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Based on record reviews (Medical Staff Bylaws and Rules and Regulations) and staff interviews, the governing body failed to ensure the medical staff operated under the current Bylaws and Rules and Regulations for History and Physical Examinations as evidenced by failing to have completed history and physical examinations (H & P) for two (#1, #16) of 6 focused sampled medical records reviewed for surgical services (#1, #16, #17, #18, #34, #37) out of a total of 40 sampled records (#1 through #40) and 1 random sampled record (R1) as per the Medical Staff Bylaws last approved by the board on July 17, 2002 and Medical Staff Rules and Regulations last approved by the board on July 17, 2002.
Findings:

Patient #1:
Review of the medical record for Patient #1 revealed the patient had a right knee arthroscopy procedure performed from 7:32 a.m. (0732) through 9:16 a.m. (0916) on 08/06/12 under general anesthesia.

Review of the "Provider Note" authenticated by S51MD on 06/29/12 at 1:45 p.m. (1345) revealed a physical and health examination was performed on Patient #1. Further review revealed this physical and health examination was documented on "Progress Notes" signed by S50MD at 07/26/12 at 1:12 p.m. (1312) for Patient #1.

The "Department of Anesthesiology Day of Surgery Anesthesia Evaluation/Addendum to Pre-Anesthetic Assessment" form dated/timed 08/06/12 at 6:50 a.m. (0650) for Patient #1 read, "H & P update referred to the surgeon/provider".

Review of the "History and Physical Exam Short Stay Form" by S50 MD for Patient #1 read, "...H & P (history and physical) completed on (date) 7/26/12 has been reviewed, the patient has been examined and: (a square blank box) I concur with the findings (a square blank box) changes are noted below..."-this section on the form was left blank.

Patient #16:
Review of the medical record for Patient #16 revealed the patient had a laparoscopic cholecystectomy and umbilical hernia repair on 08/07/12 under general anesthesia.

Review of the "History and Physical Exam Short Stay Form" signed by S54MD, Resident dated/timed 8/7/12 (08/07/12) at 6:45 a.m. (645) read, "...H & P completed on date (was left blank) has been reviewed, the patient has been examined and: (a square blank box) I concur with the findings (a square blank box) changes are noted below..."-the top portion of this section on the H & P form was left blank. Further review of the H & P revealed there was no documentation S53MD countersigned S54MD, Resident's signature prior to Patient #16's surgical procedure on 08/07/12.

The "Department of Anesthesiology Day of Surgery Anesthesia Evaluation/Addendum to Pre-Anesthetic Assessment" form dated/timed 08/06/12 at 6:50 a.m. (0650) for Patient #16 read, "H & P update referred to the surgeon/provider".

Review of the "Medical Staff Bylaws" approved by the board on July 17, 2002, adopted by the Medical Staff on June 19, 2002, page 21 of 37, page 22 of 37, revealed section, "5.B.1 History and Physical" indicated (1) All patients admitted for outpatient surgery or other procedure that involves the use of anesthesia will have a Complete H&P documented in the medical record within 24 hours. (b) If a Complete H & P has been done within 30 days of inpatient or outpatient admission, an update must be completed prior to surgery or a procedure requiring anesthesia services. If no changes have occurred, the absence of change must be documented. 2) Author of the H&P: H&P shall be the responsibility of the attending physician and/or resident who is licensed and credentialed to record a complete H&P. Residents may write or dictate and sign the H&P. The attending physician is responsible for countersigning the H&P.

Review of the "Medical Staff Rules and Regulations" approved by the Board of Directors on 07/17/02, adopted by the Medical Staff on 06/19/02, page 4 of 11, revealed section "E. History and Physical" indicated (1) All patients admitted to the hospital or registered for outpatient surgery or other procedure that places the patient at risk and/or involves the use of sedation or anesthesia will have a Complete H & P documented in the medical record within 24 hours. (b) If a Complete H & P has been done within 30 days of inpatient or outpatient admission, an update must be completed prior to surgery or a procedure requiring anesthesia services. If no changes have occurred, the absence of change must be documented. 2) Author of the H&P: H&P shall be the responsibility of the attending physician and/or resident who is licensed and credentialed to record a complete H&P...Residents may write or dictate and sign the H&P. The attending physician is responsible for countersigning the H&P.

In interviews on 08/07/12 at 2:35 p.m. and at 3:05 p.m., S55RN, ASC/PACU (ambulatory surgery center/post anesthesia care unit) Clinical Coordinator confirmed S54MD signed the bottom portion of the history and physical examination for Patient #16 on 08/07/12. S55RN further confirmed the top portion of the history and physical examination for Patient #16 was left blank where the physician's (S53MD's) signature/printed name, date and time was to be documented on the form. S55RN indicated a resident is a physician that does not require a countersignature by the attending physician, S53MD. S55RN further indicated a history and physical examination must be complete and filed in all patient's medical records prior to the surgical procedures as per policy. S55RN, ASC/PACU stated the history and physical for Patient #16 is incomplete.

During interviews held on 08/08/12 at 12:30 p.m., Chief Operating Officer (COO), S5 and the V.P. (vice president) of Quality and Safety, S10 both indicated there was no written policy regarding a H&P Examination of a patient prior to surgery. S5 and S10 both verified the H&P Examination of the patient is addressed in the Medical Staff Bylaws and in the Medical Staff Rules and Regulations that require the H&P to be documented and completed with specific components by a qualified physician and/or resident. The COO, S5 and VP of Quality and Safety, S10 further verified the H&P completed by a resident must be countersigned by the attending physician as per the Medical Staff Bylaws and the Medical Staff Rules and Regulations. S5COO and S10VP of Quality and Safety both indicated the Medical Staff Bylaws and Rules and Regulations were not being followed for H&P Examinations to be completed and countersigned by the attending physician prior to the surgical procedures.

Based on interview and record review, the hospital failed to ensure the nursing staff obtained a Physician's Order promptly for the use of restraints for 1 (#30) of 9 (#26, #27, #28, #29, #30, #31, #32, #33, #34) sampled patients.
Findings:
A review of the Physician Progress Notes for Patient #30 dated 8/6/12 at 3:50 a.m. revealed he had been having respiratory distress and oxygen saturations in the 70's on a NR (non-rebreather mask). Review of a Physician's Order for Patient #30 dated 8/6/12 at 4:05 a.m. revealed he had been intubated and placed on a ventilator.
A review was made of the document titled Restraint Order dated 8/6/12 at 0430 (4:30 a.m.) for Patient #30. The reasons for restraining Patient #30 were marked as pulling lines, intubation, and dementia. Patient #30 was also listed as having nonviolent behavior. The verbal order from a physician for the use of the restraints was documented as having been received by the nurse at 0700 (7:00 a.m.) on 8/6/12. Further review of the medical record for Patient #30 revealed no other Physician's orders for restraints on 8/6/12.
In an interview on 8/6/12 at 3:50 p.m. with the Intensive Care Unit Director (campus "a") S25, he verified the restraint order sheet for Patient #30 indicated his restraints were applied on 8/6/12 at 4:30 a.m. and the Physician was not notified until 8/6/12 at 7:00 a.m. S25 stated it was not appropriate to place a nonviolent patient in restraints without obtaining a physician's order before or shortly after the application. S25 could not find any other Physician documentation in Patient #30's medical record ordering or acknowledging restraints on 8/6/12.
A review was made of the Policy titled Restraint/Seclusion Use, Policy Number OMC.MED.006, revised on 10/09. The policy stated in part:
E. Patients shall be safely placed in restraints/seclusion on the written order of a licensed independent practitioner. The attending physician must be consulted as soon as possible if the attending did not order the restraint/seclusion.

Based on record reviews (Medical Staff Bylaws) and staff interviews, the medical staff failed to enforce the bylaws for History and Physical Examinations as evidenced by failing to have completed history and physical examinations (H & P) for two (#1, #16) of 6 focused sampled medical records reviewed for surgical services (#1, #16, #17, #18, #34, #37) out of a total of 40 sampled records (#1 through #40) and 1 random sampled record (R1) as per the Medical Staff Bylaws last approved by the board on July 17, 2002.
Findings:

Patient #1:
Review of the medical record for Patient #1 revealed the patient had a right knee arthroscopy procedure performed from 7:32 a.m. (0732) through 9:16 a.m. (0916) on 08/06/12 under general anesthesia.

Review of the "Provider Note" authenticated by S51MD on 06/29/12 at 1:45 p.m. (1345) revealed a physical and health examination was performed on Patient #1. Further review revealed there was a physical and health examination documented on the "Progress Notes" signed by S50MD at 07/26/12 at 1:12 p.m. (1312) for Patient #1.

The "Department of Anesthesiology Day of Surgery Anesthesia Evaluation/Addendum to Pre-Anesthetic Assessment" form dated/timed 08/06/12 at 6:50 a.m. (0650) for Patient #1 read, "H & P update referred to the surgeon/provider".

Review of the "History and Physical Exam Short Stay Form" by S50 MD for Patient #1 read, "...H & P (history and physical) completed on (date) 7/26/12 has been reviewed, the patient has been examined and: (a square blank box) I concur with the findings (a square blank box) changes are noted below..."-this section on the form was left blank.

Patient #16:
Review of the medical record for Patient #16 revealed the patient had a laparoscopic cholecystectomy and umbilical hernia repair on 08/07/12 under general anesthesia.

Review of the "History and Physical Exam Short Stay Form" signed by S54MD, Resident dated/timed 8/7/12 (08/07/12) at 6:45 a.m. (645) read, "...H & P completed on date (was left blank) has been reviewed, the patient has been examined and: (a square blank box) I concur with the findings (a square blank box) changes are noted below..."-the top portion of this section on the H & P form was left blank. Further review of the H & P revealed there was no documentation S53MD countersigned S54MD, Resident's signature prior to Patient #16's surgical procedure on 08/07/12.

The "Department of Anesthesiology Day of Surgery Anesthesia Evaluation/Addendum to Pre-Anesthetic Assessment" form dated/timed 08/06/12 at 6:50 a.m. (0650) for Patient #16 read, "H & P update referred to the surgeon/provider".

In interviews on 08/07/12 at 2:35 p.m. and at 3:05 p.m., S55RN, ASC/PACU (ambulatory surgery center/post anesthesia care unit) Clinical Coordinator confirmed S54MD signed the bottom portion of the history and physical examination for Patient #16 on 08/07/12. S55RN further confirmed the top portion of the history and physical examination for Patient #16 was left blank where the physician's (S53MD's) signature/printed name, date and time was to be documented on the form. S55RN indicated a resident is a physician that does not require a countersignature by the attending physician, S53MD. S55RN further indicated a history and physical examination must be complete and filed in all patient's medical records prior to the surgical procedures as per policy. S55RN, ASC/PACU stated the history and physical for Patient #16 is incomplete.

During interviews held on 08/08/12 at 12:30 p.m., Chief Operating Officer (COO), S5 and the V.P. (vice president) of Quality and Safety, S10 both indicated there was no written policy regarding a H&P Examination of a patient prior to surgery. S5 and S10 both verified the H&P Examination of the patient is addressed in the Medical Staff Bylaws requiring the H&P to be documented and completed with specific components by a qualified physician and/or resident. S5COO and S10VP of Quality and Safety further verified the H&P completed by a resident must be countersigned by the attending physician as per the Medical Staff Bylaws. S5 and S10 both indicated the Medical Staff Bylaws were not being followed for H&P Examinations to be completed and countersigned by the attending physician.

Review of the "Medical Staff Bylaws" approved by the board on July 17, 2002, adopted by the Medical Staff on June 19, 2002, page 21 of 37, page 22 of 37, revealed section, "5.B.1 History and Physical" indicated (1) All patients admitted for outpatient surgery or other procedure that involves the use of anesthesia will have a Complete H&P documented in the medical record within 24 hours. (b) If a Complete H & P has been done within 30 days of inpatient or outpatient admission, an update must be completed prior to surgery or a procedure requiring anesthesia services. If no changes have occurred, the absence of change must be documented. 2) Author of the H&P: H&P shall be the responsibility of the attending physician and/or resident who is licensed and credentialed to record a complete H&P. Residents may write or dictate and sign the H&P. The attending physician is responsible for countersigning the H&P.

Based on record review and interview the hospital failed to ensure a registered nurse performed neurological checks every 4 hours as order by the physician for 1 patient (#33) out of a sample of 9 (#26, #27, #28, #29, #30, #31, #32, #33, #34) at campus "a" as evidenced by 34 out of 36 neurological checks not having documented evidence of being performed at the times ordered. Findings:

Patient #33 was an 81 year old female who admitted to the hospital on 7/31/12 for nausea, vomiting, diarrhea, dizziness and shortness of breath.
Review of her admission orders dated 08/01/12 at 0025 (12:25 a.m.) revealed an order for neurochecks q (every) 4 hours and an order for a neuro consult for uncontrolled vertigo.
Review of the patient's Plan of Care revealed to perform neurological assessments every 4 hours.
Review of the neurological assessments in the computerized charting system revealed the neurological assessments were done only twice on 8/2/12 at 7:40 a.m. and 8/2/12 at 10:20 a.m. since ordered by the physician on 8/1/12. Only 2 times were the neurological assessments performed out of 36 times ordered by the physician from 8/1/12 until 8/7/12.
An interview was conducted with S27Telemetry Director on 8/7/12 at 10 a.m. She reported the neurological assessments were not done as ordered for Patient #33.

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Based on interviews and record reviews, the hospital failed to:
1. ensure the nursing staff developed nursing interventions for problems identified on the care plan for 1 (#27) of 9 (#26, #27, #28,#29,#30, #31, #32, #33, #34) sampled patients.
2. ensure the patient's main diagnosis/problem was included in the patient's plan of care for 1 (#26) out of 9 sampled patients on campus "a" (#26, #27, #28, #29, #30, #31, #32, #33, #34).
Findings:
1)
Patient #27
Review of the Admission Summary for Patient #27 dated 7/30/12 revealed she had been admitted to the Neonatal Intensive Care Unit (NICU) on 7/30/12. Her gestational age at birth was 29 weeks and 1 day.
Review of the document titled Interdisciplinary Plan of Care for Patient #27 revealed the following problems listed: Parenting Education R/T (related to) newborn care, Potential/Actual alteration in comfort R/T disease process, invasive procedures and skin breakdown, Ineffective Thermoregulation R/T prematurity, and Alteration in Metabolic Function Hyperbilirubinemia R/T impaired excretion of bilirubin. Further review revealed no nursing interventions were listed for the problems.
In an interview with NICU Director (Campus "a") S26 on 8/6/12 at 1:35 p.m., she verified no interventions were listed for the above mentioned problems. She also stated none of the 5 babies in the NICU or the 5 babies in the intermediate care nursery had nursing interventions listed for their problems on their care plans. S26 stated the nursing interventions were on the nurse round report.
In an interview with Infomatics Manager S28 on 8/6/12 at 1:50 p.m., he stated the nurse round report for Patient #27 contained a list of Physician's Orders, not nursing interventions. After further review, NICU Director (Campus "a") S26 agreed that the nurse round report did not contain nursing interventions.
2)

Patient #26
Review of Patient #26's medical record revealed she was a 33 year old female admitted to the hospital on 7/29/12. Her diagnoses include: End-stage renal disease, insulin-dependent diabetic, right upper extremity cellulites, hypertension, central vein stenosis or superior vena cava syndrome.
Review of the Patient's Plan of Care revealed her Problems listed on her care plan were Activity Intolerance, Risk for Injury, Altered Comfort, High Risk for Infection, and Knowledge deficit. There was no problem or interventions listed for her receiving dialysis three times a week or her diagnosis of End Stage Renal Disease(ESRD).

An interview was conducted with S27Telemetry Director on 8/6/12 at 3:35 p.m. She reported the patient's main diagnosis was End Stage Renal Disease and she was receiving dialysis and a problem for that diagnoses should have been included in her plan of care.

