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Based on record review, policy review and interview with staff, the hospital failed to ensure the medical staff was accountable to the governing body for the quality of care provided to 1 of 1 patients (patient #19) in a total sample of 30 as evidenced by: 1) not following the hospital's policy regarding admitting a patient(s) (patient #19) who was medically unstable (experienced labile blood pressures), 2) not following the hospital admission policy as evidenced by not having a documented pre-admission assessment prior to being admitted to the rehabilitation hospital and 3) the physician accepting a medically unstable patient (patient #19) that was clearly defined in the "Post-Admission Physician Evaluation Addendum to H&P" that the patient (patient #19) was not a good candidate for the rehabilitation program. Findings:

Review of the medical record revealed patient #19 was an 80 year-old who was admitted to Sterlington Rehabilitation Hospital on 7/18/2011 with diagnoses of degenerative joint disease secondary to osteoarthritis of bilateral shoulders, bilateral hips, bilateral knees, and lumbar spine, dysphagia, anemia requiring transfusions, cirrhosis of the liver, esophageal varices, anorexia, hypertension and chronic alcoholism.

On 8/24/2011 at 9:50 AM, an interview was held with S9 DON who stated she performed prescreening assessments for patients who were interested in being admitted to Sterlington Rehabilitation Hospital. She stated that before Dr. S7 resigned from the hospital medical staff, she consulted with him after performing preadmission screening assessments. She further stated that Dr. S7 reviewed her prescreening assessments and determined whether or not the patient met the criteria for admission. S9 added that Dr. S5 was now the medical director and she takes the assessments to him.

During the interview, S9 stated that patient #19 was a direct admit from their rural health clinic where Dr. S7 had an office at that time (at the time patient #19 was seen at the rural health clinic), and while he was the medical director of the rehab hospital. She also said Dr. S7 sent the patient to the hospital without her (S9) performing prescreening assessments and that he faxed over the admit physician orders for the patient. She stated the doctor had the "ultimate say so on whether the patient was admitted or not". Review of the medical record from the rural health clinic dated 7/18/2011 revealed a pre-screening examination was not performed on patient #19.

Review of a form dated 7/18/2011 and titled "Post-Admission Physician Evaluation Addendum to H&P" completed by Dr. S7 on 7/18/2011 at 12:40 PM (documentation in the medical record revealed patient #19 was admitted to Sterlington Rehabilitation Hospital on 7/18/2011 at 11:50 AM) revealed documented changes in patient #19's condition since his admission to the rehab hospital. Further review revealed "during 3 hours post pre-admit screening by both MD (medical doctor) and RN, patient's condition began to deteriorate and he became hypertensive (according to documentation in the 7/18/2011 nurse progress notes, the patient became hypotensive) and hypoxic-medically fragile".

Further review revealed a section of the evaluation form that addressed "how rehab might complicate medical/co-morbid conditions". Continued review revealed an increase in patient #19's "activity could trigger medical complications by increased activity, potentially exacerbation of a fragile system, at risk for respiratory, cardiac issues and circulatory issues & bleeding. Also risk for CVA (cerebral vascular accident), risk for falls. Risk for skin integrity issues and major bleeds, DVT's (deep vein thrombosis). Aspiration risk". Additionally, the last section of this form revealed "I CONCUR THAT ADMISSION OF THIS PATIENT TO THE IRF (intensive rehabilitation facility) IS BOTH REASONABLE AND NECESSARY". This statement was signed by Dr. S7 on 7/18/2011 (no time documented)

Review of the Admission Policy, reviewed and revised 1/2010 revealed, "all referrals are documented, and assessment personnel are contacted/given the order and dispatched to the patient's location to perform the pre-admission assessment for rehabilitation criteria. Upon completion, the assessment is returned to Sterlington Rehab Hospital for review and approval/denial based on admission criteria. Patient and/or facility are notified by staff of determination".

Further review of this policy revealed, "most acute medical problems, which would interfere with the rehabilitation program, must be resolved prior to admission to the Rehabilitation Facility". This policy also revealed that, "the patient must have a rehabilitation need as a secondary diagnosis to a medically stable, but complex medical condition. The patient requires, and can tolerate, an intensive rehabilitation program, requiring at least three hours of therapy per day, 24-hours rehabilitation nursing, and supervision by a Medical Director."

Based on review of the grievance log, review of the Patient Rights Policy and Procedures and interview with staff, the hospital failed to ensure 2of 5 patients (patient #13 and patient #29) who filed grievances received written notices of the hospital's decision.
Findings:

1. Review of the grievance log revealed on 5/25/2011 patient #13 "reported she repeatedly asked to be put back to bed after completion of therapy activities. (Patient #13) was told she needed to stay up for supper". Further review revealed patient #13 asked the LPN again to put her to bed and "she was told she would have to wait until evening shift". Continued review revealed the patient reported "she did not get into bed until 7:45 PM & (and) had been up since 5:00 am".

