HospitalInspections.org

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

1) Failing to: a) have the RN assess each patient's nursing care needs to determine the appropriateness of delegation of care of the patient to the LPN (licensed practical nurse) for 3 of 20 sampled patients (#2, #8, #15); b) have the RN assess, stage, and measure wounds upon admit for 4 of 7 patients reviewed with a wound (#1, #2, #3, #8) from a total of 20 sampled patients; and c) ensure a RN assesses patients when there is a decline in the condition of the patient for 2 of 20 sampled patients (#2, #15) (see findings in tag A0395);

2) Failing to: a) administer medications as ordered for 3 of 20 sampled patients (#1, #3, #8); b) obtain labs as ordered by the physician for 2 of 20 sampled patients (#1, #3); and c) provide wound care as ordered for 1 of 7 patients reviewed with a wound from a total of 20 sampled patients (#8) (see findings in tag A0396);

3) Failing to ensure the nursing care of each patient was assigned according to patient's needs and the qualifications/competence of the nursing staff by failing to determine the nursing staff to patient ratio with consideration of the patient's medical co-morbid conditions, the number of new admits which require a RN (registered nurse) to perform the initial assessment, and the number of discharges which required extensive paperwork and patient/family education to be performed by the nursing staff. The nursing staff assignments contributed to: a) failing to have the RN (registered nurse) assess each patient's care needs to determine the appropriateness of delegation to the LPN (licensed practical nurse) for 3 of 20 sampled patients (#2, #8, #15); b) failing to have the RN assess, stage, and measure wounds upon admit for 4 of 7 patients reviewed with a wound (#1, #2, #3, #8) from a total of 20 sampled patients; c) failing to have the RN assess a patient with a change in condition for 2 of 20 sampled patients (#2, #15); d) failing to have medications administered as ordered for 3 of 20 sampled patients (#1, #3, #8); e) failing to obtain labs as ordered by the physician for 2 of 20 sampled patients (#1, #3); and f) failing to provide wound care as ordered for 1 of 7 patients reviewed with a wound from a total of 20 sampled patients (#8) (see findings in tag A0397);

4) Failing to ensure the nursing staff followed the hospital policy and procedure for use of verbal orders by failing to obtain and document readbacks of verbal orders resulting in 13 verbal orders not read back to the physician for accuracy for 4 of 20 sampled patients (#2, #6, #11, #13) (see findings in tag A407).

Based on review of the medical records and chart audits, Medical Staff Bylaws/Rules and Regulations, and interviews with the RHIA, Medical Records staff, Administrator and Corporate Compliance Nurse, the hospital failed to meet the Condition of Participation for Medical Records as evidenced by:

1. Failing to ensure that the medical records department director maintained the department to ensure that: a) all medical records were comprehensively reviewed in order to determine completion of the medical record within 30 days and give prompt notice to physicians of pending records which needed completion; b) an accurate delinquency rate for medical records was determined in order to report data through the QA (quality assurance) department of the hospital and obtain a plan to correct the delinquency rate; c) policies and procedures of the medical records department and medical staff bylaws relative to suspension of physicians for failure to complete the medical record in accordance with federal regulations were followed (See findings at Tag A0432);

2. Failing to develop, implement and monitor a process to ensure complete and accurate medical records as evidenced by physician orders, Progress Notes, consents, History and Physicals and Medication reconciliation forms not being signed/dated and or timed and forms filed in patient charts without appropriate patient identification resulting in 8 of 20 sampled records being incomplete (See findings at Tag A0450); and

3. Failing to ensure all verbal orders had been authenticated by the physician as evidenced by approximately 33 occurrences involving 8 patients of the 20 sampled medical records not having signed verbal orders by a physician (#1, #2, #4, #6, #7, #9, #11, #15) (See findings at Tag A0457).

Based on review of physician credentialing files and interview, the hospital failed to ensure its infection control program included current nationally recognized infection control practices or guidelines of the Centers For Disease Control (CDC) which included active surveillance of all health care workers in the hospital by failing to require all physicians and nurse practitioners to be verified as free from TB (tuberculosis), a communicable disease, prior to initial appointment to the medical staff and at least annually thereafter for 8 of 8 physicians reviewed from a total of 47 credentialed physicians (S12, S35, S36, S37, S38, S39, S41, S42) and 2 of 2 nurse practitioners (NP) reviewed from a total of 8 credentialed NPs (S40, S44). Findings:

Review of Physicians' credentialing files (S12, S35, S36, S37, S38, S39, S41, S42) and NP's files (S40, S44) revealed no documented evidence that the infection control director ensured that the infection control practices of the hospital were in accordance with nationally recognized infection control practices or guidelines of the CDC. The infection control director failed to ensure that all hospital health care workers, including physicians and nurse practitioners on the medical staff of the hospital, had been found free of TB prior to appointment and at least annually thereafter in order to monitor, prevent, and control the possible spread of communicable diseases, including TB, for each hospital health care worker.

In a face-to-face interview on 01/21/10 at 11:10am, S2 DON (director of nursing) indicated the physicians were not considered employees of the hospital. He confirmed the hospital did not require physicians to be tested for TB.

Based on review of the public health inspection and interview the hospital failed to obtain a public health inspection as evidenced by the inability of the hospital to obtain one independently of the host facility. Findings:

Review of the Public Health documentation submitted to the survey team as proof of inspection revealed an inspection date of 10/21/05. Further review revealed in the section titled "Remarks" License number 418 expires 05/31/06.

The hospital could provide no further documentation an inspection by the Public Health Department had been performed since 05/31/06.

In a face to face interview on 01/20/10 at 2:50pm S1 the Administrator indicated it was not necessary for an individual inspection since he was not the host facility.

Based on record review and interview, the hospital failed to ensure a patient's right to make decisions regarding his/her care was implemented by failing to: 1) follow the hospital's policy for DNR (do not resuscitate) orders for 3 of 4 patients with DNR orders from a total of 20 sampled patients (#10, #11, #15) and 2) have the report by a family member of a previously ordered DNR for a patient communicated to the physician by the hospital social worker for 1 of 1 patient reviewed with a report of a previous DNR order from a total of 20 sampled patients (#1). Findings:

1) DNR orders:
Patient #10
Review of Patient #10's "Physician Orders" revealed an order on 01/17/10 at 1700 (5:00pm) by Physician S36 for DNR.
Review of the entire medical record revealed no documented evidence of a determination by a second physician that the DNR was medically appropriate and a discussion with the patient and/or family member prior to implementing the DNR as required by hospital policy.
In a face-to-face interview on 01/20/10 at 5:45pm, S2 DON (director of nursing) confirmed there was no documented evidence of a second physician consult and a discussion with Patient #10 or the caregiver by S36 Physician prior to implementing the DNR order.

Patient #11
Review of the Admit Orders for Patient #11 dated 01/07/10 revealed she was an 85 year old lady with the primary diagnosis of an abscess MRSA (Methycillin Resistant Staph Aureus) of the buttock, S/P I&D (Incision and Drainage) and secondary diagnosis of Diabetes Mellitus, Hypertension, Anemia and Cerebral Vascular Accident. Further review revealed ..... " Other: Pt. (Patient) is a Do Not Resuscitate. (copied from hospital transfer orders). "
Review of the entire medical record revealed no documented evidence of an Advanced Directive, Power of Attorney, or Living Will on Patient #11 ' s chart.
Observation of the chart cover of Patient #11 ' s chart revealed a sticker identifying the patient as a DNR (Do Not Resuscitate).
Review of the Physician ' s Progress Notes dated 01/08/10 through 01/18/10 revealed no documented evidence the physician had discussed the DNR order with the patient, family or power of attorney.

Patient #15
Review of Patient #15's physician orders revealed an order on 12/29/09 by S12 Physician for "Resuscitate With Modifications: Do Not Intubate, Do Not Defibrillate, Emergency Medications Only, Basic Life Support Only (CPR) (cardiopulmonary resuscitation)".
Review of the "Physician Progress Notes" revealed an entry on 12/28/09 at 11:50pm by S12 Physician of "I agree with DNR status of patient".
Review of the entire medical record revealed no documented evidence of a determination by a second physician that the DNR was medically appropriate and a discussion with the patient and/or family member prior to implementing the DNR as required by hospital policy.
In a face-to-face interview on 01/22/10 at 9:00am, S2 DON indicated he had spoken with S12 Physician who indicated he had spoken with Patient #15 about the DNR order, but he had not documented the discussion as required by hospital policy. S2 DON confirmed there was no documented evidence of a second physician consult to determine the appropriateness of the DNR order.

2) Communication by social worker to physician:
Review of Patient #1's "Interdisciplinary Progress Note" on 01/19/10 revealed an entry, in part, by S17 Social Worker of "...No living will on chart but wife tells me pt (patient) is a DNR. Will f/u (follow up) to execute living will...". Further review revealed no documented evidence Patient #1's Physician S35 was notified of the discussion with #1's wife regarding a DNR order.

In a telephone interview on 01/19/10 at 3:15pm, S17 Social Worker indicated she did not prepare a living will at the time of meeting with Patient #1's wife, because she didn't have the forms at the main campus. She further indicated she planned to obtain the form when she went to the off-site campus and return to meet with Patient #1's wife at the main campus. She confirmed that she did not report to S35 Physician her discussion with Patient #1's wife regarding him previously having a DNR order.
In a face-to-face interview on 01/21/10 at 3:40pm S17 Social Worker indicated the nurse usually discussed DNR with the patients, so she didn't do anything about a DNR for Patient #1. She confirmed that she did not relay the information she received during her initial discussion with Patient #1's wife on 01/19/10 to the nurse or S35 Physician. She indicated that she "doesn't usually get involved with this".