Based on record review and interview the hospital failed to ensure all drugs and biological were administered according to physician orders and acceptable standards of practice for 4 (#26, #32, #33, #34) out of 40 sampled patients.
Findings:
Patient #26
Review of Patient #26's medical record revealed she was a 33 year old female admitted to the hospital on 7/29/12. Her diagnoses include: End-stage renal disease, insulin-dependent diabetic, right upper extremity cellulites, hypertension, central vein stenosis or superior vena cava syndrome.
Review of Patient #26's culture results of 7/31/12 at 02:00 (2 a.m.) revealed "slight methicillin resistant staphylococcus aureus culture rt (right) stump wound. Susceptibilities...Gentamycin and Vancomycin ..."
Review of the Admission Orders dated 7/29/12 and timed 1310 (1:10 p.m.) revealed an order for Vanc (Vancomycin) 1 gram IV (intravenous) q (every) 24h (hours).
Review of the Physician's Orders for 7/30/12 at 9 a.m. revealed an order to change Vanc to 1 gr (gram) IV p (after) each dialysis.
Review of the Physician's Order for 7/30/12 at 4:15 p.m. revealed an order for Vancomycin i (1) g (gram) IVPB (intravenous piggy back) p (after) HD (hemodialysis) x i and Gentamycin 100 mg IVPB p HD x i.
Review of the MAR (Medication Admission Record) from 7/30/12 until 08/06/12 revealed the patient had never received a dose of Vancomycin 1 gram IV since admission to the hospital. Review of the patient's medical record revealed she was schedule for dialysis and received dialysis on 7/30/12, 8/02/12, and 08/04/12.
An interview was conducted with S27Telemetry Director, campus "a", on 08/06/12 at 1:30 p.m. She stated after review of the record and calling pharmacy that the patient had never received a dose of Vancomycin since being admitted to the hospital on 7/30/12.
On 8/6/12 at 2:15 S27 reported to the patient's infection disease physician, S38, that the patient had not received any Vancomycin as ordered. S38MD stated to S27Telemetry Director it was totally unacceptable and no wonder she was not getting better. S38MD also stated he had already consulted surgery, but he thought she was getting the antibiotics.
An interview was conducted with S38Infectious Disease physician on 08/06/12 at 2:40 p.m. When questioned if the missed antibiotics affected the patient's progress, he stated he had not seen a response through the weekend, there was no change in the patient's condition.
Review of the MAR from 7/30/12 to 08/06/12 revealed the patient received the Gentamycin 100 mg IVPB q HD x i on 7/31/12 at 0130 (1:30 a.m.).
An interview was conducted with S27Telemetry Director campus "a" on 08/6/12 at 1:30 p.m. She stated the patient's dialysis was completed at 1705 (5:05 p.m.) on 7/30/12 and the Gentamycin should have been given then. She confirmed the Gentamycin was administered 8 hours late on 7/31/12 at 1:30 a.m.
Review of the ID (infectious disease) physician's progress note (S38) from 08/06/12 revealed in part, "R (right) arm still swollen, still tender, Nurses notified me that vanc (Vancomycin) doses missed due to errors. Will d/c (discontinue) Vanc. Start Zyvox 600 mg IV q 12 h round the clock. Continue Gent (gentamycin). Consulted surgery for poss (possible) compartment syndrome."
Review of the Physician's Order for 8/6/12 revealed Zyvox 600 mg IV q 12 h, 1st dose stat and Gentamycin 100 mg IV after every dialysis. The order was signed by S38Infectious Disease MD, campus "a".
Review of an Incident Report (called a SOS at the hospital) dated 8/6/12 at 14:30 (2:30 p.m.) revealed S27Telemetry Director campus "a" completed the form. The incident was listed as an omission of Gentamycin. The reported incident Severity was a category E-treatment/intervention and temp (temporary) harm. "Spoke with Night shift nurse. Gentamycin given at 0130 (1:30 a.m.) the next day after recognizing that it was not given after dialysis."
Review of an Incident Report dated 08/06/12 at 14:30 (2:30 p.m.) revealed S27Telemetry Director campus "a" completed the form. The incident was list as an omission, medication/fluid error of Vancomycin. The reported incident severity was listed as category E- treatment/intervention and temp harm. "On 7/30/12, Vancomycin 1 gram ordered to be given by dialysis, no documentation of administration. Medication/Treatment ordered Zyvox 600 mg every 24 hours. Dr. S38Infectious Disease, campus "a" notified and orders for Zyvox ordered every 24 hours. Follow up list: description: Staff education regarding midnight check and 24 hour chart checks."
Review of the Admission Order dated 7/29/12 and timed 1310 (1:10 p.m.) revealed an order was noted for Administer Novolog insulin SubQ(subcutaeous) on prescribed schedule below. Administer before meals and nightly (AC/HS) for patients who are able to eat per sliding scale and administer at 0200 (2 a.m.) for patients on AC/HS monitoring per sliding scale. Moderate dose:
Glucose level Units
151-200 2 Units
201-250 4 Units
251-300 6 Units
301-350 8 Units
351-400 10 Units
>400 12 Units

Hypoglycemia protocol: any BG (blood glucose) < 60 mg/dl (milligrams per deciliter) or a BG < 80 mg/dl associated with symptoms of hypoglycemia. For patient who can take po (by mouth) give 15 g (gram) carbohydrates such as 4 oz. (ounces) of juice or 3 packets of sugar or 5 saline crackers or 3 graham cracker squares. Note: Dialysis patient; use apple or grape juice, not orange juice. If patient cannot take po, give D50W 25 ml (milliliters) 12.5 g IV push.

Review of the Nursing Nts (Notes) dated 05 Aug 2012 17:00 (8/5/12 at 5 p.m.) revealed, " PT (patient) BS (blood sugar) 31. PT stated she feels weak but shows no other signs of distress. Pushed prn (as needed) dextrose and pt drank orange juice with sugar packets. Rechecked PT BS 175. Pt sitting up in bed eating dinner ..."

An interview was conducted with S27Telemetry Director on 08/6/12 at 3:15 p.m. She confirmed the patient should not have been given orange juice since she was on dialysis and the patient was able to take glucose by mouth so the nurse should not have given dextrose intravenously. She confirmed the nurse did not follow the MD's orders.

Review of the Physician's Orders dated 08/04/12 at 2103 (9:03 p.m.) revealed on order for Flexeril 10 mg po q 8 hours prn (as needed) for muscle spasms, 1st dose now.
Review of the Medication Record for 08/04/12 revealed no documentation that the 1st dose of Flexeril 10 mg was not administered to the patient.
An interview was conducted with S27Telemetry Director on 08/6/12 at 2:30 p.m. She stated there was no documentation of the 1st dose of Flexeril given.
Review of the incident reported dated 08/06/12 at 14:30 (2:30 p.m.) completed by S27Telemetry Director revealed the Flexeril was an omission error. It was listed as a category E- treatment/intervention and temp harm.
Patient #32
Record review revealed Patient #32 was a 49 year old male found unresponsive at a local nursing home. He was admitted to the Emergency Department at the hospital on 5/14/12.
Review of Emergency Department Physician's Orders for Patient #32 revealed an order dated 5/14/12 at 06:23 a.m. for Dopamine (intravenous medicine to increase blood pressure) 400MG (milligrams)/250 mL (milliliters) D5W (5% Dextrose Solution) 5 MCG/KG/MIN (micrograms/Kilograms/minute). Further orders were for the nurse to titrate (adjust) to SBP (Systolic Blood Pressure) greater than 100 with a maximum of 20 mcg/kg/min.
Review of Intensive Care Unit (ICU) admit orders dated 5/14/12 at 11:00 (a.m.) revealed an order for Dopamine drip 5mcg/kg/min-titrate to MAP> 65 (Mean arterial pressure greater than or equal to 65).
Review of the Document for Patient #32 titled Nursing Critical Care Drips revealed the following Dopamine rates were adjusted by the nursing staff:
5/14/12 06:21 (a.m.)- 5mcg/kg/min- 10.3 cc/hr (milliliters/hour)
5/14/12 06:50 (a.m.)- (no dose recorded)- 20.6 (cc/hr)
5/14/12 09:54 (a.m.)- 15 mcg/kg/min- 30.9 cc/hr
5/14/12 11:29 a.m.- 20 mcg/kg/min- 41.3 cc/hr

Review of Emergency Department Physician's Orders dated 5/14/12 at 12:01 (p.m.?) revealed an order for Levophed (medication drip to increase heart rate) 4MG/250ML IV (intravenous) 4MG/BAG. Titrate to SBP greater than 90.
Review of the Document for Patient #32 titled Nursing Critical Care Drips revealed the following Norephinephrine (Levophed) rate:
5/14/12 12:12 (p.m.)- 5mcg/min- 18.8 cc/hr

Review of the medical record for Patient #32 revealed no Physician's Orders on how rapidly to change the rate of infusion or what amount to adjust the dosages of the Dopamine drip or the Levophed drip.

In an interview on 8/7/12 at 1:00 p.m. with Emergency Department (ED) Manager (campus "a") S29, she stated the Physician's should have written in Patient # 32's orders how they wanted the Dopamine and Levophed drips dosages adjusted and the time frames for adjustment. S29 said the orders for Patient #32's Dopamine and Levophed were incomplete and should have been clarified by the Physician. S29 stated she and her staff in the ED used drug reference books to titrate their medication drips. She said the hospital had no policies or procedures for weaning medication drips. S29 also stated she was not aware of any clinical practice guidelines for titrating drips. S29 said new hires had orientation on intravenous drips, but not titration of intravenous medications.

In an interview on 8/7/12 at 1:35 p.m. with ICU Director (campus "a") S25, he said based on the Physician's Orders in Patient #32's chart, the nurses would have made the determinations of how quickly and how much to decrease the Levophed and Dopamine drips because there were no Protocols or complete Physician's Orders. When asked if it was within a nurse's scope of practice to determine medication rates or amounts without a Physician's order, S25 replied no.

In an interview on 8/7/12 at 1:25 p.m. with Chief Nursing Officer (CNO) (campus "a") S23, she stated titration clinical guidelines for drips were in the process of being made into hospital policies, but had not yet been taught to staff. S23 also said the hospital had no policies and procedures for the titration of drips except Propofol.

In an interview on 8/7/12 at 1:30 p.m. with Performance Improvement Director (campus "a") S24, she stated the hospital had made some clinical practice guidelines for titrating drips, but they had only been approved by the medical staff, not the Governing Body. She said the guidelines were not policies and procedures and had not been taught to the staff of campus "a".

Patient #33
Patient #33 was an 81 year old female who admitted to the hospital on 7/31/12 for nausea, vomiting, diarrhea, dizziness and shortness of breath.
Review of her physician orders revealed an order dated 8/4/12 at 8:11 a.m. to increase Metoprolol (Lopressor) (arrow sign going up) to 50 mg po (by mouth) TID (three times a day).
Review of the physician order dated 08/5/12 at 8:24 a.m. to increase (arrow going up) Lopressor (Metoprolol) to 100 mg p.o. Bid (twice a day).
Review of the MAR (Medication Administration Record) dated 08/05/12 revealed Lopressor 50 mg was given at 0600 (6 am) on 8/5/12 and then at 0900 (9 a.m.) Lopressor 100 mg was given after the physician wrote the order to increase the dose at 8:24 a.m. Review of the nurse's notes and the physician order revealed the nurse did not clarify with the physician that a 6 a.m. of 50 mg of Lopressor was administered to the patient and when did he want to start the 100 mg dose.
An interview was conducted with S27Telemetry Director on 08/07/12 at 10 a.m. She stated the nurse should have clarified the order with the physician to see when he wanted the new dose started.
Review of the incident report (called an SOS report by the hospital) revealed on 08/07/12 at 15:10 (3:10 p.m.) S27Telemetry Director completed the report. The incident type was listed as an extra dose/duplication. The category was listed as C- reached patient, but caused no harm. "Patient was given a dose of Lopressor 50 mg by mouth at 0600 (6 a.m.) on 8/5/12 which was ordered three times a day. The MD changed the dose to Lopressor 100 mg by mouth twice a day at 0824 (8:24 a.m.) on 08/05/12, the patient was given Lopressor 100 mg by mouth at 0900 (9:00 a.m.) on 8/5/12."
Review of the physician orders for 08/01/12 revealed Administer Novolog insulin SubQ on prescribed schedule below.
Glucose level Units
151-200 2 Units
201-250 4 Units
251-300 6 Units
301-350 8 Units
351-400 10 Units
>400 12 Units

Review of the Blood glucose and insulin administration for Patient #33 revealed on 08/01/12 at 12:31 (12:31 p.m.) her blood glucose was 180. There was no documentation 2 units of insulin was administered per sliding scale. On 8/02/12 at 07:49 (7:49 a.m.) the patient's glucose was 186, there was no documentation 2 units of insulin was administered to the patient. The nurse's documentation revealed outside of therapeutic parameter as the reason the insulin was not given. On 8/5/12 at 11:43 (11:43 a.m.) the patient's glucose was 220 according to the computer once the glucometer data was downloaded. The nurse manually documented a glucose of 160. The patient should have received 4 units of insulin and only received 2 units.

An interview was conducted with S36LPN on 08/07/12 at 10:05 a.m. She reported she had to revise her glucose reading because she put the glucose readings of another patient in Patient #33's record. She went on to report the CNAs (certified nursing assistants) write the glucoses on a piece of paper and the nurses input the information into the computer.

An interview was conducted with S27 Telemetry Director for campus "a" on 08/07/12 at 10:15 a.m. She agreed there was a documentation error made on the glucose reading.

Review of the incident report revealed S27Telemetry Director of campus "a" completed the form on 8/7/12 at 14:58 (2:58 p.m.). Under the heading of description the following was documented, "...Noted blood sugar performed at 1231 on 8/1/12 per HIS (computer system) blood sugar 180, but not documented; on 8/2/12 blood sugar 186 at 749 (7:49 a.m.) and listed with no insulin with documentation of outside of therapeutic parameter as to the reason for not given; blood sugar on 8/5/12 at 1145 (11:45 a.m.) in HIS (computer system) 220."

Patient # 34

Patient #34 was admitted to the hospital on 8/4/12 for a lower GI (gastrointestinal bleed) and hypotension.
Review of his physician orders dated 8/6/12 at 1:30 p.m. revealed an order for "Amiodarone bolus/drip by protocol."
An interview was conducted with S32 ICU (Intensive Care Unit) clinical coordinator on 8/7/12 at 2 p.m. She confirmed it was not a complete order and the unit had no protocol on the Amiodarone drip. She went on to state the physician should have written out the order. S25 ICU Director also reported it was not a complete order and the physician should have written out the order completely.
Review of the Hospital's policy for Medication Errors, Policy Number OHS.PI.001 revealed in part, "Comprehensive and systematic reporting is vital to preventing and improving medication error rates throughout the hospital health system. Reporting Medication error through the occurrence reporting mechanism is non-punitive and is intended to foster improvement...The hospital will define Harm as a temporary or permanent impairment of the physical, emotional or psychological function or structure of the body and or pain resulting, therefore, requiring intervention...A medication error resulting in the need for increased patient monitoring or intervention must be reported and documented immediately by the physician who ordered the medication, nurse or other healthcare provider who discovered the error. Medication errors are classified according to the following levels of error and harm...2.3 Error, Harm Category E: An error occurred that may have contributed to or resulted in temporary harm to the patient and required intervention ..."
Review of the Hospital's Inpatient Medication Administration policy, Policy Number, OHS.NURS.034 revealed in part, "6. G. Discusses any unresolved concerns about the medication with the patient's physician...7. Documentation of each medication administered should include the following: a. Name of drug b. Dose-include concentration if applicable c. route d. time...9. Medication occurrences must be immediately reported to the attending physician and nurse in charge. An occurrence report must be completed in the Occurrence Reporting System by the person discovering the occurrence as soon as possible. V. Enforcement and Exceptions A. Appropriate medication administration is reviewed by audits. B. Staff who fail to adhere to this standard will be subject to corrective action.



30364

Based on observation, interviews and record reviews, the hospital failed to meet the Conditions of Participation for Medical Records as evidenced by:
1) The facility failed to ensure a system was in place to track the resident physicans with delinquent medical records and failed to follow hospital policy and procedure for staff physician with delinquent medical records.(See findings in tag A0438)
2) Failing to properly protect medical records from water damage. (See findings in tag A0438)

17091

Based on observation, interview, and record review, the facility failed to ensure
1) A system was in place to track the resident physicans with delinquent medical records and failed to follow hospital policy and procedure for staff physician with delinquent medical records
2)Medical records were properly stored to protect them from water damage.

