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Based on interview, medical record review, and policy review the facility failed to protect and promote the patient's rights. Findings include:

The facility failed to inform each patient or patient's representative of the patient's right in advance of furnishing or discontinuing patient care by not providing the important message from Medicare about the patient's rights within established time frames for 3 of 4 patients. See tag A-117.

The facility failed to ensure that patients were release from restraints at the earliest possible time on 1 of 5 restrained patients. See tag A-154.

The facility failed to ensure that restraints were initiated with an order by a physician and by hospital policy on 2 of 5 restrained patients. See tag A-168.

The facility failed to ensure that 3 of 3 restrained patients had a physician's renewal order for restraints. See tag A-173.

The facility failed to ensure that 5 of 5 restrained patients were monitored while in restraints according to the facility's policy. See tag A-175.

Based on record review and interview the facility failed to inform each patient or patient's representative of the patient's right in advance of furnishing or discontinuing patient care by not providing the important message from Medicare about the patient's rights within the time frames for 3 of 4 patients (#2, #6, #14, #15). Findings include:

On 6/30/10 at approximately 1200 review of patient #6's medical record it was noted that patient was admitted on 6/4/10 and the "Important Message from Medicare About Your Rights" form was not signed by the patient until 6/7/10. This finding was confirmed at the time by the Director of Quality Management.

On 7/1/2010 at 0900 an interview with the admissions coordinator about the "Important Message from Medicare About Your Rights" form that represents evidence that the patient received the message within 48 hours of admission stated "Anyone admitted on Friday, I would not get to it until Monday".

On 7/1/10 at approximately 0930 during medical record review patient #14's medical record revealed that he was admitted on 6/2/10 and discharged to home on 6/28/10 and no evidence that the patient received the "Important Message from Medicare About Your Rights" upon discharge. This finding was confirmed by the Manager of Medical Records.

On 7/1/10 at approximately 0930 during medical record review patient #15's medical record revealed that the patient was admitted on 5/28/10 and the "Important Message from Medicare About Your Rights" form wasn't signed by the patient's representative until 6/2/10. This finding was confirmed by the Manager of Medical Records at the time of the finding.

Based on record review and policy review the facility failed to ensure that patients were release from restraints at the earliest possible time on 1 of 5 (#21) restrained patients. Findings include:

On 6/30/10 at approximately 1400 patient patient #21's medical record revealed in the physician progress notes dated 3/14/10 and timed 3:20 p.m. that patient was "barely responding to painful stimuli" yet the "24 Hour Patient Record & Plan of Care" form indicated that the patient was in restraints for the whole 24 hour period on 3/14/10.

On 6/30/10 at approximately 1530 review of the facility's policy and procedure titled "Restraints and Seclusion" under the section titled "Purpose and Use:" has written "Restraint is to be applied for no longer than it is clearly needed, and any doubt about the need for restraint should be resolved in favor of using an alternative to restraint."

Based on medical record review and policy review the facility failed to ensure that restraints were initiated with an order by a physician and by hospital policy on 2 of 5 (#4, #11) restrained patients. Findings include:

On 6/29/10 at approximately 1255 during medical record review of patient #4's medical record revealed in the "24 Hour Patient Record & Plan of Care" that bilateral wrist restraints were applied on 6/22/10 at 2000 and yet a telephone order from a physician wasn't initiated until 2130. In addition, the "Restraint Order/Assessment Sheet" dated 6/27/10 and timed 0700 revealed that the physician didn't sign the order until 6/28/10 and that documented on the "24 Hour Patient Record & Plan of Care" indicated that the patient was in restraints from 0700 to 1200 and then restraints were reapplied at 2000 without a physician's order. These findings were confirmed by the Director of Quality Management at the time of the findings.

On 6/30/10 at approximately 1430 during medical record review, patient #11's medical record revealed on 6/16/2010 in the "24 Hour Patient Record & Plan of Care" that the patient had restraints applied at 0400 and no evidence of a physician's order is present for 6/16/10. This find was confirmed by RN #1 on 7/1/10 at approximately 0900.