In a face-to-face interview on 01/22/10 at 9:30am, Physician S35 indicated she would have expected S17 Social Worker to have reported the conversation S17 had with Patient #1's wife regarding the previous DNR order.

Review of the hospital policy titled "Do Not Resuscitate", effective 04/09 and submitted by S2 DON as the hospital's current policy for DNR, revealed, in part, "...The purpose of this policy is to establish procedures when decisions concerning "Do Not Resuscitate" ("DNR") or "Terminal Care" orders must be made. ... Procedure: A. The patient's attending physician and a consulting physician (optional) must determine if a DNR or a Terminal Care Order is medically appropriate, based on the patient's underlying terminal illness or irreversible medical condition. B. If the attending physician and the consulting physician determine that a DNR or a Terminal Care Order is medically appropriate, the physician must then discuss the matter with the patient, explaining the basis for and the consequences of, a DNR or a Terminal Care Order. If the patient is incompetent, this discussion must be held with the patient's family or legal guardian. All such discussions must be noted on the patient's medical record. The notation of such discussions shall include at least the following information: persons present, information conveyed by physician, date/time of conference with family/patient, and decision of family and legal guardian. C. If the patient is competent, the patient must consent to the entry of a DNR or Terminal Care Order...".

Based on record review and interview, the hospital failed to ensure the medical staff's appointment/reappointment was conducted according to the medical staff bylaws by failing to develop and implement a system for examination of credentials by the medical staff which resulted in: 1) 1 of 8 physicians reviewed from a total of 47 credentialed physicians (S37) having his/her appointment period expired; 2) 4 of 8 physicians reviewed for appointment/reappointment from a total of 47 credentialed physicians not being conducted according to medical staff bylaws (S35, S36, S38, S39); and 3) 1 of 2 nurse practitioners (NP) reviewed for appointment/reappointment from a total of 8 credentialed NPs not being conducted according to medical staff bylaws (S40). Findings:

1) Physician with expired appointment period:
Review of Physician S37's credentialing file on 01/21/10 revealed he was last appointed by the Governing Body on 01/16/08, which was effective for 2 years and due to expire on 01/16/10. Review of the entire credentialing file revealed no documented evidence that Physician S37 had been reappointed to the medical staff by the governing body as of 01/21/10. Further review of the application for reappointment submitted by Physician S37 on 11/05/09 revealed the health status section was incomplete, as there was no documented evidence of the most recent physical examination performed, the date it was performed, and the name of the physician performing the exam. Further review revealed the letter sent to Physician S37 by S43 Credentialing Coordinator was dated 10/15/09, 3 months prior to his reappointment date, rather than 6 months as required by the medical staff bylaws.

In a face-to-face interview on 01/21/10 at 11:45am, S5 RHIT (registered health information technician) confirmed Physician S36's appointment had expired.

2) Reappointment according to medical staff bylaws:
Review of Physician S35's credentialing file revealed her reappointment was signed by the governing body on 11/06/09. Further review revealed the 2 peer references were completed on 12/07/09 and 01/05/10, both after her reapplication had gone before and been approved by the governing body.

Review of Physician S36's credentialing file revealed his reappointment to the medical staff was approved by the governing body on 11/06/09 and by the medical executive committee (MEC) on 12/08/09. Medical staff bylaws required the reapplication to be reviewed by the MEC for approval prior to being sent to the governing body. Further review revealed the 2 peer references were completed on 12/03/09 and 12/09/09, both after the reappointment had been approved by the governing body.

Review of Physician S38's credentialing file revealed he was reappointed effective 01/31/08. Further review revealed the letter sent by S43 Credentialing Coordinator to Physician S38 notifying him to complete his reappointment application was dated 12/28/09, rather than 6 months prior to reappointment as required by medical staff bylaws. Further review revealed the letter had the following statement: "Failure to return the re-appointment application by 12/15/09 will be deemed a voluntary resignation from the medical staff" (the date listed was prior to the date of the letter being sent).

Review of Physician S39's credentialing file revealed he was appointed on 07/24/09. Further review revealed the 2 peer references were completed on 07/29/09 and 09/22/09, both after Physician S39 had been appointed by the governing body. Further review revealed the NPDB (national practitioner data bank) query had been conducted on 09/23/09, after he had been appointed. Further review revealed no documented evidence of continuing medical education certificates or a statement provided by Physician S39 of his completion as required by medical staff bylaws.

In a face-to-face interview on 01/21/10 at 11:45am, S5 RHIT confirmed the above-described deficiencies in the physician credentialing files.

3) Nurse Practitioner credentialing file:
Review of NP S40's credentialing file revealed the governing body appointed her to the medical staff on 07/24/09. Further review revealed the form signed by the medical director was incomplete as the section that read "The following criteria has been reviewed and met:" had no evidence of checks in any area for "Education/Training - NP or PA (physician assistant), Current, unrestricted license to practice in this state, Peer Recommendations/Competence Evaluations, Current malpractice insurance...".

Review of the "Delineation Of Allied Health Professional Privileges" signed by the medical director on 07/24/09 revealed the following instructions: "Nurse Practitioner - If Co-signature is required with your collaborative agreement, please indicate by a check in the co-signature required column and denote the timeframe in the designated column. If Co-signature is not required, please enter N/A (not applicable) in the co-signature required column". Review of the entire delineation of privileges revealed 4 columns had an initial in the column for co-signature required, and the timeframe was blank, and 41 columns that were checked as requested had no documented evidence of N/A in the co-signature column.

Review of the "Medical Director/Assistant Medical Director Report - Louisiana", used to drop from Provisional Status and advance to Regular Staff, was signed by the medical director on 07/24/09. Further review revealed the entire form was blank including the applicant's name, category, privileges, assessment, review of the applicant's quality/performance data, review of privileges, and recommendation.

Review of the "Approval Form For Medical Staff Appointment" revealed the governing body chairman signed it on 07/24/09. Further review revealed the form was blank including the applicant's name, category, privileges, action referred for approval of the governing board, medical director report reviewed, and governing board action of appoint/reappoint, do not appoint/reappoint, or appoint with provisions.

Review of the peer references revealed the letters sent by S43 Credentialing Coordinator were dated 10/21/09, almost 3 months after NP S40 had been appointed by the governing body. Further review revealed no peer references had been returned for NP S40.

In a face-to-face interview on 01/21/10 at 11:45am, S43 Credentialing Coordinator indicated she was responsible for the credentialing process. She further indicated she had begun this duty on 08/21/09 and had not performed credentialing prior to this time. She indicated her training was done by having the RHIT and the HIM (health information management) clerk from a sister hospital work with her for 2 weeks, after which time she could call them with questions. S43 Credentialing Coordinator indicated she sent out reapplications to the physicians who were due for reappointment 4 months before their due date (bylaws require 6 months in advance). She further indicated she didn't remember if she had ever read the appointment/reappointment process in the medical staff bylaws. She indicated that she had been told to send the peer and affiliation letters after she received the reapplication from the physician. S43 Credentialing Coordinator confirmed that she was supposed to have all required items before the physician's reapplication went to the MEC and governing body, but if it was already past the deadline for reappointment, the file would be reviewed by the governing for approval.

In the same face-to-face interview on 01/21/10 at 11:45am, S5 RHIT indicated she was the Director of the HIM Department and was the supervisor of S43 Credentialing Coordinator. She further indicated the hospital had inherited the physician's credentialing files from the previous owners around 06/09. She further indicated a representative from a sister hospital had come to inspect the files to bring them up-to-date. She further indicated the representative was at the hospital for about 3 weeks, but she had no record of what they did other than what's currently in the physician files.

In a face-to-face interview on 01/22/10 at 9:30am, Physician S35 indicated she was the Medical Director of the main campus. She indicated she was totally dependent on the credentialing coordinator for the credentialing process, and she was not aware of the problems with the credentialing process.

Review of the "Bylaws Of The Medical Staff", last revised 12/08 and submitted by S2 DON (director of nursing) as the current copy of the medical staff bylaws, revealed, in part, "...Article V Section 5.1 Procedure for Appointment 5.1.1 ... Reappointments shall be no later than two (2) years from the date of the initial appointment. It is required that the "Health Status" of each applicant be documented at the time of application and re-application. ... 5.1.2 Information required from the applicant for credentials verification and privilege granting includes: ... 5. Continuing Medical Education Credits or CME attestation statement 6. Health Statement that no health problems exist that could affect his/her ability to perform the privileges requested - which must be confirmed by an outside physician or the Medical Director. ... It shall be the responsibility of the Credentialing Department/Designee to verify a minimum of two (2) peer references and two (2) affiliations (if applicable) provided by the applicant. ... Upon receipt of all required items, ... the application and information will be referred to the Medical Executive Committee for evaluation of the above listed items and recommendation. ... Upon review by the Medical Executive Committee, it shall be recommended to the Governing Board that the applicant be accepted or rejected. ... 5.2.4 Procedure for Processing Reappointment Applications An application for reappointment shall be completed every two (2) years on the appropriate form provided by the hospital by each applicant. The re-application form will be sent to applicant at least six (6) months prior to the re-appointment date. ... Information required from the applicant for reappointment includes: 1. Re-appointment application with the delineation of privileges... 6. Continuing Medical Education Credits earned during the past 2 years or CME attestation statement 7. Health Statement that no health problems exist that could affect his/her ability to perform the privileges requested - must be confirmed by an outside physician or the Medical Director ... The process for approval will be the same as stated under "Procedure for Processing of Initial and or Reappointment Applications". ... 5.10 Allied Health Professionals The process and procedure for granting temporary privileges, initial appointment, reappointment and modification of privileges for Allied Health Professionals is the same as previously documented in these bylaws for physicians... Co-signature by supervising/collaborating physician is required only as specifically denoted on each individuals delineation of privileges in accordance with the State and Federal Law, which is maintained in the professional's credentialing file.

