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Based on observation, record review and interview the hospital failed to meet the requirements for the Condition of Participation of Governing Body by:

1) failing to ensure Emergency Services were provided to all patients per the hospital policy by not having a Respiratory Therapist as part of the Rapid Response Team 24 hours a day/7 days per week. The result of this practice is that patient's who experience an emergency situation and require intubation during the time that the hospital did not have a respiratory therapist or physician in house would not be afforded the possibility of an optimal outcome as patient's who experienced an emergency situation when a Respiratory Therapist or Physician was in the hospital. This has the potential to affect all patients in the hospital. (see findings at A0093)

2) Failing to ensure that the hospital developed emergency policies defining the procedures that would be performed by staff during a Code to include the ability to establish an airway through intubation 24/7 if the patient's emergency condition necessitated this. This has the potential to affect all patient's in the hospital. (see findings at A0093)

3) failing to ensure that the Laryngoscope located in the Emergency Crash Cart is operational at all times with back up batteries that are not outdated. The hospital failed to develop a system that ensures routine verification of the operational status of the equipment inside the crash cart which is potentially used during an emergency code. This has the potential to affect all patients in the hospital. (see findings at A0093)

4) failing to ensure that all services performed under contract were provided in a safe and effective manner. This was evidenced by the hospital's failure to ensure acceptable time frame parameters were defined for "stat" radiological tests to provide for receipt of Radiographic interpretations to assist physician's in directing medical care to patient's in an urgent or emergent situation. This has the potential to affect all patients in the hospital. (see findings at A0084)

Based on record review and interview the hospital failed to meet the Condition of Participation of Patient Rights by:

1) failing to ensure that policies and procedures regarding Advanced Directives/Do Not Resuscitate were implemented in a timely manner and according to the patient/patients representative's directions for 2 of 3 patient records reviewed for Advance Directive/DNR policy compliance in a total sample of 10. (#1, #2) (see findings at A0132)

This resulted in an Immediate Jeopardy situation with hospital notification made to S1Administrator and S2DON on 05/10/10 at 3:15 p.m. The Immediate Jeopardy situation was:

The hospital failed to ensure that policies and procedures were followed when a patient is admitted who has an established Do Not Resuscitate (DNR), the physician is immediately contacted to be informed of the patient's DNR and a physicians order is received relative to a DNR status. This failure has resulted in 2 of 3 patients with a DNR not having a physicians order for over 72 hours after admit. There was also conflicting interviews from the DON and staff nurses on whether the patient would be coded in view of not having a physicians order on the medical record for the DNR status of the patient.

On 05/11/10 at 12:40 p.m. the hospital submitted an acceptable Plan of Removal (POR) of the IJ. The POR included:

1. DNR order request initiated per patient, family or Medical Power of Attorney.

2. Nurse or Social Services/Case Manager to notify physician immediately. Notification to be documented in patient's medical record.

3. DNR order and progress note including discussion with patient/family of code status is written per attending physician or qualified designee.

4. If DNR order/progress note not written within two (2) hours of request, notify physician again. Notification to be documented in patient's medical record. Patient, family or Medical Power of Attorney will be notified of delay in obtaining order and documentation of response.

5. If DNR order/progress note not written within one (1) hour, notify physician again. Notification to be documented in patient's medical record. Patient, family or Power of Attorney will be notified of delay in obtaining order and documentation of response.

6. After one (1) hour, if physician has not written DNR order/progress note, Administrator on call and Medical Director to be notified. Patient, family or Medical Power of Attorney will be notified of delay in obtaining order and documentation of response.

7. Medical Director will appoint physician to write DNR order and progress note ASAP.

8. If no response within one (1) hour, Governing Body representative will be notified for immediate attention.

In response to DHH/HS Immediate Jeopardy Determination on 05/10/10 @ 1515 (3:15 p.m.):

(A) (patient #2) - Medical Power of Attorney obtained from family and placed on chart; DNR order and progress note written at 2 p.m. on 05/10/10 per (S6MD).

(B) (patient #1) - DNR order written 05/10/10 @ 1745 (5:45 p.m.) and Physician's Progress Note addresses DNR status signed by attending and consulting physicians as required per declaration.

(C) DNR Order Process approved by Medical Director 05/10/10 @ 1720 (5:20 p.m.).

(D) Nursing staff educated on DNR order process (above) on 05/10/10 at 1725 (5:25 p.m.) and 1800 (6:00 p.m.) (see sign in sheets), copies of process placed in nurses' mail boxes.

(E) Physicians educated on DNR process via e-mail 05/11/10; (S5MD) reviewed process in person with DON and Corporate Compliance on 05/10/10; follow up phone call to (S6MD) and (S14MD) to ensure receipt of new process on 05/11/10.

(F) Nurse Practitioners educated on DNR process via phone 05/10/10. Reviewed in person with (S11APRN) on 05/11/10 per Administrator.