Findings:

1)
Review of the "Deficiency Chart Total by Physician" list dated 08/10/12, provided by S12 HIM (Health Information) Director revealed a list of physicians with greater than 30 day, 60 day and 90 day delinquent records for the "Main Campus". The list revealed 64 records were over 30 days delinquent, 23 records were over 60 days delinquent, and 192 records were over 90 days delinquent.

On 08/10/12 at 8:25 a.m., the HIM Director, S12 and HIM Manager S40 were interviewed regarding the process for completion of medical records. S12 HIM Director stated records were to be completed within 30 days of discharge and were considered delinquent if not completed by 30 days and on day 31, the physician would have suspension of admitting privileges if delinquent records had not been completed. S40 HIM Manager stated the HIM department sent a letter to the physician when the physician had an incomplete record at 22 days after discharge. S40 HIM Manager was asked if S46 Staff Physician had been suspended since the "Deficiency Chart Total by Physician" list indicated the physician had a delinquent record over 90 days. She stated S46 Staff Physician was not suspended but was slated for suspension next week. She also stated this delinquent record was a resident physician's delinquency and was just reassigned to S46 Staff Physician. S40 HIM Manger stated the Staff Physicians were notified of delinquent records, but the resident physicians were not, because there was no system in place for addressing resident physician delinquencies. When asked if there was a policy to address resident physician completion of medical records, S40 HIM Manager stated, "No, they don't fall under the chart completion policy." When asked what the time frame was for reassigning resident delinquencies to the Staff Physician. S40 HIM Manager stated there was no defined time frame. When asked if S47 Physician had been suspended, S40 HIM Manager stated S47 was a resident.

On 08/10/12 at 10:30 a.m., S12 HIM Director provided a list titled, "Resident Deficiencies". S12 stated this was a list of resident physician delinquencies that had not been reassigned to a Staff Physician. Review of the "Resident Deficiencies" list revealed 30 resident physicians were listed as having delinquent medical records. 13 physician had records delinquent over 30 days, 3 physicians had records delinquent over 60 days, and 18 physicians had records delinquent over 90 days. S12 HIM Directer was asked to provide documentation of physician deficiencies for S43Physician, S44Physician, S45Physician, S46Physician, and S47Physician.

On 08/10/12 at 1:05 p.m. S12 HIM Director and S40 HIM Manager were interviewed after providing a deficiency list for S44Physician, S40 HIM Manager stated S44 Physician retired on 12/31/11 and had 11 incomplete records and also verified one record had 12 deficiencies with a discharge date of 07/19/2011. S40 HIM Manager stated the internal process in the HIM department had failed to identify this record as delinquent for S44Physician prior to his retirement on 12/31/11.

Review of the Deficiency List by Physician provided by the Health Information Management (HIM) Staff revealed S45 Physician had 5 medical records that were delinquent since 3/7/10, 3/9/10, 10/9/10, 12/10/11, and 9/13/11. In an interview on 8/10/12 at 1:10 p.m. with S40 HIM Manager, revealed Physician S45 did not have her privileges suspended as per policy because their department was not aware she was still a staff member until recently.
Review of the Deficiency List by Physician revealed S43 Physician had 3 medical records delinquent with one since 6/24/12 and two since 6/14/12. In an interview on 8/10/12 at 1:18 p.m. with S40 HIM Manager stated S43Physician did not have his privileges suspended as per policy because their department had S43 Physician incorrectly labeled as a resident.
Review of the Deficiency List by Physician revealed Physician S46 had a delinquent medical record from 1/15/12 that had been signed on 8/10/12. In an interview on 8/10/12 at 1:22 p.m. with S40 HIM Manager , she stated S46 Physician had only signed the delinquent chart this morning and he had not been suspended because the HIM department did not know he had a delinquent chart because it had not been " triggered " by their system. She stated delinquent charts not triggering was a problem that was currently being corrected.
Review of the Deficiency List revealed Physician S47 had 1 delinquency over 90 days listed. In an interview on 8/10/12 at 1:28 p.m. with S40 HIM Manager, she stated S47 Physician had not been suspended because he actually worked at another campus and his delinquencies inadvertently carried over to their list.
On 08/10/12 at 3:40 p.m., S12 HIM Director and S40 HIM Manager were interviewed and provided a list of Physicians who were no longer employed by the hospital, and a list of monthly delinquent record statistics. Review of the Physician list revealed the names of 22 physicians and a total of 121 deficiencies. Review of the list revealed S45Physician was no longer employed.

Review of the statistics revealed the following number of delinquent records/number of records for 2012:
January - 1116/5799
February - 1186/4536
March - 1054/5607
April - 854/4985
May - 601/6182
June - 617/5398
July - 759/5617

S40 HIM Manager and S12HIM Director stated they are continuing to verify the physicians who are available to complete records. S40 stated she did not know if the physicians identified on the list of Resident Deficiencies were available to complete the delinquencies. and the Staff Physicians are allowed a 7 day window to complete delinquencies that are re-assigned to them. S40 HIM Manager and S12 HIM Director were unable to provide a list of current physicians. S40 HIM Manger stated they were continuing to resolve the physician issues.

Review of the Medical Staff Rules and Regulations, adopted by the Medical Staff on 06/19/02, and approved by the Board of Directors on 07/17/02, and provided as current revealed the following in part:
P. Medical Record Completion

1. Medical records must be completed within 30 days after discharge or hospital outpatient procedures or the medical record will be considered delinquent. Any violation of this rule without acceptable cause will deprive the physician of elective hospital privileges until records are complete.
5. Any physician who has been continuously on suspension for 45 days or more will be referred to MEC/SEC (Medical Executive Committee/Staff Executive Committee) and a letter will be sent from the Chief of Staff informing them that they must complete their charts within 30 days of receiving this notice. If the charts are not completed within 30 days the physician's privileges will be automatically relinquished. The Practitioner may again apply for medical staff membership and clinical privileges through the regular application process.

2) The hospital failed to ensure medical records were properly stored to protect them from water damage.

In an interview on 8/10/12 at 12:05 p.m. with S40 HIM Manager , revealed once patients were discharged, their medical records were sent to the scanning department and the medical records were kept for up to 24 hours before they were scanned into a computer. S40 HIM Manager also stated the hospital began scanning medical records on 3/17/08 and prior to that date, the hospital still used the paper medical records and kept them in a storage room at the base of the parking garage.
In an observation on 8/10/12 at 12:20 p.m. of the medical records storage room located in the parking garage, thousands of medical records were stored on open shelving. Sprinkler systems were located throughout the room.
In an interview on 8/10/12 at 12:20 p.m. with S12 HIM Director, she stated the medical record storage room contained hundreds of thousands of medical records dating from current records to records that were 21 years old. She stated each linear foot contained 15-20 records and there was approximately 11,000 linear feet of shelving. She also stated medical records prior to 3/17/08 were located in the storage room and unprotected from water damage if the sprinkler system would have been activated. S12 HIM Director was unable to verify how many records were within 5 years or 10 years old, but she said approximately 104,000 records were within 10 years and approximately 52,000 were within 5 years.

Based on observations, record reviews, and interviews, the hospital failed to meet the Condition of Participation for Pharmaceutical Services as evidenced by:

1) The hospital pharmacy failed to develop an effective system for identification of errors in medication administration as evidenced by relying on self-reporting of errors by the nursing staff as the primary means of identification for non-controlled medication errors resulting in 10 unidentified medication variances through review of 40 sampled medical records. (see findings in A0500).

2) The hospital failed to ensure that non-controlled medications were monitored for the potential for medication errors for 2 out of 2 campuses reviewed for a system in place to monitor non-controlled medication errors. (see findings in A0508).

The hospital pharmacy failed to develop an effective system for identification of errors in medication administration as evidenced by relying on self-reporting of errors by the nursing staff as the primary means of identification for non-controlled medication errors resulting in 10 unidentified medication variances through review of 40 sampled medical records. Findings: .

An interview was conducted with S39 on 8/10/12 at 10 a.m. She stated the second quarter of 2012 the hospital medication error rate was 244 med errors out of 1,357,181 doses of medication distributed. The total reported medication error per 1,000 doses dispensed was 0.18. The number of medication errors causing harm was listed as 3. The figure also included campus "b" medication errors. She went on to state the hospital monitored drug errors through the SOS system, which is a self reporting medication error system. She stated this was the only system in place to monitor drug errors for non-controlled medications and the pharmacy does not do audits for non-controlled medications. She reported there was an auditing process in place for controlled drugs. The pharmacy reviewed overrides with the system, improper wastage and miscounts for controlled drugs. The audits for controlled drugs are based on discrepancies.

Another interview was conducted with S39 Pharmacy Director on 8/10/12 at 3 p.m. She stated if there was an empty drawer of K-dur in the drug dispensing machine (Pyxis) and there should had been some left according to the number of patients on the medication. S39 reported she would send a report to the nurse manager by a "dashboard report", but the only thing the pharmacy would be able to tell was when the K-dur was last refilled. When questioned if this would initiate a SOS report, she stated it would not, but it probably should. When questioned if she thought SOS was catching all the medication errors, she stated absolutely not and couldn't tell if SOS caught 2%, 20% or 80% of the errors. S39 stated that there was a medication safety meeting monthly. When questioned if this committee ever discussed or identified the need to monitor or audit medication errors on uncontrolled medications, she stated no. S39 reported the SOS report was generated when the individual who discovered the medication error initiated the SOS report. The SOS report asked which department was involved in the medication error. An alert e-mail would be generated and sent to the department involved in a 2 hours time frame. She went on to state she received the SOS reports on all the medication errors and she would investigate the error within a week usually. If the medication error was listed in the category of a harm, she would look into the error immediately. When asked if the computerized drug system would alert pharmacy if there was a missed dose of medication, she stated no. When questioned if when the pharmacy tech went to the floor to pick up medication if he/she found extra doses of antibiotics would that trigger an investigation, she stated no.

An interview was conducted with S24 for campus "a" on 8/8/12 at 12:55 p.m. She reported for the second quarter of 2012, campus "a"s number of distributed doses of medication was 248,069 and the number of medication errors identified was 142. The total reported medication errors per 1,000 doses dispensed was 0 .57. The number of medication errors causing harm was 0. She reported only the narcotic drugs are audited, no other drugs are audited for medication errors.

An interview was conducted with S31 of campus "a". He stated that he had a nurse that came in three times a week to look at narcotics. She would audit only narcotic medications. He did not have anyone auditing non-controlled medications for medication errors. When questioned about the medication variances found on the Telemetry unit, he stated he was unaware of the medication errors.

Based on record review and interview the hospital failed to have an effective system in place to accurately monitor medication errors on non-controlled medications for 2 out of 2 campuses reviewed for medication errors.

An interview was conducted with S39on 8/10/12 at 10 a.m. She stated the second quarter of 2012 the hospital medication error rate was 244 med errors out of 1,357,181 doses of medication distributed. The total reported medication error per 1,000 doses dispensed was 0.18. The number of medication errors causing harm was listed as 3. These figures also included campus "b" medication errors. She went on to state the hospital monitored drug errors through the SOS system, which is a self reporting medication error system. She stated this was the only system in place to monitor drug errors for non-controlled medications and the pharmacy does not do audits for non-controlled medications. She reported there was an auditing process in place for controlled drugs. The pharmacy reviewed overrides with the system, improper wastage and miscounts for controlled drugs. The audits for controlled drugs are based on discrepancies.

Another interview was conducted with S39 on 8/10/12 at 3 p.m. She stated if there was an empty drawer of K-dur in the drug dispensing machine (Pyxis) (for example) and there should had been some left according to the number of patients on the medication. S39 reported she would send a report to the nurse manager by a "dashboard report", but the only thing the pharmacy would be able to tell was when the K-dur was last refilled. When questioned if this would initiate a SOS report, she stated it would not, but it probably should. When questioned if she thought SOS was catching all the medication errors, she stated absolutely not and couldn't tell if SOS caught 2%, 20% or 80% of the errors. She went on to state that there was a medication safety meeting monthly. When questioned if this committee ever discussed or identified the need to monitor or audit medication errors on non-controlled medications, she stated no. S39 reported the SOS report was generated when the individual who discovered the medication error initiated the SOS report. The SOS report asked which department was involved in the medication error. An alert e-mail would be generated and sent to the department involved in a 2 hours time frame. She went on to state she received the SOS reports on all the medication errors and she would investigate the error within a week usually. If the medication error was listed in the category of a harm, she would look into the error immediately. When asked if the computerized drug system would alert pharmacy if there was a missed dose of medication, she stated no. When questioned if when the pharmacy tech went to the floor to pick up medication if he/she found extra doses of antibiotics would that trigger an investigation, she stated no.

An interview was conducted with S24 for campus "a" on 8/8/12 at 12:55 p.m. She reported for the second quarter of 2012, campus "a"s number of distributed doses of medication was 248,069 and the number of medication errors identified were 142. The total reported medication errors per 1,000 doses dispensed was 0.57. The number of medication errors causing harm was 0. She reported only the narcotic drugs are audited, no other drugs are audited for medication errors.

An interview was conducted with S31 of campus "a". He stated that he had a nurse that came in three times a week to look at narcotics. She would audit only narcotic medications. He did not have anyone auditing non-controlled medications for medication errors.

An interview was conducted with S35 at campus "a" on 8/8/12 at 1:30 p.m. She reported her title was Control Substance Monitor. She stated she only looked at narcotics usage, waste, and discrepancies on the units.

An interview was conducted with S23 at campus "a" and S24 for campus "a" on 8/8/12 at 8:15 a.m. They reported due to the medication errors found on the telemetry unit on campus "a" by the surveyor (9 medication errors in 2 patient's medical record), re-education of the nursing staff on 24 hour and 12 hour chart checks had started. They stated the 24 hours and 12 hours chart checks should have picked up the medication errors. S23 (campus "a") reported they found in the course of the education of the staff, the chart checks were not being done appropriately. She went on to state the chart checks have to be implemented from the medication order to the documentation.

Review of the policy for Guidelines for Order Reconciliation presented as the chart check policy from campus "a" revealed in part,"...Order Reconciliation should be performed by the nurse when new orders are transcribed and during the 24 hour chart check...The Unit secretary or nurse is responsible for transcribing the orders exactly as the physician ordered. The RN or LPN is responsible for validation of the orders...All order activity for the defined time frame is checked against the orders on the physician order form for accuracy. The nurse can use the order session print or orders reconciliation to perform the 24 hour chart check to ensure that all orders have been entered."

Based on observation and interviews, the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and/or quality as evidenced by failing to ensure the functionality of nurse call buttons located on the handrails of 48 beds throughout the hospital.
Findings:
In an observation on 8/9/12 at 1:10 p.m. on the post-partum unit, a button with a picture of a nurse was located on both handrails of a patient bed in an unoccupied room. Several attempts were made to alert the nursing staff with the buttons, but the call system was not functioning.
In an interview on 8/9/12 at 1:12 p.m. with the Women's Services Director S48, she stated the buttons with a nurse's picture on the handrails of the patient beds was a call system the patients could activate if they required assistance. She stated the call system on the bed was not functional because the model of the bed was different than the model of call system in the wall. She also said the electrical connection from the bed would not fit the wall receptacle. She said there was a call system connected to a cable that the patients were instructed to use if they needed assistance.
In an interview on 8/10/12 at 12:00 p.m. with Performance Improvement Director S49, she stated there were 48 beds in the hospital that were incompatible with the call system built into the wall. She stated there was 1 bed located on floor six, 3 beds on floor eight, 32 beds in the Adult Intensive Care Unit, 5 beds in the Pediatric Intensive Care Unit, and 7 beds in the Pediatric Unit that had non- functioning call buttons on the handrails. She also stated she could understand where a confused patient or a family member that had not been oriented to the alternate call system could have pushed the non-functioning call system on the side rails of the beds in an emergency.