Based on medical record review and interview with the medical record personnel the hospital failed to ensure all History and Physicals had been completed, dictated and filed on the patient's chart within 24 hours of admit as evidenced by 2 of 20 sampled patients (#8, #9). Findings:

Review of the History and Physical for Patient #8 revealed the patient had been admitted to the hospital on 01/15/10. Further review revealed the history and physical had been dictated by the physician on 01/16/10 and transcribed 01/17/10 indicating the medical record failed to have the H&P on the chart within 24 hours.

Review of the medical record for Patient #9 revealed he had been admitted on 01/19/10 for wound care. Further review of the chart revealed no documented evidence a History and Physical had been performed by the admitting physician.

In a face to face interview on 01/20/10 at 11:00am S6, the Medical records Coordinator for the main campus, indicated there are problems at times with the timeliness of getting the dictations typed and the H&P's on the chart within 24 hours.

Based on record review and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care of each patient by failing to: 1) have the RN assess each patient's care needs to determine the appropriateness of delegation to the LPN (licensed practical nurse) for 3 of 20 sampled patients (#2, #8, #15); 2) have the RN assess, stage, and measure wounds upon admit for 4 of 7 patients reviewed with a wound (#1, #2, #3, #8) from a total of 20 sampled patients; and 3) have the RN assess a patient with a change in condition for 2 of 20 sampled patients (#2, #15). Findings:

1) RN assess each patient on a daily basis:
Patient #2
Review of Patient #2's "Daily Nursing Assessment" for 01/14/10 through 01/18/10 revealed no documented evidence of a nursing assessment by the RN.

Patient #8
Review of Patient #8's "Daily Nursing Assessment" for 01/17/10 and 01/18/10 revealed no documented evidence of a nursing assessment by the RN.

Patient #15
Review of Patient #15's "Daily Nursing Assessment" for 01/03/10 through 01/08/10 and 01/12/10 through 01/15/10 revealed no documented evidence of a nursing assessment by the RN.

In a face-to-face interview on 01/22/10 at 9:00, S2 Director of Nursing (DON) confirmed there was no evidence of RN supervision of care and patient assessment by the RN from 01/03/10 through 01/08/10.

Review of the hospital policy titled "Patient Care Documentation (Nursing)", last revised 08/02 and presented by S2 DON as the hospital's current policy on assessment of patients by the RN, revealed, in part, "...All patients will have a Daily Patient Care Flow Sheet completed by an RN or LPN daily. ... General Instructions ... 7. Document a systems assessment a minimum of once per shift. ... 9. The nursing team member who provides specific aspects of care will document the care that she/he provided. ... Breakdown of Form: ... 2. Shift Assessment/Notes/Interventions/Evaluation: the RN and/or LPN will perform and document a total patient reassessment minimally once each shift and whenever the patient's condition changes. The RN and/or LPN must document interventions and evaluations in an ongoing fashion (as they occur and/or after they occur). The LPN must consult the RN for abnormal findings and changes in the patient's condition. The LPN may reassess when patient's condition changes, however, if patient's condition deteriorates, the RN must complete the reassessment. The RN will direct and coordinate patient care team members through direct assessment when appropriate, and through reviewing and updating the problem list and plan of care once every shift and PRN (as needed). ... e. The RN must evaluate the appropriateness of the patient's problem identification as documented on the Problem List every shift, update problems PRN and sign in the designated corner of shift assessment page...".

Review of the Louisiana State Board of Nursing's "Delegation Decision-Making Process" revealed, in part, "...The Louisiana State Board of Nursing has the legal responsibility to regulate the practice of nursing and to provide guidance regarding the delegation of nursing interventions by the registered nurse to other competent nursing personnel. ... In Louisiana, R.S. 37:913(14)(f) provides that registered nursing includes delegating nursing interventions to qualified nursing personnel in accordance with criteria established by the Board of Nursing. LAC 46:XLVII.3703 sets the standards for implementation of the statutory mandate. The term "delegating nursing interventions" is defined and criteria are provided for all delegatory activities, for delegation to licensed practical nurses... The registered nurse who delegates nursing interventions retains the responsibility and accountability to assure that the delegated intervention is performed in accord with established standards of practice, policies and procedures. Appropriate assessment, planning, implementation and evaluation are integral activities in the fulfillment of the registered nurse's responsibility and accountability. ...".

Review of the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII" revealed, in part, "3703. Definition of Terms Applying to Nursing Practice ... Delegating Nursing Interventions - ... The registered nurse retains the accountability for the total nursing care of the individual. ... The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. The assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. a. Any situation where tasks are delegated should meet the following criteria: i. the person has been adequately trained for the task; ii. the person has demonstrated that the task has been learned; iii. the person can perform the task safely in the given nursing situation; iv. the patient's status is safe for the person to carry out the task; v. appropriate supervision is available during the task implementation; vi. the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all. b. The registered nurse may delegate to licensed practical nurses the major part of the nursing care needed by individuals in stable nursing situations, i.e. (that is), when the following three conditions prevail at the same time in a given situation: i. nursing care ordered and directed by R.N./M.D. (medical doctor) requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable; and ii. change in the patient's clinical conditions is predictable; and iii. medical and nursing orders are not subject to continuous change or complex modification...".

2) RN assess, stage, and measure wounds upon admit:
Patient #1
Review of Patient #1's "Initial Nursing Assessment" performed by S7 RN on 01/15/10 at 1430 (2:30pm) revealed the following wound assessment: "R (right) Butt (buttock) St II (stage II) Decub (decubitus) pink (circle with line drawn through indicating no) drainage and odor; R 1st 2nd 3rd toe mult (multiple) ulcers. R ant (anterior) ft (foot) ulcer. L (left) heel/L grt (great) toe ant ulcers. Post (posterior) L calf ulcer - see w.c. (wound care) pictures)". Further review revealed no documented evidence of a description of each wound including the size, color of the wound and the surrounding tissue, drainage, and odor as required on the wound assessment sheet of the "Initial Nursing Assessment".
Review of the "Wound Care Flowsheet" revealed an assessment of all wounds with documented stage, measurements, tunnels, undermining, wound base, wound bed color, periwound skin condition, drainage amount, color, and odor, presence of pedal pulses, edema, and wound pain was performed on 01/15/10 by S8 LPN. Further review revealed the first documented evidence of an assessment of wounds by the RN was performed on 01/18/10, 3 days after admit.
In a face-to-face interview on 01/19/10 at 2:50pm, S2 DON confirmed the initial wound assessment was performed by the LPN. He indicated the wound care RN was based out of the off-site location and came to the main campus each Monday.
In a face-to-face interview on 01/19/10 at 3:10pm, S7 RN indicated she had performed the wound assessment at admit and was present when the LPN took the measurements. She confirmed the medical record did not include evidence of her wound assessment.

Patient #2
Review of Patient #2's "Initial Nursing Assessment" performed by S9 RN on 01/11/10 at 1805 (6:05pm) revealed the following wound assessment: "R leg surgical incision from fem-pop (femoral popliteal bypass) -red & (and) swollen-steri-strips; R great toe & bottom of foot-diabetic ulcers". Further review revealed no documented evidence of a "Wound Care Flowsheet" with the baseline assessment by S9 RN.
Review of the "Wound Care Flowsheet" for Patient #2 revealed the wounds were assessed on 01/12/10, the day after admit, by S8 LPN. Further review revealed no documented evidence of an assessment of the wounds by the RN from admit through the day of the surveyor's review of the medical record on 01/19/10, 8 days after admit.
In a face-to-face interview on 01/20/10 at 10:55am, S2 DON indicated he was familiar with the state board's standards for assessments but was not familiar as they related to assessment of wounds. He further indicated the wound care RN came to the main campus on Mondays, and the LPN did wound assessments on the other days of the week. He confirmed there was no wound assessment documented by the RN for Patient #2.

Patient #3
Review of Patient #3's "Initial Nursing Assessment" performed by S10 RN on 01/18/10 at 2030 (8:30pm) revealed the wound assessment included "(S) L knee" (surgical left knee).
Review of the "Wound Assessment Flowsheet" completed by S8 LPN revealed the following documented wounds: rash, with arrow pointing to sacrum; 18 cm (centimeters) incision with 21 staples to left knee; 2 by 2.3 , no documented evidence of the measurement used, deep tissue injury to left posterior calf; and red sacrum. Further review revealed no documented evidence of an assessment of Patient #3's wounds by the RN as of the time the record was reviewed by the surveyor on 01/20/10, 2 days after admit.
In a face-to-face interview on 01/20/10 at 11:15am, S2 DON could offer no explanation for the wounds not being assessed by the RN.