(G) Revised DNR process, to include: Advanced Directives, Living Wills, Declarations, and Do Not Resuscitate Orders will be added to hospital DNR policy/procedure, Medical Staff By-Laws, hospital QA/PI processes and monitored through Corporate Compliance.

(H) Training will be initiated for all hospital medical staff, APRN's, nursing staff to include case manager and Social worker Re: Advanced Directives, Living Wills, Declarations, and Do Not Resuscitate Orders, to begin on 05/11/10 with projected completion date of 05/14/10 for all full time employees. All staff, as named above, will have received education prior to direct patient care by 05/21/10.

The Immediate Jeopardy was lifted on 05/11/10 at 3:00 p.m. S1Administrator and S2DON were present.

The deficient practice under the CoP of Patient Rights continues at the condition level.

2) failing to provide documented evidence to indicate the patient's response to least restrictive measures/interventions in order to ensure that the use of physical restraints was the least restriction measure/intervention that could have been used in the provision of patient care. This was noted in the medical record of 1 of 2 patients (Patient #9) reviewed for restraints out of a total sample of 10 patients. (see findings at A0165)

3) failing to provide documented evidence to indicate the rationale for the continued use of physical restraints. This was noted in the medical record of 1 of 2 patients (Patient #9) reviewed for restraints out of a total sample of 10 patients. (see findings at A0188)

Based on record review and interview, the hospital's governing body failed to ensure that all services performed under contract were provided in a safe and effective manner. This was evidenced by the hospital's failing to ensure that acceptable time frame parameters were defined for "stat" radiological tests. Findings:

Patient #2: Medical record review revealed that the patient was admitted to the hospital on 4/20/10. Review of the physician orders revealed an order dated 4/28/10 at 9:54 a.m. for "Stat CXR to confirm PICC line placement". Review of the radiological results revealed that the "Stat CXR" was performed on 4/28/10 at 12:47 p.m. (2 hours and 53 minutes after being ordered "Stat")

The Director of Nursing was interviewed on 5/11/10 at 9:20 a.m. The Director of Nursing reviewed the medical record of Patient #4 and confirmed that the stat chest xray was obtained 2 hours and 53 minutes after being ordered. The Director of Nursing reported that she was not aware of any hospital approved policies/procedures that defined an acceptable time frame for radiological test that are ordered "Stat".

The Medical Director was interviewed on 5/11/10 at 9:25 a.m. The Medical Director reported that he was not aware of any hospital approved policies/procedures that defined an acceptable time frame for radiological test that are ordered "Stat". The Medical Director reported that there needs to be a time frame for "stat" orders.

The contract between the hospital and the radiology service provider was reviewed. The contract documents "All 'Stat' procedures will be done as a 'Priority Based Exam'. Arrival time will be based on geographical location. (Drive time from the present location to the location of Patient)" The contract fails to indicate a time frame for stat procedures.

Based on observation, record review and interview the hospital failed to 1) ensure Emergency Services were provided per the hospital policy by not having a a Respiratory Therapist capable of intubating the patient experiencing a medical emergency in house as part of the Rapid Response Team 24 hours a day/ 7 days per week . This has the potential to affect all patients in the hospital. 2) failed to ensure that the Laryngoscope located in the Emergency Crash Cart was operational and there was a policy for routine verification of the operational status of the equipment. Findings:

1) In an interview on 05/12/10 at 10:00 a.m. with S1 (Administrator), S1 reported that the hospital does not have respiratory services available on a 24 hour 7 day a week basis. S1 reported that she serves a dual role of Administrator and Respiratory Therapist. S1 reported that there are no additional respiratory therapist on staff at this hospital other than her and that she is not available to respond to emergency situations on a 24 hour 7 day a week basis.

In an interview on 05/12/10 at 10:00 a.m. with S1Administrator she stated that "if the Respiratory Therapist were present they should intubate a patient experiencing a medical emergency requiring intubation."

Review of a hospital policy titled Care of the Patient Experiencing a Medical Emergency", policy number II-C.3.03.0, issued 06/07, last revised (no date), presented as current hospital policy reads in part: ""Purpose: To outline the procedure for staff response to a patient medical emergency. Definitions: Rapid Response Team: is a team of clinicians who bring emergency care to the patient bedside or wherever care is needed......Procedure: I. Response Team members consist of the RN Charge Nurse and the Respiratory Therapist and the attending physician (physician is not required to be in house 24 hours per day to be considered part of the team). Each shift will have the charge nurse and respiratory therapist assigned as the response team members for that shift...."

Review of a hospital policy titled "Intubation", policy number RC.5.08, effective 04/09, presented as current hospital policy reads in part: "Purpose: To provide guidelines for Respiratory Therapists to follow when invasive airway management via endotracheal intubation is essential. Policy:.....A Respiratory Therapist does not require an order to intubate during resuscitation attempts......"



2) In an observation made on 05/12/10 at 9:00 a.m. with S3RN of the Emergency Crash Cart it was noted that the Laryngoscope used for emergency intubation of patients was not functional. Further review of the Emergency Crash Cart revealed the replacement batteries for the Laryngoscope had expired in Jan. 2002. These findings were confirmed by S3RN at the time of the findings.