On 6/30/2010 at approximately 1500 upon review of the policy and procedure titled "Restraints and Seclusion" under the section titled "Orders to Initiate Restraint" it states, "If a patient is removed from restraint before the current order expires and must be returned to restraints a new physician order is required." In addition, under the section titled "Procedure 1." it states, "If a physician or licensed independent practitioner (LIP) is not available to issue such an order, a registered nurse initiates restraint use based on an appropriate assessment of the patient. In that case, the MD/DO or LIP is notified immediately as clinically possible, of the initiation or restraint, and a telephone order is obtained from that practitioner and entered into the patient's medical record.

Based on record review and interview the facility failed to ensure that 3 of 3 (#4, #10, #11) restrained patients had a physician's renewal order for restraints. Findings include:

On 6/29/10 at approximately 1300 during a review of patient #4's medical record it was noted that the "Restraint Order/Assessment Sheet" dated 6/28/2010 and 6/29/10 were not signed by a physician and one dated 6/24/10 was signed by a physician yet the physician's signature was dated 6/23/10. The "24 Hour Patient Record & Plan of Care" indicated that the patient was in restraints on these dates. This finding was confirmed by the Director of Quality Management at that time.

On 6/30/10 at approximately 1600 while reviewing patient #10's medical record was absent of a physician's order for restraint use on 6/16/10, 6/17/10, 6/18/10, 6/19/10, 6/21/10, and 6/22/10. The "24 Hour Patient Record & Plan of Care" indicated that the patient was in restraints on these days. This finding was confirmed by RN #1 on 7/1/10 at approximately 0830.

On 6/30/10 at approximately 1530 while reviewing patient #11's medical record, the "24 Hour Patient Record & Plan of Care" indicated that the patient was in restraints at 0800 and then placed back into restraints at 2000. "The Restraint Order/Assessment Sheet" had the restraints ordered on 6/14/10 at 0730. This finding was confirmed by RN #1 on 7/1/10 at approximately 0830.

On 6/30/2010 at approximately 1500 upon review of the policy and procedure titled "Restraints and Seclusion" under the section titled "Orders to Initiate Restraint" it is written "If a patient is removed from restraint before the current order expires and must be returned to restraints a new physician order is required." In addition, under the section titled "Procedure 2." it is written "A written order, based on an examination of the patient by the MD/DO or LIP is entered into the patient's medical record on a daily basis when restraint use in clinically appropriate and section titled "Procedure 3." Obtain a physician's order prior to the application of a restraint."

Based on record review and interview the facility failed to ensure that 5 of 5 (#4, #5, #10, #11, #12)restrained patients were monitored while in restraints according to the facility's policy: Findings include:

On 6/30/10 at approximately 1600 during medical record review regarding monitoring patients in restraints the following was found:
Patient #4: On the "24 Hour Patient Record & Plan of Care" form dated 6/23/10 no restraint monitoring of patient was documented from 1300 through 1900.

Patient #5: On the "24 Hour Patient Record & Plan of Care" form dated 5/27/10 no restraint monitoring of patient was documented from 1600 through 2000. On the "24 Hour Patient Record & Plan of Care" form dated 6/2/10 no restraint monitoring of patient was documented from 1300 through 1900. On the "24 Hour Patient Record & Plan of Care" form dated 6/4/10 no restraint monitoring of patient was documented from 1500 through 2000. On the "24 Hour Patient Record & Plan of Care" form dated 6/15/10 no restraint monitoring of patient was documented from 1200 through 1900. On the "24 Hour Patient Record & Plan of Care" form dated 6/27/10 no restraint monitoring of patient was documented from 1600 through 2000.

Patient #10: On the "24 Hour Patient Record & Plan of Care" form dated 6/16/10 no restraint monitoring of patient was documented from 1600 through 2000.

Patient #11: On the "24 Hour Patient Record & Plan of Care" form dated 6/14/10 no restraint removal for 10 minutes every 2 hour was documented from 1900 through 2400.