Patient #8
Review of Patient #8's "Initial Nursing Assessment" performed by S10 RN on 01/15/10 at 1830 (6:30pm) revealed the following wound assessment: "R groin drsg (dressing) CDI (clean, dry, and intact) WNL (within normal limits); bruises bil (bilateral) upper ext (extremity) blue/purple WNL; rash abd (abdomen) folds (arrow pointing upward) thighs-dk (dark) pink OTA (open to air) WNL; buttocks red very small St (stage) I R buttock WNL; rash-pink under bil breasts WNL; BLE (bilateral lower extremities) bluish/purple discoloration/edema WNL; multiple scars from previous surgeries". Further review revealed no documented evidence of an assessment by S10 RN of the groin surgical incision to include the number of staples, the surrounding skin appearance, the measurement of the incision, the sacral ulcer including the measurement, presence or absence of tunneling and undermining, the wound bed color, the periwound skin condition, drainage amount, color, and odor, and the presence of an ulcer to the left buttock.
Review of the "Wound Assessment Flowsheet" completed by S8 LPN on 01/16/10, the day after admit, revealed bruises to the right antecubital area and left inner calf, incision with sutures to the right groin, reddened area to the right flank area, and pressure ulcers to the sacrum and left buttock. Further review revealed no documented evidence of an assessment by the RN until 01/18/10, 3 days after admit.
In a face-to-face interview on 01/20/10 at 11:25am, S2 DON could offer no explanation for the wounds not being assessed by the RN upon admit and until 3 days after Patient #8 was admitted.

Review of the hospital policy titled "Nursing Documentation Guidelines", submitted by S2 DON as the current policy for documenting the initial patient assessment, revealed, in part, "...A Registered Nurse shall be responsible for completing the initial patient assessment...".

Review of the hospital policy titled "Patient Care Documentation (Nursing)", last revised 08/02 and presented by S2 DON as the hospital's current policy on assessment of patients by the RN, revealed, in part, "...a. Assessment ... 1) Integumentary-indicate site of wound beside the word "wound". Describe wound condition in Notes/Interventions section. ... Photos will be taken on admission...".

Review of the hospital policy titled "Photographic Method of Wound Documentation", submitted by S2 DON as the current policy for documenting the photographs of wounds, revealed, in part, "...Attach the photo to a wound documentation form, and document written description and location of the wound including measurements of size and depth, color, phase of healing, presence of necrotic and granulation tissue, etc. (and so forth)...".

Review of the Louisiana State Board of Nursing's "Declaratory Statement Scope of Practice For Registered Nurses - Wound Care Management" revealed, in part, "Registered nurses render care that is directed towards the prevention and treatment of wounds. ... Nursing care of skin/wound conditions involves the identification, assessment, management, and ongoing evaluation of patients with alterations in skin/tissue integrity, that includes but is not limited to draining wounds, pressure ulcers, and vascular ulcers... Scope of Practice - The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, teaching, evaluation, and supervision are the major responsibilities of the registered nurse in the practice setting. The registered nurse is responsible for performing a nursing assessment and physical examination for preventative and restorative nursing and for providing patient/family teaching. ... The registered nurse initiates appropriate wound preventative measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by an authorized prescriber. ... The registered nurse may delegate to a licensed practical nurse wound care interventions in any situation when the registered nurse has deemed the patients status is stable, the intervention is based on a relatively fixed and limited body of scientific knowledge, can be performed by following a defined nursing procedure with minimal alteration, responses of the individual to the nursing care are predictable and changes in the patient's clinical condition are predictable. Furthermore, the patient's medical and nursing orders are not subject to continuous change or complex modification, appropriate RN supervision is available, and provided that the LPN has been adequately trained and demonstrates competency in the performance of the specific nursing intervention and this said training and competence is documented in the LPN's file...".
3) RN assessment of a patient with a change in condition:
Patient #2
Review of Patient #2's "Daily Nursing Assessment" for 01/18/10 revealed an entry by S14 LPN at 1455 (2:55pm) of "pt returned from receiving cenral line. drsg (dressing) line intact minimal drainage". Further review of the entire nursing note for 01/18/10 revealed no documented evidence of an assessment by the RN following the patient's return to the hospital following the placement of a central line.
In a face-to-face interview on 01/20/10 at 10:55am, S2 DON could offer no explanation for the assessment by the RN after the insertion of a central line not being performed for Patient #2.

Patient #15
Review of Patient #15's respiratory care flowsheet revealed an entry by S11 Lead RRT (registered respiratory therapist) on 01/01/10 at 1130 (11:30am) of "stopped tx (treatment) RN aware EKG (electrocardiogram) done-notifying MD". Further review revealed no documented evidence of the name of the RN to whom S11 Lead RRT reported the change in condition.
Review of the "Communication Sheet" on Patient #15's medical record revealed the following documentation: To S12 Physician From S13 LPN Date 01/01/10, with no documented evidence of the time of the communication, - Pt (patient) had a run of V-Tach (ventricular tachycardia) highest rate 172. PACs (premature atrial contractions) & PVCs (premature ventricular contractions) while taking resp (respiratory) tx (treatment). Please review 12 lead & strip and advise...; To S12 Physician From S11 Lead RRT Date 01/01/10, with no documented evidence of the time of the communication, - Pt had a run of SVT (supraventricular tachycardia) while on resp tx. May we change (designated by triangle symbol) frequency from Q (every) 4 hours to TID (three times a day) & PRN...".
Review of the entire medical record revealed no documented evidence of the LPN reporting the change in the patient's condition to the RN, an assessment of Patient #15 by the RN, and the report of the change in condition by the RN to S12 Physician.
Review of the "Physician Orders" revealed an order on 01/01/10 at 8:50pm by S12 Physician, more than 9 hours after the change in condition during the respiratory treatment, to decrease the frequency of the Xopenex aerosol to every 8 hours.

In a face-to-face interview on 01/22/10 at 9:00am, S2 DON confirmed there was no documented evidence that S12 Physician had been notified of Patient #15's change in condition by the RN, S13 LPN, and/or S11 Lead RRT.

Review of the hospital policy titled "Nursing Documentation Guidelines", submitted by S2 DON as the hospital's current policy on assessment of patients, revealed, in part, "...Changes in the patient status will result in a head-to-toe reassessment. The reassessment is to be documented in patient's daily record and communicated to the physician and other disciplines involved in the patient's care...". Further review revealed no documented evidence that the reassessment had to be performed by the RN.

Based on record review and interviews, the hospital failed to ensure the nursing staff implemented the patient's plan of care by failing to: 1) administer medications as ordered for 3 of 20 sampled patients (#1, #3, #8); 2) obtain labs as ordered by the physician for 2 of 20 sampled patients (#1, #3); and 3) provide wound care as ordered for 1 of 7 patients reviewed with a wound from a total of 20 sampled patients (#8). Findings:

1) Administer medications as ordered:
Patient #1
Review of Patient #1's "LTAC (long term acute care) Admit Physician Orders" dated 01/14/10 at 1700 (5:00pm) revealed an order for Neurontin 600 mg (milligrams) by mouth BID (twice a day).
Review of the "Physician Orders" revealed a telephone order received 01/17/10 at 0845 (8:45am) to change Neurontin to 300 mg by mouth every night at bedtime.
Review of Patient #1's MAR (medication administration record) for 01/17/10 revealed the 9:00am dose of Neurontin was held, with no documented evidence of the reason it was held and that the physician was notified it was held, and the 9:00pm dose of Neurontin administered was 600 mg, rather than 300 mg as ordered at 8:45am that day.
In a face-to-face interview on 01/20/10 at 10:40am, S2 DON (director of nursing) offered no explanation for the medication not being administered as ordered.

Patient #3
Review of Patient #3's "Physician Orders" revealed a clarification telephone order received on 01/19/10 at 9:00am for Qualaquine 324 mg by mouth at bedtime.
Review of Patient #3's MAR for 01/19/10 revealed Qualaquine was not administered at 9:00pm as ordered with a note "none in stock". Further review of the medical record revealed no documented evidence the physician was notified of the medication not being available and not given.
In a face-to-face interview on 01/20/10 at 11:15am, S2 DON could offer no explanation for the medication not being administered as ordered, the pharmacy not being contacted to obtain the medication, and the physician not being notified that the medication was not administered as ordered.

Patient #8
Review of Patient #8's "Physician Orders" revealed an order on 01/19/10 at 2015 (8:15pm) to add Coumadin 10 mg by mouth every evening.
Review of the MAR for 01/19/10 revealed no documented evidence the Coumadin was administered the night of 01/19/10 as ordered.
In a face-to-face interview on 01/20/10 at 11:25am, S2 DON could offer no explanation for the Coumadin not being administered as ordered.

Review of the hospital policy titled "Standards of Practice", issued 09/05 and submitted by S2 DON as the hospital's policy on medication administration, revealed, in part, "...The Professional Practice Standards and the following expanded Standards of Nursing Practice specifically define what the Nursing Staff will do for and/or with patients and their significant other(s) in order to provide the Standards of Patient Care. ... Standards: 4. Medication Standard of Care The patient can expect to receive the correct medication, the correct dose, via the correct route, at the correct time with appropriate follow-up side effects, complications, and effectiveness...".

Review of the hospital policy titled "Ordering Medications From Pharmacy", last revised 09/04 and submitted by S2 DON as the hospital's current policy on obtaining medications from the pharmacy, revealed, in part, "... Stock and after hours procedure: 14. This process is to be used only for PRN (as needed) orders, first doses, and stat doses. 15. The nurse will notify the pharmacist on call of the medication order. 16. The pharmacist on call will assess that the 1st dose medication is in conjunction with the most current patient profile via the pharmacy profile link. ... 18. In the event that the medication is not in stock, the pharmacist will contact the local 24-hour back up contracted pharmacy for dispensing and delivery of the medication...".

