HospitalInspections.org

Based on observation, record reviews, and interviews, the hospital failed to meet the requirements for the Condition of Participation for Nursing services as evidenced by:

1) Failing to ensure the Registered Nurse (RN) supervised and evaluated the nursing care of each patient as evidenced by:

a) Failure to ensure the RN assessed, measured, and staged wounds as required by the Louisiana State Board of Registered Nurses as evidenced by having the RN delegate this task to LPNs for 7 (#1, #3, #4, #R2, #R4,#R6, #R8 ) of 7current inpatients reviewed for wounds;

b) Failure to ensure an RN assessed Patient #1 when her PEG (Percutaneous Endoscopic Gastrostomy) tube became dislodged, failed to document a physician's order to insert a urinary catheter in the PEG site, and failed to observe Patient #1 to determine that her condition was stable before delegating her care to an LPN. Patient #1's temporary urinary catheter remained in the PEG site for 3 days before placement was verified by x-ray and remained for 15 days without S7MD (Medical Doctor) or S12PA-C (Physician Assistant - Certified) being informed by the RN;

c) Failure to ensure the RN clarified the physician's order when Patient #3 was admitted on 01/28/15 with "bloody urine" and had physician orders for Warfarin (anticoagulant) and Clopidogrel (inhibits blood clots) to determine if he wanted to continue the prescribed medications in light of Patient #1's blood in the urine;

d) Failure of the RN to assess and identify all of Patient #2's wounds which were documented by the physicians at the receiving hospitals (Hospital "A" and Hospital "B"), when the patient was transferred for a higher level of care on 11/5/14 and 11/13/14(see findings in tag A0395);

2) Failing to ensure the skill and competence of all individuals providing direct patient care had been evaluated as evidenced by failing to maintain documented evidence of skills competency and annual performance evaluations for 3 direct patient care Registered Nurses' (RN) (S6Charge Nurse, S11RN, S15RN) and 4 Licensed Practical Nurses' (LPN) ( S5LPN, S8LPN, S9LPN, S17WoundCare) personnel records reviewed for competency from a total of 9 employed staff RNs and 13 employed staff LPNs (see findings in tag A0397); and

3) Failing to ensure that hospital nursing personnel for whom current licensure is required had a valid and current license as evidenced by failing to have documentation of verification of current licensure for 4 direct care staff Licensed Practical Nurses' (LPN) (S5Wound Care, S8LPN, S9LPN, S17Woundcare) employee files reviewed for verification of licensure from a total of 13 direct care LPNs and 1 (S15) of 3 (S6, S11, S15) direct care staff Registered Nurses' personnel files reviewed for verification of licensure from a total of 9 direct care staff RNs (see findings in tag A0394).


30984

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

1) Failing to ensure an individual with the necessary knowledge, experience, and capabilities had been designated as the Director of Rehabilitation (Rehab) Services and was responsible for supervising and administering the services. There was no documented evidence provided by the hospital that any staff member or contracted staff had been appointed as Director of Rehab Services (see findings in tag A1125);

2) Failing to ensure Rehab Services had an adequate number of qualified therapists to provide physical therapy (PT) services at the frequency ordered by the physician as evidenced by failing to provide physical therapy 5 times a week as ordered by the physician when the only employed PT was off for 4 (#1, #3, #R1, #R7) of 4 current inpatients receiving PT services from a total sample of 5 patients and 8 random patients (see findings in tag A1124);

3) Failing to ensure that PT, occupational therapy (OT), and speech therapy-language pathology (ST) services were provided by qualified therapists as evidenced by failure to have current license verification and competency evaluations for 3 (S4, S13, S14) of 3 rehab employees whose personnel files were reviewed for qualifications from a total of 3 rehab employees (see findings in tag A1126); and

4) Failing to ensure rehab services were provided under the orders of a physician and according to hospital policies and procedures. There was no documented evidence that the physician signed the orders for rehab services prior to treatment being initiated, of frequency and/or duration for services, and/or the plan of care for 5 (#1, #3, #5, #R1, #R7) of 6 patient records reviewed with physician orders for rehab services (#1, #2, #3, #5, #R1, #R7) from a total sample of 5 patients and 8 random patients (see findings in tag A1132).

Based on personnel record reviews and interview, nursing service failed to ensure that hospital nursing personnel for whom current licensure is required had a valid and current license as evidenced by failing to have documentation of verification of current licensure for

-4 direct care staff Licensed Practical Nurses' (LPN) (S5Wound Care, S8LPN, S9LPN, S17WoundCare) employee files reviewed for verification of licensure from a total of 13 direct care LPNs and
-1 (S15) of 3 (S6, S11, S15) direct care staff Registered Nurses' personnel files reviewed for verification of licensure from a total of 9 direct care staff RNs.
Findings:

No policies and procedures related to Human Resources, such as verification of licensure, were presented by S1Administrator as of the time of exit on 02/19/15 at 4:15 p.m.

Review of the "Employee Handbook", presented by S1Administrator, revealed that all employees are hired for a probationary period of 90 days. At the end of the first 90 days, a performance evaluation is made by the Supervisor as to the employee's suitability for position held, progress in work performance, knowledge of duties, general conduct, appearance, and attitude. Further review revealed all employees' records must include evidence of qualifications and licensure or registration if applicable. Additional review revealed it is the responsibility of the employee to make sure that his/her license, registration, or certification is current and renewed before it expires. The employee must provide his/her Supervisor with a copy of his/her current license, registration, or certification, and it will be placed in his/her personnel file.

S5Wound Care LPN
Review of S5Wound Care LPN's personnel file revealed she was hired on 07/03/12. Further review revealed the copy of her license in her personnel file had expired 01/31/15. There was no documented evidence that S5Wound Care LPN's nursing license had been verified to be active and unencumbered before it expired.

S8LPN
Review of S8LPN's personnel file revealed she was hired on 10/23/14. Further review revealed no documented evidence of verification of a current unencumbered nursing license.

S9LPN
Review of the personnel record, presented as current, for S9LPN revealed no documentation of verification of current licensure from the Louisiana State Board of Practical Nurse Examiners. Further review revealed a copy of S9LPN's license, dated 2013, with an expiration date of 1/31/14.

S15RN
Review of S15RN's personnel file revealed he was hired on 08/03/11. Further review revealed no documented evidence of verification of a current unencumbered nursing license.

S17Wound Care
Review of the personnel record, presented as current, for S17WoundCare (LPN) revealed no documentation of verification of current licensure from the Louisiana State Board of Practical Nurse Examiners. Further review revealed a copy of S17Wound Care's license, dated 2013, with an expiration date of 1/31/14.

In an interview on 2/19/15 at 4:30 p.m. with S1Administrator, she confirmed the above referenced personnel files contained no documentation of verification of current licensure for the above-listed nursing staff.


30984

30984


Based on observation, record review, and interview, the registered nurse (RN) failed to ensure the supervision of nursing care provided to each patient as evidenced by:
1. Failing to ensure the RN assessed, measured, and staged wounds as required by the Louisiana State Board of Registered Nurses as evidenced by having the RN delegate this task to LPNs for 7 (#1, #3, #4, #R2, #R4,#R6, #R8 ) of 7 current inpatients reviewed for wounds.

2.RN failing to assess and identify all of Patient #2's wounds which were documented by the physicians at the receiving hospitals (Hospital "A" and Hospital "B"), when the patient was transferred for a higher level of care on 11/5/14 and 11/13/14.