Patient #12: On the "24 Hour Patient Record & Plan of Care" form dated 3/2/10 no restraint monitoring of patient was documented from 1000 through 2000. On the "24 Hour Patient Record & Plan of Care" form dated 3/4/10 no restraint monitoring of patient was documented from 0100 through 0600. On the "24 Hour Patient Record & Plan of Care" form dated 3/5/10 no restraint monitoring of patient was documented from 1600 through 1900. On the "24 Hour Patient Record & Plan of Care" form dated 3/12/10 no restraint removal for 10 minutes every 2 hour was documented from 1500 through 2000.

The above findings were confirmed by the Director of Quality Management on 7/1/10 at approximately 0900.

On 6/30/2010 at approximately 1500 upon review of the policy and procedure titled "Restraints and Seclusion" under the section titled "Medical Record Documentation and Plan of Care" it is written "Interdisciplinary Team Member documentation must: ... State observations/interventions/findings from periodic observations, to include: safety, comfort, mobility, skin integrity, food/hydration and toileting - to include removal of restraints at least 10 minutes every two hours or more often."

Based on record review and interview the facility failed to ensure that a registered nurse supervised and evaluated the nursing care provided for each patient on a regular basis on 6 of 9 (#2, #4, #5, #10, #12, #21) patient records reviewed for nursing services. Findings include:

On 6/30/10 at approximately 1600 during medical record review regarding repositioning of the patients the following was found:
Patient #2: On the "24 Hour Patient Record & Plan of Care" form dated 6/28/10 no repositioning of patient was documented from 1800 through 2100.

Patient #4: On the "24 Hour Patient Record & Plan of Care" form dated 6/22/10 no repositioning of patient was documented from 0700 through 1600. On the "24 Hour Patient Record & Plan of Care" form dated 6/24/10 no repositioning of patient was documented from 0700 through 1100. On the "24 Hour Patient Record & Plan of Care" form dated 6/25/10 no repositioning of patient was documented from 1400 through 2100. On the "24 Hour Patient Record & Plan of Care" form dated 6/26/10 no repositioning of patient was documented from 1600 through 2100. On the "24 Hour Patient Record & Plan of Care" form dated 6/27/10 no repositioning of patient was documented from 0700 through 1100 and 1600 through 1900.

Patient #5: On the "24 Hour Patient Record & Plan of Care" form dated 6/6/10 no repositioning of patient was documented from 1400 through 1900. On the "24 Hour Patient Record & Plan of Care" form dated 6/7/10 no repositioning of patient was documented from 1400 through 1900. On the "24 Hour Patient Record & Plan of Care" form dated 6/11/10 no repositioning of patient was documented from 1500 through 1900. On the "24 Hour Patient Record & Plan of Care" form dated 6/14/10 no repositioning of patient was documented from 2000 through 0600. On the "24 Hour Patient Record & Plan of Care" form dated 6/18/10 no repositioning of patient was documented from 1700 through 2100. On the "24 Hour Patient Record & Plan of Care" form dated 6/19/10 no repositioning of patient was documented from 0700 through 1100 and 1400 through 2000.

Patient #10: On the "24 Hour Patient Record & Plan of Care" form dated 6/21/10 no repositioning of patient was documented from 1400 through 1900.

Patient #12: On the "24 Hour Patient Record & Plan of Care" form dated 3/18/10 no repositioning of patient was documented from 1200 through 2100. On the "24 Hour Patient Record & Plan of Care" form dated 6/19/10 no repositioning of patient was documented from 0700 through 1900.

On the "Nursing Wound Documentation" form the prescription for wound care indicates change frequency-daily for the PEG site. It was noted that between 3/8/10 and 3/28/10 the following dates were not documented as having completed the wound care 3/12, 3/13, 3/17, 3/18, 3/23, 3/24, 3/25, 3/26, and 3/27. On the "Nursing Wound Documentation" form the prescription for wound care indicates change frequency-daily for the buttock. It was noted that between 2/26/10 and 4/1/10 the following dates were not documented as having completed the wound care 3/6, 3/7, 3/18, 3/19, 3/30, 3/31, and 4/1. On the "Nursing Wound Documentation" form the prescription for wound care indicates change frequency-daily for the right post shoulder. It was noted that between 2/26/10 and 3/22/10 the following dates were not documented as having completed the wound care 2/27, 3/3, 3/6, 3/7, 3/10, 3/11, 3/14, 3/17, 3/18, and 3/19.