2) Obtain labs as ordered by the physician:
Patient #1
Review of Patient #1's "LTAC (long term acute care) Admit Physician Orders" received by verbal order on 01/14/10 at 1700 (5:00pm) revealed an order to obtain a CBC (complete blood count), CMP (comprehensive metabolic profile), and a urinalysis in the morning.
Review of the "Initial Nursing Assessment" revealed Patient #1 was admitted on 01/15/10 at 2:30pm.
Review of the lab results revealed the CBC and CMP were collected on 01/16/10, and the urinalysis was collected on 01/19/10, 3 days after it was ordered to be collected.
Review of Patient #1's "Physician Orders" revealed an order on 01/17/10 at 4:45pm to draw a CBC, CMP, HgbA1C (hemoglobin A1C) in the morning.
Review of the lab results revealed no documented evidence the HgbA1C was drawn as ordered.
Review of the "Laboratory/X-Ray Log Test" revealed no documented evidence that a HgbA1C was drawn on 01/18/10. Further review revealed no documented evidence of the CBC and CMP being logged as drawn on 01/18/10.
In a face-to-face interview on 01/20/10 at 10:40am, S2 DON indicated the hospital kept a log of the labs drawn. After review of the log, S2 DON could offer no explanation for the inaccurate log as well as the HgbA1C not being collected as ordered.

Patient #3
Review of Patient #3's "LTAC (long term acute care) Admit Physician Orders" received 01/18/10 revealed orders for CBC, CMP, urinalysis and culture and sensitivity, ESR (erythrocyte sedimentation rate), and CRP (C-Reactive Protein) to be drawn in the morning.
Review of the lab results revealed no documented the CRP and ESR were drawn when the CMP, CBC, and urinalysis were collected on 01/19/10.
Review of the "Laboratory/X-Ray Log Test" revealed the ESR and CRP were logged as collected on 01/10/10 at 7:45am.
In a face-to-face interview on 01/20/10 at 11:15am, S2 DON could offer no explanation for labs not being drawn as ordered.

Review of the policy titled "General Laboratory Procedures", last revised 06/06 and submitted by S2 DON as the current policy for labs ordered by the physician, revealed, in part, "...Routine Laboratory Work: 1. Upon obtaining the physician's order, the laboratory requisition will be initiated. The order will be logged in the lab logbook. 2. The appropriate personnel shall obtain the specimen following procedure. ... 6. Upon courier pick up of specimen, the lab logbook entry will be completed. B. Reporting Laboratory Results 1. All lab test results will be reviewed by the charge nurse and then placed in the laboratory section of the patient's chart".

3) Provide wound care as ordered:
Review of Patient #8's "Physician Orders" revealed a telephone order received on 01/16/10 at 11:00AM by S8 LPN (licensed practical nurse) to apply Betadine paint to the right groin incision daily and Calazime to buttocks/sacrum, with no documented evidence of the frequency of application ordered.
Review of the "Treatment Administration Record" revealed the treatment was to apply Calazime to buttocks/sacrum twice a day and PRN. Further review of the "Treatment Administration Record" and the "Daily Nursing Assessment" for 01/18/10 revealed no documented evidence the Betadine and Calazime were applied on 01/18/10.
In a face-to-face interview on 01/20/10 AT 11:25AM, S2 DON reviewed the wound care treatment record and could offer no explanation for the wound care not being performed on 01/18/10 as ordered.

Review of the hospital policy titled "Patient Care Documentation (Nursing)", last revised 08/02 and submitted by S2 DON as the hospital's current policy for documenting wound care, revealed, in part, "... e. Treatment/Procedures - document initials in box corresponding to time of treatment/procedure; evaluate outcomes of treatments in evaluation section of shift assessment page. 1) Wound care - explain type of wound, specific care (including supplies and equipment used) and assessment of wound condition in notes/intervention section of shift assessment page...".

Based on record review and interview, the hospital failed to ensure the nursing care of each patient was assigned according to patient's needs and the qualifications/competence of the nursing staff by failing to determine the nursing staff to patient ratio with consideration of the patient's medical co-morbid conditions, the number of new admits which require a RN (registered nurse) to perform the initial assessment, and the number of discharges which required extensive paperwork and patient/family education to be performed by the nursing staff. The nursing staff assignments contributed to: 1) failing to have the RN (registered nurse) assess each patient's care needs to determine the appropriateness of delegation to the LPN (licensed practical nurse) for 3 of 20 sampled patients (#2, #8, #15); 2) failing to have the RN assess, stage, and measure wounds upon admit for 4 of 7 patients reviewed with a wound (#1, #2, #3, #8) from a total of 20 sampled patients; 3) failing to have the RN assess a patient with a change in condition for 2 of 20 sampled patients (#2, #15); 4) failing to have medications administered as ordered for 3 of 20 sampled patients (#1, #3, #8); 5) failing to obtain labs as ordered by the physician for 2 of 20 sampled patients (#1, #3); and 6) failing to provide wound care as ordered for 1 of 7 patients reviewed with a wound from a total of 20 sampled patients (#8). Findings:

Review of the "Staffing Grid" presented by S2 DON (director of nursing) as the current staffing plan revealed the breakdown of census (numbers of patient) with the number of nurses and CNAs (certified nursing assistants) assigned. Further review revealed no documented evidence of whether the nurses were to be RNs or LPNs.

Review of the daily staffing assignment sheets revealed the list of nurses who worked and their patient assignments. Further review revealed no documented evidence of the acuity of patients, the number of expected discharges and admits, and the expected procedures or treatments required during the shift (wound care, intravenous medications).

Review of 20 patient medical records revealed no documented evidence that 3 of 20 patients (#2, #8, #15) were assessed by the RN to determine the appropriateness of delegation to the LPN (see findings at tag A0395).

Review of medical records of 7 patients with wounds revealed 4 patients (#1, #2, #3, #8) with no documented evidence the patients' wounds were assessed by the RN upon admit to include the assessment, staging, and measurements of the wounds (see findings in tag A0395).

Review of the medical records of 20 patients revealed no documented evidence that 2 of the patients (#2, #15) with a change in condition were assessed by the RN (see findings in tag A0395).

Medical record review revealed 3 of 20 sampled patients (#1, #3, #8) failed to receive medications as ordered by the physician (see findings in tag A0396).

Medical record review revealed 2 of 20 sampled patients (#1, #3) failed to have labs drawn as ordered by the physician (see findings in tag A0396).

Medical record review of 7 patients with wounds from a total of 20 sampled patients revealed 1 patient (#8) failed to have wound care provided as ordered by the physician (see findings in tag A0396).

In a face-to-face interview on 01/21/10 at 3:05pm, S2 DON indicated he was given a number of nurses to be assigned for staffing from the corporate office. He confirmed that the hospital's staffing plan did not include patient acuity in the determination of number and types of nurses needed for each shift.

Review of the hospital policy titled "Staffing Plan", last revised 04/09 and submitted by S2 DON as the current hospital policy for staffing, revealed, in part, "...Specific staffing for the facility is commensurate with the care requirements, staff expertise, availability of support services, and method of patient care delivery. ... The facility staffing plans include staffing patterns at various census levels that are built from historical trends, benchmark data, and practice guidelines. If the staffing needs shift during the course of the fiscal year, the plan is assessed for modifications accordingly. Acuity that deviates from the projected needs is assessed and accommodated in the shift-to-shift allocation of staff. In addition to acuity, including patient diagnosis, age, functioning of the patients, and co-occurring conditions are considered. ... D. Staffing: 1. All patient care areas are staffed based upon: a. Expertise and skill levels of the scheduled personnel. b. Special needs identified by staff and/or DON...".

Review of the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII" revealed, in part, "... The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. This assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required...".

Based on record review of medical records and the medical staff rules and regulations and interview with the Director of Nursing the hospital failed to follow their policy and procedure for use of verbal orders by failing to obtain and document readbacks of verbal orders resulting in 13 verbal orders not readback to the physician for accuracy for 4 of 20 sampled patients (#2, #6, #11, #13). Findings:

Patient #2
Review of the Physician's Orders for Patient #2 revealed the following verbal orders: 01/11/10 at 1720 (5:20pm) Restasis 0.5mg two drops OU (both eyes) every 12 hours; 01/14/10 at 1130am Demerol 25mg and Phenergan 12.5mg IM today's dose only; and 01/18/10 at 2125 (9:25pm) Oxycodone 10mg one or two every 4 hours for pain. Further review revealed no documented evidence the nurse receiving the order performed a readback to ensure accuracy of the orders.

Patient #6
Review of the Physician's Orders for Patient #6 revealed the following verbal orders: 09/19/09 at 1330 (1:30pm) Discontinue Epogen 20,000 units; 09/19/09 at 1545 (3:45pm) Vancomycin 1 gram IVPB time 1 dose only and a random Vanc level in the am; 09/26/09 1410 (2:10pm) Benadryl 25mg po X 1 dose now; 09/30/09 at 0215 (2:15am) Normal Saline bolus 250mg over 30 minutes. Hold all BP (Blood Pressure) meds today; 10/05/09 at 12:13pm May ambu-bag ventilate patient during transport; 10/14/09 at 1730 (5:30pm) OK to leave PICC in midline position; and 10/15/09 at 0030 (12:30am) okay to use PICC line. Further review revealed no documented evidence the nurse receiving the order performed a readback to ensure accuracy of the orders.