Review of a hospital policy titled "Crash Cart", policy number II-C.3.02, issued 12/02, last revised 08/02, presented as current hospital policy, lists the responsibilities of the pharmacist and nursing staff in regards to checking the Crash Cart. Review of the entire policy revealed that there is no indication of who is to check the Laryngoscope operation and what frequency the checks are to be done.

In an interview on 05/12/10 at 9:20 a.m. with S2DON she confirmed the policy for the Crash Cart checks does not include the Laryngoscope.

Based on record review and interview the hospital failed to ensure that policies and procedures regarding Advanced Directives/Do Not Resuscitate were implemented in a timely manner and according to the patient/patients representative's directions for 2 of 3 patient records reviewed for Advance Directive/DNR policy compliance in a total sample of 10. (#1, #2) Findings:

This resulted in an Immediate Jeopardy situation with hospital notification made to S1Administrator and S2DON on 05/10/10 at 3:15 p.m. The Immediate Jeopardy situation was:

The hospital failed to ensure that policies and procedures were followed when a patient is admitted who has an established Do Not Resuscitate (DNR), the physician is immediately contacted to be informed of the patient's DNR and a physicians order is received relative to a DNR status. This failure has resulted in 2 of 3 patients with a DNR not having a physicians order for over 72 hours after admit. There was also conflicting interviews from the DON and staff nurses on whether the patient would be coded in view of not having a physicians order on the medical record for the DNR status of the patient.

On 05/11/10 at 12:40 p.m. the hospital submitted an acceptable Plan of Removal (POR) of the IJ. The POR included:

1. DNR order request initiated per patient, family or Medical Power of Attorney.

2. Nurse or Social Services/Case Manager to notify physician immediately. Notification to be documented in patient's medical record.

3. DNR order and progress note including discussion with patient/family of code status is written per attending physician or qualified designee.

4. If DNR order/progress note not written within two (2) hours of request, notify physician again. Notification to be documented in patient's medical record. Patient, family or Medical Power of Attorney will be notified of delay in obtaining order and documentation of response.

5. If DNR order/progress note not written within one (1) hour, notify physician again. Notification to be documented in patient's medical record. Patient, family or Power of Attorney will be notified of delay in obtaining order and documentation of response.

6. After one (1) hour, if physician has not written DNR order/progress note, Administrator on call and Medical Director to be notified. Patient, family or Medical Power of Attorney will be notified of delay in obtaining order and documentation of response.

7. Medical Director will appoint physician to write DNR order and progress note ASAP.

8. If no response within one (1) hour, Governing Body representative will be notified for immediate attention.

In response to DHH/HS Immediate Jeopardy Determination on 05/10/10 @ 1515 (3:15 p.m.):

(A) (patient #2) - Medical Power of Attorney obtained from family and placed on chart; DNR order and progress note written at 2 p.m. on 05/10/10 per (S6MD).

(B) (patient #1) - DNR order written 05/10/10 @ 1745 (5:45 p.m.) and Physician's Progress Note addresses DNR status signed by attending and consulting physicians as required per declaration.

(C) DNR Order Process approved by Medical Director 05/10/10 @ 1720 (5:20 p.m.).

(D) Nursing staff educated on DNR order process (above) on 05/10/10 at 1725 (5:25 p.m.) and 1800 (6:00 p.m.) (see sign in sheets), copies of process placed in nurses' mail boxes.

(E) Physicians educated on DNR process via e-mail 05/11/10; (S5MD) reviewed process in person with DON and Corporate Compliance on 05/10/10; follow up phone call to (S6MD) and (S14MD) to ensure receipt of new process on 05/11/10.

(F) Nurse Practitioners educated on DNR process via phone 05/10/10. Reviewed in person with (S11APRN) on 05/11/10 per Administrator.

(G) Revised DNR process, to include: Advanced Directives, Living Wills, Declarations, and Do Not Resuscitate Orders will be added to hospital DNR policy/procedure, Medical Staff By-Laws, hospital QA/PI processes and monitored through Corporate Compliance.

(H) Training will be initiated for all hospital medical staff, APRN's, nursing staff to include case manager and Social worker Re: Advanced Directives, Living Wills, Declarations, and Do Not Resuscitate Orders, to begin on 05/11/10 with projected completion date of 05/14/10 for all full time employees. All staff, as named above, will have received education prior to direct patient care by 05/21/10.

The Immediate Jeopardy was lifted on 05/11/10 at 3:00 p.m. S1Administrator and S2DON were present.

The deficient practice under the CoP of Patient Rights continues at the condition level.

Patient #1


Patient # 1 was admitted to the hospital on Friday May 7, 2010 at 11:30 a.m..

Review of the medical record of patient #1 on 05/10/10 at 10:00 a.m. revealed the medical record contained a form titled "General Power of Attorney." Further review of this document revealed documentation highlighted in yellow that read "This document does not authorize anyone to make medical or other health care decisions for you."

