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Based on record review and interviews, this hospital did not demonstrate that the patient and/or family were involved in the care planning process in 8 of 10 (Patients #3, 4, 5, 6, 7, 8, 9, and 10) medical record reviews

Findings include:

Review of Lakeview Specialty Hospital and Rehab Hospital Patient and Family Handbook effective date April 14, 2003 revealed under "What to Expect after you arrive at Lakeview Specialty Hospital", Within 72 hours of admission: "Your Case Manager will record your social history and help develop an initial discharge plan" and "Case Managers will meet with patients within 72 hours of admission to develop a plan of care."

Per review of Patient #3's open medical record on 10/16/17 at 2:30 PM, revealed Patient #3 was admitted to the facility on 9/25/17 and remains a current patient. The Case Manager Notes state: "9/30/17 Intake completed with patient and friend in room."

Per review of Patient #4's open medical record on 10/16/17 at 2:50 PM, revealed Patient #4 was admitted to the facility on 10/6/17 and remains a current patient. The Case Manager Admission Evaluation and Case Manager Notes remain blank.

Per review of Patient #5's open medical record on 10/16/17 at 3:10 PM, revealed Patient #5 was admitted to the facility on 10/13/17 and remains a current patient. The Case Manager Admission Evaluation and Case Manager Notes remain blank.

Per review of Patient #6's open medical record on 10/17/17 at 9:30 AM, revealed Patient #6 was admitted to the facility on 9/25/17 and remains a current patient. The Case Manager Notes state: "9/30/17 Patient intake completed on this date."

Per review of Patient #7's open medical record on 10/17/17 at 10:35 AM, revealed Patient #7 was admitted to the facility on 10/3/17 and remains a current patient. The Case Manager Admission Evaluation and Case Manager Notes remain blank.

Per review of Patient #8's open medical record on 10/17/17 at 10:50 AM, revealed Patient #8 was admitted to the facility on 10/14/17 and remains a current patient. The Case Manager Admission Evaluation and Case Manager Notes remain blank.

Per review of Patient #9's open medical record on 10/17/17 at 11:15 AM, revealed Patient #9 was admitted to the facility on 8/10/17 and remains a current patient. The Case Manager Admission Evaluation and Case Manager Notes remain blank.

Per review of Patient #10's open medical record on 10/17/17 at 11:35 AM, revealed Patient #10 was admitted to the facility on 8/21/17 and remains a current patient. The Case Manager Notes state: "9/4/17 Writer spoke with Power of Attorney/brother and obtained intake information on patient."

During an interview with Chief Nursing Officer B, Quality Director C, and Chief Operating Officer D on 10/17/17 at 12:20 PM, Chief Nursing Officer B confirmed the Case Manager admission evaluation and notes were not completed or the forms were completed later than the 72 hours during review of the medical records. Chief Operating Officer stated, "The Case Managers should be completing the Admission Evaluation within 72 hours of admission, the Case Managers fell behind due to changes in staff, not surprised some have fallen through the cracks."

Based on record review and interview, the hospital failed to ensure that all patient/patient representatives were informed about the right to formulate an advanced directive in 8 of 10 (Patient #2, 3, 4, 5, 6, 7, 8, and 9) patient records reviewed.

Findings include:

Review or policy titled Advance Directives and Do Not Resuscitate Orders, policy #3.110, dated 12/16 revealed under, Procedure: revealed, "A. At the time of admission to the facility, the Director of Admissions or designee will inquire whether the patient has executed an Advance Directive and/or whether a surrogate or substitute decision-maker exists and will document such in on the "Acknowledgement and Signature" page of the admitting documents. If an Advanced Directive exists, the Director of Admissions or Designee will ask for a copy of the Advanced Directive or court order, as applicable. The Substitute Decision Maker must be informed that a copy of his/her authority, including proof of activation as appropriate, must be provided to the facility. B. If at the time of admission the patient does not have an Advanced Directives, the Director of Admissions or designee will offer information regarding advanced directives to the patient and his/her responsible party. The case manager assigned to the patient will follow up with the patient/family regarding the development of advanced directives."

Per review of patient #2's medical record on 10/16/17 at 2:00 PM, revealed the admission assessment under Advanced Directive, "Does the patient have an Advanced Directive", the question is left unanswered. "Was further information given to the patient/family", the question is left unanswered.

Per review of patient #3's medical record on 10/16/17 at 2:30 PM, revealed the admission assessment under Advanced Directive, "Does the patient have an Advanced Directive", the No box is marked. "Was further information given to the patient/family", the question is left unanswered.

Per review of patient #4's medical record on 10/16/17 at 2:50 PM, revealed the admission assessment under Advanced Directive, "Does the patient have an Advanced Directive", the No box is marked. "Was further information given to the patient/family", the question is left unanswered.

Per review of patient #5's medical record on 10/16/17 at 3:10 PM, revealed the admission assessment under Advanced Directive, "Does the patient have an Advanced Directive", the question is left unanswered. "Was further information given to the patient/family", the question is left unanswered.

Per review of patient #6's medical record on 10/17/17 at 9:30 AM, revealed the admission assessment under Advanced Directive, "Does the patient have an Advanced Directive", the No box is marked. "Was further information given to the patient/family", the question is left unanswered.

Per review of patient #7's medical record on 10/17/17 at 10:50 AM, revealed the admission assessment under Advanced Directive, "Does the patient have an Advanced Directive", the No box is marked. "Was further information given to the patient/family", the question is left unanswered.