Patient #11
Review of the Physician's Orders for Patient #11 revealed the following verbal orders: 01/08/10 (no time documented) for Glucerna; 01/10/10 at 1708 (5:08pm) Random Vanc (Vancomycin) level in AM (morning); 01/12/10 at 1730 (5:30pm) KDur 30meq one by mouth hen Q day (every day); 01/13/10 at 0540 (5:40am) Potassium 40meq by mouth tid (three times a day) X (times) 6 doses then 40meq by mouth every day; and 01/14/10 (no time documented) dc (discontinue) all Potassium meds and recheck K+ (Potassium Level) in AM. Further review revealed no documented evidence the nurse receiving the order performed a readback to ensure accuracy of the orders.

Patient #13
Review of the Physician's Orders for Patient #13 revealed the following verbal orders: 01/16/10 at 0500 (5:00am) Continue to hold D5 ? with 20mEq K+ (Potassium) at 75ml/hour, 01/17/10 at 1810 (6:10pm) dc (discontinue) D5 ? NS (Normal Saline) with 20mEq K+, and 01/17/10 at 1820 (6:20pm). Further review revealed no documented evidence the nurse receiving the order performed a readback to ensure accuracy of the orders.

In a face to face interview on 01/21/10 at 9:35am S2, the Director of Nursing (DON)
indicated this problem with nurses not performing readbacks had been identified before and he had discussed this with the nurses during a staff meeting.

Review of the Medical Staff Rules and Regulations, last revised 01/10, revealed.... "F. Orders 4. Verbal orders or telephone orders received for the care and treatment of patient shall be written by the caregiver (nurse, therapist, dietitian) on a physician's order form. Read back verification will be documented on the order after the physician has verified that the order is correct with, VRB and the caregiver's initials...."

Review of the Monthly Medical Point of Care Record Reviews presented for the time period of November and December 2009 revealed no documented evidence compliance with readback of verbal orders had been monitored by the Medical Record Department.

Based on review of the medical records and chart audits, observation of the separate Medical Records Departments of the main and off-site campuses and interviews with Medical Records staff, Administrator and Corporate Compliance Nurse the hospital failed to ensure that the medical records department director maintained the department to ensure that: 1) all medical records were comprehensively reviewed in order to determine completion of the medical record within 30 days and give prompt notice to physicians of pending records which needed completion; 2) an accurate delinquency rate for medical records was determined in order to report data through the QA (quality assurance) department of the hospital and obtain a plan to correct the delinquency rate; 3) policies and procedures of the medical records department and medical staff bylaws relative to suspension of physicians for failure to complete the medical record in accordance with federal regulations were followed. Findings:

1) Medical records reviewed to determine completion within 30 days:
Review of 4 of 4 closed medical records (Patient #4, #5, #6, #7) revealed slickers had been placed on the pages of the medical record which needed to be completed by the physician. The charts were stacked on a table in the left corner of the medical records department of the main campus. Further review revealed delinquency for completion dated back to September 09.

Review of the Medical Staff Bylaws/Rules and Regulations, last revised 01/10, revealed.... E. Medical Records c. All medical records shall be completed by the attending physician within 25 days of discharge. The administrator and responsible physician will be notified of deficiencies pending completion periodically throughout the 25 day process via the HIM Coordinator."

In a face to face interview on 01/22/10 at 9:35am S35 Medical Director of the main campus indicated that during the transition in ownership a backlog of charts developed. Further she indicated there had been a good working relationship between medical records and herself and she depended on them to prepare the charts and let her know when she needed to get involved. At the present time, the medical records department is overwhelmed and physicians have not received notification to complete charts.

2) Accurate delinquency rate determined:
Review of the chart audits dated November 2009 through December 2009 submitted to the survey team revealed the criteria for use in the audit did not contain indicators to determine the delinquency rate of closed medical records.

The hospital could not submit a complete list of delinquent medical records, time period of delinquency (> 25 days, 30 days, 60 days, etc), individual physician delinquency rate or corrective action taken.

In a face to face interview on 01/22/10 at 10:00am S15, Corporate Compliance Nurse, indicated the RHIT had recently come on board and her skills are still weak. Further S15 indicated she may need assistance from another more experienced Medical Records Director.

In a face to face interview on 01/22/10 at 10;00am S1, Administrator, indicated the RHIT had not sent out any letters to the physician concerning delinquent charts.

3) Policies and procedures and medical staff bylaws followed by the medical records department relating to suspension of physicians:
Review of the Medical Staff Bylaws/Rules and Regulations, last revised 01/10, revealed.... E. Medical Records c. All medical records shall be completed by the attending physician within 25 days of discharge. The administrator and responsible physician will be notified of deficiencies pending completion periodically throughout the 25 day process via the HIM Coordinator. If the records are not completed within 25 days, the HIM Coordinator will notify the Administrator. The Administrator/Designee will notify the responsible physician that his/her admitting privileges have been suspended until such time as the records are complete."

In a face to face interview on 01/22/10 at 10:00am S1, Administrator, indicated the RHIT had not sent suspended any privileges of any physician with known delinquent charts.

In a face to face interview on 01/22/10 at 9:35am S35 Medical Director of the main campus indicated that during the transition in ownership a backlog of charts developed. Further she indicated there had been a good working relationship between medical records and herself and she depended on them to prepare the charts and let her know when she needed to get involved. At the present time, the medical records department is overwhelmed and she takes responsibility for not becoming more involved with supervision of the physicians in the completion of medical records.

Based on review of medical records and interviews with the RHIT, medical staff personnel, Corporate Compliance Nurse and Medical Director of the main campus the hospital failed to develop, implement and monitor a process to ensure complete and accurate medical records as evidenced by physician orders, Progress Notes, consents, History and Physicals and Medication reconciliation forms not being signed/dated and or timed and forms filed in patient charts without appropriate patient identification resulting in 8 of 20 sampled records being incomplete (#1, #2, #3, #4, #7, #8, #11, #13). Findings:

Patient #1
Review of the Progress Notes for Patient #1 dated 01/16/10 and 01/18/10 revealed no documented evidence the time the note had been written as evidenced by a blank in the space provided for time.

Patient #2
Review of the medical record for Patient #2 revealed no documented evidence of the following: Progress Notes dated 01/17/10 the time the note had been written as evidenced by a blank in the space provided for time and the time the History and Physical had been performed as evidenced by a blank in the space provided for the time. Further review revealed Treatment and Administration records dated 01/11/10 through 01/17/10, Wound Assessment Flowsheet dated 01/12/10 and Wound Care Flowsheet dated 01/12/10 (for three different wound sites without documentation of the Patient's name, DOB, or medical records number.

Patient #3
Review of the medical record of Patient #3 revealed Treatment and Administration records dated 01/08/10 through 01/24/10, Wound Assessment Flowsheet dated 01/19/10 and Wound Care Flowsheets dated 01/18/10 through 01/19/10 and a Pressure Ulcer Healing Chart without the Patient's name, DOB, or medical records number.

Patient #4
Review of the medical record for Patient #4 revealed no documented evidence of the following: History and Physical dated 01/08/10 had been timed by the physician as evidenced by a blank in the space designated for time; Progress Notes dated 01/11/10, 01/11/10, 01/12/10, 01/14/10, 01/15/10 and 01/18/10 had been timed as evidenced by a blank in the space provided for time.
Review of the Admit Orders dated 10/30/09 for Patient #5 revealed no documented evidence of the time and date the physician signed the orders as evidenced by a blank space designated for time and date.

Patient #7
Review of the medical record for Patient # 7 revealed no documented evidence of the following: History and Physical dated 12/24/09 had been reviewed for accuracy and authenticated by the physician as evidenced by the multiple blank spaces (11) in the typed copy and a blank in the space designated for the physician's signature; Consent for Transfusion of Blood and Blood Components dated/timed 12/26/09 at 2215 (10:15pm) as evidenced by blank spaces designated for the authorized physician or group, signature of the physician and date/time signed; Death Summary dated 12/31/09 had been authenticated as evidenced by the blank space designated for signature, date and time; Functional Screen dated 12/24/09 had been authenticated by the physician as evidenced by the blank spaces in the areas designated for the signature, date and time; Physician Sliding Scale Insulin Orders dated 12/29/09 at 2100 (9:00pm) had been authenticated by the physician as evidenced by the blank spaces in the areas designated for the signature, date and time.

Patient #8
Review of the medical record for Patient #8 admitted to the hospital on 01/15/10 revealed the following: Progress Notes dated 01/18/10 had no documented evidence of the time the physician wrote the note as evidenced by a blank in the space provided and the History and Physical had been dictated by the physician on 01/16/10, and transcribed 01/17/10 indicating the medical record failed to have the H&P on the chart within 24 hours.

Patient #11
Review of the medical record for Patient # 11 revealed no documented evidence of the following: Consent for Transfusion of Blood and Blood Components dated/timed 01/09/10 at 2330 (11:30pm) as evidenced by blank spaces designated for the authorized physician or group, signature of the physician and date/time signed.

Patient #13
Review of Consultation Form found in Patient #13's medical record revealed no documented evidence of the date of request, time of request, notification of the consulting physician, name of attending physician, reason for the consultation or the date or time the consultation had been completed as evidence by blanks in the spaces designated for this information. Review of the Medication and Reconciliation form obtained upon admission dated 01/06/10 for Patient #13 revealed no documented evidence the physician had reviewed the information as evidenced by a blank in the space designated for physician signature and date/time signed. Review of the History and Physical dated 01/06/10 (dictated on 01/07/10) revealed no documented evidence the physician had reviewed for accuracy and signed as evidenced by the blank in the space designated for physician signature.