3. Failing to ensure a RN assessed Patient #1 when her PEG (Percutaneous Endoscopic Gastrostomy) tube was dislodged, failed to document a physician's order to insert a urinary catheter in the PEG site, and failed to observe Patient #1 to determine that her condition was stable before delegating her care to an LPN. Patient #1's temporary urinary catheter remained in the PEG site for 15 days without S7MD (Medical Doctor) or S12PA-C being informed by the RN.

4. Failing to ensure the RN clarified the physician's order when Patient #3 was admitted on 01/28/15 with "bloody urine" and had physician orders for Warfarin (anticoagulant) and Clopidogrel (inhibits blood clots) to determine if he wanted to continue the prescribed medications in light of Patient #1's blood in the urine.

5. Failing to ensure Patient #1's residual from her PEG tube assessed as equal to or greater than 120 ml (milliliters) was reported to the RN by the LPN and to the physician as ordered.

Findings:

1) Failing to ensure the RN assessed, measured, and staged wounds as required by the Louisiana State Board of Registered Nurses as evidenced by having the RN delegate this task to LPNs:
Review of the Louisiana State Board of Registered Nurse's "Declaratory Statement Scope of Practice For Registered Nurses - Wound Care Management" revealed the following:
a) 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 physician must always prescribe wound care.
b) 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.
c) In accord with the Law Governing the Practice of Nursing (RS 37:913(14)
the registered nurse may delegate select nursing interventions to qualified nursing
personnel as set forth in the Board's rules on delegation (LAC 46:XLVII.3703.). The
registered nurse retains the accountability for the total nursing care of the individual.
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.

Review of the hospital policy titled "Admit Nursing Assessment", presented by S1 Administrator as a current policy, revealed no documented evidence that the admit nursing assessment was to be performed by an RN as evidenced by the policy stating that "the nurse gathers information relevant to the patient". Further review revealed the "nurse" was to perform a head to toe assessment.

Review of the hospital policy titled "Charge Nurse Responsibilities", presented as a current policy by S1Administrator, revealed that the overall management by the RN included admitting patients and completing a comprehensive assessment including a skin assessment. If the patient presented with a wound, the RN was to make the initial skin assessment within 24 hours that included measurements and photos to establish a baseline for wound progression and/or deterioration. The Charge RN was to assess the wound weekly with Wound care and document with pictures and measurements.

Review of the hospital policy titled "Wound Care Protocol", presented as a current policy by S1Administrator, revealed that each patient would have an initial skin assessment performed by an RN within 24 hours of admission. Wounds would be documented with pictures and measurements. The RN and the Wound Care nurses would coordinate wound management as the Wound Care team. The RN, at a minimum, will conduct an assessment weekly to evaluate the status of the wound with a wound care nurse. Wounds will be documented, at a minimum, with pictures and measurements on a weekly basis after the initial assessment.

Patient #1
Review of Patient #1's medical record revealed she was a 61 year old female admitted on 02/03/15 with diagnoses of Debility, Burns, Wound Infection (Scalp), Respiratory Failure, and Sepsis.
Review of Patient#1's Routine Admission Orders, dated 2/3/15, revealed an order for wound care assessment. Further review of Patient #1's medical record revealed Physician Orders, dated 2/4/15, for wound care. The orders were signed off by S17Woundcare (LPN).

Review of Patient #1's medical record revealed her wounds to the right upper thigh, bilateral legs, left face and scalp, left and right shoulder, and sacrum were assessed, measured, staged, and photographed by an LPN on 02/04/15, 02/09/15, and 02/16/15. There was no documented evidence that an RN was present during the assessments.

Patient #3
Review of Patient #3's medical record revealed she was a 60 year old female admitted on 01/28/15 with diagnoses of Non-Healing Left Foot Wound status post Amputation of Left 1st, 2nd, 3rd, and 4th Toes, Deconditioning, Vascular Occlusion, and Diabetes Mellitus. Review of her admit orders dated 01/28/15 revealed an order for "Wound Care Assessment", and her wound care orders were documented by S5Wound Care LPN on 01/29/15 at 9:00 a.m.

Review of Patient #3's wound documentation revealed her wound photographs, measurements, and staging were performed on 01/29/15, 02/02/15, 02/09/15, and 02/16/15 by an LPN.

Patient #4
Review of Patient #4's medical record revealed an admission date of 2/12/15 with admission Diagnoses of NHW (non-healing wound) and Infected Sacral Decubitus. Review of Patient#4's Routine Admission Orders, dated 2/12/15, revealed an order for wound care assessment.Further review of Patient #4's medical record revealed Physician Orders, dated 2/13/15, for wound care. The orders were signed off by S17WoundCare (LPN).

Patient #R2
Review of Patient #R2's medical record revealed an admission date of 2/11/15 with admission Diagnoses of Chronic lower extremity cellulitis and NHW. Review of Patient#R2's Routine Admission Orders, dated 2/11/15, revealed an order for wound care assessment.Further review of Patient #R2's medical record revealed Physician Orders, dated 2/12/15, for wound care. The orders were signed off by S5WoundCare (LPN).

Patient #R4
Review of Patient #R4's medical record revealed an admission date of 1/7/15 with admission Diagnoses of cellulitis lower extremity and NHW.
Review of the Patient #R4's Routine Admission Orders, dated 1/7/15, revealed an order for wound care assessment. Further review of Patient #R4's medical record revealed Physician Orders, dated 1/8/15, for wound care. The orders were signed off by S5WoundCare (LPN).

Patient #R6
Review of Patient #R6's medical record revealed an admission date of 1/27/15 with admission Diagnosis of NHW Sacrum. Review of Patient #R6's Routine Admission Orders, dated 1/27/15, revealed an order for wound care assessment. Further review of Patient #R6's medical record revealed Physician Orders, dated 1/8/15, for wound care. The orders were signed off by S5WoundCare (LPN).

Patient #R8
Review of Patient #R8's medical record revealed an admission date of 2/18/15 with admission Diagnosis of NHW Stage IV Decubitus, Right Buttock Wound. Review of Patient #R8's Routine Admission Orders, dated 2/18/15, revealed an order for wound care assessment.Further review of Patient #R8's medical record revealed Physician Orders, dated 2/19/15, for wound care. The orders were signed off by S9LPN (Wound Care Director).

In an interview on 2/18/15 at 1:59 p.m. with S11RN, he indicated the wound care nurses assessed patients for wounds and performed all wound assessments, both initial and on an ongoing basis. He said the assessments included both measurements and staging. He confirmed all of the wound care nurses were LPNs.