Per review of patient #8's medical record on 10/17/17 at 10:35 AM, revealed the admission assessment under Advanced Directive, "Does the patient have an Advanced Directive", the No box is marked. "Was further information given to the patient/family", N/A is written.

Per review of patient #9's medical record on 10/17/17 at 11:15 AM, revealed the admission assessment under Advanced Directive, "Does the patient have an Advanced Directive", the Yes box is marked. "Is copy available", the question is left unanswered", "Advanced Directive on chart", the No box is marked.

During an interview with Chief Nursing Officer B, Quality Director C, and Chief Operating Officer D on 10/17/17 at 12:20 PM, Chief Nursing Officer B confirmed the advance directives information was not completed. Chief Operating Officer stated, "The staff should be completing all the questions on the admission assessment regarding advanced directives."

Based on record review and interview the facility failed to ensure that a comprehensive care plan that is individualized, and updated based on assessments of the patient's nursing care needs and has appropriate nursing interventions in 4 of 10 patients (patient's #1, 2, 4, and 6 ) medical records reviewed.

Findings include:

The facility policy titled Interdisciplinary Team Care Planning- Hospital, policy # 7.835, dated 8/13, revealed under Purpose: To develop, integrate, and coordinate the plan of treatment for persons served; to ensure adequate and timely care plan to meet the individual medical/rehabilitative needs... Under 14. The patient is reassessed on an ongoing basis and provides for recognizing progress towards goals and objectives and allows for revision of goals and objectives.

Review of patent #1's medical record on 10/16/17 at 12:40 PM revealed a Comprehensive Plan of Care initiated on 6/15/17 with the following problem listed, "Dependent on tube feeding for nutritional support and hydration with potential for complications". Review of the transfer log on 10/16/17 at 9:55 AM, patient #1 has been sent to the hospital to have the Gastro-Jejunal tube (small bore tube feeding) replaced due to being clogged on 7/19/17, 8/31/17, 9/15/17, and 9/20/17. There are no updates or added interventions to the care plan to prevent the feeding tube from clogging.

Review of patient #2's medical record on 10/16/17 at 2:00 PM revealed an Admission History and Physical completed on 9/22/17 indicated patient #2 was admitted following being "stabbed multiple times in her neck, chest, and shoulder. In fact, her left ear is badly injured since sutured up." Comprehensive Plan of Care has the following problem listed, "potential for pressure ulcer" instead of altered skin integrity.

Review of patient #4's medical record on 10/16/17 at 2:50 PM revealed on the Wound Care Document, "10/13/17 3:05 PM- Foley catheter discontinued due to tear at penile meatus". Comprehensive Plan of Care with the following problem listed, "At risk for complication related to indwelling foley catheter". Nursing staff continued to initial and date care plan (10/14/17 and 10/15/17) indicating the care plan was reviewed and remained current.

Review of patient #6's medical record on 10/17/17 at 9:30 AM revealed on the initial nursing care plan dated 9/25/17 that patient #6's had a decubitus ulcer on coccyx. The comprehensive plan of care initiated on 9/27/17 indicated patient #6 has the "Potential for pressure ulcers" instead of actual pressure ulcer or altered skin integrity.

Findings were confirmed with Chief Nursing Officer B on 10/17/17 at 12:30 PM. Chief Nursing Officer stated in an interview "the care plans should be updated and reflect the current status of the patients".

Based on record review and interview the staff failed to ensure verbal and telephone orders are authenticated by the physician within 48 hours in 6 of 10 medical records reviewed (Patient #2, 3, 4, 5, 6, and 10).

Findings include:

Review of policy titled Order Read Back Documentation- Hospital, policy #7.455, dated 12/16, revealed under Procedure: 4. A physician is required to sign the order within 48 hours.

Review of Patient 1's open medical record on 10/16/17 at 12:40 PM revealed a telephone order written on 9/20/17 at 10:30 PM and 9/21/17 at 6:00 PM, and was authenticated by the physician on 10/4/17. Telephone order written on 9/15/17 at 1:00 PM and was authenticated by the physician on 10/13/17. Telephone order written on 9/15/17 at 5:20 PM, and was authenticated by the physician on 10/5/17.

Review of Patient 2's medical record on 10/16/17 at 2:00 PM revealed a telephone order written on 9/22/17 at 8:00 PM was not authenticated by the physician.

Review of Patient 3's medical record on 10/16/17 at 2:30 PM revealed a telephone order written on 9/26/17 at 1:00 PM and was authenticated by the physician on 10/12/17.

Review of Patient 4's medical record on 10/16/17 at 2:50 PM revealed a telephone order written on 10/6/17 at 1:51 PM was not authenticated by the physician.

Review of Patient 5's medical record on 10/16/17 at 3:10 PM revealed a telephone order written on 10/15/17 at 5:20 PM was not authenticated by the physician.

Review of Patient 6's medical record on 10/17/17 at 9:30 AM revealed a telephone order written on 10/16/17 at 11:01 AM was not authenticated by the physician. A telephone order written on 10/1/17 at 5:30 PM was not authenticated by the physician.

Review of patient #10's medical record on 10/17/17 at 11:35 AM, revealed a telephone order written on 9/27/17 at 4:00 PM was not authenticated by the physician. A telephone order written on 10/12/17 at 3:50 PM was not authenticated by the physician.

Findings in medical records were confirmed with Chief Nursing Officer B on 10/17/17 at 12:20 PM. Per interview on 10/17/17 at 9:00 AM, Chief Nursing Officer B stated that all telephone orders should be authenticated by the physician within 48 hours.