Based on review of medical records, Medical Staff Bylaws/Rules and Regulations and interviews the hospital failed to ensure all verbal orders had been authenticated by the physician as evidenced by approximately 33 occurrences involving 8 patients of the 20 sampled medical records (#1, #2, #4, #6, #7, #9, #11, #15) Findings:

Patient #1
Review of the Physician ' s Orders for Patient #1 revealed the following verbal orders: 01/15/10 at 1430 (2:30pm) a sliding scale for insulin and 01/15/10 at 1430 (2:30pm) a functional screening. Further review revealed no documentation of a signature by the physician as evidenced by a blank in the space provided.

Patient #2
Review of the Physician ' s Orders for Patient #2 revealed the following verbal orders: 01/14/10 at 1130am Demerol 25mg and Phenergan 12.5mg IM today ' s dose only; 01/18/10 at 1000 (no documentation of am or pm) send to hospital for care. Further review revealed no documentation of a signature by the physician as evidenced by a blank in the space provided.

Patient #4
Review of the Physician ' s Orders for Patient #4 revealed the following verbal orders: Functional Screen date 01/07/10 at 1700 (5:00pm); Admit Orders dated 01/07/10; Medication Reconciliation and Order form dated 01/07/10 at 2100 (9:00pm); 01/07/10 at 1530 (3:30pm) for Duoderm to the sacrum, 01/07/10 at 1815 (6:15pm) Spiriva 18meq every day and Advair 250/50 bid (twice a day), 01/08/10 1330 (1:30pm) Nutrition Therapy, and 01/14/10 at 2150 (9:50pm), Increase Cardizem to 60mg by mouth every 6 hours. Further review revealed no documented evidence any of the orders had been authenticated with a signature and/or date or time signed.

Patient #6
Review of the Physician ' s Orders for Patient #6 revealed the following Verbal orders: Admit orders dated 10/30/09; 09/19/09 at 1545 (3:45pm) Vancomycin 1 gram IVPB time 1 dose only and a random Vanc level in the am; 09/22/09 at 1400 (2:00pm) Albumin 25gm IV now;09/22/09 (no date documented) Change TF to Optimental at 60cc/hour; 09/22/09 at 1500 (3:00pm) Bronch scheduled for 1:30pm Wednesday 09/23/09; 09/26/09 1410 (2:10pm) Benadryl 25mg po X 1 dose now; 09/30/09 at 0215 (2:15am) Normal Saline bolus 250mg over 30 minutes. Hold all BP (Blood Pressure) meds today; 09/30/09 at 1200 Normal Saline bolus 250mg over 1 hour, CBC in AM; 10/05/09 at 12:13pm May ambu-bag ventilate patient during transport; 10/11/09 at 1400 (2:00pm) ABG on CPAP; 10/14/09 at 1730 (5:30pm) OK to leave PICC in midline position; 10/15/09 at 0030 (12:30am) okay to use PICC line. Further review revealed no documented evidence any of the orders had been authenticated with a signature and/or date or time signed.

Patient #7
Review of the Physician ' s Orders for Patient #7 revealed the following verbal orders: Admit Orders dated/timed 12/23/09 at 11:25 (am or pm not documented); 12/26/09 at 10:15 (am or pm not documented), Type and cross 2 units PRBC (Packed Red Blood Cells); 12/28/09 at 0750 (7:50am) add BNP to labs, puree diet, continue PT (Physical Therapy); 12/30/09 at 10:30 (am or pm not documented), to decrease TPN to 60ml/hr (hour); 12/30/09 at 1030 (am or pm not documented), Zofran 4mg IVP (Intravenous Push) Q 4hrs (every four hours) prn (as needed) nausea; 12/30/09 1032 (am or pm not documented), hold AM meds til nausea subsides; 12/30/09 1231 (am or pm not documented), Dopamine 2.5mcg/Kg IV til SBP (Systolic Blood Pressure) > 90 or above; clarification Dopamine 10mcg/Kg IV til SBP (Systolic Blood Pressure) > 90 or above then reduce to 5mcg/Kg/min (minute); and 12/31/09 1350 (1:30pm) Morphine 2mg IVP x (times) 1 now. Further review revealed no documented evidence any of the orders had been authenticated with a signature of the physician.

Patient #9
Review of the Physician ' s Orders for Patient #8 revealed the following verbal orders: 01/17/10 at 1330 (1:30pm) Zofran 4mg IV every 6 hours prn nausea and Dulcolax 10mg by mouth every day for constipation. Further review revealed no documented evidence any of the orders had been authenticated with a signature of the physician.

Patient #11
Review of the Physician ' s Orders for Patient #11 revealed the following verbal orders: 01/08/10 1200 Nutritional Therapy - Glucerna no documented date/time signed; 01/09/10 Hold Vancomycin for now; 01/10/10 at 1708 (5:08pm) Random Vanc (Vancomycin) level in AM (morning); 01/12/10 at 1730 (5:30pm) KDur 30meq one by mouth hen Q day (every day); 01/13/10 at 0540 (5:40am) Potassium 40meq by mouth tid (three times a day) X (times) 6 doses then 40meq by mouth every day; and 01/14/10 (no time documented) dc (discontinue) all Potassium meds and recheck K+ (Potassium Level) in AM. Further review revealed no documented evidence the orders had been authenticated within 48 hours per hospital policy as evidenced by the lack of a dated and timed signature.

Review of the Physician's Orders for Patient #15 revealed the following verbal orders: 01/04/10 Abdominal x-ray flat and erect; Further review revealed no documented evidence any of the orders had been authenticated with a signature of the physician.

Review of the Medical Staff Bylaws/Rules and Regulations dated 12/08 revealed..... "Orders: 4. ............ "All verbal orders must be dated, times and authenticated by the ordering physician or another practitioner who is responsible for the care of the patient and authorized to write orders by this facility. All verbal/telephone orders must be signed within 48 hours."

In a face to face interview on 01/22/10 at 9:35am S35 Medical Director of the main campus indicated that during the transition in ownership a backlog of charts developed. Further she indicated there had been a good working relationship between medical records and herself and she depended on them to prepare the charts and let her know when she needed to get involved. At the present time, the medical records department is overwhelmed and she takes responsibility for not becoming more involved with supervision of the physician in the completion of medical records.

In a face to face interview on 01/20/10 at 2:00pm S6, medical records staff member, indicated the problem with verbal orders has been ongoing. Further she indicated a stamp had been orders indicating the need for the date, time and signature of the verbal which is used to remind the physician the order needs to be authenticated.

Based on observations, review of the Dietary and Housekeeping logs and interview with the Director of Nursing the hospital failed to ensure the physical plant and supplies had been maintained for quality and safety as evidenced by uneven flooring, expired supplies, unclean refrigerator, unmopped floor, undusted shelving, stained and/or missing ceiling tiles and cracked and pealing floor tiles, and damp dust particles in the dish washroom of the kitchen. Findings:

Observations on 01/19/10 at 10:15am with S32 the Business Development Coordinator revealed the following:
Central Supply Room - uneven flooring in the main aisle; dust covered shelves with empty plastic wrappers where patient supplies were stored; visible dust and black particles on floor; and expired supplies located first on the shelf available for patient use (11 Glucerna Select 8 ounce cans with expiration date of 10/09 and a Silver Touch Catheter with the expiration date of 11/09.
Anti-room behind central supply containing the water heater - 2 boxes of cups and 1 box of urinals stored on the floor, unlabeled lab equipment, large area of missing and stained ceiling tiles over the sprinkler system and a floor containing rust colored stains and dust particles.
Nourishment room - floor contained dust particles, spoons and paper towels in the corner and behind open shelving and there was a part of a tile missing exposing the insulation.
Refrigerator in Nourishment room - freezer contained a large area of a sticky red substance on the bottom self and 2 large cups of ice in unlabeled Styrofoam cups, refrigerator section shelves had particles of dried food and unidentifiable liquid spills, 3 unlabeled plastic containers with food, 3 unlabeled cups containing unidentifiable substances; an unlabeled container of oyster soup; 2 cups of open and unlabeled applesauce; open and unlabeled 64 ounce bottle of cranberry juice; 1 open and unlabeled can of Nepro which expired 11/09; 1 open and unlabeled can of Glucerna Select which expired 10/09; and 6 cans of Pulmocare which expired 008/09.
Medical Records Department - a step down when entering door not identified, a round cover plate sunken into the flooring not identified, carpet unraveling around sunken plate.

Observation on 01/21/10 at the off-site campus revealed > than 12 cracked and pealing tiles in the hallway outside of the medical records department. Further review revealed stained ceiling tiles in the physical therapy room in the first floor and lint/dust particles on the floor and dirt in the corners next to the three compartment sink in the kitchen.

Review of the Dietary audits for the past three months revealed no documented evidence nutritional supplements had been monitored for expiration.

Review of a blank housekeeping log submitted by the hospital as the one presently in use revealed no documented evidence the housekeeping department was responsible for cleaning the Central Supply Room or the Nourishment Room.

In a face to face interview on 01/21/10 at 4:00pm S2, Director of Nursing indicated the main campus facility is limited to the repairs that can be made to the physical plant because they only rent and all requests must be made to the landlord. The maintenance man employed by the hospital is responsible for both the main and off-site campuses, however his office is at the off-site campus. Monitoring of the refrigerators should be done by the person who is checking the temperature and monitored by the charge nurse.

Based on review of the contract list, contract binder and interview with the Administrator the hospital failed to ensure an agreement had been made with an eye bank. Findings:

Review of the contract list submitted to the survey team by the hospital revealed no documented evidence of a contract with an eye bank.

Review of the contract binder submitted to the survey team by the hospital revealed no documented evidence of a contract with an eye bank.

