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Based on review of documentation and interviews with staff, it was determined that the facility failed to ensure that specific confidentiality of patient record requirements were met.

Findings included:

A review of patient medical record #1 revealed the following:

Nurses notes dated 8/7/12 at 10:17pm revealed the nurse noted "I then told patient I need to go check on another pt (patient), moving (patient #2) who had fallen during the day shift..." The nurse documented in patient #1's medical record about patient #2. The nurse documented patient #2's name in another patient's medical record.

Review of facility document "Patient Rights and Responsibilities" stated "The Patient has the Right to: Expect full recognition of individuality, including privacy in treatment and care. In addition, all communications and records will be kept confidential."

In interviews the afternoon of 10/15/12 with the Chief Nursing Officer and the Chief Executive Officer, it was confirmed that the nurse documented patient #2's name and that the patient had fallen in patient #1's medical record. The facility staff concurred that this was a violation of patient #2's right to confidentiality.

Based on review of documentation and interviews with staff, it was determined that the facility failed to staff adequate number of nursing personnel for the care of patients.

Findings included:

A review of the following facility documentations revealed:

1. A review of the last Governing Body minutes dated 7/24/12 stated "nursing station vacant, need more nurse presents. Would like a visible employee for physician communication and would like staff available between 7am and 9am." Further review of the Governing Body minutes revealed that at the Medical Executive Committee Meeting the physicians discussed they wanted more staff available (10 nurses/2 techs for 55 patients).

2. Nurse's notes dated 8/7/12 at 9:30pm revealed patient #1 was assisted to the restroom, voided, and had a bowel movement. Documentation revealed that the staff didn't assisted patient #1 back to the bed until 9:55pm.

3. Nurses notes dated 8/7/12 at 10:17pm revealed the nurse noted "I then told patient I need to go check on another pt (patient), moving (patient #2) who had fallen during the day shift..."

Review of facility document "Nurse Staffing Plan" stated "Policy: It is the policy of the Nursing Service Department of HEALTHSOUTH of Arlington to support the provision of quality care in a safe, cost-effective manner by appropriately using qualified, skilled staff...There will be adequate numbers of Registered Nurses, Licensed Vocational Nurses and other personnel to provide nursing care to all patients."

In interviews the afternoon of 10/15/12 with the Chief Nursing Officer and the Chief Executive Officer, it was confirmed that the Governing Body had discussed physician concerns regarding the nurse staffing issues.

Based on review of documentation and interviews with staff, it was determined the nursing staff failed to supervised and evaluate the care of patient #1.

Findings included:

A review of the medical record of patient #1 revealed the following:

Patient #1 was a 54 year old who presented to HealthSouth Rehabilitation Hospital on 7/31/12 at 7:48pm. The History & Physical stated she was admitted from another facility and transferred to HealthSouth Rehab for acute inpatient rehabilitation. The patient had MS (Multiple Sclerosis) Exacerbation and would continue IV SoluMedrol for 5 days. The patient continued to complain of pain and stated that she takes IV Demerol. The patient had a history of congenital deformity right lower extremity in addition to other conditions. The nurse noted on 7/31/12 at 7:30pm that the patient's pain level was a 7 on a scale of 1 to 10.

1. Medication Administration Record (MAR) dated 7/31/12 revealed the nurse noted medications were given at 12:26am but the patient did not receive any medications to alleviate her pain. This was confirmed with the Chief Nursing Officer the afternoon of 10/15/12.

2. Physician Progress dated 8/8/12 revealed that the patient stated she had a reaction to the Fentanyl Patch. Patient #1 stated she felt "overmedicated and itchy." The physician documented the patient did not have a rash. Documentation revealed the patient removed the patch. The physician documented that he would discontinue the Fentanyl Patch.

3. A review of the Medication Administration Record revealed the Fentanyl Patch was not discontinued as per the physician's orders.

Review of facility document "Pain Management Assessment Care and Documentation" stated "The purpose of pain management is to provide for a pro-active interdisciplinary approach that ensures the highest level of comfort for patients by: 1. Minimizing the intensity, duration, and the physiologic cost of pain. 2. Promoting an optimal level of function and maximizing the patient's ability to participate in the rehabilitation program."

Review of facility document "Medication Administration Record" stated "2. The MAR will be initiated on admission and updated for each patient as new orders are written."

In interviews the afternoon of 10/15/12 with the Chief Nursing Officer and the Chief Executive Officer, it was confirmed that the patient#1 did not received any medication for pain. It was also confirmed that patient #1 voiced concerns regarding a medication reaction, the physician discontinued the Fentanyl Patch, and the nurse ' s failed to follow the physician's order.