In an interview on 2/18/15 at 3:14 p.m. with S9LPN (Wound Care Director), she indicated she had held the position of Wound Care Director, at this facility, for at least 10 years. She explained she only worked two days a week (Mondays and Wednesdays) and had still been left in charge of the Wound Care Department. S9LPN said she had always been told that a RN should have been in charge of the Wound Care Department. She indicated she had been told to do her best when she had questioned the hospital regarding whether or not a LPN could be in charge of the Wound Care Department. S9LPN said she had been told, by the hospital, that State Office had indicated a LPN could be the Director of the Wound Care Department as long as there was a RN in-house. S9LPN indicated that she and the two LPNs who worked with her comprised the wound care team. S9LPN confirmed she was not certified in wound care. She said she had received on the job training with a previous wound care nurse. She also indicated the only training S5WoundCare and S17WoundCare had received was the training she had provided. S9LPN explained she had only been given four days to review paperwork and orient new staff. She indicated she had not documented skills performance evaluations for S5WoundCare and S17WoundCare. S9LPN said no one had ever told her she needed to document evaluations of the wound care nurses' assessment skills/performance. S9LPN indicated she had felt that she could not keep up to speed with evaluation of patient wounds because the photos and measurements had been obtained several days before she had an opportunity to compare them with the actual wounds. S9LPN explained she had, at times, noted discrepancies in measurements and Braden Skin Risk Assessment Scores that had been obtained by the wound care staff. She confirmed RNs had not been performing the wound assessments (staging and measurements) when they performed their initial assessments. She explained that if the wound was dressed, upon admit, the RNs did not remove it to assess the wound. S9LPN said the RNs had been told wound assessments were to be performed by the wound care nurses. S9LPN also confirmed the RN co-signature on the wound assessments was based upon review of the LPN's assessment (staging/measurements) and not upon direct visualization of the wound/assessment.

In an interview on 2/18/15 at 3:17 p. m. with S10RN, she confirmed the wound care nurses performed initial wound assessments (staging and measurements). She also confirmed the RN co-signature on the wound assessments was based upon review of the LPN's assessment (staging/measurements) and not upon direct visualization of the wound/assessment.

In an interview on 2/19/15 at 12:18 p.m. with S2DON, she indicated initial and subsequent wound assessment/measurement/staging was performed by the all LPN wound care staff. She confirmed patients' wounds had not been assessed by the admitting RN during the initial assessment. S2DON also confirmed dressings had not been removed to visualize the wounds directly and all that had been documented had been the integrity of the dressing. S2DON said staff had been told photos and measurements/staging of wounds was to be performed by the wound care team. S2DON confirmed the Wound Care Department should have been managed by a RN. S2DON indicated she had not been aware that initial assessments/staging of wounds could not be delegated to a LPN by a RN. She indicated that a certified wound care nurse should have assessed the skills/competency of S9LPN (Wound Care Director). S2DON also indicated she had not been aware there were no documented skills competency/evaluations for S5Woundcare and S17WoundCare.

2.RN failing to assess and identify all of Patient #2's wounds which were documented by the physicians at the receiving hospitals (Hospital "A" and Hospital "B") , when the patient was transferred for a higher level of care on 11/5/14 and 11/13/14.

Patient #2:
Review of Patient #2's medical record revealed an admission date of 10/13/14, and an admission diagnosis of scrotal abscess. Further review revealed the following co-morbidities/problems: Obesity (380 pounds), Diabetes Mellitus, wound vac. (vacuum)to Scrotal Abscess, PVD ( Peripheral Vascular Disease) with LE (Lower Extremity) Edema, Chronic Anemia, and DVT (Deep Vein Thrombosis).

Review of Patient # 2's Admission Nursing Assessment, dated 10/13/14, revealed the following, in part: Right scrotum with wound vac intact at 125mm (millimeters) of Hg (mercury) continuous;
Right groin dressing dry, intact;
Sacrum dressed.
Further review revealed no documented assessment of the actual wounds. Additional review of the patient's medical record revealed no subsequent documentation of a sacral wound or the reason a dressing had been in place over the sacrum on admission.

Review of Patient #2's Routine Admission Physician Orders, dated 10/13/14, revealed an order for Wound Care Assessment.

Further review of Patient #2's medical record revealed the following wound care orders:
10/15/14:
1. Photos and measurements weekly; 2. C&S (culture and sensitivity) scrotal wound; 3. Clean scrotal wound with normal saline, black foam, clear film, suction catheter and attach to suction at 120 mm (millimeters) of Hg (mercury). Change weekly and PRN (as needed); D/C (discontinue) wound care when wound is resolved.
11/4/14:
Left 3rd, 4th, and 5th posterior toes, cleanse with normal saline, apply Dermagran gel, 4x4's, ABD pads, Kerlix and tape. Change q (every) day and PRN. C&S (culture and sensitivity) of left posterior toes.

Review of Patient #2's medical record revealed the following documentation from his hospitalization (11/5/14-11/11/14) at Hospital "A":
Time Seen: 11/5/14 at 1:00 p.m.:
Associated Diagnoses: Foot ulcer and Sacral Decubitus Ulcer.
History of Present Illness:
Patient has been on IV (intravenous) antibiotics for multiple wound infections on buttocks, left foot, and right scrotum.
Physical Examination:
Musculoskeletal: Left foot, plantar aspect of 3rd and 4th digits with 1 cm (centimeter) area each of linear skin breakdown. Some oozing of blood noted. No purulent drainage.
Gastrointestinal: Bilateral buttocks with obvious skin breakdown surrounding anal opening with oozing blood and tenderness with palpation. No purulent drainage.

Review of Patient #2's medical record revealed the following documentation, in part, from his hospitalization (11/13/14) at Hospital "B":
Consultation, date: 11/13/14:
Reason for Consultation:
Right lateral abdominal infected wound and left 4th toe laceration.
History of present illness:
This is a 49 year old male, poor historian, multiple medical problems. ...He was brought over here for bleeding, but he was also noted to have a left 4th toe laceration at the base of the 4th toe on the plantar aspect, which is fairly deep, and also to have a right lateral abdominal wound that is open and draining with some mild purulent material. Patient is unaware of either of these things. He is sore at the sites but does not know where he got these problems.
Assessment and Plan:
This is a 49 year old male with a right abdominal wound that solely needs wound care, as it is already open.. ....Wound care cleaning and packing the area would be sufficient.

Review of Patient #2's nurses' note entries dated 10/13/14-11/5/14 and 11/11/14-11/13/14 revealed no identification/documentation of wounds on the patient's sacrum, buttocks, or abdomen.

Review of Patient #2's wound care notes/assessments (measurements and staging) from 10/14/14-11/5/14 and 11/11/14-11/13/14 revealed no identification/documentation of wounds on the patient's sacrum, buttocks, or abdomen.

In an interview on 2/18/15 at 9:25 a.m. with S7MD, he indicated that he had treated Patient #2. S7MD said he had no recollection of any other wounds besides Patient #2's scrotal wound and the lacerations on the patient's toes on his left foot.

In an interview on 2/18/15 at 12:29 p.m. with S12PA-C, he indicated that he had treated Patient #2. He reviewed Patient #2's medical record and confirmed no other wounds had been documented during his hospitalization (at the rehabilitation hospital) except for the scrotal wound and the left foot toe lacerations.

In an interview on 2/18/15 at 3:17 p. m. with S10RN, she said the wound care nurses performed initial wound assessments (staging and measurements). She also confirmed the RN co-signature on the wound assessments was based upon review of the LPN's assessment (staging/measurements) and not upon direct visualization of the assessment.

In an interview 2/18/15 at 3:14 p.m. with S9LPN (Wound Care Director), she indicated, after review of all of Patient #2's rehabilitation hospital records that the patient had no other wounds documented except for the scrotal wound and the lacerations on the toes of his left foot. She said she had not seen a wound on the patient's abdomen or on his sacrum/buttocks. S9LPN agreed that the abdominal wound could have been within a skin fold and she could have missed it when she assessed the patient.