Review of the grievance log revealed a second grievance was filed on 6/01/2011 by S2 CNA on behalf of patient #13. Review of the grievance revealed patient #13 "reported to (S2) that she felt uncomfortable asking to be taken to the bathroom by CNA (certified nursing assistant) due to CNAs 'bad attitude' when asked to help her". Further review revealed the patient reported "having to wait extended period of time to have needs met after pushing call button & (and) CNA did not respond to pt (patient) on intercom". There failed to be documented evidence that the hospital investigated the grievances or sent a written response to the complainant.

2. Review of the grievance log revealed patient #29 filed a grievance on 6/22/201. Review of the grievance revealed patient #29 "stated she was in pain. Discovered she was on bedpan. Pt. (patient #29) stated was left on bedpan from the time of her admit @ (at) 1:45 pm until I took her off of bedpan at 1925 (7:25 PM)". Further review revealed the patient reported that the CNA (certified nursing assistant) was "suppose to come back & (and) take her off the pan but never came". Documentation on the grievance form revealed patient #29 stated "I hope you all take better care of me than that first group did. Pt had red indentation on buttocks & legs from being on bed pan so long". Continued review revealed the hospital failed to provide the patient with a written response to her grievance.

Review of the patient rights policy revealed a complainant should "submit a written statement of specific grievance to the Administrator. Receive a verbal follow up from Administrator within one (1) working day. If the complaining party is still not satisfied, Administrator will investigate and respond in writing within 3 working days". This contridicts the federal regulation which addresses when a resolution is made the hospital must give the patient a written notices of the it's decision.

Based on review of Medical Staff Bylaws and interview with the administrator the hospital failed to ensure Medical Staff bylaws were enforced by not adopting rules and regulations. Findings:

On 8/23/2001 at 3:30 PM, after reviewing the Medical Staff Bylaws, the survey team asked the administrator for the Medical Staff Rules and Regulations. In an interview at that time the administrator confirmed that the medical staff did not have rules and regulations. Review of the Medical Staff Bylaws revealed the "Medical Staff shall adopt such rules and regulation as may be necessary to implement more specifically the general principles found within these bylaws".

Based on record review, policy review and interviews, the registered nurse failed to evaluate the nursing care of 1of 1 patients (patient #19) in a total sample of 30 by failing to: 1) increase assessments of blood pressure for of patient #19 after labile blood pressures changes in the patient level of conscious were identified by the CNA (interview with staff revealed they could not remember the name of the CNA) on 7/18/2011 at 3:40 PM and 2) notify the physician responsible for the care of patient #19 of significant changes in the patient's status as evidenced by labile blood pressures for 3 hours and 50 minutes on 7/18/2011. Vital signs were taken at the end of the 3 hours and 50 minutes when a CNA (interview with staff revealed they could not remember the name of the CNA) entered patient #19's room and found him "unresponsive" and #3) administer blood in a timely manner when ordered by the physician as evidenced by allowing 3 hours and 54 minutes to pass before the order for blood was sent to the lab when lab results were marked that patient #19 had a critically low hemoglobin of 5.5 (normal-13.0-16.6) was critically low. Findings:

Review of the medical record revealed patient #19 was an 80 year-old who was admitted to Sterlington Rehabilitation Hospital on 7/18/2011 with diagnoses of degenerative joint disease secondary to osteoarthritis of the shoulders, bilateral hips, bilateral knees, and lumbar spine, dysphagia, anemia requiring transfusions, cirrhosis of the liver, esophageal varices, anorexia, hypertension and chronic alcoholism.

Review of the 7/18/2011 nursing admit assessments (initial assessments) at 11:50 AM by S8 RN revealed a blood pressure of 80/34 sitting and 70/30 lying, temperature 97.2 (F) Fahrenheit, respirations 18 breaths per minute and heart rate 63 beats per minute. Further review of his admit assessments revealed the patient was oriented times 2 and confused. Review of the 7/18/2011 at 11:50 AM nurse progress notes revealed the family reported that patient #19 was confused at times. Further review revealed the patient had 2 plus edema in both lower extremities. Documentation failed to reveal S8 RN notified the physician of the abnormal blood pressure and 2 plus edema. Documentation also failed to reveal S8 implemented nursing measures to try and increase patient #19's blood pressure. Review of the 7/18/2011 nurse progress notes revealed S8 RN did not notify the attending physician until 25 minutes later when he reassessed the patient #19's blood pressure at 80/36 but did not reassess the patient's level of conscious. Review of the medical record failed to reveal documentation that the attending physician responded after being notified of the labile blood pressure and there failed to be documentation of physician orders at that time. Further documentation revealed the nurse did not obtain another set of vital signs until 3:40 PM (3 hours and 50 minutes after the 11:50 AM set of vitals were obtained and 3 hours and 25 minutes after the blood pressure was taken at 12:15 PM) and that was after a CNA (did not document which CNA) found patient #19 in his room "unresponsive" which was a change in the patient's level of consciousness from admit (oriented times 2 and confused at times).