Based on record reviews, observations, and staff interviews, the infection control officer failed to maintain a sanitary physical environment as evidenced by: 1) failing to ensure proper hand washing technique was performed after touching contaminated item as evidenced by S71Transport talking on the telephone in the hallway located on the unit "b" wearing gloves, walked to stretcher located parked up against the wall, accessed the elevator to unit "a", parked the stretcher in hallway across the hall from the nurses' station/countertop, removed right hand glove and placed it in pocket, removed right hand glove from pocket and discarded it in the trash can located across the hall, walked to the sink area located in the nurses' station (no hand washing performed), walked from the nurses' station sink area to a nurse documentation station located across the hall from the station, picked up the telephone, hung up the telephone, walked back to nurses' station/countertop, picked up an ink pen, filled out a yellow transport ticket, removed left hand glove, discarded the left hand glove in the trash can next to the nurse doc station, donned gloves (no hand washing performed), walked to stretcher, pushed the stretcher to the end of the hallway stopping in front of door labeled, room "a" as per the "Hand Hygiene" policy;
2) failed to ensure PPE (personal protective equipment) was worn by all staff as evidenced by: a) S55RN, ASC/PACU failing to ensure her front bangs four inches in width was covered by her hair net, two thick long strands of hair was hanging out of the hair net eight inches in length, and four inches of her back hair was not covered by the Airet as per protocol, b) S61Surgery Unit Director and S62Administrative Clinical Coordinator of Surgery failing to ensure the front bangs area, side burns, hair on the back of their necks were covered by the hair net as per protocol, and c) S69Central Supply Supervisor walking four feet into the area and walked back out without wearing a hair net as per protocol.
Findings:
1)

During an observation performed on 08/08/12, S71Transport was observed talking on the telephone in the hallway located on unit "b" wearing gloves at 10:05 a.m. and she walked to a stretcher that was parked up against the wall. At 10:06 a.m., S71 accessed the elevator to unit "a" and she parked the stretcher in hallway across the hall from the nurses' station/countertop. At 10:07 a.m. S71 removed her right hand glove and placed it in her pocket, removed it from her pocket and discarded it in the trash can located across the hall from the nurses' station. From 10:07 a.m. through 10:10 a.m., S71Transport was observed walking to the sink area located in the nurses station (no hand washing performed), walking from the nurses station sink area to a nurse documentation station located across the hall from the station, picking up the telephone, hung up the telephone, and walked back to nurses station/countertop. At 10:10 a.m. S71 picked up an ink pen located on top of the countertop at the nurses station and filled out a yellow transport ticket. From 10:10 a.m. through 10:12 a.m., S71 was observed removing her left hand glove, discarded it in the trash can next to the nurse documentation station, and donned gloves without performing handwashing. She (S71) walked to the stretcher, pushed the stretcher to the end of the hallway stopping in front of door labeled, room "a". At 10:12 a.m., S71Transport was observed removing her gloves, discarded them in a nearby trash can, and used the hand sanitizer mounted on the wall. During this observation, S71Transport confirmed there was no hand washing performed after removing and donning gloves as per protocol. At 10:12 a.m., S5COO (chief operating officer) confirmed the above findings.


The policy titled, "Hand Hygiene Policy", Policy Number OHS.IC.001, Issue date of August of 2011, with no reviewed and/or revised date(s), revealed hand hygiene is considered a necessary step to reduce transmission of pathogenic organisms to patients, personnel, and visitors in the healthcare settings. It is generally considered the most important single procedure for preventing healthcare-associated infections. It is expected of all employees to conduct hand hygiene. When hands are visibly dirty or contaminated with proteinaceous material or visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all clinical situations. Decontaminate hands after contact with a patient's skin. Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin if hands are not visibly soiled. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. Decontaminate hands after removing gloves. When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers until hands are dry. Change gloves during patient care if moving from a contaminated body site to a clean body site. Each department manager/director is responsible for ensuring all employees conduct hand hygiene to prevent harm to patients, employees, and visitors to the hospital. The definition of indirect contact refers to touching an inanimate object for example, a healthcare worker touching a patient bed or linen, equipment, or room furnishings.

2)

S55RN, ASC/PACU:

During a tour of the ambulatory surgery center on 08/07/12 from 1:55 p.m. through 2:30 p.m., S55RN, ASC/PACU was observed with her front bangs four inches in width not covered by her hair net. Further observation revealed she had two thick long strands of hair hanging out of the hair net eight inches in length. S55 had four inches of her back hair not covered by the hair net during this observation. S55RN confirmed the findings during this observation.

S61Surgery Unit Director and S62Administrative Clinical Coordinator of Surgery:

A tour of the operating room (OR) "a" was performed on 08/06/12 from 1:00 p.m. through 1:30 p.m. and operating room "d" from 1:32 p.m. through 1:45 p.m. with the chief operating officer (COO, S5), the Surgery Unit Director (S61) and the Administrative Clinical Coordinator of Surgery (S62). During this same tour, S61 and S62 were both observed with their side burn hairs, forehead hairs, and hair on the back of their necks not covered by the hair net. At 1:50 p.m., S5, S61 and S62 all confirmed S61's and S62's side burns, foreheads, and neck hairs were not covered by the hair net as per protocol.

S69Central Supply Supervisor:

During an observation of the decontamination /soiled area on 08/06/12 from 1:47 p.m. through 2:15 p.m. with S5COO, S61Surgery Unit Director, and S62Administrative Clinical Coordinator of Surgery, there was a sign posted on the door that read, "PPE (personal protective equipment) must be worn in the central supply and decontamination area". At 1:55 p.m., S69Central Supply Supervisor walked four feet into the decontamination area without wearing a hair net and she exited the area. S69 indicated all personnel decontaminating the equipment, (SCD machines, bedside commodes) must wear PPE including a uniform and hair net.

In an interview on 08/06/12 at 2:15 p.m., the Director of Central Supply, S70 confirmed the sign posted on the decontamination area read, "PPE must be worn in the central supply and decontamination areas". S70Director indicated PPE requires all employees to wear hair nets prior to entering the room. The Director, S70 indicated further S69 is required to wear a hair net upon entry into the decontamination area as per protocol. S70 denied knowledge S69Central Supply Supervisor was not aware that the PPE protocol is required by all staff entering the area.

On 08/06/12 at 1:55 p.m., S5COO, S61Surgery Unit Director, and S62Administrative Clinical Coordinator of Surgery verified the sign posted on the decontamination area read, "PPE must be worn in the central supply and decontamination areas". S5, S61, and S62 indicated PPE requires all employees to wear hair nets.

Based on record reviews, observations, and staff interviews, the hospital:
1) failed to ensure the surgical services followed the manufacturer's instructions for the decontamination process for all surgery instruments as evidenced by:
a) failing to ensure the surgical (peripheral vascular, gastrointestinal) instruments dwelled for three (3) minutes in the "RTU Mini-Foamer Autron Medical" cleaner, and
b) failing to mix the "Prolystica Ultra Concentrate Enzymatic Cleaner" with one tenth to one fortieth (1/10 - 1/40) ounce per gallon by filling sink 1 with two (2) inches of water (one and a half gallons of water) above the fill-line marked in sink 2;
2) failed to ensure the sanitation of the surgical equipment in the OR (operating room) was performed as per policy as evidenced by: failing to ensure operating room (OR) "a"'s equipment, (cushion velcro areas with yellowish/whitish substance or lent; arm boards with a bluish/whitish substance and sticky substance on the outer surfaces of the boards; electrocardiogram machine outer edges with a grayish/black substance; small square pillow with a sticky substance measuring two by five inches; Bipolar machine with a grey substance covering the inside areas of the plug-in), pediatric bed in the hallway with a cached black substance in all four corners, light source in the hallway with a sticky black adhesive area covering the outer edges of the performance inspection sticker were cleaned as per the "Sanitation of the Surgical Suite" policy;
3) failed to ensure there was a separation between the decontamination (dirty) area and clean area for all patient equipment (sequential compression devices /SCD-a machine used to prevent blood clots after surgery, and bedside commodes) as evidenced by failing to have a system in place for the dirty SCD machines to be to be transported to the designated clean area and/or different areas of the hospital without passing through the dirty area as per the "Sterile Processing Decontamination and Clean Area: Traffic Patterns and Preparation for Sterilization" policy;
4) failed to ensure the turnover cleaning of the operating room (OR) "d" was performed using proper practices as evidenced by:
a) S66Operating Room Assistant (ORA) wiping all equipment (overhead lights time three, arm boards times two, mayo stand, and operating room table) with the same Cavi-Wipe,
b) S67ORA gloved and moved the table over two feet, got a clean Cavi-Wipe from the container, dropped the Cavi-Wipe on the floor, picked it up off the floor, wiped the rolling trash can bowl with the dirty Cavi-Wipe, and mopped the floor from front to back without de-gloving and/or hand washing, and
c) S68ORA donned gloves, wiped the mayo stand from top to bottom (touching the floor), wiped the pillow laying on top of the metal table at the back of the room, placed the pillow on top of the OR table, wiped both arm boards, wiped the support monitor from top to bottom-touched the floor with the wipe, threw the gloves in the trash can without performing hand washing and/or changing gloves as per "Sanitation of the Surgical Suite" and "Hand Hygiene" policies. Findings:

1)

Review of the manufacturer's instruction sheet for the "RTU Mini-Foamer Autron Medical Model #ZUTR50106" cleaner revealed all instruments are to be treated to prevent drying of bioburden by applying an even layer of foam. Allow enzymatic foam to soak for about 3 minutes.

During an observation of the decontamination process conducted on 08/07/12 from 10:06 a.m. through 10:20 a.m., S63Sterile Processing Tech removed the peripheral vascular (PV) instruments from the top of the dirty instrument cart from operating room (OR) "c". At 10:07 a.m., S63 placed the instrument tray into sink 2 that was empty with a line marked, "fill-line", removed the instruments from the tray and placed them into sink 1 that was filled with a blue substance. S63 stated these instruments do not require a pre-soaking process at this time; They will soak in the enzymatic cleaner for five (5) minutes- she pointed to sink 1 area at this time. At 10:10 a.m., she removed the gastrointestinal (GI) instrument tray from operating room "c" cart and placed them into sink 2. She grabbed the spray handle from the wall mount labeled, "RTU Mini-Foamer Autron Medical" cleaner by sink #2. S63 rinsed the GI instruments with running water in sink 2 and she placed them into sink 1. Further observation revealed all of the GI instruments were not covered with the foam cleaner at this time. At 10:10 a.m., the Sterile Processing Tech, S63 confirmed all GI instruments were not covered with the foam cleaner. She indicated there is no pre-soaking of these instruments required when using the foam cleaner. S63 further indicated the GI instruments do not have to soak in the foam cleaner for any length of time; They soak in the enzymatic cleaner for 5 minutes. At this time, S63 denied knowledge of the enzymatic cleaner's name. At 10:15 a.m., S63Sterile Processing Tech indicated sink 1 was filled with water and two (2) squirts of the enzymatic cleaner. She confirmed there was no fill-line marked in sink 1. The Sterile Processing Tech stated there is one and a half gallons of water in sink 1. She stated further sink 1 is filled two (2) inches above the fill-line marked in sink 2. S63 indicated the fill-line marking in sink 1 came out of the sink about two (2) months ago. The Sterile Processing Tech, S63 further indicated she informed her supervisor, S64 at this time. S63 stated S64Sterile Process Director told me to continue using sink 1 to perform the decontamination process until the fill-line can be replaced. The Sterile Processing Tech, S63, denied knowledge of when the Sterile Process Director indicated the fill-line in sink 1 would be done.

In an interview on 08/07/12 at 10:20 a.m., the Sterile Process Director, S64, verified sink 1 was two inches above the fill-line marked in sink 2. S64 indicated this dilutes the enzymatic cleaner. S64Sterile Process Director indicated further S63 failed to follow the manufacturer's instructions to mix the cleaner. S64 stated all instruments must be pre-soaked in the Mini-Foamer Autron Medical" cleaner mounted on the wall for 3 minutes as per manufacturer's instructions.

Review of the "Prolystica Ultra Concentrate Enzymatic Cleaner" manufacturer's instructions revealed the cleaner is highly concentrated for use in hospital disinfector units. It provides superior cleaning performance against blood, mucous and the most challenging fatty soils associated with orthopedic cases. The dual enzyme system works exceptionally well regardless of water quality or type. The enzymatic cleaner is also compatible with stainless steel including aluminum. All of this at 1/10 - 1/40 ounce per gallon.

During the same observation on 08/07/12 from 10:06 a.m. to 10:20 a.m. with S63Sterile Processing Tech, there were two (2) aluminum sinks (sink 1 on the left and sink 2 on the right). Sink 2 had a fill-line marked inside the sink area. Sink 1 was observed with no fill-line marked on its inside. Further observation revealed sink 1 was filled 2 inches above the designated fill-line marked in sink 2 with two (2) squirts of Prolystica Enzymatic Cleaner. At 10:15 a.m., she verified there was no fill-line marked inside of sink 1. S63 indicated there were 2 squirts of the Prolystica Enzymatic Cleaner in sink 1 with one gallon and a half of water. She confirmed sink 1 was filled 2 inches above the fill-line marked in sink 2 diluting the cleaner. The Sterile Processing Tech, S63, indicated she reported there was no fill-line marked in sink 1 to S64Supervisor two months ago. She further indicated the Director, S64 told me to continue using sink 1 to do soak the instruments in the enzymatic cleaner.

In the same interview on 08/07/12 at 10:20 a.m. the Sterile Process Director, S64, confirmed there was no fill-line marking in sink 1. The Director, S64, verified sink 1 had 2 inches of water above the marked fill-line in sink 2- diluting the cleaner. He (S64) indicated the Sterile Processing Tech, S63 failed to mix the Prolystica Enzymatic Cleaner in one gallon of water as per the manufacturer's instructions.

2)

During an observation of surgery on 08/06/12 from 1:00 p.m. through 1:36 p.m. with S5COO, S60Unit Surgery Director, and S61Administrative Clinic Coordinator of Surgery, operating room "a's" cushion velcro areas were observed covered with yellow/white substance. Further observation revealed the two arm board's outer surfaces were covered with a sticky substance and the velcro area had bluish/whitish substance covering it. There was a electrocardiogram machine observed with a piece of tape measuring one and a half inches width by two inches in depth with its outer edges grayish/black in color. A small square pillow was observed on the table with a sticky substance measuring two by five inches in width and length. There was a "Bipolar" machine observed with the plug-in areas, labeled "Bipolar, Monopolar 1, and Monopolar 2" that were covered with a grey substance. At 1:20 p.m., a pediatric bed was observed in the hallway by OR "a". Further observation of the bed revealed all four (4) corners had a cached black substance in them. At 1:23 p.m., there was a light source noted in the hallway past OR "a" observed with a black sticky adhesive area covering the outer surface of the performance inspection sticker with an expiration date of March of 2013.

At 1:10 p.m., S5COO, S61Unit Surgery Director, and S62Administrative Clinic Coordinator of Surgery all confirmed the velcro areas on the table and both arm boards were covered with lint. S5, S61, and S62 all verified the arm board had a sticky substance on the outer surfaces of the boards. S5, S61, and S62 all confirmed the small square pillow on the table had a sticky substance measuring two by five inches. At 1:15 p.m., S5, S61, and S62 all verified the electrocardiogram machine had the outer edges grayish/black in color noted on the one and a half inches by two inches piece of tape. S5, S61, and S62 all confirmed the machine plug-in areas labeled, "Bipolar, Monopolar 1, and Monopolar 2" were covered with a grey substance. At 1:20 p.m., S5, S61 and S62 all verified the pediatric bed in the hallway had a cached black substance noted in all four corners. At 1:23 p.m., S5, S61 and S62 all confirmed the light source in the hallway had a sticky black adhesive area that covered the outer edges of the performance inspection sticker.

Review of the policy titled, "Sanitation of the Surgical Suite", Issue date of June, 2012, with no revised and/or reviewed date(s), revealed all item, that come into contact with the patient during the surgical procedure is considered contaminated. After the patient leaves the room (operating room), all efforts should be directed at removing contaminated material and preparing the room for the arrival of the next patient. This is performed by the O.R. (operating room) personnel. The horizontal surfaces of the furniture and equipment used in the surgical procedure are cleaned using the approved hospital grade chemical germicide. Other pieces of furniture or equipment which may have become soiled are cleaned. Daily cleaning of each O.R. shall begin after the completion of the day's schedule including furnishings and equipment. Furniture and equipment is thoroughly scrubbed with disinfectant/detergent solution and clean cloth. O.R. beds are disassembled and thoroughly cleaned. Hand washing is performed after removing gloves.