Further review of the medical record revealed forms titled "Resuscitation Orders" and "Physician's Progress Note - Do Not Resuscitate" that were not filled out or contained any signatures of the patient/patients representative, physician or witnesses.

Included in the medical record was a second form titled "Physician's Orders - Resuscitation orders." Further review of this document revealed that it read in part "In order to establish guidelines for use in resuscitation of this patient, the following orders are in effect. These orders may be rescinded or modified by new orders regarding resuscitation." Under "Category III." the "Do Not Resuscitate" line is checked. The only other documentation on this form is the signature of the patients son. Review of the document further revealed no documentation of whether this was per family request, patient request or due to the patient's medical condition. The lines for documentation of when the hospital requested and/or received a Power of Attorney are blank.

Review of the History and Physical (H&P) dated/timed 05/08/10 at 1900 (7:00 p.m.) by S7, APRN, FNP, revealed it had "DNR" written in the upper left corner of the H&P.

In an interview on 05/12/10 with S12APRN she stated it was not in her scope of practice to write a DNR order. S12APRN further indicated she did not inform the supervising physician who signed her Collaborative Practice Agreement of the DNR request of the son of patient #1.

The patient's medical record was noted to be in a "Red" chart. In an interview on 05/10/10 at 12:45 p.m. with S4RN, Charge Nurse, he confirmed the red chart is used for patient's who are DNR.

Review of the nursing notes dated 05/07/10, 05/08/10 and 05/09/10 revealed each had documentation that read " DNR" on the line for code status.

In an interview on 05/10/10 at 10:10 a.m. with S12LPN, assigned the care of patient #1 on 05/10/10, she stated that patient #1 was a DNR and no resuscitation efforts would be performed should the patient experience cardiopulmonary arrest.

In an interview on 05/10/10 at 10:10 a.m. with S2DON she stated that she was the nurse that admitted patient #1 on 05/07/10. She further indicated that the son of patient #1 clearly indicated to her that he wanted his mother to be a DNR. S2DON further indicated that she did not notify the physician responsible for the care of patient #1 of the DNR request of the son of patient #1. S2DON stated that she should have notified the physician of the patients representative's request.

In an interview on 05/10/10 at 10:50 a.m. with S2DON she confirmed that the Power of Attorney (POA) on the medical record of patient #1 was not a medical POA. S2DON further indicated that since the physician had not discussed the matter with the patients representative and done the documentation to include a physician's order for DNR since admission on 05/07/10 that if the patient were to "Code" the staff would conduct full resuscitation efforts.

In an interview on 05/10/10 at 12:45 a.m. with S4RN, Charge Nurse, he stated that he rounded with S5MD, Medical Director. S4RN further stated that he made rounds with S5MD this morning and did not inform the physician of the request of #1's son that she be a "DNR."

During the same interview S4RN confirmed that it is "normal practice" for a new admit with "to go over the weekend without DNR paperwork being filled out."

In an interview on 05/10/10 at 12:50 p.m. with S2DON she stated that "normal hospital practice" is that DNR/Advance Directive issues that arise after the physicians round on Friday would not be handled until Monday. She further stated that "probably 100% of Friday admits with DNR go to Monday without a DNR order."

In an interview on 05/10/10 at 1:10 p.m. with S5MD, Medical Director, the physician stated he was aware of the patient and that "there was never a lapse in her DNR status because she was a DNR at the previous hospital." S5MD further indicated that he was not aware that of the need to "re-do" the DNR order and progress notes per hospital policy and procedure.

Review of the medical record of patient #1 on 05/11/10 at 9:30 a.m. revealed there was now a Living Will on the record dated 05/07/1992 and signed by patient #1 and two witnesses.

In an interview on 05/11/10 at 9:30 a.m. with S2DON she stated that the patient's son had delivered the document on 05/10/10 after the surveyor's departed.

Further review of the medical record revealed there was a Physician's Progress note that read in part: "1. The DNR status is based on one or more of the following: "Patient's request and Family's request " are checked. The form is signed and dated on 05/10/10 (no time indicated) S5MD, Attending Physician and another physician (S14MD) listed under "consulting" physician. Further review revealed a form Titled "Resuscitation Orders" that read in part: "Do Not Resuscitate." The form is signed by S5MD with a date/time of 05/10/10 at 1745 (5:45 p.m.)


Review of a hospital policy titled "Advanced Directives in Louisiana", policy number I-A.1.04, effective 06/07, last revised 03/08, reads in part: "Purpose: To establish a mechanism for execution of advanced directives for hospital inpatients. Advanced Directives are the documents used to help a person express his or her wishes And values about medical care in case the person cannot, at some future time, speak for him or herself....Policy: A living will is a document which tells the physician or other health care providers whether or not life-sustaining treatments or procedures will be administered if there is a terminal or irreversible condition....Procedure: 1. All inpatients are assessed for presence of Advanced Directive......4. If the patient has an advanced directive, a copy will be requested and obtained from the patient/family...."