Further review of the medical record revealed at 3:40 PM after the CNA found the patient unresponsive, his blood pressure was measured at 70/30, heart rate 88 beats per minute and respirations 22 breaths per minute. Continued documentation at that time revealed the nurse continued "attempts to arouse for verbal response" but was "unsuccessful" and he notified the attending physician. Further review failed to reveal if the physician responded or if he gave an order for the patient. Further review also revealed a lack of documentation as to what nursing measures, if any, were implemented to arouse the patient and to increase his blood pressure.

Review of the nurse progress notes revealed S8 RN documented patient #19's vitals signs on 7/18/2011 at 6:00 PM (2 hours and 20 minutes later) and his blood pressure was 82/32, heart rate 76 beats per minute and respirations 22 breaths per minute and also he was in "no distress @ (at) this time". Further review revealed the nurse failed ro reassess the patient to determine his level of conscious. There failed to be documentation that S8 RN implemented nursing measures or reported the abnormal blood pressure to the physician.

Review of the Provision of Emergency Services policy, reviewed and revised 1/2008 revealed if a patient was medically unstable the "RN (registered nurse) on-duty will obtain an order from the attending physician to transfer the patient" from Sterlington Rehabilitation Hospital "to an acute care facility or setting". Further review of this policy revealed "nursing staff is expected to follow nursing standards of care for all patients at all times and to operate within the nursing scope of practice". There failed to be documented evidence in the medical record that the nurse requested a physician order to transfer patient #19 to an acute care hospital.

Review of the nursing progress notes, 7/18/2011 at 3:40 PM revealed S8 RN documented that the physician ordered lab studies. Review of the physician orders revealed there failed to be an order for that lab. Review of the lab results revealed the lab tech collected blood from patient #19 at 3:15 PM. Review of the lab results dated 7/18/2011 revealed as follow: red blood count 2.03 (4.12-5.60), hemoglobin 5.5 (13.0-16.6) and hematocrit 16.7 (18.7-48.1).

Review of the 7/18/2011 (no time noted) physician orders signed off by S8 RN at 4:30 PM revealed an order written by Dr. S7 to transfuse patient #19 with 2 units of packed red blood cells. Review of the contracted lab's copy of the 7/18/2011 physician orders revealed the order for blood was not faxed to the lab until 7/18/2011 at 8:36 PM (3 hours and 54 minutes after it was ordered).

In an interview on 8/24/2011 at 9:50 AM, S9 DON stated that on 7/18/2011 Dr. S7 came to the hospital before lunch, around 12:40 PM and again that evening to visit patient #19. She stated the family told Dr S7 that they did not want patient #19 to be sent to their host hospital which was an acute care hospital (this was not documented in the medical record). She further stated the patient's family reported to her that patient #19 was an inpatient at their host hospital and was treated for 3 days and sent home. She said they did not tell her why the patient was dissatisfied with the hospital.

Further interview with S9 revealed that when patient #19 was first admitted to his room he was a very sick man and his blood pressure had "fallen out". She said normally when a patient's blood pressure is below 90 systolic, the nurse elevates the patient's feet. She reviewed patient #19's medical record and stated the nurse did not document any nursing interventions for the labile blood pressures. S9 said the nurse should have assessed patient #19 more often and also obtained blood pressures at least every 15 to 30 minutes or more often. Additionally, she said the hospital did not have a policy for taking vital signs on a regular basis or when the patient is experiencing liable blood pressures.