3. Failing to ensure an RN assessed Patient #1 when her PEG (Percutaneous Endoscopic Gastrostomy) tube was pulled out, failed to document a physician's order to insert a urinary catheter in the PEG site, and failed to observe Patient #1 to determine that her condition was stable before delegating her care to an LPN. Patient #1's temporary urinary catheter remained in the PEG site for 15 days without S7MD (Medical Doctor) or S12PA-C being informed by the RN.
Review of the Louisiana State Board of Nursing's (LSBN) "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...".
Review of the hospital policies presented by S1Administrator revealed no documented evidence that a policy had been developed that addressed the RN's process of reinserting a dislodged PEG tube with a urinary catheter.

Review of the hospital policy titled "Charge Nurse Responsibilities", presented as a current policy by S1Administrator, revealed that the Charge RN does not take patients but is responsible for the overall management of all the patients in the assigned shift. Further review revealed the Charge RN was to make assignments to each LPN based on the patient's individualized needs and experience of the staff.

Observation on 02/18/15 at 1:45 p.m. revealed Patient #1 had a 24 French urinary catheter with a 30 cc (cubic centimeter) balloon in place to her PEG site.

Review of Patient #1's medical record revealed she was a 61 year old female admitted on 02/03/15 with diagnoses of Debility, Burns, Wound Infection (Scalp), Respiratory Failure, and Sepsis. Review of her physician orders revealed an order on 02/07/15 at 12:05 p.m. to do a portable KUB (kidneys, ureters, bladder) now for a diagnosis of PEG placement. There was no documented evidence of a physician order on 02/04/15 to replace the PEG tube with a temporary urinary catheter.

Review of Patient #1's "Nursing Assessment" documented by S6Charge Nurse on 02/03/15 at 3:00 p.m. revealed Patient #1 had a PEG tube. Review of her "Nurses Notes" revealed an entry on 02/04/15 at 10:00 p.m. by S8LPN that Patient #1 had pulled her PEG tube out, "Charge Nurse S11RN inserted a foley to keep site opened, pt (patient) tolerated well..." Review of Patient #1's nurses' notes from admission through 02/18/15 revealed no documented evidence that the urinary catheter had been changed to a permanent PEG tube, and there was no documented evidence related to the reason for the KUB being ordered. There was no documented evidence of an assessment performed by S11RN on 02/04/15 when Patient #1's PEG became dislodged, a report to the physician of the event with a subsequent order to place the temporary urinary catheter in the PEG site, the technique used to insert the catheter, and observation of Patient #1 by an RN to determine that she had no complications from the reinsertion of the urinary catheter PEG tube prior to delegating her care to the LPN.

Review of the physician progress notes revealed no documented evidence of a progress note documented by the physician who saw Patient #1 on 02/07/15 and ordered the KUB.

Review of S11RN's personnel file revealed no documented evidence that he was evaluated for competency in inserting PEG tubes.

In an interview on 02/18/15 at 12:29 p.m., S12PA-C (Physician Assistant-Certified) indicated he received a phone call from S11RN who reported that Patient #1's PEG tube had become dislodged, and he (S11RN) had replaced it with a foley (urinary catheter). State some thought, S12PA-C indicated he wasn't sure the call was about Patient #1, because he had 2 patients recently with dislodged PEG tubes. He further indicated that he didn't know if the urinary catheter had been replaced with a permanent PEG tube, but the way he wrote his note on 02/09/15, "it looks like it was replaced with a PEG tube."

In an interview on 02/18/15 at 1:05 p.m., S6Charge Nurse (RN) indicated he provided care to Patient #1 on 02/05/15, and she had the urinary catheter in place as her PEG tube, and she still has the urinary catheter in place of the PEG tube as of today. S6Charge Nurse indicated he called S7MD on 02/05/15 to report the PEG site having the urinary catheter in place, and S7MD told him (S6Charge Nurse) to let S12PA-C assess Patient #1 and to reinsert her PEG tube. S6Charge Nurse indicated when he spoke with S12PA-C, S12PA-C said that he wanted S7MD to reinsert the PEG tube. He further indicated that he called S7MD who said he (S7MD) would make rounds sometimes that week. S6Charge Nurse indicated he told someone to address at staffing on 02/11/15 that the patient still had the urinary catheter (being used as a temporary substitue for a PEG tube) in place, but he didn't know if it had been addressed. S6Charge Nurse confirmed that he did not document the discussions he had with S12PA-C, S7MD, or the person he reported to about the staffing discussion needed for Patient #1. S6Charge Nurse indicated he had not told S7MD or S12PA-C that Patient #1 still had the urinary catheter in place in her PEG site.

In a telephone interview on 02/18/15 at 1:50 p.m., S11RN indicated he called S12PA-C to inform him that Patient #1's PEG tube had become dislodged, and he (S12PA-C) wanted him to put a foley in to keep it open. He further indicated he inserted the foley, and when he knew it was in, he inflated the balloon of the urinary catheter, aspirated and got stomach contents back in the syringe. When asked how he knew it was in, he indicated he tried to insufflate air, and the LPN said she didn't "hear anything", so he "pulled back and got stomach contents." When asked about his not having documentation of his assessment and physician order to insert the urinary catheter, S11RN indicated he didn't have Patient #1 as a patient and was working the floor that night. He further indicated that Patient #1 was the LPN's patient that night. When asked if he was aware of the LSBN's ruling on the RN delegating to the LPN, he indicated "Yes, she checks placement every time."

In an interview on 02/19/15 at 12:15 p.m., S2DON indicated S11RN should have documented his assessment of Patient #1 after her PEG tube became dislodged, and he should have documented his technique of inserting the urinary catheter in place of a PEG tube. She further indicated if the patient was managed by an LPN, there should be documentation of the abdomen without distention and the amount of residuals obtained, She also indicated she reviews charts for labs and to be sure signatures are present, but she "needs to be more involved." She further indicated that she thought Patient #1's PEG tube had been replaced.

In an interview on 02/19/15 at 1:00 p.m., S12PA-C indicated he wasn't aware that the urinary catheter had remained as Patient #1's PEG tube. He further indicated that was something that should be brought to their attention, because a urinary catheter as a PEG tube is a temporary thing."

In an interview on 02/19/15 at 1:50 p.m., S7MD indicated he didn't know that Patient #1 still had a urinary catheter as her PEG tube.

In an interview on 02/19/15 at 3:50 p.m., S18LPN indicated she worked on 02/07/15, the day that the physician ordered the KUB for Patient #1. She further indicated that he ordered it, because the Charge RN asked to have the placement of the PEG tube checked. S18LPN confirmed she didn't document that a KUB had been done or the reason why it was ordered. She indicated it wasn't ordered because Patient #1 was having any problems.

4. Failing to ensure the RN clarified the physician's order when Patient #3 was admitted on 01/28/15 with "bloody urine" and had physician orders for Warfarin (anticoagulant) and Clopidogrel (inhibits blood clots) to determine if he wanted to continue the prescribed medications in light of Patient #1's blood in the urine.

Review of Patient #3's medical record revealed she was a 60 year old female admitted on 01/28/15 with diagnoses of Non-Healing Left Foot Wound status post Amputation of Left 1st, 2nd, 3rd, and 4th Toes, Deconditioning, Vascular Occlusion, and Diabetes Mellitus.

Review of Patient #3's "Physician's Orders" at admit dated 01/28/15, revealed medication orders included Warfarin 5mg (milligrams) orally at 5:00 p.m. on Monday, Wednesday, and Friday, Warfarin 7.5 mg orally at 5:00 p.m. on Tuesday, Thursday, Saturday, and Sunday, and Clopidogrel 75 mg orally each day. Further review revealed an order on 01/29/15 at 8:00 a.m. to hold Plavix and Coumadin (Warfarin) now.