Patient #2

Review of the medical record for patient #2 on 05/10/10 at 10:15 a.m. revealed the patient was admitted 05/06/10 at 1321 (1:21 p.m.).

Further review revealed the chart contained a Living Will dated 11/09/2006 and was signed by patient #2 with 2 witnesses. The Living Will read in part: "if, at any time, should I have an incurable injury, disease, or illness certified to be a Terminal and Irreversible condition by two physician's who have personally examined me........the life-sustaining procedures I choose to have withheld or withdrawn include but are not limited to: Mechanical Ventilator, Tube Feedings, Intravenous feedings....In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this declaration be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment...."

The daughter of patient #2 is listed as the Power of Attorney (POA) on the admission form, the consent for treatment, privacy practices, and patient right acknowledgment form dated 05/06/10.

Review of the nurses notes for 05/06/10, 05/07/10, 05/08/10 and 05/09/10 have "DNR" written in code status information.

The patient's medical record was noted to be in a "Red" chart. In an interview on 05/10/10 at 12:45 p.m. with S4RN, Charge Nurse he confirmed the red chart is used for patient's who are DNR.

Further review of the medical record revealed a forms titled "Resuscitation Orders" and "Physician's Progress Note - Do Not Resuscitate" that were in the physician's order section but not filled out.

In an interview on 05/10/10 at 10:30 a.m. with S13LPN, assigned patient #2 for the day shift, stated that patient #2 was DNR and no resuscitation would be attempted is patient #2 were to have cardiopulmonary arrest.

In an interview on 05/10/10 at 10:35 a.m. with S2DON she stated that the daughter of patient #2 specifically told her upon admission that she wanted her mother to be DNR. S2DON indicated that she notified S6MD on Thursday May 6th, 2010. S2DON stated that S6MD indicated he would take care of it when he rounded.

Review of the medical record of patient #2 on 05/11/10 at 9:30 a.m. revealed there was now a Medical Power of Attorney form on the chart listing the daughter of #2 as medical POA. Further review of the medical record revealed a form titled "Resuscitation Orders", dated/timed 05/10/10 at 2:00 p.m. that read: " Resuscitate With Modifications - Do Not Intubate and Comfort measures only." The form was signed by S6MD. Further review revealed a physician's progress note signed by S6MD dated/timed 05/10/10 at 2:00 p.m.

Review of a hospital policy titled "Advanced Directives in Louisiana", policy number I-A.1.04, effective 06/07, last revised 03/08, reads in part: "Purpose: To establish a mechanism for execution of advanced directives for hospital inpatients. Advanced Directives are the documents used to help a person express his or her wishes And values about medical care in case the person cannot, at some future time, speak for him or herself....Policy: A living will is a document which tells the physician or other health care providers whether or not life-sustaining treatments or procedures will be administered if there is a terminal or irreversible condition....Procedure: 1. All inpatients are assessed for presence of Advanced Directive......4. If the patient has an advanced directive, a copy will be requested and obtained from the patient/family...."

Based on record review and interview, the hospital failed to provide documented evidence to indicate the patient's response to least restrictive measures/interventions in order to ensure that the use of physical restraints was the least restriction measure/intervention that could have been used in the provision of patient care. This was noted in the medical record of 1 of 2 patients (Patient #9) reviewed for restraints out of a total sample of 10 patients. Findings:

Patient #9: Medical record review revealed that the patient was admitted to the hospital on 2/11/10. Documentation indicated that the patient was confused and disoriented. Review of the record revealed orders to place the patient in bilateral wrist restraints on 2/14/10 at 7:00 p.m. Documentation on the "Restraint Order Sheet" revealed that the patient was confused, climbing over side rails and uncooperative. Documentation in the nursing notes indicated that the patient had pulled out a peripheral IV line prior to being placed in bilateral wrist restraints. Review of the "Restraint Management Documentation Form" revealed that the patient was placed in restraints on 2/14/10 at 7:00 p.m. and remained in restraints until 3/08/10 (21 days). Documentation on the "Restraint Order Sheet" revealed a section titled "Alternatives to Restraints Tried" that indicated that alternatives to restraints including education, reorientation, increased observation, diversional activities, concealing lines, repositioning patient had been tried, but there was no documentation to indicate the time of the intervention/interventions, the treatment team member who provided the intervention/interventions, or the patient's response, or the patient's failure to respond, to the intervention/interventions used in relation to less alternative methods that would warrant the continued use of the physical restraints.

