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Based on medical record review, policy review and staff interview, it was determined that for 1 of 1 (100%) restrained patients in the sample (Patient #4), a restraint was applied without a physician's order. Findings include:

The hospital policy entitled "Restraints and Seclusion" stated, "...Restraint must be ordered by a physician...Obtain...order prior to the application of a restraint..."

Patient #4
Review of the "24 Hour Patient Record & Plan of Care" documentation, revealed that restraints were applied on:
11/16/11: 8:00 - 10:00 AM and 10:00 PM - 6:00 AM
11/23/11: 8:00 - 10:00 AM and 8:00 PM - 2:00 AM

Review of "Physicians Orders" and "Restraint Order/Assessment Sheet" documentation provided no evidence to support that a physician's order was obtained for restraint application on 11/16 and 11/23/11.

Interview with Director of Quality Management A on 12/14/11 at 3:35 PM confirmed these findings.

Based on medical record review, policy review and staff interview, it was determined that for 1 of 1 (100%) restrained patients in the sample (Patient #4), a restraint was ordered by the physician on an "as needed" (PRN) basis. Findings include:

The hospital policy entitled "Restraints and Seclusion" stated, "...The order...may never be written...on an as needed (PRN) basis... at a minimum, documentation must include...time limited order by a physician..."

The hospital policy entitled "Orders, Physician" stated, "...Each order will be verified as having all necessary information entered...any necessary requisitions are complete and accurate..."

Patient #4
Review of "Physician's Orders" revealed two (2) orders for the use of PRN restraints on the following dates:

11/30/11
"...Restraint in evening for pt (patient) safety when sitter leaves..."

12/4/11
"...Restraints for pt safety in the PM after sitter leaves..."

Interview with Director of Quality Management A on 12/14/11 at 3:35 PM confirmed these findings. The Director stated the physician failed to complete the hospital restraint order form.

During the exit conference on 12/14/11 at 4:08 PM, Director of Quality Management A and the Chief Executive Officer confirmed that the use of PRN orders for restraint use was unacceptable.

Based on medical record review, job description review and staff interview, it was determined that staff failed to ensure patient care was provided as ordered by the physician for 2 of 5 (20%) patients in the sample (Patient #'s 2 and 4). Findings include:

The hospital's job description for the registered nurse stated, "...Duties and responsibilities...assures that medical orders are transcribed and processed accurately and integrates the medical care plan into the provision of nursing care...Administers medications as ordered..."

A. Patient #2
Review of "Admission Orders", dated 12/2/11 at 5:30 PM, revealed an order for the antibiotic Levofloxacin to be administered orally every 48 hours.

Review of the "Medication Discharge Summary" received from the transferring facility revealed the patient received the ordered medication on 12/2/11 at 9:16 AM.

Review of the "Medication Administration Record" revealed that Patient #2 did not receive the next ordered dose of the antibiotic until 12/5/11 at 9:00 PM, 83 hours between doses.

Interview with Director of Quality Management A on 12/14/11 at 3:38 PM confirmed this finding.

B. Patient #4
1. Review of the medical record revealed Patient #4 was admitted to the hospital on 11/7/11 with a surgical abdominal wound and a sacral (lower back) wound. Treatment orders included the following:

a. Sacral wound
- 11/7/11 "Admission Orders" - Hydrocolloid dressing (dressing which covers and interacts with wound discharge) to be changed every three (3) days until wound on sacrum healed
- 11/28/11 "Telephone or Verbal Orders" - Order changed to increase frequency of wound care to daily until healed

b. Abdominal Surgical Wound
- 11/7/11 "Admission Orders" - Hydrogel (absorbs wound discharge) to be applied to wound daily

2. Review of "Wound Documentation", "24 Hour Patient Record & Plan of Care" forms and other medical record documentation revealed that nursing staff failed to provide wound care or dressing changes as ordered on the following dates:

a. Sacral wound: 11/10/11 and 12/3/11

b. Abdominal wound: 11/10, 11/25 and 12/3/11.