Review of a Urology Consult Note from the transferring hospital dated 01/22/15 at 7:32 p.m. revealed that Patient #3's urine was "currently draining clear like water, no hematuria." Review of a progress note documented by the same physician on 01/26/15 at 7:36 a.m. revealed "urine has already cleared."

Review of Patient #1's admission nursing assessment documented by S15RN on 01/28/15 at 9:30 p.m. revealed her urinary catheter was draining "bloody drainage." Review of her nurses' notes revealed no documented evidence that S15RN notified S7MD of Patient #1's bloody drainage from her urinary catheter to determine if he wanted to hold the Warfarin and Plavix orders.

In an interview on 02/19/15 at 12:15 p.m., S2DON indicated S15RN should have reported Patient #1's bloody urinary output to S7MD, since Patient #1 had orders for anticoagulants.

5. Failing to ensure Patient #1's residual from her PEG tube assessed as equal to or greater than 120 ml (milliliters) was reported to the RN by the LPN and to the physician as ordered.

Review of Patient #1's medical record revealed she was a 61 year old female admitted on 02/03/15 with diagnoses of Debility, Burns, Wound Infection (Scalp), Respiratory Failure, and Sepsis. Review of her physician admit orders dated 02/03/15 at 1:00 p.m. revealed an order to check residuals from her PEG tube site every 4 hours and hold feedings and notify the physician of residuals greater than or equal to 120 ml.

Review of Patient #1's "Nurses Notes" revealed an entry by S16LPN on 02/09/15 at 2:00 a.m. that residual from the PEG tube was 120 and that 3:00 a.m. the residual was 180 cc with the feeding held. There was no documented evidence that the residual of 120 ml and above was reported to the RN, that an RN had assessed Patient #1, and that the physician was notified as ordered.

In an interview on 02/19/15 at 12:15 p.m., S2DON indicated she didn't see any documentation that S16LPN had reported the residuals of 120 ml and 180 ml to the RN, an assessment by the RN, or that S7MD was notified as ordered. She further indicated that the RN should have assessed Patient #1 and should have notified the physician.

Based on record review and interview, the hospital failed to ensure the skill and competence of all individuals providing direct patient care had been evaluated as evidenced by failing to maintain documented evidence of skills competency and annual performance evaluations for 3 direct patient care Registered Nurses' (RN) (S6Charge Nurse, S11RN, S15RN) and 4 Licensed Practical Nurses' (LPN) ( S5LPN, S8LPN, S9LPN, S17WoundCare) personnel records reviewed for competency from a total of 9 employed staff RNs and 13 employed staff LPNs.

Findings:

No policies and procedures related to Human Resources, such as requirements upon hiring, specific requirements of staff, such as certification in CPR (cardiopulmonary resuscitation), verification of licensure, competency evaluations, and performance evaluations, were presented by S1Administrator as of the time of exit on 02/19/15 at 4:15 p.m.

Review of the "Employee Handbook", presented by S1Administrator, revealed that all employees are hired for a probationary period of 90 days. At the end of the first 90 days, a performance evaluation is made by the Supervisor as to the employee's suitability for position held, progress in work performance, knowledge of duties, general conduct, appearance, and attitude. Further review revealed all employees' records must include evidence of qualifications and licensure or registration if applicable. Further review revealed it is the responsibility of the employee to make sure that his/her license, registration, or certification is current and renewed before it expires. The employee must provide his/her Supervisor with a copy of his/her current license, registration, or certification, and it will be placed in his/her personnel file.

S5LPN
Review of S5LPN's personnel file revealed her hire date was 07/03/12. Further review revealed she had no job description in her file for Wound Care Nurse (listed on employee roster as "LPN woundcare"). Further review revealed no documented evidence that an evaluation of competency in performing her job duties including wound care treatment and measurements had been conducted as evidenced by having a self-assessment documented by S5LPN and the column labeled "Skill Verbal/Demo" being blank. Further review revealed no documented evidence that a 90 probationary evaluation or annual evaluations had been performed.

S6Charge Nurse
Review of S6Charge Nurse's (RN) personnel file revealed he was hired on 10/16/14. Review of his competency evaluation signed by S6Charge Nurse and S2DON on 10/15/14 revealed self-assessment of competency was documented by S6Charge Nurse. Further review revealed all competency was assessed either by demonstration or verbally by S2DON on 10/16/14. The following competencies were assessed verbally and not demonstrated to determine if S6Charge Nurse was competent to perform or supervise the performance of these duties: regulates intravenous drip rates; converts intravenous line to a heparin lock; demonstrates skill in handling emergency and life-threatening situations; locates and uses crash cart items; initiates CPR; provides nursing care to meet patient needs by performing digital stimulation, intermittent sterile catheterization, collecting urine specimens, performing hemocult test, performing neuro assessment, identifying appropriate safety measures for a seizuring patient; obtaining specimens for wound culture; performing stump care and monitoring skin conditions; demonstrates use of scale; measures and applies anti-embolism stockings. Further review revealed no documented evidence that a 90 probationary evaluation or annual evaluations had been performed.

S8LPN
Review of S8LPN's personnel file revealed her hire date was 10/23/14. Review of her competency evaluation revealed S8LPN documented a pre-orientation and post-orientation self-assessment. Further review revealed the column titled "Preceptors Signature W/Date (with date)" revealed the initials of an LPN with no documented evidence of the date the evaluation was conducted and whether a return demonstration was observed or verbal explanation was given. The column titled "Skill/Verbal/Demo" had a date of 10/25/14 with the initials of S8LPN in each space. There was no documented evidence that a RN observed S8LPN in performing the duties of her job to determine her competency. Further review revealed no documented evidence that a 90 probationary evaluation or annual evaluations had been performed.

S9LPN
Review of S9LPNs personnel file, presented as current, revealed no documented evidence of current evaluation of S9LPN 's skills competency. Further review revealed the last documented LPN skills competency evaluation was dated 6/16/10. Additional review revealed no documented evidence of wound care skills competency evaluation nor was there documented evidence of current annual performance evaluations.

S11RN
Review of S11RN's personnel file, presented as current, revealed no documented evidence of current evaluation of S11RN's skills competency. Further review revealed the last documented skills competency evaluation was dated 8/16/11. Additional review revealed no documented evidence of current annual performance evaluations.

S15RN
Review of S15RN's personnel file revealed he was hired on 08/03/11. Further review revealed no documented evidence that he had been evaluated for competency as evidenced by a self-assessment being documented by S15RN pre-orientation and post-orientation and the column titled "Practice Date/Initials" being blank and the column titled "Competency Achieved Skill/Verb (verbal)/ Demo (demonstration) Date" having the date "8/2/11" with a line drawn down the column with no documented evidence whether the skill was verbalized or demonstrated. Further review revealed no documented evidence that a 90 probationary evaluation or annual evaluations had been performed.

S17WoundCare
Review of S17WoundCare's personnel file, presented as current, revealed no documented evidence of current evaluation of S17WoundCare's skills competency. Further review revealed the last documented LPN skills competency evaluation was dated 6/26/12. Additional review revealed no documented evidence of wound care skills competency evaluation nor was there documented evidence of current annual performance evaluations.