The Director of Nursing was interviewed on 5/12/10 at 9:25 a.m. The Director of Nursing reviewed the medical record of Patient #9 and confirmed that the patient was placed in bilateral wrist restraints on 2/14/10 at 7:00 p.m. and remained in restraints until 3/08/10 for a total of 21 days. The Director of Nursing reported that the documentation on the "Restraint Order Sheet" indicated that alternatives to restraints including education, reorientation, increased observation, diversional activities, concealing lines, repositioning patient had been tried, but stated that there was no documentation to indicate the time of the intervention/interventions, the treatment team member who provided the intervention/interventions, or the patient's response to the intervention/interventions that would warrant the continued use of the physical restraints. The Director of Nursing provided the hospital's policy/procedure titled "Restraints" at the request of the surveyor. Review of the policy/procedure revealed that the patient's symptoms or condition that warranted the use of the restraint and the patient's response to the intervention used in relation to less alternative methods must be documented in the medical record.

Based on record review and interview, the hospital failed to provide documented evidence to indicate the rationale for the continued use of physical restraints. This was noted in the medical record of 1 of 2 patients (Patient #9) reviewed for restraints out of a total sample of 10 patients. Findings:

Patient #9: Medical record review revealed that the patient was admitted to the hospital on 2/11/10. Documentation indicated that the patient was confused and disoriented. Review of the record revealed orders to place the patient in bilateral wrist restraints on 2/14/10 at 7:00 p.m. Documentation on the "Restraint Order Sheet" revealed that the patient was confused, climbing over side rails and uncooperative. Documentation in the nursing notes indicated that the patient had pulled out a peripheral IV line prior to being placed in bilateral wrist restraints. Review of the "Restraint Management Documentation Form" revealed that the patient was placed in restraints on 2/14/10 at 7:00 p.m. and remained in restraints until 3/08/10 (21 days). Documentation on the "Restraint Order Sheet" revealed a section titled "Alternatives to Restraints Tried" that indicated that alternatives to restraints including education, reorientation, increased observation, diversional activities, concealing lines, repositioning patient had been tried, but there was no documentation to indicate the time of the intervention/interventions, the treatment team member who provided the intervention/interventions, or the patient's response to the intervention/interventions that would warrant the continued use of the physical restraints.

The Director of Nursing was interviewed on 5/12/10 at 9:25 a.m. The Director of Nursing reviewed the medical record of Patient #9 and confirmed that the patient was placed in bilateral wrist restraints on 2/14/10 at 7:00 p.m. and remained in restraints until 3/08/10 for a total of 21 days. The Director of Nursing reported that the documentation on the "Restraint Order Sheet" indicated that alternatives to restraints including education, reorientation, increased observation, diversional activities, concealing lines, repositioning patient had been tried, but stated that there was no documentation to indicate the time of the intervention/interventions, the treatment team member who provided the intervention/interventions, or the patient's response to the intervention/interventions that would warrant the continued use of the physical restraints. The Director of Nursing provided the hospital's policy/procedure titled "Restraints" at the request of the surveyor. Review of the policy/procedure revealed that the patient's symptoms or condition that warranted the use of the restraint and the patient's response to the intervention used, including the need for continued use of the intervention must be documented in the medical record.

Based on record review and interview, the Registered Nurse failed to supervise and evaluate the care provided to 2 of 10 sampled patients (#7 & #6) by failing to implement follow up interventions including notifying the physician responsible for the care of Patient #7 of changes in the patient's condition such as a significant weight loss and by failing to verify the accuracy of a documented significant variation in the recorded weight of Patient #6. Findings:

Patient #7: Review of the medical record of patient #7 revealed the patient had an admission weight of 137.1 pounds.

In an interview on 05/12/10 at 9:15 a.m. with S3RN, Charge Nurse, she indicated she admitted patient #7 on 02/18/10. She further indicated that she zeroed out the bed scale prior to placing the patient on the bed and personally obtained the documented weight. S3RN was asked to review the CNA's weight sheet. Documentation next to the 137.1 reads"Bed Problem?." S3RN stated she had no problems with the bed scale that day and she had no idea who wrote that next to the weight she obtained or when that was written.

Further review of the admission orders revealed the physician ordered the patient (#7) to be weighed upon admission and weekly.

The next documented weight for patient #7 is on 03.01/10 and the weight is 124.2, a loss of 12.9 pounds in 11 days. There is no documented evidence of notification of the physician, changes in the care plan or notification of the dietician or Registered nurse of the weight loss of patient #7.

In an interview on 05/12/10 at 12:35 p.m. with S9LPN, assigned the care of patient #7 on 05/01/10, she stated that the weight documented on the nursing notes was not done by her. She further indicated that a weight loss of 12.9 pounds in 11 days should be reported to the physician.

Further review of patient #7's record revealed she was next weighed on 03/08/10 and her weight was documented as 121.8, a 15.3 pound weight loss since admission.

In an interview on 05/11/10 at 12:15 p.m. S2DON was asked to review the chart for any notification of the physician regarding the weight loss of #7, changes to the care plan to address the weight loss of patient #7, nurses note indicating the staff was aware of the weight loss, or any documentation of notification of the dietician of the weight loss.

In an interview on 05/12/10 at 1:20 p.m. with S2DON she indicated she could find no notification of the physician regarding the weight loss of #7, changes to the care plan to address the weight loss of patient #7, nurses note indicating the staff was aware of the weight loss, or any documentation of notification of the dietician of the weight loss.