Patient #21: On the "24 Hour Patient Record & Plan of Care" form dated 3/13/10 no repositioning of patient was documented from 1400 through 1900.

On 7/1/10 at approximately 1000 review of the facility's policy titled "Guidelines and Protocols-Nursing" under section titled " Activity/Mobility" has written "Bedfast patients turned. document position (R-Repositioned B-Back to Bed)" "Minimum Frequency Every 2 hours".

Based on record review and interview the facility failed to ensure that all patient medical entries were complete, dated, timed, and authenticated by the person responsible for providing care and consistent with the facility's policies and procedures in 9 of 15 medical records reviewed. Findings include:

On 6/29/10 between the hours of 1200 and 1500 during a tour of the facility upon review of open medical records the following was noted:

Patient #4: Two of the "Restraint Order/Assessment Sheet" forms were absent of the nurses date and time of assessment.

Patient #5: A "Restraint Order/Assessment Sheet" form was absent of a nurses date and time and signature of assessment and two of the "Restraint Order/Assessment Sheet" forms were absent of the nurses date and time of assessment.

Patient #7: A telephone order taken by a nurse on 6/27/10 was not dated and timed by the physician when it was authenticated.

Patient #8: A telephone order taken by a nurse on 6/24/10 was not dated and timed by the physician when it was authenticated and a telephone order taken by a nurse on 6/26/10 was not dated, timed, or authenticated by a physician.

Patient #9: A telephone order taken by a nurse on 6/25/10 was not dated, timed, or authenticated by a physician. A telephone order taken by a nurse on 6/27/10 was not dated, timed, or authenticated by a physician.

Patient #10: A "Restraint Order/Assessment Sheet" form was absent of a date and one of the "Restraint Order/Assessment Sheet" forms was absent of the nurses date and time of assessment.

Patient #11: Three "Restraint Order/Assessment Sheet" forms were absent of the nurses date and time of assessment and one "Restraint Order/Assessment Sheet" form was absent of a nurses date and time and signature of assessment.

Patient #15: A protocol order was written by an LPN on 6/9/10 on the physician's orders sheet and was not authenticated by a physician.

On 6/29/10 during the tour with the Director of Quality Management confirming all the above listed findings, when queried regarding the authentication of orders, she stated "they have to be signed within 24 hours and the doctors know that they need to date and time." In addition, when queried about the incomplete "Restraint Order/Assessment Sheet" forms she stated, "they know better than this, I can't believe this".

On 6/30/10 at approximately 1000 upon review of patient #2's medical record the "Medication Administration Record" dated 6/29/10 was obliterated with wavy markings across the medications and across what appears and was verified the documented dosages that were given to patient #2 earlier that day. At the time of the finding the Director of Quality Management was queried she stated "they know better than this", "this is not how we discontinue a medication".

Based on observation and interview the infection control officer failed to prevent and control infections within the hospital. Findings include:

On 6/29/10 during tour of the the facility at approximately 1200 Room 832 labeled as "Contact Isolation" was two female visitors in the room with no personal protective equipment on to protect them from cross contamination, this observed by the surveyor. One of the female visitors was sitting on the patient's bed and touching the patient.

On 6/29/10 during tour of the the facility at approximately 1430 the following was observed in Room 838 labeled as "Contact Isolation". Respiratory Therapist #1 and #2 were in the patient's room with only gloves on and LPN #1 that was in the hall outside of room 838 stated that "they are suctioning the patient" Respiratory Therapist #1 had his hands lifted up and palms turned in when the surveyor glanced in the room as if the gloves were dirty. This observation was witnessed by the Infection Control Officer and the Director of Quality Management at that time. The Director of Quality Management was queried about the lack of applying appropriate personal protective equipment for the care they were rendering and she stated "we always have trouble getting "respiratory therapist #1" to cooperate".