In a continued interview S9 stated on 7/18/2011 at approximately 3:45 PM the CNA (could not recall which one) told S8 RN to come down to patient #19's room because he was unresponsive. She said she went to the room and the CNA and S8 were calling "wake up, wake up" and the patient started snoring. S9 said she then called Dr S7 and he said start an IV and she tried to stick the patient twice but could not obtain an access site and did not document in the medical record the number of attempts and the areas of the body that she stuck the patient. She said Dr. S7 (the administrator told the surveyors on 8/23/2011 at 11:00 AM that Dr. S7 is no longer on staff at this hospital and he would not be back) came to the hospital and started an access in the jugular vein. S9 stated that staff administered IV (intravenous) fluids and antibiotics to keep patient #19 comfortable because "clearly he was in his last days". She also stated that Dr. S7 told staff that if he could get fluids in him (the patient) he would get better, but he did not. She said according to documentation by the nurse, there were no nursing measures implemented to try and increase the patient's blood pressure. She said she thought this patient was not a good candidate for rehabilitation and according to the findings by the physician he should not have been admitted to the hospital. She also said patient #19 would not have benefited from rehabilitation therapy.

Further interview with S9 revealed after Dr. S7 placed the jugular access, he wrote orders for IVs fluids and to transfuse 2 units of packed red blood cells and it was 4:30 PM when S8 RN signed the orders off and the nurse did not administer the blood until after 10:00 PM on 7/18/2011. She stated she did not know the reason it took the nurse so long to send the orders to the contracted lab so the blood could be administered because patient #19 had critical values and needed the blood. Additionally, S9 stated that the physician did not write an order to type and cross match the blood nor did the RN obtain an order for it.

On 8/24/2011 at 2:00 PM an interview was held with S4 RN who worked the 7:00 PM to 7:00 AM shift on 7/18/2011(the day patient #19 was admitted to Sterlington Rehabilitation Hospital). She stated when she (S4) made rounded after report patient #19's family was in his room and he was "not doing good". She said his blood pressure was "low" the entire shift and the doctor had ordered blood for him. The survey team asked S4 who obtained blood pressures at Sterlington Rehabilitation Hospital and she stated that "the CNAs" and they report when the systolic is below 90. She also stated that the hospital did not have a policy for labile blood pressures; it was just told to them by nursing services to report this.

S4 said in a continued interview that she looked at patient #19's medical record after she rounded on him and saw an order for a blood transfusion. She said she called upstairs to the contracted lab and asked if it (the blood) was ready and the technician replied they have not receive an order for blood. S4 stated she immediately faxed an order down for the blood and the technician immediately came down and drew blood from patient #19 so a type and crossmatch could be performed. She stated it took a while for the lab to perform a type and crossmatch but could not remember how long. She reported that it was about 10:00 PM on 7/18/2011 when she transfused the first unit of blood that was ordered around 4:30 PM on 7/18/2011.

Based on record review and interview with staff, the hospital failed to update and individualize care plan approaches based on the patient's needs as evidenced by not making changes in 1 of 1 patient's (patient #19's) nursing care plan in a total sample of 30 who experienced labile blood pressures and became unresponsive. Findings:

Review of the medical record revealed patient #19 was an 80 year-old who was a direct admit from S7 physician's office to Sterlington Rehabilitation Hospital on 7/18/2011 with diagnoses including anemia requiring transfusions, cirrhosis of the liver, esophageal varices, anorexia and hypertension.

Review of the 7/18/2011 nursing admit assessments (initial assessments) at 11:50 AM revealed a blood pressure of 80/34 sitting and 70/30 lying, temperature 97.2 Fahrenheit, respirations 18 breaths per minute and heart rate 63 beats per minute. Review of the 7/18/2011 at 11:50 AM nurse progress notes revealed the family reported that patient #19 was confused at times. Further review revealed the patient had 2 plus edema in both lower extremities. Documentation failed to reveal that the nurse notified the physician of the abnormal blood pressure.

Review of the 7/18/2011 at 12:15 PM nurse progress notes revealed the nurse obtained a blood pressure of 80/36 (The nurse failed to obtain a complete set of vital signs.) and notified the physician (25 minutes after the initial blood pressure at 11:50 AM. Further documentation revealed the nurse did not obtain another set of vitals until 3:40 PM when a CNA (did not document which CNA) found patient #19 in his room "unresponsive". Further review revealed at 3:40 PM the patients blood pressure was 70/30, heart rate 88 beats per minute and respirations 22 breaths per minute. Continued documentation at that time revealed the nurse continued "attempts to arouse for verbal response" but was "unsuccessful" and notified the physician.

Review of the nursing care plan approaches revealed the nurse will assess vital signs, blood pressure and peripheral pulses. Further review failed to reveal nursing interventions for monitoring low blood pressures or when to notify the physician. Review of the medical record failed to reveal the nurse measured patient #19's peripheral pulses. In an interview on 8/24/2011 at 9:50 AM the S9 DON (Director of Nursing Services) confirmed that the nurse failed to write specific individualized care plan approaches for patient #19 and failed to address the patient's hypotension.

















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