Patient #6: Review of the medical record of Patient #6 revealed that Patient #6 weighed 183.7 pounds on 3/23/10, 160.2 pounds on 3/24/10, 160.3 pounds on 3/25/10, 165.2 pounds on 3/26/10, and 159.6 pounds on 3/27/10.

The Director of Nursing was interviewed on 5/11/10 at 10:30 a.m. The Director of Nursing reviewed the medical record of Patient #6 and confirmed that there were significant variations in the recorded weights of Patient #6. The Director of Nursing reported that she would have expected the nursing staff to follow up on the weight variations in order to determine the cause. The Director of Nursing reported that she felt that the weights were not accurate and stated that the reason for the variations had more to do with the process or techniques used by staff to weight patients such as failing to ensure that the scales of Zero'd out prior to weighing the patients. The Director of Nursing reported that she had previously been notified by the nurse practitioner of problems with obtaining weights on patients.

Based on record review and interview the hospital failed to ensure the Registered Nurse kept a current care plan for 1 of 10 sampled patients (#7) by not making changes in the care plan when the patient was having significant weight loss. Findings:

Review of the medical record of patient #7 revealed the patient had an admission weight of 137.1 pounds.

In an interview on 05/12/10 at 9:15 a.m. with S3RN, Charge Nurse, she indicated she admitted patient #7 on 02/18/10. She further indicated that she zeroed out the bed scale prior to placing the patient on the bed and personally obtained the documented weight. S3RN documented the weight to be 137.1 pounds on 02/18/10.

Further review of the admission orders revealed the physician ordered the patient (#7) to be weighed upon admission and weekly.

The next documented weight for patient #7 is on 03/01/10 and the weight is 124.2, a loss of 12.9 pounds in 11 days. There is no documented evidence of changes in the care plan or notification of the dietician of the weight loss of patient #7.

In an interview on 05/12/10 at 12:35 p.m. with S9LPN, assigned the care of patient #7 on 05/01/10, she stated that the weight documented on the nursing notes of 124.2 pounds was not done by her. She further indicated that a weight loss of 12.9 pounds in 11 days should be reported to the physician.

Further review of patient #7's record revealed she was next weighed on 03/08/10 and her weight was documented as 121.8, a 15.3 pound weight loss since admission.

In an interview on 05/11/10 at 12:15 p.m. S2DON was asked to review the chart for any changes to the care plan to address the weight loss of patient #7, nurses note indicating the staff was aware of the weight loss, or any documentation of notification of the dietician of the weight loss.

In an interview on 05/12/10 at 1:20 p.m. with S2DON she indicated she could find no changes to the care plan to address the weight loss of patient #7, nurses note indicating the staff was aware of the weight loss, or any documentation of notification of the dietician of the weight loss.

Based on observation and interview the hospital failed to ensure that outdated medications were not available for patient use by having outdated/unlabeled medications in the patient medication refrigerator that were expired and/or not dated when first opened/punctured. Findings:

In an observation made of the patient medication refrigerator on 05/10/10 at 9:45 a.m. the following medications were found:

1 vial of Novolin R Insulin with an opened date of 04/04/10.

1 vial of Novolin 70/30 with an opened date of 04/26 (no year).

1 vial of Tuberculin (PPD) with an opened date of 02/10. (manufacturer's directions on vial read: "discard 30 days after opening).

In an interview with S4RN, Charge Nurse, at the time of the finding, he confirmed all were expired and should not be available for patient use.

Review of a hospital policy titled "Medication Storage", policy number 3.06A, issued 04/16/08, last revised 01/09/09, reads in part: "Novolin vials - expires 30 days after opening/puncturing.....Novolin 70/30 - vials expire 30 days after opening/puncturing....Tuberculin (PPD) Discard vials in use after 30 days.

Based on observations, record review and interview, the hospital failed to ensure that all facilities, supplies and equipment were maintained in a manner to ensure the safety and well being of patients. This was evidenced by:

1. Failing to ensure that the Laryngoscope located in the Emergency Crash Cart was operational and there was a policy for routine verification of the operational status of the equipment. Findings:

In an observation made on 05/12/10 at 9:00 a.m. with S3RN of the Emergency Crash Cart it was noted that the Laryngoscope used for emergency intubation of patients was not functional. Further review of the Emergency Crash Cart revealed the replacement batteries for the Laryngoscope had expired in Jan. 2002. These findings were confirmed by S3RN at the time of the findings.

Review of a hospital policy titled "Crash Cart", policy number II-C.3.02, issued 12/02, last revised 08/02, presented as current hospital policy, lists the responsibilities of the pharmacist and nursing staff in regards to checking the Crash Cart. Review of the entire policy revealed that there is no indication of who is to check the Laryngoscope operation and what frequency the checks are to be done.

In an interview on 05/12/10 at 9:20 a.m. with S2DON she confirmed the policy for the Crash Cart checks does not include the Laryngoscope.