3)

During an observation of the decontamination /soiled area on 08/06/12 from 1:47 p.m. through 2:15 p.m. with S5COO, S61, and S62, there was a sign posted on the door that read, "PPE (personal protective equipment) must be worn in the central supply and decontamination area". At 1:55 p.m., S69Central Supply Supervisor walked four feet into the decontamination area without wearing a hair net and she exited the area. At this time, S69 was stopped prior to leaving this area by the surveyor. S69 indicated all personnel decontaminating the equipment, SCD machines-she pointed to a table located on the left side of the room with SCD machines stacked on top of it and/or the bedside commodes-she then pointed to the right side of the room where there were twenty (20) bedside commodes located; S69 further indicated the SCD machines and bedside commodes are dirty equipment that must be cleaned; This equipment is brought back through the dirty area then through the door to the clean area located on the other side of the decontamination area. There is one entrance and exit door for the decontamination area. Further observation revealed there was a four feet aisle separating the two dirty sides, SCD machines and bedside commodes. S69 indicated I do not have to wear a hair net because I am not decontaminating any equipment. She further indicated all clean equipment is transported through the dirty area and brought to the clean area.

At 2:15 p.m. on 08/06/12, there were six (6) SCD machines observed on a cart that exited through the decontamination area (dirty) and was brought to a unit located in the hospital as clean equipment.

In an interview on 08/06/12 at 2:15 p.m., the Director of Central Supply, S70 confirmed the sign posted on the decontamination area read, "PPE must be worn in the central supply and decontamination areas". S70Director indicated PPE requires all employees to wear hair nets prior to entering the room. The Director, S70 indicated further S69 is required to wear a hair net upon entry into the decontamination area as per protocol. S70 denied knowledge S69Central Supply Supervisor was not aware that the PPE protocol is required by all staff entering the area. The Director, S70 indicated the cart with SCD machines is clean equipment. This equipment is brought through the dirty, decontamination area and it is sent to the clean area and/or to the unit for patient use. S70 Director of Central Supply further indicated the decontamination (dirty) area has the same entrance and exit. There is no separation in the decontamination area for dirty and clean; S70Director of Central Supply stated the area is dirty. Director, S70 stated this process has been in process since 2007 (five years).


On 08/06/12 at 1:55 p.m., S5COO, S61Surgery Unit Director, and S62Administrative Clinical Coordinator of Surgery verified the sign posted on the decontamination area read, "PPE must be worn in the central supply and decontamination areas". S5, S61, and S62 indicated PPE requires all employees to wear hair nets.

Review of the policy titled, "Sterile Processing Decontamination and Clean Area: Traffic Patterns and Preparation for Sterilization", Policy Number SPD.166.03, with no revised and/or reviewed dates, revealed it was policy for the decontamination and cleaning processes to be standardized and maintained for the proper sterilization of instruments. The design of traffic patterns expected within the decontamination and clean areas are to be followed by all staff and visitors in the Department. The traffic patterns procedure is that the clean items will be separated from soiled/contaminated materials by space, time, and traffic patterns. Clean items are not to be transported through the decontamination area.

4)

During an observation of the turnover cleaning of OR "d" on 08/06/12 from 1:32 p.m. through 1:45 p.m. with S5COO (chief operating officer), S61Surgery Unit Director, and S62Administrative Clinical Coordinator of Surgery, the Operating Room Assistants' (S66, S67, S68) were observed as follows: At 1:35 p.m., S66 was observed donning gloves, wiping all equipment (overhead lights time three, arm boards times two, mayo stand, and operating room table) with the same Cavi-Wipe. At 1:35 p.m., S67 was observed donning gloves, moved the table over two feet, got a clean Cavi-Wipe from the container, dropped it on the floor, picked it up off the floor, wiped the rolling metal trash can bowl with the same dirty Cavi-Wipe, and grabbed the mop from the mop bucket at the entrance of the room, and mopped the floor from front to back without de-gloving and/or performing hand washing. At 1:36 p.m., S68 was observed donning glove upon entry into the room, walked to the back of the room where the mayo stand was, wiped the mayo stand from top to bottom (touching the floor), picked up a black pillow that was laying on top of the metal table located next to the mayo stand, wiped the pillow with the same Cavi-Wipe, placed the pillow on top of the OR table, wiped both arm boards, wiped the support monitor from top to bottom-touched the floor with the wipe, and threw the Cavi-Wipe and both gloves in the trash can next to the anesthesia cart without performing changing gloves and/or Cavi-Wipes or performing hand washing. S5, S61, and S62 confirmed the above findings during this observation of the turnover cleaning.

Review of the policy titled, "Sanitation of the Surgical Suite", Issue date of June, 2012, with no revised and/or reviewed date(s), revealed all item, that come into contact with the patient during the surgical procedure is considered contaminated. After the patient leaves the room (operating room), all efforts should be directed at removing contaminated material and preparing the room for the arrival of the next patient. This is performed by the O.R. (operating room) personnel. The horizontal surfaces of the furniture and equipment used in the surgical procedure are cleaned using the approved hospital grade chemical germicide. Other pieces of furniture or equipment which may have become soiled are cleaned. Daily cleaning of each O.R. shall begin after the completion of the day's schedule including furnishings and equipment. Furniture and equipment is thoroughly scrubbed with disinfectant/detergent solution and clean cloth. O.R. beds are disassembled and thoroughly cleaned. Stretchers are cleaned and redressed. Note that all cleaning procedures mentioned above will be performed while wearing gloves. Hand washing is performed after removing gloves.

The policy titled, "Hand Hygiene Policy", Policy Number OHS.IC.001, Issue date of August of 2011, with no reviewed and/or revised date(s), revealed it is expected of all employees to conduct hand hygiene. When hands are visibly dirty or contaminated with proteinaceous material or visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all clinical situations. Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin if hands are not visibly soiled. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. Decontaminate hands after removing gloves. The definition of indirect contact refers to touching an inanimate object for example, a healthcare worker touching a patient bed or linen, equipment, or room furnishings.

Based on record reviews, and staff interviews, the hospital failed to have a written policy in place for History and Physical Examinations to be completed, documented, and in the record prior to surgical procedures requiring anesthesia services for two (#1, #16) of 6 focused sampled medical records reviewed for surgical services (#1, #16, #17, #18, #34, #37) out of a total of 40 sampled records (#1 through #40) and 1 random sampled record (R1). Findings:

There was no written policy for a medical history and physical examination indicating what the components and requirements were for patients undergoing anesthesia services presented during the survey conducted from 08/06/12 through 08/10/12.

Patient #1:
Review of the medical record for Patient #1 revealed the patient had a right knee arthroscopy procedure performed from 7:32 a.m. (0732) through 9:16 a.m. (0916) on 08/06/12 under general anesthesia.

Review of the "Provider Note" authenticated by S51MD on 06/29/12 at 1:45 p.m. (1345) revealed a physical and health examination was performed on Patient #1. Further review revealed this physical and health examination was documented on "Progress Notes" signed by S50MD at 07/26/12 at 1:12 p.m. (1312) for Patient #1.

The "Department of Anesthesiology Day of Surgery Anesthesia Evaluation/Addendum to Pre-Anesthetic Assessment" form dated/timed 08/06/12 at 6:50 a.m. (0650) for Patient #1 read, "H & P update referred to the surgeon/provider".

Review of the "History and Physical Exam Short Stay Form" by S50 MD for Patient #1 read, "...H & P (history and physical) completed on (date) 7/26/12 has been reviewed, the patient has been examined and: (a square blank box) I concur with the findings (a square blank box) changes are noted below..."-this section on the form was left blank.

Patient #16:
Review of the medical record for Patient #16 revealed the patient had a laparoscopic cholecystectomy and umbilical hernia repair on 08/07/12 under general anesthesia.

Review of the "History and Physical Exam Short Stay Form" signed by S54MD, Resident dated/timed 8/7/12 (08/07/12) at 6:45 a.m. (645) read, "...H & P completed on date (was left blank) has been reviewed, the patient has been examined and: (a square blank box) I concur with the findings (a square blank box) changes are noted below..."-the top portion of this section on the H & P form was left blank. Further review of the H & P revealed there was no documentation S53MD countersigned S54MD, Resident's signature prior to Patient #16's surgical procedure on 08/07/12.

The "Department of Anesthesiology Day of Surgery Anesthesia Evaluation/Addendum to Pre-Anesthetic Assessment" form dated/timed 08/06/12 at 6:50 a.m. (0650) for Patient #16 read, "H & P update referred to the surgeon/provider".

In interviews on 08/07/12 at 2:35 p.m. and at 3:05 p.m., S55RN, ASC/PACU (ambulatory surgery center/post anesthesia care unit) Clinical Coordinator confirmed S54MD signed the bottom portion of the history and physical examination for Patient #16 on 08/07/12. S55RN further confirmed the top portion of the history and physical examination for Patient #16 was left blank where the physician's (S53MD's) signature/printed name, date and time was to be documented on the form. S55RN indicated a resident is a physician that does not require a countersignature by the attending physician, S53MD. S55RN further indicated a history and physical examination must be complete and filed in all patient's medical records prior to the surgical procedures as per policy. S55RN, ASC/PACU stated the history and physical for Patient #16 is incomplete.

During interviews held on 08/08/12 at 12:30 p.m., Chief Operating Officer (COO), S5 and the V.P. (vice president) of Quality and Safety, S10 both indicated there was no written policy regarding a H&P Examination of a patient prior to surgery. S5 and S10 both verified the H&P Examination of the patient is addressed in the Medical Staff Bylaws and in the Medical Staff Rules and Regulations that require the H&P to be documented and completed with specific components by a qualified physician and/or resident. The COO, S5 and VP of Quality and Safety, S10 further verified the H&P completed by a resident must be countersigned by the attending physician as per the Medical Staff Bylaws and the Medical Staff Rules and Regulations. S5COO and S10VP of Quality and Safety both indicated the Medical Staff Bylaws and Rules and Regulations were not being followed for H&P Examinations to be completed and countersigned by the attending physician prior to the surgical procedures.

Review of the "Medical Staff Bylaws" approved by the board on July 17, 2002, adopted by the Medical Staff on June 19, 2002, page 21 of 37, page 22 of 37, revealed section, "5.B.1 History and Physical" indicated (1) All patients admitted for outpatient surgery or other procedure that involves the use of anesthesia will have a Complete H&P documented in the medical record within 24 hours. (b) If a Complete H & P has been done within 30 days of inpatient or outpatient admission, an update must be completed prior to surgery or a procedure requiring anesthesia services. If no changes have occurred, the absence of change must be documented. 2) Author of the H&P: H&P shall be the responsibility of the attending physician and/or resident who is licensed and credentialed to record a complete H&P. Residents may write or dictate and sign the H&P. The attending physician is responsible for countersigning the H&P.

Review of the "Medical Staff Rules and Regulations" approved by the Board of Directors on 07/17/02, adopted by the Medical Staff on 06/19/02, page 4 of 11, revealed section "E. History and Physical" indicated (1) All patients admitted to the hospital or registered for outpatient surgery or other procedure that places the patient at risk and/or involves the use of sedation or anesthesia will have a Complete H & P documented in the medical record within 24 hours. (b) If a Complete H & P has been done within 30 days of inpatient or outpatient admission, an update must be completed prior to surgery or a procedure requiring anesthesia services. If no changes have occurred, the absence of change must be documented. 2) Author of the H&P: H&P shall be the responsibility of the attending physician and/or resident who is licensed and credentialed to record a complete H&P...Residents may write or dictate and sign the H&P. The attending physician is responsible for countersigning the H&P.

Based on record review, staff interview, and review of Louisiana Physical Therapy Practice Act and Louisiana State Board Medical Examiners, the hospital failed to ensure that physical therapy (PT) and occupational therapy (OT) services were provided only under the orders of a licensed practitioner by failing to obtain physician's orders for therapy services provided after the initial evaluation by the therapist for 3 of 3 sampled patients reviewed for physical and occupational therapy (#2, #3, and #13) out of a total sample of 40. Findings:

Patient #2
Review of the patient's medical record revealed the patient was a 42 year old female admitted to the rehabilitation unit on 06/28/12 with a diagnosis of Right MCA (Middle Cerebral Artery) Stroke. Review of the physician's orders revealed an order dated/timed 06/28/12 at 1750 (5:50 p.m.) for physical therapy to evaluate and treat with gait training and therapeutic exercises. The physician's order also included an order for occupational therapy to evaluate and treat with restore function ADL training and therapeutic exercises. There was no documented evidence of any further physician's order for physical or occupational therapy.

Review of the physical therapy evaluation dated 06/29/12 revealed the physical therapist planned to continue physical therapy for 14 days with therapy provided twice daily including Saturday and/or Sunday. Modalities documented on the evaluation included bed mobility, transfer training, gait training, wheelchair mobility, range of motion/positioning, endurance training, strengthening, balancing training and patient/caregiver education.

Review of the occupational therapy evaluation dated 06/29/12 revealed the occupational therapist planned to continue occupational therapy for 14 days with therapy provided twice daily at 7:30 a.m. to 8:30 a.m. and 11:15 a.m. to 11:45 a.m.. Modalities documented on the evaluation included functional transfer training, upper extremity therapeutic exercises, equipment training, family/caregiver education, safety training, bed mobility fine motor training, functional endurance training, neuromuscular re-education, functional standing training, functional balance training, functional mobility training, active and passive range of motion.

On 08/06/12 at 3:00 p.m., S3 Director of Nursing & Rehab Services, and S22 Unit Director were interviewed. After reviewing the electronic and hand written medical record for Patient #2, they confirmed the only physician's order for the physical and occupation therapy was the evaluate and treat order. S3 confirmed there were no specific orders for therapy after the evaluations were done by the therapist.


Patient #3
Review of the patient's medical record revealed the patient was a 78 year old male admitted to the Rehab Unit on 06/08/12 and discharged to home on 06/15/12. The record revealed the patient had a diagnosis of Closed Head Injury. Review of the physician's orders revealed an order dated/timed 06/08/12 at 6:30 p.m. for physical therapy to evaluate. The physician's order also included an order for occupational therapy to evaluate and treat. There was no documented evidence of any further physician's order for physical or occupational therapy.

Review of the physical therapy evaluation dated 06/10/12 revealed the physical therapist planned to continue physical therapy for 7 days with therapy provided twice daily Monday through Friday including Saturday and/or Sunday. Modalities documented on the evaluation included bed mobility, transfer training, gait training, wheelchair mobility, endurance training, strengthening, balancing training, neuromuscular re-education, and patient/caregiver education.

Review of the occupational therapy evaluation dated 06/29/12 revealed the occupational therapist planned to continue occupational therapy for 7 days with therapy provided twice daily, Monday through Friday and Saturday or Sunday. Modalities documented on the evaluation included self-care retraining, functional transfer training, upper extremity therapeutic exercises, family/caregiver education, safety training, bed mobility, fine motor training, functional endurance training, postural control, neuromuscular re-education, functional standing training, functional balance training, functional mobility training, and active range of motion.

On 08/06/12 at 3:00 p.m., S3 Director of Nursing & Rehab Services, and S22 Unit Director were interviewed. After reviewing the electronic and hand written medical record for Patient #3, they confirmed the only physician's order for the physical and occupation therapy was the evaluate and treat order. S3 confirmed there were no specific orders for therapy after the evaluations were done by the therapist.


Patient #13
Review of the patient's medical record revealed the patient was a 42 year old male admitted to the CCU (Cardiac Care Unit) on 07/24/12 with diagnoses of Liver Failure, Multi-organism Sepsis, Kidney Failure, and Encephalitis. Review of the physician's orders dated/timed 07/31/12 at 0730 (7:30 a.m.) revealed an order, "Consult PT. Eval and treat". Further review of the physician's orders revealed an order dated/timed 08/04/12 at 7:45 a.m. as follows: PT/OT eval and treat. There was no documented evidence of any further physician's order for physical or occupational therapy.

