HospitalInspections.org

Based on review of policies, procedures, medical records, hospital documents, and interviews with staff and patient families, the Administration staff at the Long Term Acute Care Hospital (LTACH) failed to ensure staff protected and promoted each patient's rights.

1. Failure to provide patient's and/or their representative of their Rights and Responsibilities. (Refer to A 117)

2. Failure to obtain a consent for admission and treatment upon admission from the patient or the designated authorized person(s) prior to the patient receiving care and services. (Refer to A131)

3. Failure to inform patients and/or their representative of Advanced Directives, review and affirm the Do Not Resuscitate (DNR) status for patients upon admission to the hospital. (Refer to 132)

4. Failure to complete the mandatory requests for clearance of conviction for all personnel prior to employment. (Refer to A145)


The cumulative effect of these systemic failures and deficient practices resulted in the hospital's failure to ensure patient's and/or family members received their patient rights upon admission, reviewed and consented to medical treatment options.

Based on review of policies, documents, medical records, staff and family interviews, the Administration staff failed to have a system in place to ensure staff obtained physician orders for nursing care and services to provide treatments for all patients with multiple medical diagnoses. The Chief Nursing Officer (CNO) identified an average daily census of 24 patients.

Failure of the Administration staff to ensure the nursing staff obtained physician's orders for treatments, procedures and to communicate patient needs to other members of the interdisciplinary team could potentially result in poor outcomes for patients including death.

1. Administration staff failed to ensure staff were aware of their responsibilities during patient admissions. (Refer to A 386)

2. The House Supervisor failed to monitor and evaluate the nursing care provided to Patient #8 and as a result the patient did not receive enteral NG feedings for 12 hours to maintain fluid and nutrition status. (Refer to A 395)

3. Nursing staff failed to obtain a physician's order for a Do Not Resuscitate (DNR) status upon Patient #8's admission. (Refer to A 395)

4. The House Supervisor failed to maintain all physician orders in the patients' medical records. (Refer to A 386)

5. Nursing staff failed to obtain a physician's order for an NPO (nothing by mouth) diet for a patient who had been NPO for 2 weeks prior to admission. (Refer to A 395)

6. Nursing staff failed to follow a physician's order for Patient #8's oxygen saturation status and failed to clarify discharge summary respiratory orders with the patient's physician upon admission for 3 hours after the patient's admission. (Refer to A 395)

7. Nursing staff failed to follow physicians orders for telemetry services for Patient #27 resulting in a period of 5 days when the patient's cardiac status was not monitored. (Refer to A 395)

The cumulative effect of these systemic failures and deficient practices resulted in the hospital's inability to ensure patient needs were met by following physician orders.

Based on review of policies, document, medical records and staff interview the Long Term Acute Care Hospital (LTACH) Administration staff failed to ensure the LTACH had a system in place to ensure all patients received respiratory therapy when prescribed by the physician and to ensure staff followed physician orders for respiratory services for 2 of 10 patient reviewed (Patient #8 and Patient #23). The Chief Nursing Officer (CNO) identified an average daily census of 24 patients.

Failure to to have a system in place to ensure all patients received respiratory therapy when prescribed by the physician and to ensure staff followed physician orders for respiratory services could potentially result in a patient's rapid decline in respiratory status and/or death.

Findings include:

1. Review of a hospital document titled, " LTACH Scope and Services" included in part, "...Our expertise extends to patients who have the following: COPD (Chronic Obstructive Pulmonary Disease) ...Acute respiratory ailments...Pneumonia (Infection that inflames one or both of the air sacs in one or both of the lungs.)....Consider these specialty programs... complex respiratory conditions...respiratory therapists available 24 hours a day, seven days a week..."

2. Review of a policy titled, "Oxygen Administration" revised 3/06 included in part, ..."No oxygen can be initiated without a physician's order."

Review of policy titled, "Pulse Oximetry" (A device that measures the oxygen saturation of the arterial blood.) dated 3/8/06 included in part, "...common tool used to determine the gas exchange status of oxygen...Spot Check all patients with low flow O2 (oxygen) Nasal Cannula...on high flow nasal cannula..chart SpO2 (saturation of peripheral oxygen) on treatment flow sheet every 4 hours...Weaned from mechanical ventilation with trach (A tube placed through the neck into the trachea to provide a passage for a person to breath.)...capping...Chart Sp02 on treatment flow sheet every 4 hours..."