2. Failing to ensure that staff members were trained and knowledgeable in the proper use of the disinfectants as per the manufacturers recommendations for use. Findings:

S10 (contracted housekeeper) was interviewed on 5/12/10 at 1:45 p.m. relating to the disinfectants used at the hospital. S10 reported that she uses Virex to disinfect patient care equipment and patient care areas including beds rails and mattresses. S10 reported that she sprays the Virex on the surface and then wipes it off with a dry cloth. S10 reported that she may or may not let the Virex remain on the surface prior to wiping it off. S10 reported that she was not aware of a contact time or a dwell time for the Virex to remain in contact with the surface in order to ensure disinfection.

Review of the manufacturer's recommendations for "Virex" as a cleaner/disinfectant revealed that the product would require a 10 minute contact time or dwell time to ensure disinfection.

The Infection Control Nurse was interviewed on 5/12/10 at 1:50 p.m. The Infection Control Nurse reported that the staff need more education regarding the proper use of the disinfectant products used at the hospital.

3. Failing to ensure that glucometer test strips are not outdated. Findings:

In an observation made on 05/10/10 at 9:15 a.m. with S4RN, Charge Nurse, it was noted that the Contour Glucometer Test Strips had no documented date of opening.

Review of the manufacturer's instructions printed on the label indicated "discard 6 months after opening."

In an interview at the time of the observation with S4RN, Charge Nurse, he stated there is no way to determine when the 6 months would lapse since the bottle was not dated when opened.

Review of a hospital policy titled "Glucometer Quality Testing", policy number II-C.3.32, issued 02/04,
last revised 01/07, presented as current hospital policy reads in part: "Policy: Quality Control on the Glucometer will be performed to ensure accurate and reliable testing.....Procedure:......2. Always check Expiration date on the test strip. Follow instructions on the packet or carton before using. Throw away expired test strips....."

Based on review of the hospital's current QA/PI (Quality Assurance/Performance Improvement) data and interviews with staff, the hospital failed to measure, analyze, and track quality indicators for all hospital departments and contracted services. Findings:

The hospital's QA/PI data including the meeting minutes for the most recent 2 meetings were reviewed. Review of this data revealed no documentation to indicate that measurable quality indicators were implemented and tracked in relation to the following service areas: Dietary Services (which is a contracted service), Radiology Services (which is a contracted service), Housekeeping Services (which is a contracted service).

The Quality Director was interviewed on 05/12/10 at 1:45 p.m. The Quality Director confirmed that there was no evidence to indicate that specific measurable quality indicators relating to Dietary Services, Radiology Services, and Housekeeping Services were being measured, analyzed, and tracked.

Based on review of the hospital's QA/PI (Quality Assurance/Performance Improvement) data and interviews with staff, the hospital failed to set priorities for its performance improvement activities that focused on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas that affect health outcomes and quality of care. This was evidenced by:

1) Failing to identify the need to implement quality indicators and monitor the effectiveness of services in regards to advanced directives and/or DNR orders. Findings:

Deficiencies were identified relating to the hospital's failure to ensure that policies and procedures regarding Advanced Directives/Do Not Resuscitate orders were implemented in a timely manner and according to the patient/patients representative's directions for 2 of 3 patient records reviewed for Advance Directive/DNR policy compliance in a total sample of 10. (Patient #1 & Patient #2).

Review of the QAPI data revealed no evidence to indicate that quality indicators were developed, implemented and monitored in regards to the previously identified breakdowns with advanced directives and/or DNR orders.

In an interview with the Quality Director on 5/12/10 at 1:45 p.m., the Quality Director confirmed that there have been previously identified problems in the way that the hospital handles patients with advanced directives and/or DNR orders. The Quality Director reported that information relating to advanced directives and/or DNR orders had been discussed in the meeting of the Governing Body on January 27, 2010. When asked if there were any quality indicators implemented relating to this identified problem, the Quality Director reported that there were no quality indicators being tracked through QAPI relating to advanced directives and/or DNR orders.


2) Failing to identify the need to implement quality indicators and monitor the effectiveness of services in regards to obtaining accurate weights on patients and following up on significant changes in a patients weight. Findings:

Deficiencies were identified relating to the hospital's failure to ensure that accurate weights were consistently obtained on patients and/or failing to follow up on significant changes in a patients weight. This was noted in the medical records of 2 of 3 patient records reviewed for weight gain/weight loss out of a total sample of 10. (Patient #6 & Patient 7).

Review of the QAPI data revealed no evidence to indicate that quality indicators were developed, implemented and monitored in regards to the previously identified breakdowns with obtaining weights and/or follow up on patients with significant weight changes.

In an interview with the Quality Director on 5/12/10 at 1:45 p.m., the Quality Director confirmed that there have been previously identified problems with the accuracy of patient weights. The Quality Director reported that she had been made aware by the family nurse practitioner several months ago about inconsistencies and/or inaccuracies in relation to weights obtained on patients.