Review of the physical therapy notes revealed an evaluation was attempted by S60PT on 07/31/12, but the patient was unable to be seen due to other treatments. Review of the physical therapy notes revealed an evaluation of the patient was done by a physical therapist on 08/01/12. The plan documented on the evaluation was as follows: Continue PT: 2-3 times a week for 6 visits, Monday through Friday to address long term goals through range of motion/positioning, strengthening, and patient/caregiver education. Further review of the physical therapy notes revealed the PT provided therapy to the patient on 08/03/12 and 08/06/12.

Review of the occupational therapy notes revealed an evaluation was documented on 08/06/12. The plan documented on the evaluation was as follows: Continue OT Monday through Friday, 10 visits. Address long term goals through self-care retraining, functional transfer training, upper extremity therapeutic exercises, equipment training, family/caregiver education, safety training, bed mobility, fine motor training, functional endurance training, postural control, functional balance training, functional standing training, functional mobility training, cognitive retraining, and active range of motion.

On 08/07/12 at 3:40 p.m. S59RN was interviewed. After reviewing the hand written and electronic medical record for Patient #13, S59 verified the only order written for physical and occupational therapy was, "eval and treat". S59 confirmed there were no specific orders for the PT or OT after the patient was evaluated. S59 confirmed both PT and OT were currently providing services for the patient.

On 08/07/12 at 4:05 p.m. S60 PT was interviewed and confirmed he had attempted to evaluate Patient #13 on 07/31/12. S60 stated the current process for physician orders for therapy was the physician wrote an order to evaluate and treat and that was the only physician order written for therapies. S60 stated the physician can see the therapist's evaluation in the computer. S60 verified the therapist does not obtain an order for the services identified in the evaluation.

Review of the hospital policy titled Rehabilitation Services, number 350-1, revised 04/06, and provided as current by S3 Director of Nursing & Rehab Services as current, revealed in part the following:
Policy: The definitions and the practice of the professions within the department shall be consistent with Louisiana Law....
Procedure:
I. Physical Therapy
B. Practice: 1. A licensed physical therapist shall not provide treatment without a prescription or referral of a person licensed to practice medicine, surgery, dentistry, or podiatry. 3. All physical therapists and physical therapist assistants will practice within the Law as defined by the law set forth in the Louisiana Practice Act and Rules and Regulations...II. Occupational Therapy. B. Practice: 1...Implementation of direct occupational therapy to individuals for their specific medical condition or conditions shall be based on a referral or order from a physician licensed to practice in Louisiana. 2. All occupational therapists and assistants shall practice within the law as defined by the Occupational Therapy Practice Act and Rules and Regulations...


Review of the Louisiana Revised Statutes, 37:2401-37:2424 Chapter 29. Louisiana Physical Therapy Practice Act revealed in part the following:
?2418. Authority to practice as a physical therapist or physical therapist assistant
A. A physical therapist or physical therapist assistant licensed in Louisiana is authorized to practice physical therapy as defined in this Chapter. A physical therapist is responsible for managing all aspects of the physical therapy care of each patient. B. Without prescription or referral, a physical therapist may perform an initial evaluation or consultation of a screening nature to determine the need for physical therapy and may perform physical therapy or other services provided in Subsection C of this Section. However, implementation of physical therapy treatment shall otherwise be based on the prescription or referral of a person licensed to practice medicine, surgery, dentistry, podiatry, or chiropractic. C. Except as to an initial evaluation or consultation, as provided in Subsection B of this Section, physical therapy services may be performed without a prescription or by referral only under the following circumstances: (1) To a child with a diagnosed developmental disability pursuant to the child's plan of care. (2) To a patient of a home health care agency pursuant to the patient's plan of care. (3) To a patient in a nursing home pursuant to the patient's plan of care. (4) Related to conditioning or to providing education or activities in a wellness setting for the purpose of injury prevention, reduction of stress, or promotion of fitness.(5) To an individual for a previously diagnosed condition or conditions for which physical therapy services are appropriate after informing the health care provider rendering the diagnosis. The diagnosis shall have been made within the previous ninety days. The physical therapist shall provide the health care provider who rendered such diagnosis with a plan of care for physical therapy services within the first fifteen days of physical therapy intervention..."

Review of the Louisiana State Board of Medical Examiners Subchapter B. Standards of Practice, provided by S3 Director of Nursing & Rehab Services as the Standard of Practice for Occupational Therapy, revealed in part the following:
A. This Subchapter provides the minimum standards for occupational therapy practice applicable to all persons licensed to practice occupational therapy in the state of Louisiana.
4915. Individual Program Implementation
A. Implementation of direct occupational therapy to individuals for their specific medical condition or conditions shall be based on a referral or order from a physician licensed to practice in the state of Louisiana.

Based on record review, policy and procedure review, and interview, the hospital failed to ensure care and services were provided in accordance with the plan of care by failing to ensure recreational therapy services were provided as ordered by the physician for 2 of 2 (#2 and #3) sampled rehabilitation unit patients out of a total of 13 current rehabilitation unit patients (Campus b). Findings:

On 08/06/12 at 9:05 a.m. an observation was made of the Rehabilitation Unit on Campus b with the Unit Director, S22. The unit was observed to have a Recreational Therapy Gym. S22 stated recreational therapy was part of the rehabilitation program along with physical, occupational, and speech therapies. S22 further indicated the rehab unit patient records were electronic and paper records with therapy and nursing documented in the electronic record.

Patient #2
Review of the patient's medical record revealed the patient was a 42 year old female admitted to the rehabilitation unit on 06/28/12 with a diagnosis of Right MCA (Middle Cerebral Artery) Stroke. Review of the Standing Orders dated/timed 06/28/12 at 1410 (2:10 p.m.) revealed the physician had circled Recreational Therapy, Physical Therapy, Occupational Therapy, Psychology, Speech Therapy, and Nutrition consults.

Review of the Recreational Therapy notes in the electronic record revealed only one note dated 08/03/12 that indicated the patient attended the unit volley ball game for 60 minutes, and signed by S21 Recreational Therapist (Campus b). There was no documented evidence of a Recreational Therapy assessment, or any other Recreational Therapy notes.

On 08/06/12 at 11:45 a.m., S57LOTR (Licensed Occupational Therapist), Rehab Unit Therapy Supervisor (Campus b) was interviewed. After reviewing the electronic record, S57 stated he only saw the one note on 08/03/12. S57 stated usually the Recreational Therapist does an assessment and a plan for continued recreational therapy. S57 verified there was no documented evidence of an assessment or any plan to continue Recreational Therapy. S57 contacted S21 Recreational Therapist by telephone. S21 was interviewed by speaker phone. S21 stated she did an assessment of the patient, but did not enter the assessment into the electronic record. S21 stated she did not know the date of the assessment. S21 also stated the patient had refused Recreational Therapy. S21 stated she would have to come in to the facility to look for her assessment.

Review of the Team Meeting Minutes revealed that S21 Recreational Therapist had attended the team meetings. There was no documented evidence that the patient was refusing the Recreational Therapy.

On 08/06/12 at 12:00 p.m., an interview was conducted with S3 Director of Nursing & Rehab Services (Campus b), S57 Rehab Unit Therapy Supervisor (Campus b), and S22 Unit Director (Campus b) and they confirmed the Recreational Assessment and notes should have been entered in the electronic records. S57 stated the procedure on the unit for any therapy assessment and notes was for the information to be incorporated into the electronic record.

On 08/06/12 at 2:35 p.m., a face-to-face interview was conducted with S21 Recreational Therapist. S21 provided a hand written, one page document as her assessment of Patient #2 and stated she had found the assessment in her office. Review of the document revealed the date of assessment line was left blank. 07/03/12 (5 days after admission) was documented on the line adjacent to "Recreation Therapist". Review of the document revealed disability information was checked. There was no documented evidence of an individualized plan for recreation therapy on the form, nor was there any evidence of an assessment of the patient's activity interests and needs. There was no documented evidence of a signature of the person who documented the assessment. S21 stated that she planned to continue recreation therapy for Patient #2, but she had a "high refusal rate". When asked if the patient's refusal of recreation therapy was documented and reported to her supervisor, she stated no.

Patient #3
Review of the patient's medical record revealed the patient was a 78 year old male admitted to the Rehab Unit on 06/08/12 and discharged to home on 06/15/12. The record revealed the patient had a diagnosis of Closed Head Injury. Review of the Standing Orders dated/timed 06/08/12 at 6:30 p.m. revealed the physician had circled Recreational Therapy, Physical Therapy, Occupational Therapy, and Speech Therapy consults.

Review of the completed electronic record revealed no documented evidence that a recreational therapy assessment had been done, and there was no documented evidence that any recreational therapy had been provided to Patient #3.

On 08/06/12 at 3:00 p.m., S21 Recreational Therapist was interviewed and confirmed she had not assessed Patient #3 and had not provided any recreation therapy for Patient #3. S21 stated she does not see every patient. S21 stated if there are 16-18 patients on the unit (28 bed capacity), she can't see all of them. When asked how she determined which patients she should see, S21 stated she tried to see the stroke patients, the depressed patients, or the patients therapy directed her to see.

On 08/06/12 at 3:50 p.m., S3 Director of Nursing & Rehab Services was interviewed. S3 stated the expectation was the Recreation Therapist would assess all stroke patients and all patients should be assessed. S3 verified Patient #2 should have been assessed and the assessment in the electronic record. S3 confirmed a Recreation Therapy consult was ordered by the physician and had not been done.

Review of the job description for the Recreation Therapist, job code 2604, approved 10/10/11, and provided by S3 Director of Nursing & Rehab Services as current, revealed the following:
II. General Summary: Plans, directs, coordinates medically approved recreation programs for patient on Rehab Unit. Participates as part of the Rehab Interdisciplinary Team. Assesses each patient's recreation needs, plans appropriate interventions, evaluates effectiveness, and documents same....May assess a patient condition and recommend appropriate recreation therapy.
IV. Essential Job Duties
1. Assess recreation needs and develop treatment plan that is meaningful and based on the persons served input, interests and objectives.
2. Observe, analyze and document patients' participation, reactions, and progress during treatment session and modify as needed....

Review of the policy titled, "Recreational Activities Program", policy number 350-46, revised 06/11, and provided as current by S3 Director of Nursing & Rehab Services as current, revealed the following:
Policy: Recreational activities will be available to patients admitted to the Rehab Unit based on individual assessment.
Procedure:
1. All patients will have a completed Recreational Assessment within 72 hours after admission to the unit by a certified recreation therapist.
2. All assessments will be documented in Mediserve on approved template and placed in the patient's medical record.

30364


Based on interviews and record reviews, the hospital failed to:
1. ensure the nursing staff developed nursing interventions for problems identified on the care plan for 1 (#27) of 9 (#26, #27, #28,#29,#30, #31, #32, #33, #34) sampled patients.
2. ensure the patient's main diagnosis/problem was included in the patient's plan of care for 1 (#26) out of 9 sampled patients on campus "a" (#26, #27, #28, #29, #30, #31, #32, #33, #34).
Findings:
1)
Patient #27
Review of the Admission Summary for Patient #27 dated 7/30/12 revealed she had been admitted to the Neonatal Intensive Care Unit (NICU) on 7/30/12. Her gestational age at birth was 29 weeks and 1 day.
Review of the document titled Interdisciplinary Plan of Care for Patient #27 revealed the following problems listed: Parenting Education R/T (related to) newborn care, Potential/Actual alteration in comfort R/T disease process, invasive procedures and skin breakdown, Ineffective Thermoregulation R/T prematurity, and Alteration in Metabolic Function Hyperbilirubinemia R/T impaired excretion of bilirubin. Further review revealed no nursing interventions were listed for the problems.
In an interview with NICU Director (Campus "a") S26 on 8/6/12 at 1:35 p.m., she verified no interventions were listed for the above mentioned problems. She also stated none of the 5 babies in the NICU or the 5 babies in the intermediate care nursery had nursing interventions listed for their problems on their care plans. S26 stated the nursing interventions were on the nurse round report.
In an interview with Infomatics Manager S28 on 8/6/12 at 1:50 p.m., he stated the nurse round report for Patient #27 contained a list of Physician's Orders, not nursing interventions. After further review, NICU Director (Campus "a") S26 agreed that the nurse round report did not contain nursing interventions.
2)

Patient #26
Review of Patient #26's medical record revealed she was a 33 year old female admitted to the hospital on 7/29/12. Her diagnoses include: End-stage renal disease, insulin-dependent diabetic, right upper extremity cellulites, hypertension, central vein stenosis or superior vena cava syndrome.
Review of the Patient's Plan of Care revealed her Problems listed on her care plan were Activity Intolerance, Risk for Injury, Altered Comfort, High Risk for Infection, and Knowledge deficit. There was no problem or interventions listed for her receiving dialysis three times a week or her diagnosis of End Stage Renal Disease(ESRD).

An interview was conducted with S27Telemetry Director on 8/6/12 at 3:35 p.m. She reported the patient's main diagnosis was End Stage Renal Disease and she was receiving dialysis and a problem for that diagnoses should have been included in her plan of care.

Based on record review and interview the hospital failed to ensure all drugs and biological were administered according to physician orders and acceptable standards of practice for 4 (#26, #32, #33, #34) out of 40 sampled patients.
Findings:
Patient #26
Review of Patient #26's medical record revealed she was a 33 year old female admitted to the hospital on 7/29/12. Her diagnoses include: End-stage renal disease, insulin-dependent diabetic, right upper extremity cellulites, hypertension, central vein stenosis or superior vena cava syndrome.
Review of Patient #26's culture results of 7/31/12 at 02:00 (2 a.m.) revealed "slight methicillin resistant staphylococcus aureus culture rt (right) stump wound. Susceptibilities...Gentamycin and Vancomycin ..."
Review of the Admission Orders dated 7/29/12 and timed 1310 (1:10 p.m.) revealed an order for Vanc (Vancomycin) 1 gram IV (intravenous) q (every) 24h (hours).
Review of the Physician's Orders for 7/30/12 at 9 a.m. revealed an order to change Vanc to 1 gr (gram) IV p (after) each dialysis.
Review of the Physician's Order for 7/30/12 at 4:15 p.m. revealed an order for Vancomycin i (1) g (gram) IVPB (intravenous piggy back) p (after) HD (hemodialysis) x i and Gentamycin 100 mg IVPB p HD x i.
Review of the MAR (Medication Admission Record) from 7/30/12 until 08/06/12 revealed the patient had never received a dose of Vancomycin 1 gram IV since admission to the hospital. Review of the patient's medical record revealed she was schedule for dialysis and received dialysis on 7/30/12, 8/02/12, and 08/04/12.
An interview was conducted with S27Telemetry Director, campus "a", on 08/06/12 at 1:30 p.m. She stated after review of the record and calling pharmacy that the patient had never received a dose of Vancomycin since being admitted to the hospital on 7/30/12.
On 8/6/12 at 2:15 S27 reported to the patient's infection disease physician, S38, that the patient had not received any Vancomycin as ordered. S38MD stated to S27Telemetry Director it was totally unacceptable and no wonder she was not getting better. S38MD also stated he had already consulted surgery, but he thought she was getting the antibiotics.
An interview was conducted with S38Infectious Disease physician on 08/06/12 at 2:40 p.m. When questioned if the missed antibiotics affected the patient's progress, he stated he had not seen a response through the weekend, there was no change in the patient's condition.
Review of the MAR from 7/30/12 to 08/06/12 revealed the patient received the Gentamycin 100 mg IVPB q HD x i on 7/31/12 at 0130 (1:30 a.m.).
An interview was conducted with S27Telemetry Director campus "a" on 08/6/12 at 1:30 p.m. She stated the patient's dialysis was completed at 1705 (5:05 p.m.) on 7/30/12 and the Gentamycin should have been given then. She confirmed the Gentamycin was administered 8 hours late on 7/31/12 at 1:30 a.m.
Review of the ID (infectious disease) physician's progress note (S38) from 08/06/12 revealed in part, "R (right) arm still swollen, still tender, Nurses notified me that vanc (Vancomycin) doses missed due to errors. Will d/c (discontinue) Vanc. Start Zyvox 600 mg IV q 12 h round the clock. Continue Gent (gentamycin). Consulted surgery for poss (possible) compartment syndrome."
Review of the Physician's Order for 8/6/12 revealed Zyvox 600 mg IV q 12 h, 1st dose stat and Gentamycin 100 mg IV after every dialysis. The order was signed by S38Infectious Disease MD, campus "a".
Review of an Incident Report (called a SOS at the hospital) dated 8/6/12 at 14:30 (2:30 p.m.) revealed S27Telemetry Director campus "a" completed the form. The incident was listed as an omission of Gentamycin. The reported incident Severity was a category E-treatment/intervention and temp (temporary) harm. "Spoke with Night shift nurse. Gentamycin given at 0130 (1:30 a.m.) the next day after recognizing that it was not given after dialysis."
Review of an Incident Report dated 08/06/12 at 14:30 (2:30 p.m.) revealed S27Telemetry Director campus "a" completed the form. The incident was list as an omission, medication/fluid error of Vancomycin. The reported incident severity was listed as category E- treatment/intervention and temp harm. "On 7/30/12, Vancomycin 1 gram ordered to be given by dialysis, no documentation of administration. Medication/Treatment ordered Zyvox 600 mg every 24 hours. Dr. S38Infectious Disease, campus "a" notified and orders for Zyvox ordered every 24 hours. Follow up list: description: Staff education regarding midnight check and 24 hour chart checks."
Review of the Admission Order dated 7/29/12 and timed 1310 (1:10 p.m.) revealed an order was noted for Administer Novolog insulin SubQ(subcutaeous) on prescribed schedule below. Administer before meals and nightly (AC/HS) for patients who are able to eat per sliding scale and administer at 0200 (2 a.m.) for patients on AC/HS monitoring per sliding scale. Moderate dose:
Glucose level Units
151-200 2 Units
201-250 4 Units
251-300 6 Units
301-350 8 Units
351-400 10 Units
>400 12 Units