Wound Care Nurse A reviewed Patient #4's medical record on 12/14/11 at 2:45 PM and confirmed these findings.

Based on medical record review, policy review and staff interview, it was determined that for 1 of 5 (20%) patients in the sample (Patient #1), staff failed to revise the plan of care. Findings include:

The hospital policy entitled "Nursing Care Plan" stated, "...On the 24 Hour Patient Record and Plan of Care, the nurse will implement and document approaches related to key nursing care issues...The nursing care plan is kept current by ongoing assessments of the patient's needs...updating or revising the patient's nursing care plan in response to assessments..."

Patient #1
Review of the "24 Hour Patient Record & Plan of Care" revealed nursing staff failed to update the nursing plan of care when the following dietary changes were ordered by the physician:

Review of "Telephone or Verbal Orders" dated 12/7/11 at 9:00 AM included diet orders for a 2 gram potassium pureed diet with honey-thick liquids and no orange juice.

Review of the "24 Hour Patient Record & Plan of Care" dated 12/13/11 revealed that nursing staff had failed to update the nursing care plan to include the potassium and orange juice dietary restrictions as ordered by the physician.

On 12/14/11 at 10:15 AM, Quality Coordinator A reviewed Patient #1's nursing care plan and confirmed this finding.

Based on medical record review, policy review, review of "Medical Staff Rules and Regulations" and staff interview, it was determined that for 2 of 5 (40%) patients in the sample (Patient #'s 3 and 4), the medical record entries failed to contain required or accurate elements. Findings include:

The Hospital's Bylaws Article VII "Rules and Regulations of the Medical Staff" stated, "...All clinical entries in the patient's medical record shall be accurately dated, timed, and authenticated..."

The hospital policy entitled "Orders, Physician" stated, "...Each order will be verified as having all necessary information entered...any necessary requisitions are complete and accurate..."

A. Patient #3
On 12/9/11, review of Patient #3's medical record revealed that the "History and Physical (H&P)" dictated on 11/30/11 at 4:24 PM did not contain the physician's signature or date of authentication. A xeroxed copy of the H&P was obtained on 12/9/11.

On 12/9/11, Surveyor B interviewed Director of Quality Management A at 1:30 PM and Health Information and Credentialing Manager (HICM) A at 3:00 PM. Both reviewed the patient's medical record and confirmed that the physician had not yet signed the patient's H&P. HICM A confirmed there was no other record of the physician signing the dictated H&P.

On 12/12/11, Surveyor B completed the review of Patient #3's medical record and discovered the H&P, unsigned/undated on 12/9/11, was now signed by the physician and dated "11/30/11".

On 12/12/11 at 10:10 AM, Director of Quality Management A and HICM A again reviewed the patient's medical record and the "History and Physical". HICM A stated that the H&P was presented to the physician on 12/9/11 after 3:00 PM and the physician signed the H&P at the time of presentation.

B. Patient #4
Review of the "Restraint Order/Assessment Sheet" documentation revealed that at the time of order authentication, the physician failed to include the date and/or time of authentication on the following:

- No recorded date or time of authentication on 11/7, 11/8, 11/10, 11/14, 11/15, 11/17, 11/20, 11/21, 11/22, 11/24, 12/1 and 12/3/11

- No recorded time of authentication on 11/11, 11/12, 11/13, 11/18, 11/19 and 12/14/11

Interview with Director of Quality Management A on 12/14/11 at 3:35 PM confirmed these findings.

Based on medical record review, job description review, document review and staff interview, it was determined that for 1 of 5 (20%) patients in the sample (Patient #4), the medical record failed to contain treatment data. Findings include:

The "Registered Nurse Job Description" stated, ...Duties and responsibilities...integrates the medical care plan into the provision of nursing care...Assures that documents in the medical record are complete..."