Review of a policy titled, "Assessment and Reassessment - Respiratory Therapy" revised 4/11 included in part, "...All patients receive a respiratory screen upon admission...those patients requiring less extensive therapy (ex: O2/mask, cannula) will be assessed within 8 hours of admission..."

Review of a policy titled, "Assessment and Reassessment - All Disciplines" revised 10/14 included in part, "...All patients receiving care or treatment at hospital will be assessed by qualified professionals...all nursing components of the initial data collection will be documented within 8 hours of admission. The initiation of the interdisciplinary team goals will be within 72 hours of admission..."

3. During an interview on 7/28/15 at 9:00 AM, the CNO reported when a patient is transferred and admitted to the LTACH on oxygen the staff would leave the patient on the same amount of oxygen that the patient arrived on. The CNO reported the respiratory therapist had up to 8 hours to assess and treat all patients after they are admitted. The CNO acknowledged Patient #8 arrived on 2 liters of oxygen via a nasal cannula and staff failed to provide oxygen monitoring to ensure Patient #8's oxygen level was at 88% or greater in accordance with the physician's order.

4. During an interview on 7/28/15 at 1:35 PM, the surveyor requested the patient discharge summaries from the transferring hospitals that House Supervisor Registered Nurse (RN) U reported he shredded. The Chief Executive Officer (CEO) reported she would request a copy of those documents from the transferring hospitals. The CEO did provide a copy of the discharge summary from the transferring hospitals for Patient #8 and #23.

a. Review of a document from the transferring hospital for Patient #8 titled, "Discharge Summary", dated 4/14/15 included in part, "...Verbal report given to [Practitioner A] by phone...Respiratory: NIPPV (Noninvasive positive pressure ventilation is a procedure when the patient wears a mask delivering continuous oxygen to keep their airway open and their oxygen level up to an acceptable level.) 10/5 centimeters with O2 (oxygen) at 6 L/min, flow rate to keep SpO2 88% or greater..." Documentation on the admission orders failed to show the above orders and staff failed to monitor and document Patient #8's oxygen level upon admission and throughout the patient's first 3 hours and 20 minutes at the LTACH (at that time the patient's oxygen level was 86%) to ensure the patient's oxygen level was at 88% or greater or if the patient required the NIPPV.

b. Review of a document from the transferring hospital for Patient #23 titled, "Discharge Summary" dated 3/27/15 included in part "...continue with incentive spirometry (A manual device used to perform breathing exercises and to measure how much air is inhaled in the person's lungs)..." Documentation on the admission orders failed to show the patient continued the use of an incentive spirometry.

5. Review of Patient #8's medical record revealed the following:

a. A document titled, "History and Physical" dated 4/14/15 included in part, "...Admission diagnosis Pneumonia, severe deconditioning, (To diminish physical strength and be weaken.) mycoplasma, (A bacteria found in the urinary and reproductive organs.) pneumonia... problem with volume overload and respiratory compromise...respiratory status is borderline... continues to have shortness of breath...oxygen in place..."

b. Review of document titled, "Nursing Admission Database" dated 4/14/15 at 1:00 PM included in part, "...lungs were coarse bilaterally...oxygen 2 liters nasal cannula..." Nursing staff failed to document the patient oxygen level upon admission and every 4 hours in accordance with the LTACH policy.

c. Review of a document titled, "Respiratory Therapy Initial Assessment and Care Plan" dated 4/14/15 at 4:20 PM stated in part, "...Respiratory Therapist evaluated and treated the patient 3 hours and 20 minutes after the patient was admitted. The patient's oxygen level was at 86%. The Respiratory Therapist increased the patient's oxygen to 3 liters per minute..." Documentation showed staff failed to evaluate and document Patient 8's oxygen level until 3 hours and 20 minutes after the patient was admitted.

6. Documentation revealed Patient #8's breathing suddenly changed on 4/15/15 at 1:10 AM. Patient was pale, irregular breathing, and although staff used an ambu bag (Self reinflating bag used as a manual resuscitator to deliver oxygen.) for ventilation the patient expired at 1:17 AM.