Hypoglycemia protocol: any BG (blood glucose) < 60 mg/dl (milligrams per deciliter) or a BG < 80 mg/dl associated with symptoms of hypoglycemia. For patient who can take po (by mouth) give 15 g (gram) carbohydrates such as 4 oz. (ounces) of juice or 3 packets of sugar or 5 saline crackers or 3 graham cracker squares. Note: Dialysis patient; use apple or grape juice, not orange juice. If patient cannot take po, give D50W 25 ml (milliliters) 12.5 g IV push.

Review of the Nursing Nts (Notes) dated 05 Aug 2012 17:00 (8/5/12 at 5 p.m.) revealed, " PT (patient) BS (blood sugar) 31. PT stated she feels weak but shows no other signs of distress. Pushed prn (as needed) dextrose and pt drank orange juice with sugar packets. Rechecked PT BS 175. Pt sitting up in bed eating dinner ..."

An interview was conducted with S27Telemetry Director on 08/6/12 at 3:15 p.m. She confirmed the patient should not have been given orange juice since she was on dialysis and the patient was able to take glucose by mouth so the nurse should not have given dextrose intravenously. She confirmed the nurse did not follow the MD's orders.

Review of the Physician's Orders dated 08/04/12 at 2103 (9:03 p.m.) revealed on order for Flexeril 10 mg po q 8 hours prn (as needed) for muscle spasms, 1st dose now.
Review of the Medication Record for 08/04/12 revealed no documentation that the 1st dose of Flexeril 10 mg was not administered to the patient.
An interview was conducted with S27Telemetry Director on 08/6/12 at 2:30 p.m. She stated there was no documentation of the 1st dose of Flexeril given.
Review of the incident reported dated 08/06/12 at 14:30 (2:30 p.m.) completed by S27Telemetry Director revealed the Flexeril was an omission error. It was listed as a category E- treatment/intervention and temp harm.
Patient #32
Record review revealed Patient #32 was a 49 year old male found unresponsive at a local nursing home. He was admitted to the Emergency Department at the hospital on 5/14/12.
Review of Emergency Department Physician's Orders for Patient #32 revealed an order dated 5/14/12 at 06:23 a.m. for Dopamine (intravenous medicine to increase blood pressure) 400MG (milligrams)/250 mL (milliliters) D5W (5% Dextrose Solution) 5 MCG/KG/MIN (micrograms/Kilograms/minute). Further orders were for the nurse to titrate (adjust) to SBP (Systolic Blood Pressure) greater than 100 with a maximum of 20 mcg/kg/min.
Review of Intensive Care Unit (ICU) admit orders dated 5/14/12 at 11:00 (a.m.) revealed an order for Dopamine drip 5mcg/kg/min-titrate to MAP> 65 (Mean arterial pressure greater than or equal to 65).
Review of the Document for Patient #32 titled Nursing Critical Care Drips revealed the following Dopamine rates were adjusted by the nursing staff:
5/14/12 06:21 (a.m.)- 5mcg/kg/min- 10.3 cc/hr (milliliters/hour)
5/14/12 06:50 (a.m.)- (no dose recorded)- 20.6 (cc/hr)
5/14/12 09:54 (a.m.)- 15 mcg/kg/min- 30.9 cc/hr
5/14/12 11:29 a.m.- 20 mcg/kg/min- 41.3 cc/hr

Review of Emergency Department Physician's Orders dated 5/14/12 at 12:01 (p.m.?) revealed an order for Levophed (medicati

17091

Based on observation, interview, and record review, the facility failed to ensure
1) A system was in place to track the resident physicans with delinquent medical records and failed to follow hospital policy and procedure for staff physician with delinquent medical records
2)Medical records were properly stored to protect them from water damage.

Findings:

1)
Review of the "Deficiency Chart Total by Physician" list dated 08/10/12, provided by S12 HIM (Health Information) Director revealed a list of physicians with greater than 30 day, 60 day and 90 day delinquent records for the "Main Campus". The list revealed 64 records were over 30 days delinquent, 23 records were over 60 days delinquent, and 192 records were over 90 days delinquent.

On 08/10/12 at 8:25 a.m., the HIM Director, S12 and HIM Manager S40 were interviewed regarding the process for completion of medical records. S12 HIM Director stated records were to be completed within 30 days of discharge and were considered delinquent if not completed by 30 days and on day 31, the physician would have suspension of admitting privileges if delinquent records had not been completed. S40 HIM Manager stated the HIM department sent a letter to the physician when the physician had an incomplete record at 22 days after discharge. S40 HIM Manager was asked if S46 Staff Physician had been suspended since the "Deficiency Chart Total by Physician" list indicated the physician had a delinquent record over 90 days. She stated S46 Staff Physician was not suspended but was slated for suspension next week. She also stated this delinquent record was a resident physician's delinquency and was just reassigned to S46 Staff Physician. S40 HIM Manger stated the Staff Physicians were notified of delinquent records, but the resident physicians were not, because there was no system in place for addressing resident physician delinquencies. When asked if there was a policy to address resident physician completion of medical records, S40 HIM Manager stated, "No, they don't fall under the chart completion policy." When asked what the time frame was for reassigning resident delinquencies to the Staff Physician. S40 HIM Manager stated there was no defined time frame. When asked if S47 Physician had been suspended, S40 HIM Manager stated S47 was a resident.

On 08/10/12 at 10:30 a.m., S12 HIM Director provided a list titled, "Resident Deficiencies". S12 stated this was a list of resident physician delinquencies that had not been reassigned to a Staff Physician. Review of the "Resident Deficiencies" list revealed 30 resident physicians were listed as having delinquent medical records. 13 physician had records delinquent over 30 days, 3 physicians had records delinquent over 60 days, and 18 physicians had records delinquent over 90 days. S12 HIM Directer was asked to provide documentation of physician deficiencies for S43Physician, S44Physician, S45Physician, S46Physician, and S47Physician.

On 08/10/12 at 1:05 p.m. S12 HIM Director and S40 HIM Manager were interviewed after providing a deficiency list for S44Physician, S40 HIM Manager stated S44 Physician retired on 12/31/11 and had 11 incomplete records and also verified one record had 12 deficiencies with a discharge date of 07/19/2011. S40 HIM Manager stated the internal process in the HIM department had failed to identify this record as delinquent for S44Physician prior to his retirement on 12/31/11.

Review of the Deficiency List by Physician provided by the Health Information Management (HIM) Staff revealed S45 Physician had 5 medical records that were delinquent since 3/7/10, 3/9/10, 10/9/10, 12/10/11, and 9/13/11. In an interview on 8/10/12 at 1:10 p.m. with S40 HIM Manager, revealed Physician S45 did not have her privileges suspended as per policy because their department was not aware she was still a staff member until recently.
Review of the Deficiency List by Physician revealed S43 Physician had 3 medical records delinquent with one since 6/24/12 and two since 6/14/12. In an interview on 8/10/12 at 1:18 p.m. with S40 HIM Manager stated S43Physician did not have his privileges suspended as per policy because their department had S43 Physician incorrectly labeled as a resident.
Review of the Deficiency List by Physician revealed Physician S46 had a delinquent medical record from 1/15/12 that had been signed on 8/10/12. In an interview on 8/10/12 at 1:22 p.m. with S40 HIM Manager , she stated S46 Physician had only signed the delinquent chart this morning and he had not been suspended because the HIM department did not know he had a delinquent chart because it had not been " triggered " by their system. She stated delinquent charts not triggering was a problem that was currently being corrected.
Review of the Deficiency List revealed Physician S47 had 1 delinquency over 90 days listed. In an interview on 8/10/12 at 1:28 p.m. with S40 HIM Manager, she stated S47 Physician had not been suspended because he actually worked at another campus and his delinquencies inadvertently carried over to their list.
On 08/10/12 at 3:40 p.m., S12 HIM Director and S40 HIM Manager were interviewed and provided a list of Physicians who were no longer employed by the hospital, and a list of monthly delinquent record statistics. Review of the Physician list revealed the names of 22 physicians and a total of 121 deficiencies. Review of the list revealed S45Physician was no longer employed.

Review of the statistics revealed the following number of delinquent records/number of records for 2012:
January - 1116/5799
February - 1186/4536
March - 1054/5607
April - 854/4985
May - 601/6182
June - 617/5398
July - 759/5617

S40 HIM Manager and S12HIM Director stated they are continuing to verify the physicians who are available to complete records. S40 stated she did not know if the physicians identified on the list of Resident Deficiencies were available to complete the delinquencies. and the Staff Physicians are allowed a 7 day window to complete delinquencies that are re-assigned to them. S40 HIM Manager and S12 HIM Director were unable to provide a list of current physicians. S40 HIM Manger stated they were continuing to resolve the physician issues.

Review of the Medical Staff Rules and Regulations, adopted by the Medical Staff on 06/19/02, and approved by the Board of Directors on 07/17/02, and provided as current revealed the following in part:
P. Medical Record Completion

1. Medical records must be completed within 30 days after discharge or hospital outpatient procedures or the medical record will be considered delinquent. Any violation of this rule without acceptable cause will deprive the physician of elective hospital privileges until records are complete.
5. Any physician who has been continuously on suspension for 45 days or more will be referred to MEC/SEC (Medical Executive Committee/Staff Executive Committee) and a letter will be sent from the Chief of Staff informing them that they must complete their charts within 30 days of receiving this notice. If the charts are not completed within 30 days the physician's privileges will be automatically relinquished. The Practitioner may again apply for medical staff membership and clinical privileges through the regular application process.

2) The hospital failed to ensure medical records were properly stored to protect them from water damage.

In an interview on 8/10/12 at 12:05 p.m. with S40 HIM Manager , revealed once patients were discharged, their medical records were sent to the scanning department and the medical records were kept for up to 24 hours before they were scanned into a computer. S40 HIM Manager also stated the hospital began scanning medical records on 3/17/08 and prior to that date, the hospital still used the paper medical records and kept them in a storage room at the base of the parking garage.
In an observation on 8/10/12 at 12:20 p.m. of the medical records storage room located in the parking garage, thousands of medical records were stored on open shelving. Sprinkler systems were located throughout the room.
In an interview on 8/10/12 at 12:20 p.m. with S12

Based on record reviews, observations, and staff interviews, the infection control officer failed to maintain a sanitary physical environment as evidenced by: 1) failing to ensure proper hand washing technique was performed after touching contaminated item as evidenced by S71Transport talking on the telephone in the hallway located on the unit "b" wearing gloves, walked to stretcher located parked up against the wall, accessed the elevator to unit "a", parked the stretcher in hallway across the hall from the nurses' station/countertop, removed right hand glove and placed it in pocket, removed right hand glove from pocket and discarded it in the trash can located across the hall, walked to the sink area located in the nurses' station (no hand washing performed), walked from the nurses' station sink area to a nurse documentation station located across the hall from the station, picked up the telephone, hung up the telephone, walked back to nurses' station/countertop, picked up an ink pen, filled out a yellow transport ticket, removed left hand glove, discarded the left hand glove in the trash can next to the nurse doc station, donned gloves (no hand washing performed), walked to stretcher, pushed the stretcher to the end of the hallway stopping in front of door labeled, room "a" as per the "Hand Hygiene" policy;
2) failed to ensure PPE (personal protective equipment) was worn by all staff as evidenced by: a) S55RN, ASC/PACU failing to ensure her front bangs four inches in width was covered by her hair net, two thick long strands of hair was hanging out of the hair net eight inches in length, and four inches of her back hair was not covered by the Airet as per protocol, b) S61Surgery Unit Director and S62Administrative Clinical Coordinator of Surgery failing to ensure the front bangs area, side burns, hair on the back of their necks were covered by the hair net as per protocol, and c) S69Central Supply Supervisor walking four feet into the area and walked back out without wearing a hair net as per protocol.
Findings:
1)

During an observation performed on 08/08/12, S71Transport was observed talking on the telephone in the hallway located on unit "b" wearing gloves at 10:05 a.m. and she walked to a stretcher that was parked up against the wall. At 10:06 a.m., S71 accessed the elevator to unit "a" and she parked the stretcher in hallway across the hall from the nurses' station/countertop. At 10:07 a.m. S71 removed her right hand glove and placed it in her pocket, removed it from her pocket and discarded it in the trash can located across the hall from the nurses' station. From 10:07 a.m. through 10:10 a.m., S71Transport was observed walking to the sink area located in the nurses station (no hand washing performed), walking from the nurses station sink area to a nurse documentation station located across the hall from the station, picking up the telephone, hung up the telephone, and walked back to nurses station/countertop. At 10:10 a.m. S71 picked up an ink pen located on top of the countertop at the nurses station and filled out a yellow transport ticket. From 10:10 a.m. through 10:12 a.m., S71 was observed removing her left hand glove, discarded it in the trash can next to the nurse documentation station, and donned gloves without performing handwashing. She (S71) walked to the stretcher, pushed the stretcher to the end of the hallway stopping in front of door labeled, room "a". At 10:12 a.m., S71Transport was observed removing her gloves, discarded them in a nearby trash can, and used the hand sanitizer mounted on the wall. During this observation, S71Transport confirmed there was no hand washing performed after removing and donning gloves as per protocol. At 10:12 a.m., S5COO (chief operating officer) confirmed the above findings.


The policy titled, "Hand Hygiene Policy", Policy Number OHS.IC.001, Issue date of August of 2011, with no reviewed and/or revised date(s), revealed hand hygiene is considered a necessary step to reduce transmission of pathogenic organisms to patients, personnel, and visitors in the healthcare settings. It is generally considered the most important single procedure for preventing healthcare-associated infections. It is expected of all employees to conduct hand hygiene. When hands are visibly dirty or contaminated with proteinaceous material or visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all clinical situations. Decontaminate hands after contact with a patient's skin. Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin if hands are not visibly soiled. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. Decontaminate hands after removing gloves. When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers until hands are dry. Change gloves during patient care if moving from a contaminated body site to a clean body site. Each department manager/director is responsible for ensuring all employees conduct hand hygiene to prevent harm to patients, employees, and visitors to the hospital. The definition of indirect contact refers to touching an inanimate object for example, a healthcare worker touching a patient bed or linen, equipment, or room furnishings.