In an interview on 2/18/15 at 3:14 p.m. with S9LPN (Wound Care Director), she indicated she had held the position of Wound Care Director, at this facility, for at least 10 years. She explained that she and the two LPNs who worked with her comprised the wound care team. She indicated she had not documented skills performance evaluations for S5WoundCare and S17WoundCare. S9LPN said no one had ever told her she needed to document evaluations of the wound care nurses' assessment skills/performance.

In an interview on 2/19/15 at 12:18 p.m. with S2DON, she confirmed that a certified wound care nurse should have assessed the skills/competency of S9LPN (Wound Care Director). S2DON also indicated she had not been aware there were no documented skills competency/evaluations for S5WoundCare and S17WoundCare. She agreed S5WoundCare and S17WoundCare should have had documented skills competency/evaluations.

In an interview on 2/19/15 at 4:30 p.m. with S2DON, she confirmed the employee files referenced above, presented as current, had no current documented skills competencies or annual evaluations. S2DON said the hospital had recently realized the former HR (Human Resources) Director had not kept personnel files current. S2DON also indicated she was not sure where the former HR Director had put employee training documentation. She said she may have thrown some of it away.









30984

Based on record reviews and interview, the hospital failed to ensure rehabilitation (rehab) services had an adequate number of qualified therapists to provide physical therapy services at the frequency ordered by the physician as evidenced by failing to provide PT (physical therapy) 5 times a week as ordered by the physician when the only employed PT was off for 4 (#1, #3, #R1, #R7) of 4 current inpatients receiving PT services from a total sample of 5 patients and 8 random patients.
Findings:

Review of the hospital policy titled "PT (Physical Therapy) OT (Occupational Therapy) ST (Speech Therapy) Referrals", presented as a current policy by S1Administrator, revealed that therapy treatment shall not begin until the physician has signed and authorized the treatment plan of care, frequency, and duration of the treatments.

Review of the hospital policy titled "Physical Therapy Department Hours of Operation", presented as a current policy by S1Administrator, revealed that the days and hours of operation for the Physical Therapy Department are Monday through Friday from 8:00 a.m. to 4:30 p.m. with no Saturday status and no on-call status.

Review of the hospital policy titled "Physical Therapy Staffing", presented as a current policy by S1Administrator, revealed that the staffing level of the department is designed to meet the needs of the patients and is determined by the Physical Therapist with consultation as necessary with the Administrator. Further review revealed the department had the current desired staffing of a Physical Therapist, Physical Therapy Assistant, and a Rehabilitation Technician.

Review of the "Employee Roster", presented as the current list of hospital employees by S1Administrator, revealed no documented evidence that a Physical Therapy Assistant and a Rehabilitation Technician were currently employed.

Patient #1
Review of Patient #1's medical record revealed she was a 61 year old female admitted on 02/03/15 with diagnoses of Debility, Burns, Wound Infection (Scalp), Respiratory Failure, and Sepsis. Further review revealed she had physician orders on 02/03/15 at 1:00 p.m. for a PT and OT evaluation.

Review of Patient #1's PT evaluation conducted on 02/03/15 by S4PT revealed her frequency of PT services was to be 5 times a week until discharged. Review of her medical record revealed no documented evidence that Patient #1 received PT services on 02/16/15, 02/17/15, and 02/18/15.

Patient #3
Review of Patient #3's medical record revealed she was a 60 year old female admitted on 01/28/15 with diagnoses of Non-Healing Left Foot Wound status post Amputation of Left 1st, 2nd, 3rd, and 4th Toes, Deconditioning, Vascular Occlusion, and Diabetes Mellitus. Review of her physician admit orders revealed an order for a PT and OT evaluation.

Review of Patient #3's PT evaluation conducted on 01/29/15 by S4PT revealed her frequency of PT services was to be 5 times a week until discharged. Review of her medical record revealed no documented evidence that Patient #3 received PT services on 02/16/15, 02/17/15, and 02/18/15.

Patient #R1
Review of Patient #R1's medical record revealed she was a 55 year old female admitted on 02/11/15 with a diagnosis of Infected Non-Union Right Femoral Shaft with Hardware Removal. Review of her physician admit orders revealed an order for a PT and OT evaluation.

Review of Patient #R1's PT evaluation conducted on 02/12/15 by S4PT revealed her frequency of PT services was to be 5 times a week until discharged. Review of her medical record revealed no documented evidence that Patient #R1 received PT services on 02/16/15, 02/17/15, and 02/18/15.

Patient #R7
Review of Patient #R7's medical record revealed she was a 48 year old female admitted on 02/13/15 with diagnoses of Urinary Tract Infection, Chronic Back Pain, and Bacteremia with Escherichia coli. Review of her physician admit orders revealed an order to consult PT and OT.

Review of Patient #R7's PT evaluation conducted on 02/16/15 by S4PT revealed the frequency of PT services was to be 5 times a week with no documented evidence of the duration. Review of her medical record revealed no documented evidence of a visit note for 02/16/15 (completed by S4PT for Patients #1, #3, and #R1 on the days their evaluation was conducted), 02/17/15, and 02/18/15.

In a telephone interview on 02/19/15 at 10:50 a.m., S4PT indicated she was off on 02/16/15, 02/17/15, and 02/18/15. She offered no explanation for having a PT evaluation documented for Patient #R7 on 02/16/15 when she was off. She confirmed that no one provided PT services for Patients #1, #3, #R1, and #R7 on 02/16/15, 02/17/15, and 02/18/15 while she was off. S4PT indicated she tried to find a replacement to provide PT, but "no one wants to go there." When asked what she meant by "no one wants to go there", S4PT indicated the hospital "has been in the news quite a few times recently." She further indicated that with the rehab reimbursement rate, the hospital can't pay for anyone else, and "I go there for very little money." She indicated that she had planned to write an addendum to each patient's record for PT to be provided 3 times this week and do visits on 02/19/15, 02/20/15, and 02/21/15. When asked how she could justify PT 3 times a week for one week when her evaluation revealed services were needed 5 times a week, S4PT indicated "it's not a typo, but when I did the evaluation, I didn't realize I wouldn't be there this week."

Based on record reviews and interviews, the hospital failed to ensure an individual with the necessary knowledge, experience, and capabilities had been designated as the Director of Rehabilitation (Rehab) Services and was responsible for supervising and administering the services. There was no documented evidence provided by the hospital that any staff member or contracted staff had been appointed as Director of Rehab Services.
Findings:

Review of the "Employee Roster", provided as the current list of employees by S1Administrator, revealed no documented evidence that anyone was designated as the Director of Rehab Services.

Review of the personnel file of S4PT (Physical Therapist) revealed her job description was for PT and had no evidence that she was designated as the Director of Rehab Services. Further review revealed that her supervisor was the Program Director and/or Administrator. Additional review revealed her current license contained in her personnel file had expired on 04/30/13, and there was no documented evidence that S4PT had been evaluated for competency in providing PT services.

In an interview on 02/18/15 at 3:20 p.m., S1Administrator indicated that S4PT was Director of Rehabilitation Services.

In a telephone interview on 02/19/15 at 10:50 a.m., S4PT indicated she was "Rehab Director in name only." She further indicated she doesn't conduct performance evaluations for S13OT (Occupational Therapist) and S14ST (Speech Therapist), because she was never made aware that she should be doing evaluations of the Rehab Staff. S4PT indicated she has a current PT license and had provided a copy to the hospital.