In a face to face interview on 01/20/10 at 4:50pm S1, Administrator, verified the hospital did not have an agreement with an eye bank.

Based on record review and interview, the hospital failed to ensure rehab services were provided according to a written plan of treatment by failing to obtain a physician's order for the treatment plan established as a result of the physical/occupational therapy evaluation for 4 of 16 sampled patients receiving rehab services from a total of 20 sampled patients (#1, #2, #3, #8). Findings:

Patient #1
Review of Patient #1's "LTAC (long term acute care) Admit Physician Orders" dated 01/14/10 at 1700 (5:00pm) revealed an order for PT (physical therapy) to evaluate "OOB (out of bed) to w/c (wheelchair) daily with assist (assistance)".
Review of the "Physical Therapy Initial Evaluation" revealed the PT evaluation was completed on 01/18/10 at 1400 (2:00pm). Further review revealed the treatment plan included a frequency of 5 to 6 times a week for balance training, therapeutic procedures, and therapeutic activities, and there were short term and long term goals established.
Review of the entire physician orders revealed no documented evidence of a physician's order for the plan of treatment for Patient #1.

Patient #2
Review of Patient #2's "LTAC Admit Physician Orders" dated 01/11/10 at 1500 (3:00pm) revealed orders for PT and OT to evaluate.
Review of the "Physical Therapy Initial Evaluation" revealed the PT evaluation was completed on 01/12/10 at 1315 (1:15pm). Further review revealed the treatment plan included a frequency of 5 to 6 times a week for gait training, balance training, therapeutic procedures, and therapeutic activities, and there were short term and long term goals established.
Review of the "Interdisciplinary Progress Note" revealed the OT evaluation was performed on 01/12/10 at 1400 (2:00pm).
Review of the entire physician orders revealed no documented evidence of a physician's order for the plan of treatment for PT and OT for Patient #2.
In a face-to-face interview on 01/20/10 at 1:55pm, S20 PT indicated Patient #2 was independent with wheelchair mobility and transfers, and because he was non-compliant with staying off his feet, Patient #2 did not require PT services at the present time. He confirmed that he had no discussion with S36 Physician after he performed the initial evaluation to obtain orders, and he did not speak with S36 about the decision to cancel PT services. S20 PT confirmed that he should have contacted S36 Physician for orders to treat and to cancel PT.

Patient #3
Review of Patient #3's "LTAC Admit Physician Orders" dated 01/18/10, with no documented evidence of the time of the order, revealed orders for PT and OT to evaluate.
Review of the "Physical Therapy Initial Evaluation" revealed the PT evaluation was completed on 01/18/10 at 11:00am. Further review revealed the treatment plan included a frequency of 5 to 6 times a week for gait training, balance training, therapeutic procedures, and therapeutic activities, and there were short term and long term goals established.
Review of the "Occupational Therapy Initial Evaluation" revealed the OT evaluation was completed on 01/19/10 at 9:15am. Further review revealed the treatment plan included a frequency of 3 to 5 times a week for self-care/home management, wheelchair management and training, therapeutic exercise, therapeutic activities, group therapy, and neuromuscular reeducation, and there were short term and long term goals established.
Review of the entire physician orders revealed no documented evidence of a physician's order for the plan of treatment for PT and OT for Patient #3.

Patient #8
Review of Patient #8's "LTAC Admit Physician Orders" dated 01/15/10 at 1630 (4:30pm) revealed orders for PT and OT to evaluate.
Review of the "Physical Therapy Initial Evaluation" revealed the PT evaluation was completed on 01/18/10 at 1415 (2:15pm). Further review revealed the treatment plan included a frequency of 5 to 6 times a week for gait training, therapeutic procedures, and therapeutic activities, and there were short term and long term goals established.
Review of the "Occupational Therapy Initial Evaluation" revealed the OT evaluation was completed on 01/18/10 AT 1400 (2:00PM). Further review revealed the treatment plan included a frequency of 3 to 5 times a week for self-care/home management, wheelchair management and training, therapeutic exercise, therapeutic activities, group therapy, and neuromuscular reeducation, and there were short term and long term goals established.
Review of the entire physician orders revealed no documented evidence of a physician's order for the plan of treatment for PT and OT for Patient #8.

In a face-to-face interview on 01/19/10 at 2:30pm, S20 PT indicated the physician signed the interdisciplinary notes, but no order was written with the PT and OT plan of care after an evaluation was performed. He could offer no explanation for the original orders being to evaluate and the PT/OT not obtaining an order for the plan of care.

Review of the hospital policy titled "Therapist Responsibilities", submitted by S2 DON (director of nursing) as the current policy for therapist responsibilities, revealed, in part, "...The following is a list of the primary therapist's responsibilities. 1. Complete the initial evaluation of all patients assigned within 72 hours...". Further review revealed no documented evidence that the hospital policy required the therapist to obtain a written physician's order for the plan of treatment after completing the therapy evaluation.

Review of the hospital policy titled "Occupational Therapy Services", issued 09/05 and submitted by S2 DON as the current policy for OT services, revealed, in part, "...Occupational therapy treatments shall be rendered only by the personnel licensed and certified to practice those treatments, and only under physician order...".

Review of the hospital policy titled "Physical Therapy Services", issued 09/05 and submitted by S2 DON as the current policy for PT services, revealed, in part, "...Physical therapy treatments shall be rendered only the personnel licensed and certified to practice those treatments, and only under physician order...".

Review of the "Physical Therapy Practice Act Louisiana Revised Statutes 37:2401-37:421 As Amended 2003" revealed, in part, "...Initial physical therapy evaluation means the physical therapy assessment and resulting interpretation of a patient's condition through use of patient history, signs, symptoms, objective tests, or measurements to determine neuromusculoskeletal and biomechanical dysfunctions to determine the need for physical therapy... The results of an initial physical therapy evaluation ... shall be reported to the referring or treating physician... Practice ... Initial evaluation ... of a screening nature to determine the need for physical therapy may be performed by a physical therapist without referral, but implementation of physical therapy treatment to individuals for their specific condition or conditions shall be based on the prescription or referral of a person licensed to practice medicine...".

Review of the "Louisiana Occupational Therapy Practice Act Louisiana Revised Statutes 37:3001 thru 37:30 (As Amended 1988)" revealed, in part, "...Implementation of direct occupational therapy to individuals for their specific medical condition or conditions shall be based on a referral or order from a physician licensed to practice in the state of Louisiana...".

Based on record review and interview, the hospital failed to ensure medications were administered by the nursing staff as ordered by the physician for 3 of 20 sampled patients (#1, #3, #8). Findings:

Patient #1
Review of Patient #1's "LTAC (long term acute care) Admit Physician Orders" dated 01/14/10 at 1700 (5:00pm) revealed an order for Neurontin 600 mg (milligrams) by mouth BID (twice a day).
Review of the "Physician Orders" revealed a telephone order received 01/17/10 at 0845 (8:45am) to change Neurontin to 300 mg by mouth every night at bedtime.
Review of Patient #1's MAR (medication administration record) for 01/17/10 revealed the 9:00am dose of Neurontin was held, with no documented evidence of the reason it was held and that the physician was notified it was held, and the 9:00pm dose of Neurontin administered was 600 mg, rather than 300 mg as ordered at 8:45am that day.
In a face-to-face interview on 01/20/10 at 10:40am, S2 DON (director of nursing) offered no explanation for the medication not being administered as ordered.

Patient #3
Review of Patient #3's "Physician Orders" revealed a clarification telephone order received on 01/19/10 at 9:00am for Qualaquine 324 mg by mouth at bedtime.
Review of Patient #3's MAR for 01/19/10 revealed Qualaquine was not administered at 9:00pm as ordered with a note "none in stock". Further review of the medical record revealed no documented evidence the physician was notified of the medication not being available and not given.
In a face-to-face interview on 01/20/10 at 11:15am, S2 DON could offer no explanation for the medication not being administered as ordered, the pharmacy not being contacted to obtain the medication, and the physician not being notified that the medication was not administered as ordered.

Patient #8
Review of Patient #8's "Physician Orders" revealed an order on 01/19/10 at 2015 (8:15pm) to add Coumadin 10 mg by mouth every evening.
Review of the MAR for 01/19/10 revealed no documented evidence the Coumadin was administered the night of 01/19/10 as ordered.
In a face-to-face interview on 01/20/10 at 11:25am, S2 DON could offer no explanation for the Coumadin not being administered as ordered.

Review of the hospital policy titled "Standards of Practice", issued 09/05 and submitted by S2 DON as the hospital's policy on medication administration, revealed, in part, "...The Professional Practice Standards and the following expanded Standards of Nursing Practice specifically define what the Nursing Staff will do for and/or with patients and their significant other(s) in order to provide the Standards of Patient Care. ... Standards: 4. Medication Standard of Care The patient can expect to receive the correct medication, the correct dose, via the correct route, at the correct time with appropriate follow-up side effects, complications, and effectiveness...".

Review of the hospital policy titled "Ordering Medications From Pharmacy", last revised 09/04 and submitted by S2 DON as the hospital's current policy on obtaining medications from the pharmacy, revealed, in part, "... Stock and after hours procedure: 14. This process is to be used only for PRN (as needed) orders, first doses, and stat doses. 15. The nurse will notify the pharmacist on call of the medication order. 16. The pharmacist on call will assess that the 1st dose medication is in conjunction with the most current patient profile via the pharmacy profile link. ... 18. In the event that the medication is not in stock, the pharmacist will contact the local 24-hour back up contracted pharmacy for dispensing and delivery of the medication...".