Patient #4

A. Review of the medical record revealed Patient #4 was admitted to the hospital on 11/7/11 with a surgical abdominal wound and a sacral (lower back) wound. Treatment orders included the following:

1. Sacral wound
- 11/7/11 "Admission Orders" - Hydrocolloid dressing (dressing which covers and interacts with wound discharge) to be changed every three (3) days until wound on sacrum healed
- 11/28/11 "Telephone or Verbal Orders" - Order changed to increase frequency of wound care to daily until healed

2. Abdominal surgical wound
- 11/7/11 "Admission Orders" - Hydrogel (absorbs wound discharge) to be applied to wound daily

B. Review of "Wound Documentation", "24 Hour Patient Record & Plan of Care" forms and other medical record documentation revealed that nursing staff failed to document wound care or dressing changes as ordered on the following dates:

1. Sacral wound: 11/10/11 and 12/3/11

2. Abdominal surgical wound: 11/10, 11/25 and 12/3/11

Wound Care Nurse A reviewed Patient #4's medical record on 12/14/11 at 2:45 PM and confirmed these findings.

Based on observation, patient and staff interview, policy review and review of medical records, it was determined that for 3 of 5 (60%) patients in the sample (Patient #'s 1, 2 and 4) receiving dietary services, the patients' meals were not provided as prescribed by the physician. Findings include:

The hospital policy entitled "Orders, Physician" stated, "...All patient...diet[s]...must have a physician's order...the unit secretary or nurse will transcribe the physician's orders from the chart onto the appropriate forms/systems...orders will be co-signed by a registered nurse to ensure accuracy and initiation by the end of each shift..."

The hospital policy entitled "Diet Orders and Diet Changes" stated, "...The diet order, or any change...or modification of the diet order is made by a physician...Modification of the diet order is communicated to the contract/host facility Department of Food and Nutrition Services from the nursing unit..."

A. Patient #1
Review of "Telephone or Verbal Orders" dated 12/7/11 at 9:00 AM included diet orders for a 2 gram potassium pureed diet with honey-thick liquids and no orange juice.

On 12/14/11 at 8:06 AM, Director of Quality Management A and Surveyor A checked Patient #1's breakfast tray for accuracy prior to room delivery. Patient #1's breakfast tray was observed to contain no fluids. Review of the "Breakfast Menu" meal selection paper accompanying the tray contained a "NO Juice" handwritten notation and the juice and beverage options on the menu had been "crossed-off".

During an interview with Registered Dietitian (RD) A on 9:28 AM on 12/14/11, RD A confirmed that the Unit Clerk had entered a message to the Dietary Department to provide no juice on Patient #1's tray even if juices were marked. RD A confirmed that the physician had not changed Patient #1's diet order and that although Patient #1 had an orange juice restriction, other honey-thick fluids were permitted.

B. Patient #2
Review of "Physician's Orders" included an order dated 12/9/11 at 12:40 PM to revise the diet to "...thins (liquids) with straw...aspiration precautions..."

On 12/12/11 at 12:00 PM, Surveyor B and Director of Quality Management A observed lunch tray delivery to Patient #2. The tray included liquid drinks with no straw on the tray and a matching meal selection paper accompanying the tray which contained a "No Straw" handwritten notation.

Interview with Patient #2 on 12/12/11 at 12:10 PM confirmed that liquids were consumed without a straw.

On 12/12/11 at 12:15 PM, Director of Quality Management A and Speech Language Therapist A reviewed Patient #2's medical record and confirmed that the "no straw" directive on the meal selection paper was inaccurate. Speech Language Therapist A and Director of Quality Management A confirmed that Patient #2's meal was not provided in accordance with the prescribed physician's order for "thin liquids with a straw".

C. Patient #4
Review of a "Telephone or Verbal Order" dated 12/8/11 included a change in Patient #4's diet to mechanical soft with thin liquids.

On 12/9/11 at 12:20 PM, Surveyor B and Director of Quality Management A observed lunch tray delivery to Patient #4. The tray contained a regular menu and nectar thickened liquids meal selection paper. Patient #4 did not receive thin liquids as ordered by the physician.

Interview with registered nurse (RN) A and Director of Quality Management A on 12/9/11 at 12:27 PM confirmed that the meal Patient #4 received was not in accordance with the current diet order.