No documented evidence of current license verification of S4PT and written designation of her appointment as the Rehab Services Director was provided by S1Administrator by the time of the survey exit on 02/19/15 at 4:15 p.m.

Based on record reviews and interviews, the hospital failed to ensure that physical therapy (PT), occupational therapy (OT), and speech therapy-language pathology (ST) services were provided by qualified therapists as evidenced by failure to have current license verification and competency evaluations for 3 (S4, S13, S14) of 3 rehabilitation (rehab) employees whose personnel files were reviewed for qualifications from a total of 3 rehab employees. Findings:

No policies and procedures related to Human Resources, such as requirements upon hiring, specific requirements of staff, such as certification in CPR (cardiopulmonary resuscitation), verification of licensure, competency evaluations, and performance evaluations, were presented by S1Administrator as of the time of exit on 02/19/15 at 4:15 p.m.

Review of the "Employee Handbook", presented by S1Administrator, revealed that all employees are hired for a probationary period of 90 days. At the end of the first 90 days, a performance evaluation is made by the Supervisor as to the employee's suitability for position held, progress in work performance, knowledge of duties, general conduct, appearance, and attitude. Further review revealed all employees' records must include evidence of qualifications and licensure or registration if applicable. Further review revealed it is the responsibility of the employee to make sure that his/her license, registration, or certification is current and renewed before it expires. The employee must provide his/her Supervisor with a copy of his/her current license, registration, or certification, and it will be placed in his/her personnel file.

S4PT
Review of S4PT's personnel file revealed she was hired on 12/28/09. Further review revealed her license contained in her personnel file had expired on 04/30/13, and there was no documented evidence that S4PT had been evaluated for competency since she was hired.

S13OT
Review of S13OT's personnel file revealed she was hired on 12/28/09. Further review revealed her license contained in her personnel file had expired on 11/30/13, and there was no documented evidence that S4PT had been evaluated for competency since she was hired.

S14ST
Review of S14ST's personnel file revealed she was hired on 08/12/12. Further review revealed her license contained in her personnel file had expired 06/30/14, and there was no documented evidence that S4PT had been evaluated for competency since she was hired.

In a telephone interview on 02/19/15 at 10:50 a.m., S4PT indicated she was "Rehab Director in name only." She further indicated she doesn't conduct performance evaluations for S13OT and S14ST, because she was never made aware that she should be doing evaluations of the Rehab Staff.

In an interview on 02/19/15 at 9:40 a.m., S1Administrator indicated the hospital did not have policies and procedures for Human Resources. She further indicated that she was told when she was hired that the "Employee Handbook" was used in place of policies and procedures.

In an interview on 02/19/15 at 3:10 p.m., S1Administrator had no explanation when informed that review of the personnel files of S4PT, S13OT, and S14ST revealed no verification of current licensure, no evaluation of competency, and no 90 day performance evaluation or annual performance evaluations. She further offered no explanation when informed that the "Employee Handbook" didn't address which employees were required to have CPR certification, whether licenses were to be verified other than by visual inspection of the license, and the frequency at which performance evaluations were to be conducted.

Based on record reviews and interviews, the hospital failed to ensure rehabilitation (rehab services were provided under the orders of a physician and according to hospital policies and procedures. There was no documented evidence that the physician signed the orders for rehab services prior to treatment being initiated, of frequency and/or duration for services, and/or the plan of care for 5 (#1, #3, #5, #R1, #R7) of 6 patient records reviewed with physician orders for rehab services (#1, #2, #3, #5, #R1, #R7) from a total sample of 5 patients and 8 random patients.
Findings:

Review of the hospital policy titled "Physical Therapy Service Request for Inpatients", presented as a current policy by S1Administrator, revealed that physical therapy (PT) orders should contain a working diagnosis, any precautions or contraindications, treatment plans, goals, and frequency and duration of treatment. Further review revealed that any order that does not contain all of the above information will be considered an order for an evaluation. The therapist will evaluate the patient and consult with the referring physician to develop an appropriate treatment plan and goals as needed.

Review of the hospital policy titled "Occupational Therapy Department Progress Notes", presented as a current policy by S1Administrator, revealed that the initial occupational therapy (OT) evaluation would include subjective information that includes what the patient states relevant to his problem and his goals for OT, objective information that includes the evaluation, the assessment that includes conclusions drawn for the subjective and objective information, and the plan that includes goals and the treatment plan. There was no documented evidence that the policy addressed the need for the duration and frequency of treatment to be included in the evaluation as well as the physician orders.

Review of the hospital policy titled "Speech Pathology Policies & (and) Procedures Documentation", presented as a current policy by S1Administrator, revealed that the findings of the assessment procedures would be categorized under the headings of history, objective, assessment, and plan of therapy. The assessment portion of the evaluation should state the patient's specific speech diagnosis, and short and long-term goals should be stated in measurable and functional language. Further review revealed that the plan of therapy should outline the speech therapy program to be initiated, provide the frequency of therapy sessions, and the timeframe for achievement of the plan. There was no documented evidence that the policy required the evaluation, plan of care, and duration and frequency of services to be ordered by the physician.

Patient #1
Review of Patient #1's medical record revealed she was a 61 year old female admitted on 02/03/15 with diagnoses of Debility, Burns, Wound Infection (Scalp), Respiratory Failure, and Sepsis. Further review revealed she had physician orders on 02/03/15 at 1:00 p.m. for a PT and OT evaluation. Further review revealed a physician's order on 02/11/15 at 8:50 a.m. to consult ST for evaluation. There was documentation on the physician order sheet on 02/12/15 at 2:00 p.m. by S14ST of "ST: ST evaluation completed. Pt. (patient) may have ice chips sparingly for pleasure. Sit pt. up at or near 90 [degrees] when administering ice chips. There was no documented evidence that this ST order was received verbally from a physician.

Review of Patient #1's medical record on 02/18/15 at 11:15 a.m. revealed no documented evidence of the ST evaluation that was performed on 02/12/15 (as noted by documentation on the physician order sheet on 02/12/15 at 2:00 p.m. by S14ST). A request was made to S1Administrator for documentation of Patient #1's ST evaluation. A second request was made of S1Administrator on 02/18/15 at 3:20 p.m. for Patient #1's ST evaluation.

Review of Patient #1's ST evaluation, presented by S1Administrator after the second request was made, revealed the start of care date was 02/11/15, the frequency was 3x/wk (3 times per week) for 30 days, and the plan of care was dysphagia evaluation, oral function therapy, sensory integration activity, and neuromuscular re-education. There was no documented evidence that a physician had signed the evaluation that included the frequency, duration, goals, and plan of care prior to Patient #1 receiving PT services on 02/16/15 and 02/18/15 as required by hospital policy.

In a telephone interview on 02/19/15 at 11:55 a.m., S14ST indicated she started Patient #1's ST evaluation on 02/11/15 and completed it on 02/12/15. She also indicated that she had conducted ST visits with Patient #1 on 02/11/15, 02/12/15, 02/16/15, and 02/18/15. She further indicated she documents a weekly ST note, separated by daily notes, and does a weekly summary. She offered no explanation for her ST evaluation not being in Patient #1's medical record at the time of review on 02/18/15 at 11:15 a.m. (6 days since the evaluation had been completed).

