of facility documents, personnel file (PF), and staff interviews (EMP), it was determined the facility failed to designate an infection control officer or officers in writing.
Findings include:
Review of the May 17, 2005 Medical Staff Bylaws of the Ellwood City Hospital revealed, "When a function is to be carried out by a person or committee, the person, or the committee through its chairperson, may delegate performance of the function to one or more qualified designees..."
1. Review of the 2012 infection control plan failed to identify an infection control officer or officers.
2. Review of 2012 Infection Control Committee Minutes revealed minutes for the January 17, 2012, and April 17, 2012 meetings listed EMP3 with initials "ICC" after his/her name [Infection Control Coordinator]. EMP35 was listed as "IC" [Infection Control] RN. The January 17, 2012, minutes revealed EMP3 asked EMP35 to "run any future meetings of this committee."
3. Review of the personnel file for EMP3 on September 7, 2012, revealed a copy of a job description for an Infection Control Nurse. The job description failed to include qualifications for the position that demonstrated that education, training, experience, or certification were requirements for the position.
4. Interview with EMP3 on September 6, 2012, at 9:35 AM when asked who was the infection control officer or coordinator revealed, "I would guess I was." When asked if EMP3 had been given a job description for the position of infection control coordinator, EMP3 replied, "I don't know about a job description." EMP3 added, "EMP35 does all of the infection control." When asked when EMP35 worked, EMP3 replied, "[He/she] is only part time."
5. Interview on September 7, 2012, at approximately 2:45 PM with EMP2 confirmed that the job description had just been added to EMP3's personnel file after it was requested by the surveyor.

Based on review of facility documents, review of medical records (MR), and staff interview (EMP), it was determined the facility failed to identify all patients who are likely to suffer adverse health consequences upon discharge if there is no adequate discharge planning as evidenced by a lack of documentation of discharge planning for one of 16 medical records (MR22).
Findings include:
Review of the "Procedure for Discharge Planning" policy revised February 2009, revealed, " 1. The Social Service Department of the Ellwood City Hospital and Mary Evans Extended Care Center shall be responsible for Discharge Planning ... 4. Discharge objectives will be identified and discussed with the patient and his/her representatives at the time of the initial interview, which will be prior to or on admission. 5. The Discharge Coordinator will evaluate the physical-social and emotional factors involved in the total plan ... "
Review of "Discharge Planning Social Service Discharge Planning/Continuity of Care" policy revised/reviewed February 2009, revealed, "Discharge planning ensures continuity of care for each patient which begins on admission and is developed throughout the hospital stay in order to reach the appropriate level of care ..."
1. Review of MR22 on September 7, 2012 at 10:25 AM revealed the patient was an elderly patient admitted to the hospital with chest pain on September 6, 2012. The nursing admission assessment revealed the patient also had a history of high blood pressure, macular degeneration, colon cancer, diabetes mellitus, and renal insufficiency. The assessment further revealed that the patient lived alone, and had one child that did not live at home. The patient was noted to have a "swelling" under the left knee from a fall from approximately a month previously and a fall assessment noted, "Patient is 'at risk' for a fall. The discharge plan indicated that social services had seen the patient and would "follow" but did not include if the patient was to go home, would require additional services, etc.
2. Interview on September 7, 2012, at 10:05 AM with EMP26 revealed, "[MR22] is discharged today."
3. Interview on September 7, 2012, at 10:25 AM with EMP26 confirmed that the patient was discharged and there was no documentation of what the plan was for when the patient was discharged.

Based on review of facility documents and medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure that Histories and Physicals (H&P), completed within 30 days prior to admission, were updated after admission and prior to surgery, for two of two medical records (MR13, MR14) and failed to ensure that a new History and Physical was completed for one of one record (MR15), whose H&P was older than 30 days.

Findings include:

Review of the Ellwood City Hospital Medical Staff Rules and Regulations, approved May 2, 2012, revealed, "Surgical Department Rules and Regulations ... 4. Requirements prior to anesthesia and operation: History and Physical on chart or note that the patient has been physiologically cleared for surgery, H&P done within 7 days. An update must be done if the H&P if [sic.] more than seven days old. Physicians are to perform History and Physicals for exams and procedures regardless of the type of anesthesia used as well as procedures which involve no anesthesia or a local."

1. Review of MR13 revealed an H&P dictated July 3, 2012. The review further revealed no update to the H&P for a procedure performed on July 5, 2012.

On September 6, 2012, at 11:20 AM EMP2 confirmed there was no update to the H&P, "No. It's not there."

2. Review of MR14 revealed an H&P dictated June 27, 2012. The review further revealed no update to the H&P for a procedure performed on June 28, 2012.

3. Review of MR15 revealed an H&P dictated June 18, 2012. The review further revealed that a new H&P was not completed for a procedure performed on July 19, 2012.