2)

S55RN, ASC/PACU:

During a tour of the ambulatory surgery center on 08/07/12 from 1:55 p.m. through 2:30 p.m., S55RN, ASC/PACU was observed with her front bangs four inches in width not covered by her hair net. Further observation revealed she had two thick long strands of hair hanging out of the hair net eight inches in length. S55 had four inches of her back hair not covered by the hair net during this observation. S55RN confirmed the findings during this observation.

S61Surgery Unit Director and S62Administrative Clinical Coordinator of Surgery:

A tour of the operating room (OR) "a" was performed on 08/06/12 from 1:00 p.m. through 1:30 p.m. and operating room "d" from 1:32 p.m. through 1:45 p.m. with the chief operating officer (COO, S5), the Surgery Unit Director (S61) and the Administrative Clinical Coordinator of Surgery (S62). During this same tour, S61 and S62 were both observed with their side burn hairs, forehead hairs, and hair on the back of their necks not covered by the hair net. At 1:50 p.m., S5, S61 and S62 all confirmed S61's and S62's side burns, foreheads, and neck hairs were not covered by the hair net as per protocol.

S69Central Supply Supervisor:

During an observation of the decontamination /soiled area on 08/06/12 from 1:47 p.m. through 2:15 p.m. with S5COO, S61Surgery Unit Director, and S62Administrative Clinical Coordinator of Surgery, there was a sign posted on the door that read, "PPE (personal protective equipment) must be worn in the central supply and decontamination area". At 1:55 p.m., S69Central Supply Supervisor walked four feet into the decontamination area without wearing a hair net and she exited the area. S69 indicated all personnel decontaminating the equipment, (SCD machines, bedside commodes) must wear PPE including a uniform and hair net.

In an interview on 08/06/12 at 2:15 p.m., the Director of Central Supply, S70 confirmed the sign posted on the decontamination area read, "PPE must be worn in the central supply and decontamination areas". S70Director indicated PPE requires all employees to wear hair nets prior to entering the room. The Director, S70 indicated further S69 is required to wear a hair net upon entry into the decontamination area as per protocol. S70 denied knowledge S69Central Supply Supervisor was not aware that the PPE protocol is required by all staff entering the area.

On 08/06/12 at 1:55 p.m., S5COO, S61Surgery Unit Director, and S62Administrative Clinical Coordinator of Surgery verified the sign posted on the decontamination area read, "PPE

Based on record reviews, observations, and staff interviews, the hospital:
1) failed to ensure the surgical services followed the manufacturer's instructions for the decontamination process for all surgery instruments as evidenced by:
a) failing to ensure the surgical (peripheral vascular, gastrointestinal) instruments dwelled for three (3) minutes in the "RTU Mini-Foamer Autron Medical" cleaner, and
b) failing to mix the "Prolystica Ultra Concentrate Enzymatic Cleaner" with one tenth to one fortieth (1/10 - 1/40) ounce per gallon by filling sink 1 with two (2) inches of water (one and a half gallons of water) above the fill-line marked in sink 2;
2) failed to ensure the sanitation of the surgical equipment in the OR (operating room) was performed as per policy as evidenced by: failing to ensure operating room (OR) "a"'s equipment, (cushion velcro areas with yellowish/whitish substance or lent; arm boards with a bluish/whitish substance and sticky substance on the outer surfaces of the boards; electrocardiogram machine outer edges with a grayish/black substance; small square pillow with a sticky substance measuring two by five inches; Bipolar machine with a grey substance covering the inside areas of the plug-in), pediatric bed in the hallway with a cached black substance in all four corners, light source in the hallway with a sticky black adhesive area covering the outer edges of the performance inspection sticker were cleaned as per the "Sanitation of the Surgical Suite" policy;
3) failed to ensure there was a separation between the decontamination (dirty) area and clean area for all patient equipment (sequential compression devices /SCD-a machine used to prevent blood clots after surgery, and bedside commodes) as evidenced by failing to have a system in place for the dirty SCD machines to be to be transported to the designated clean area and/or different areas of the hospital without passing through the dirty area as per the "Sterile Processing Decontamination and Clean Area: Traffic Patterns and Preparation for Sterilization" policy;
4) failed to ensure the turnover cleaning of the operating room (OR) "d" was performed using proper practices as evidenced by:
a) S66Operating Room Assistant (ORA) wiping all equipment (overhead lights time three, arm boards times two, mayo stand, and operating room table) with the same Cavi-Wipe,
b) S67ORA gloved and moved the table over two feet, got a clean Cavi-Wipe from the container, dropped the Cavi-Wipe on the floor, picked it up off the floor, wiped the rolling trash can bowl with the dirty Cavi-Wipe, and mopped the floor from front to back without de-gloving and/or hand washing, and
c) S68ORA donned gloves, wiped the mayo stand from top to bottom (touching the floor), wiped the pillow laying on top of the metal table at the back of the room, placed the pillow on top of the OR table, wiped both arm boards, wiped the support monitor from top to bottom-touched the floor with the wipe, threw the gloves in the trash can without performing hand washing and/or changing gloves as per "Sanitation of the Surgical Suite" and "Hand Hygiene" policies. Findings:

1)

Review of the manufacturer's instruction sheet for the "RTU Mini-Foamer Autron Medical Model #ZUTR50106" cleaner revealed all instruments are to be treated to prevent drying of bioburden by applying an even layer of foam. Allow enzymatic foam to soak for about 3 minutes.

During an observation of the decontamination process conducted on 08/07/12 from 10:06 a.m. through 10:20 a.m., S63Sterile Processing Tech removed the peripheral vascular (PV) instruments from the top of the dirty instrument cart from operating room (OR) "c". At 10:07 a.m., S63 placed the instrument tray into sink 2 that was empty with a line marked, "fill-line", removed the instruments from the tray and placed them into sink 1 that was filled with a blue substance. S63 stated these instruments do not require a pre-soaking process at this time; They will soak in the enzymatic cleaner for five (5) minutes- she pointed to sink 1 area at this time. At 10:10 a.m., she removed the gastrointestinal (GI) instrument tray from operating room "c" cart and placed them into sink 2. She grabbed the spray handle from the wall mount labeled, "RTU Mini-Foamer Autron Medical" cleaner by sink #2. S63 rinsed the GI instruments with running water in sink 2 and she placed them into sink 1. Further observation revealed all of the GI instruments were not covered with the foam cleaner at this time. At 10:10 a.m., the Sterile Processing Tech, S63 confirmed all GI instruments were not covered with the foam cleaner. She indicated there is no pre-soaking of these instruments required when using the foam cleaner. S63 further indicated the GI instruments do not have to soak in the foam cleaner for any length of time; They soak in the enzymatic cleaner for 5 minutes. At this time, S63 denied knowledge of the enzymatic cleaner's name. At 10:15 a.m., S63Sterile Processing Tech indicated sink 1 was filled with water and two (2) squirts of the enzymatic cleaner. She confirmed there was no fill-line marked in sink 1. The Sterile Processing Tech stated there is one and a half gallons of water in sink 1. She stated further sink 1 is filled two (2) inches above the fill-line marked in sink 2. S63 indicated the fill-line marking in sink 1 came out of the sink about two (2) months ago. The Sterile Processing Tech, S63 further indicated she informed her supervisor, S64 at this time. S63 stated S64Sterile Process Director told me to continue using sink 1 to perform the decontamination process until the fill-line can be replaced. The Sterile Processing Tech, S63, denied knowledge of when the Sterile Process Director indicated the fill-line in sink 1 would be done.

In an interview on 08/07/12 at 10:20 a.m., the Sterile Process Director, S64, verified sink 1 was two inches above the fill-line marked in sink 2. S64 indicated this dilutes the enzymatic cleaner. S64Sterile Process Director indicated further S63 failed to follow the manufacturer's instructions to mix the cleaner. S64 stated all instruments must be pre-soaked in the Mini-Foamer Autron Medical" cleaner mounted on the wall for 3 minutes as per manufacturer's instructions.

Review of the "Prolystica Ultra Concentrate Enzymatic Cleaner" manufacturer's instructions revealed the cleaner is highly concentrated for use in hospital disinfector units. It provides superior cleaning performance against blood, mucous and the most challenging fatty soils associated with orthopedic cases. The dual enzyme system works exceptionally well regardless of water quality or type. The enzymatic cleaner is also compatible with stainless steel including aluminum. All of this at 1/10 - 1/40 ounce per gallon.

During the same observation on 08/07/12 from 10:06 a.m. to 10:20 a.m. with S63Sterile Processing Tech, there were two (2) aluminum sinks (sink 1 on the left and sink 2 on the right). Sink 2 had a fill-line marked inside the sink area. Sink 1 was observed with no fill-line marked on its inside. Further observation revealed sink 1 was filled 2 inches above the designated fill-line marked in sink 2 with two (2) squirts of Prolystica Enzymatic Cleaner. At 10:15 a.m., she verified there was no fill-line marked inside of sink 1. S63 indicated there were 2 squirts of the Prolystica Enzymatic Cleaner in sink 1 with one gallon and a half of water. She confirmed sink 1 was filled 2 inches above the fill-line marked in sink 2 diluting the cleaner. The Sterile Processing Tech, S63, indicated she reported there was no fill-line marked in sink 1 to S64Supervisor two months ago. She further indicated the Director, S64 told me to continue using sink 1 to do soak the instruments in the enzymatic cleaner.

In the same interview on 08/07/12 at 10:20 a.m. the Sterile Process Director, S64, confirmed there was no fill-line marking in sink 1. The Director, S64, verified sink 1 had 2 inches of water above the marked fill-line in sink 2- diluting the cleaner. He (S64) indicated the Sterile Processing Tech, S63 failed to mix the Prolystica Enzymatic Cleaner in one gallon

Based on record review, staff interview, and review of Louisiana Physical Therapy Practice Act and Louisiana State Board Medical Examiners, the hospital failed to ensure that physical therapy (PT) and occupational therapy (OT) services were provided only under the orders of a licensed practitioner by failing to obtain physician's orders for therapy services provided after the initial evaluation by the therapist for 3 of 3 sampled patients reviewed for physical and occupational therapy (#2, #3, and #13) out of a total sample of 40. Findings:

Patient #2
Review of the patient's medical record revealed the patient was a 42 year old female admitted to the rehabilitation unit on 06/28/12 with a diagnosis of Right MCA (Middle Cerebral Artery) Stroke. Review of the physician's orders revealed an order dated/timed 06/28/12 at 1750 (5:50 p.m.) for physical therapy to evaluate and treat with gait training and therapeutic exercises. The physician's order also included an order for occupational therapy to evaluate and treat with restore function ADL training and therapeutic exercises. There was no documented evidence of any further physician's order for physical or occupational therapy.

Review of the physical therapy evaluation dated 06/29/12 revealed the physical therapist planned to continue physical therapy for 14 days with therapy provided twice daily including Saturday and/or Sunday. Modalities documented on the evaluation included bed mobility, transfer training, gait training, wheelchair mobility, range of motion/positioning, endurance training, strengthening, balancing training and patient/caregiver education.

Review of the occupational therapy evaluation dated 06/29/12 revealed the occupational therapist planned to continue occupational therapy for 14 days with therapy provided twice daily at 7:30 a.m. to 8:30 a.m. and 11:15 a.m. to 11:45 a.m.. Modalities documented on the evaluation included functional transfer training, upper extremity therapeutic exercises, equipment training, family/caregiver education, safety training, bed mobility fine motor training, functional endurance training, neuromuscular re-education, functional standing training, functional balance training, functional mobility training, active and passive range of motion.

On 08/06/12 at 3:00 p.m., S3 Director of Nursing & Rehab Services, and S22 Unit Director were interviewed. After reviewing the electronic and hand written medical record for Patient #2, they confirmed the only physician's order for the physical and occupation therapy was the evaluate and treat order. S3 confirmed there were no specific orders for therapy after the evaluations were done by the therapist.


Patient #3
Review of the patient's medical record revealed the patient was a 78 year old male admitted to the Rehab Unit on 06/08/12 and discharged to home on 06/15/12. The record revealed the patient had a diagnosis of Closed Head Injury. Review of the physician's orders revealed an order dated/timed 06/08/12 at 6:30 p.m. for physical therapy to evaluate. The physician's order also included an order for occupational therapy to evaluate and treat. There was no documented evidence of any further physician's order for physical or occupational therapy.

Review of the physical therapy evaluation dated 06/10/12 revealed the physical therapist planned to continue physical therapy for 7 days with therapy provided twice daily Monday through Friday including Saturday and/or Sunday. Modalities documented on the evaluation included bed mobility, transfer training, gait training, wheelchair mobility, endurance training, strengthening, balancing training, neuromuscular re-education, and patient/caregiver education.

Review of the occupational therapy evaluation dated 06/29/12 revealed the occupational therapist planned to continue occupational therapy for 7 days with therapy provided twice daily, Monday through Friday and Saturday or Sunday. Modalities documented on the evaluation included self-care retraining, functional transfer training, upper extremity therapeutic exercises, family/caregiver education, safety training, bed mobility, fine motor training, functional endurance training, postural control, neuromuscular re-education, functional standing training, functional balance training, functional mobility training, and active range of motion.

On 08/06/12 at 3:00 p.m., S3 Director of Nursing & Rehab Services, and S22 Unit Director were interviewed. After reviewing the electronic and hand written medical record for Patient #3, they confirmed the only physician's order for the physical and occupation therapy was the evaluate and treat order. S3 confirmed there were no specific orders for therapy after the evaluations were done by the therapist.


Patient #13
Review of the patient's medical record revealed the patient was a 42 year old male admitted to the CCU (Cardiac Care Unit) on 07/24/12 with diagnoses of Liver Failure, Multi-organism Sepsis, Kidney Failure, and Encephalitis. Review of the physician's orders dated/timed 07/31/12 at 0730 (7:30 a.m.) revealed an order, "Consult PT. Eval and treat". Further review of the physician's orders revealed an order dated/timed 08/04/12 at 7:45 a.m. as follows: PT/OT eval and treat. There was no documented evidence of any further physician's order for physical or occupational therapy.

Review of the physical therapy notes revealed an evaluation was attempted by S60PT on 07/31/12, but the patient was unable to be seen due to other treatments. Review of the physical therapy notes revealed an evaluation of the patient was done by a physical therapist on 08/01/12. The plan documented on the evaluation was as follows: Continue PT: 2-3 times a week for 6 visits, Monday through Friday to address long term goals through range of motion/positioning, strengthening, and patient/caregiver education. Further review of the physical therapy notes revealed the PT provided therapy to the patient on 08/03/12 and 08/06/12.

Review of the occupational therapy notes revealed an evaluation was documented on 08/06/12. The plan documented on the evaluation was as follows: Continue OT Monday through Friday, 10 visits. Address long term goals through self-care retraining, functional transfer training, upper extremity therapeutic exercises, equipment training, family/caregiver education, safety training, bed mobility, fine motor training, functional endurance training, postural control, functional balance training, functional standing training, functional mobility training, cognitive retraining, and active range of motion.

On 08/07/12 at 3:40 p.m. S59RN was interviewed. After reviewing the hand written and electronic medical record for Patient #13, S59 verified the only order written for physical and occupational therapy was, "eval and treat". S59 confirmed there were no specific orders for the PT or OT after the patient was evaluated. S59 confirmed both PT and OT were currently providing services for the patient.

On 08/07/12 at 4:05 p.m. S60 PT was interviewed and confirmed he had attempted to evaluate Patient #13 on 07/31/12. S60 stated the current process for physician orders for therapy was the physician wrote an order to evaluate and treat and that was the only physician order written for therapies. S60 stated the physician can see the therapist's evaluation in the computer. S60 verified the therapist does not obtain an order for the services identified in the evaluation.

Review of the hospital policy titled Rehabilitation Services, number 350-1, revised 04/06, and provided as current by S3 Director of Nursing & Rehab Services as current, revealed in part the following:
Policy: The definitions and the practice of the professions within the department shall be consistent with Louisiana Law....
Procedure:
I. Physical Therapy
B. Practice: 1. A licensed physical therapist shall not provide treatment without a prescription or referral of a person licensed to practice medicine, surgery, dentistry, or podiatry. 3. All physical therapists and physical therapist assistants will practice within the Law as defined by the law set forth in the Louisiana Prac