Review of Patient #1's PT evaluation completed by S4PT on 02/03/15 revealed her treatment diagnosis was Minimal weakness, her frequency and duration were 5x/wk through discharge, and her plan of care included evaluation, gait training when able, therapeutic exercises and activity, caregiver education and training, and safety education. Further review revealed S7MD (Medical Doctor) signed the evaluation with no documentation of the date that he signed the evaluation. There was no way to determine that S7MD signed Patient #1's PT plan of treatment prior to PT visits being conducted as required by hospital policy.

Review of Patient #1's OT evaluation completed on 02/03/15 by S13OT revealed her diagnosis was 2nd degree burns to the scalp/hands/head. There was no documented evidence of the duration and frequency of visits and the plan of care to be provided by S13OT when S7MD signed the OT evaluation on 02/03/15.

Patient #3
Review of Patient #3's medical record revealed she was a 60 year old female admitted on 01/28/15 with diagnoses of Non-Healing Left Foot Wound status post Amputation of Left 1st, 2nd, 3rd, and 4th Toes, Deconditioning, Vascular Occlusion, and Diabetes Mellitus. Review of her physician admit orders revealed an order for a PT and OT evaluation.

Review of Patient #3's PT evaluation conducted on 01/29/15 by S4PT revealed her frequency of PT services was to be 5 times a week until discharged, and her plan of care included evaluation, therapeutic activity and exercises, caregiver education and training, and safety education. Further review revealed S7MD signed the evaluation with no documentation of the date that he signed the evaluation. There was no way to determine that S7MD signed Patient #3's PT plan of treatment prior to PT visits being conducted as required by hospital policy.

Review of Patient #3's OT evaluation completed by S13OT on 01/29/15 included the diagnosis of Minimal weakness, and a frequency of 5x/wk. There was no documented evidence of the duration of visits and the plan of care to be provided by S13OT when S7MD signed the OT evaluation on 01/29/15.

Patient #5
Review of Patient #5's medical record revealed he was a 72 year old male admitted on 01/24/15 with diagnoses of Sepsis, Altered mental Status, Non-Healing Wound, Anemia, and Pseudomonas Infection to Scrotum. Further review revealed he was discharged on 02/07/15. Review of his admit physician orders revealed an order for a PT and OT evaluation.

Review of Patient #5's PT evaluation documented by S4PT on 01/26/15 revealed the frequency and duration were 5x/wk through discharge, and his plan of care included evaluation, therapeutic activity and exercises, caregiver education and training, and safety education. Further review revealed S7MD signed the evaluation with no documentation of the date that he signed the evaluation. There was no way to determine that S7MD signed Patient #5's PT plan of treatment prior to PT visits being conducted as required by hospital policy.

Review of Patient #5's OT evaluation completed by S13OT on 01/26/15 included the diagnosis of Minimal weakness, and a frequency of 5x/wk. There was no documented evidence of the duration of visits and the plan of care to be provided by S13OT when S7MD signed the OT evaluation on 01/26/15.

Patient #R1
Review of Patient #R1's medical record revealed she was a 55 year old female admitted on 02/11/15 with a diagnosis of Infected Non-Union Right Femoral Shaft with Hardware Removal. Review of her physician admit orders revealed an order for a PT and OT evaluation.

Review of Patient #R1's PT evaluation conducted on 02/12/15 by S4PT revealed her frequency of PT services was to be 5 times a week until discharge, and her plan of care included evaluation, gait training, and therapeutic activity and exercises. Further review revealed S7MD signed the evaluation with no documentation of the date that he signed the evaluation. There was no way to determine that S7MD signed Patient #R1's PT plan of treatment prior to PT visits being conducted as required by hospital policy.

Review of Patient #R1's OT evaluation completed by S13OT on 02/12/15 included the diagnosis of Minimal weakness, and a frequency of 5x/wk. There was no documented evidence of the duration of visits and the plan of care to be provided by S13OT when S7MD signed the OT evaluation on 02/12/15.

Patient #R7
Review of Patient #R7's medical record revealed she was a 48 year old female admitted on 02/13/15 with diagnoses of Urinary Tract Infection, Chronic Back Pain, and Bacteremia with Escherichia coli. Review of her physician admit orders revealed an order to consult PT and OT.

Review of Patient #R7's PT evaluation conducted on 02/16/15 by S4PT revealed the frequency of PT services was to be 5 times a week with no documented evidence of the duration, and her plan of care included evaluation, gait training, and therapeutic activity and exercises. Further review revealed S7MD signed the evaluation with no documentation of the date that he signed the evaluation. There was no way to determine that S7MD signed Patient #R7's PT plan of treatment prior to PT visits being conducted as required by hospital policy.

Review of Patient #R7's OT evaluation completed by S13OT on 02/14/15 included the diagnosis of Minimal weakness and a frequency of 5x/wk. There was no documented evidence of the duration of visits and the plan of care to be provided by S13OT when S7MD signed the OT evaluation on 02/14/15.

In an interview on 02/18/15 at 9:20 a.m., S7MD indicated he doesn't date or time his signature when he signs the PT and ST evaluations. He further indicated that he didn't remember when he signed the above-listed evaluations and couldn't be certain that he signed the plan of care before therapy was initiated as required by hospital policy. After reviewing the OT evaluations for patients listed above, S7MD confirmed that the OT evaluations did not include a duration of service or a plan of care to be administered by OT.

Based on record reviews and interviews, the hospital failed to ensure that all rehabilitation (rehab) services provided were documented in the patient's medical records in accordance with requirements at ?482.24 as evidenced by failing to have documentation of the speech therapy (ST) evaluation performed in the medical record for 1 (#1) of 1 patient with physician orders for a ST evaluation from a total of 6 (#1, #2, #3, #5, #R1, #R7) patient receiving rehab services.
Findings:

Review of "?482.24(c)(2)(vi) Content of Record - Orders, notes, reports" revealed the medical record must document all reports of treatment and other information necessary to monitor the patient's condition.

Review of Patient #1's medical record revealed she was a 61 year old female admitted on 02/03/15 with diagnoses of Debility, Burns, Wound Infection (Scalp), Respiratory Failure, and Sepsis. Further review revealed a physician's order on 02/11/15 at 8:50 a.m. to consult ST for evaluation. There was documentation on the physician order sheet on 02/12/15 at 2:00 p.m. by S14ST of "ST: ST evaluation completed. Pt. (patient) may have ice chips sparingly for pleasure. Sit pt. up at or near 90 [degrees] when administering ice chips. There was no documented evidence that this ST order was received verbally from a physician.

Review of Patient #1's medical record on 02/18/15 at 11:15 a.m. revealed no documented evidence of the ST evaluation that was performed on 02/12/15 (as noted by documentation on the physician order sheet on 02/12/15 at 2:00 p.m. by S14ST). A request was made to S1Administrator for documentation of Patient #1's ST evaluation. A second request was made of S1Administrator on 02/18/15 at 3:20 p.m. for Patient #1's ST evaluation.

Patient #1's ST evaluation was presented by S1Administrator after the second request was made.

In a telephone interview on 02/19/15 at 11:55 a.m., S14ST indicated she started Patient #1's ST evaluation on 02/11/15 and completed it on 02/12/15. She further indicated that she had conducted ST visits with Patient #1 on 02/11/15, 02/12/15, 02/16/15, and 02/18/15. She further indicated she documents a weekly ST note, separated by daily notes, and does a weekly summary. She offered no explanation for her ST evaluation not being in Patient #1's medical record at the time of review on 02/18/15 at 11:15 a.m. (6 days since the evaluation had been completed).