4. On September 6, 2012, at 1:30 PM EMP2 confirmed there was no update to the H&P for MR14 and MR15.

Based on review of facility documents and medical records (MR), and staff interviews (EMP), it was determined the facility failed to ensure that diprivan, a medication used to sedate patients, was administered in accordance with orders of the practitioner(s) responsible for the patient's care in three of three medical records (MR18, MR19 and MR20).
Findings include:
Review of the Ellwood City Hospital Medical Staff Rules and Regulations reviewed and revised May 2, 2012, revealed, "Medication or treatment shall be administered only upon the written and signed orders of a physician..."
Review of "Administering Medications" policy, no date provided, revealed, "1. Any medication administered to a patient is based on a written order by a physician ... 2. A Complete medication order includes the name of the patient, the name of the drug, dosage, route, frequency of administration, date and time of order and physician's signature ... Verbal orders and telephone orders are to be countersigned by the physician within 24 hours."
Review of "General Orders Dosing Guidelines for Dosing for Sedation and Analgesia" revealed, "Propofol (Patient must be mechanically ventilated with an artificial airway to order Propofol.) -10-20 mg IV every 2-5 minutes to obtain sedation goal. Maximum 40 mg -Titrate continuous infusion by 10 mcg/kg/min every 5 minutes until sedation goal is achieved to a maximum of 50 mcg/kg/min ... Propofol ... Initial dose___ [blank] mg IV, may repeat in 5 minutes x 1 if needed to obtain sedation goal ... Infusion rate to begin at ____ [blank] mcg/kg/min. Titrate infusion to increments of ____ [blank] mcg/kg/min; dosage may be increased every 15 minutes ... Richmond Agitation-Sedation Scale (RASS level) _____ [blank] (A goal Richmond Agitation-Sedation Scale level must be selected for the guidelines to be utilized ..." There was a line for the signature of the person ordering the protocol and the date and time the order was written.
1. Review of MR18 revealed the patient was ordered a Diprivan drip PRN for sedation following intubation in the Emergency Department on January 14, 2012. There was no specific order for the rate of the IV or level of sedation at which the patient was to be maintained. Interview on September 6, 2012, at 11:25 AM with EMP21 confirmed the lack of a specific order and level of sedation desired, and revealed that the patient's medication was adjusted by the nurses in the ICU. "In the ICU we have a protocol for Diprivan." When asked to confirm there was no copy of a protocol in the medical record, EMP21 confirmed there was no copy in the medical record because the ED physician was the one that ordered the medication initially and did not order the protocol to be followed. The nurses' notes revealed that the Diprivan was increased to 50 mcg for a procedure on the day of admission, that the Diprivan was "titrated down" to 30 mcg a half hour later, and that the Diprivan was stopped an hour after the first titration.
2. Review of MR19 revealed the patient was ordered Diprivan in the Emergency Department when he/she was intubated and placed on mechanical ventilation on February 2, 2012. The order was for Diprivan 25 mcg/kg/min. "Titrate for sedation." No level of sedation was specified. The patient was transferred to the Intensive Care Unit (ICU) where the medication was adjusted by the RN eight times prior to the medication being discontinued without a written order as to the desired level of sedation. Interview on September 6, 2012, at approximately 11:55 AM with EMP21 confirmed there was no written order with a level of desired sedation and revealed, "We don't normally get the [written] orders when the patient comes to us from the ER. If we initiate it [the Diprivan] we ask the physician for the protocol."
3. Review of MR20 on September 6, 2012, at approximately 2:00 PM revealed the patient was ordered Diprivan in the Emergency Department when he/she was intubated and placed on mechanical ventilation on July 18, 2012. The order noted the Diprivan was to be titrated PRN "not exceed 50." No sedation level was indicated to guide nursing staff in determining how to titrate the medication to maintain the level of sedation desired by the physician. Further review of the medical record revealed the medication was adjusted six times without any order designating what sedation level was desired. Interview with EMP21 at the time of the review confirmed there was no desired level of sedation included in the physician order and revealed, "The order doesn't say, but the physician likes the sedation level to be around negative 2."

Based on review of facility documents and medical records (MR), and employee interview (EMP), it has been determined that the facility failed to provide documentation in the patients' medical record that the freedom of choice list was given to the patient or person acting on the patient's behalf in three of three charts reviewed for patients discharged with home health. (MR1, MR2, and MR3)

Review of the facility's procedure for discharge planning revealed, " ... The Discharge Coordinator will assist patients and their families with obtaining such services as ... medical equipment, ... home nursing visits, when necessary the patient and or family member will be referred to the appropriate community agency which can best assist them in obtaining the service needed."
Review of the facility policy for social service discharge planning revealed, " ... Goals: ... 4. Provide facility and community resource information for patients and family awareness/ involvement in decision making ..."
Review of the facility policy for Social Service/ Discharge Planning, Social Service Referrals Procedure states, " ... Responsibility Social Service/ Discharge Coordinator ... 4. Document on patient's record."
1. Review of MR3 on September 6, 2012, at 11:30 AM revealed an order for a Home Health referral on July 17, 2012, at 10:10 AM. The order read, "Home Health consult for wound care and follow up in the office on July 20, 2012." There is no documentation of the patient being provided a list of Home Health Agencies from which to choose.
2. Review of MR2 on September 6, 2012, at 11:15 AM revealed an order for home health on December 6, 2011. A note on December 6, 2011, at 1:11 PM states "Discharge to home and will follow with physician. Home Health Care to follow at time of discharge." There is no documentation of the patient being provided a list of Home Health Agencies form which to choose.
3. Review of MR1 on September 6, 2012, at 11:00 AM revealed an order for Home Health which was written on August 1, 2012. at 10:45 AM, "Home health for nursing and physical therapy, and home oxygen." The social services note documented, "Discharge to home and will follow with physician. [Patient] will continue with services from Ellwood Respiratory where [patient] has [his/her] oxygen. Now orders faxed ... [Patient] will be followed by Ellwood City Home Health."
Interview with EMP2 and EMP6 on September 6, 2012, at 1:20 PM confirmed that if there is no documentation in the computer system, then freedom of choice would not be documented in the medical record.