7. During an interview on 7/23/15 at 8:45 AM, Lead Respiratory Therapist W said she was not familiar with Patient #8. After reviewing the patient's document titled, "Respiratory Therapy Initial Assessment" she said the patient's respiratory rate at 36 was "a little" high. The SpO2 was low at 86% and the respiratory therapist adjusted the oxygen rate from 2 liters to 3 litters. Lead Respiratory Therapist W reported if accessory muscles are documented that would mean the patient is breathing fast and using muscles around the diaphragm because "they're" working harder to breathe. Respiratory Therapist W acknowledged the discharge summary from the transferring hospital had documented BiPap but it was not re-ordered when the patient was admitted to the LTACH. She said on 4/15/15 at 12:15 AM, when the patient's respiratory status declined rapidly, the respiratory therapist vented (The use of a manual resuscitator to assist with the person's breathing.) the patient with an Ambu Bag with 100% oxygen.

8. During an interview on 7/27/15 at 5:15 PM, Respiratory Therapist CC acknowledged Patient #8's medical record lacked a physician's order for oxygen services and SpO2 orders. Respiratory Therapist CC said nursing staff are able to monitor a patient's SpO2 at any time and in this case they should have at the very least checked the patients oxygen saturation level when the patient admitted for a baseline. She said given the patient's respiratory failure history, she would expect the nurses would check the patients oxygen saturation level.

9. During a telephone interview on 7/24/15 at 9:50 AM, Patient #8's representative said one of the main reasons they as a family choose to transfer their parent to Davenport was they were assured the hospital could provide BiPap services.

10. During an interview on 7/29/15 at 9:50 AM when asked why the House Supervisor did not add the physician order for oxygen to Patient #8's admission orders, House Supervisor Registered Nurse (RN) U stated, "For me that is a range order. I don't know what oxygen rate they came in on. If I write an order for less than what they are on when they arrive, then the staff may decrease the oxygen rate which could cause distress for the patient. When asked if the discharge summary showed additional respiratory therapy services ordered. House Supervisor RN U stated, "Bipap and it says 6 liters, that is two different things. It's unclear to me." When asked what RN U did with an unclear physician order RN U stated, "For me I'm just taking discharge orders and putting them on admission orders. It's up to the nurses and doctors to fill in what I don't have on the admission orders." When asked if RN U contacted the physician to verify all admission orders. RN U stated, "Not always."

11. During an interview on 7/29/15 at 3:30 PM with the CNO and CEO, the CNO acknowledged staff did not transfer all the physician orders from the patient's discharge summary and staff did not follow the physician orders. The CEO reported the House Supervisor is responsible to ensure all physician orders are transferred from the discharge summary onto the patient admission orders.


The cumulative effect of these systemic failures and deficient practices resulted in the hospital's inability to ensure patients received physician ordered respiratory therapy services.

Based on review of policies, procedures, personnel records, medical records, staff and family interviews, the Long Term Acute Care Hospital (LTACH) staff failed to inform the patient and/or the patient's legal representative of the Patient Rights and Responsibilities upon admission for 4 of 10 sampled patients reviewed (Patient #8, #11 #12, and Patient #14). The Chief Nursing Officer (CNO) identified an average daily census of 24 patients.

Failure to ensure staff provided patients and/or their legal representative with Patient Rights and Responsibilities upon admission may potentially result in the patients' lack of knowledge regarding their rights and their inability to exercise their rights in all aspects of their medical care and treatment.

Findings include:

1. Review of policy titled, "Patient Rights" revised 1/10 included in part, "...Every patient admitted to Hospital has certain rights and responsibilities. These rights are guaranteed and respected by the personnel of Hospital, but must also be adhered to by the physicians...each patient/family admitted to Hospital will receive a copy of the Patient Rights and Responsibilities policy upon admission..."

Review of policy titled, "Admission Process" revised 1/10, included in part, "...On the scheduled day of admission, the Admissions Coordinator...patient/responsible party will finalize any admission forms, consent forms and other relevant documentation..."

2. Review of hospital document titled, "LTACH Plan for the Provision of Patient Care" revised 2/13 included in part, "...Everyone admitted to the LTACH has both rights and responsibilities...Each patient/family will be given a copy of Patient Rights and Responsibilities upon admission....The interdisciplinary team will ensure that the patient and/or when appropriate, the family is provided education that enhances their knowledge...to fully benefit from the healthcare interventions provided by the LTACH..."

3. Review of medical records showed the following:

a. Patient #8's medical record lacked documented evidence showing staff provided notification of Patient Rights and Responsibilities upon admission to the hospital on 4/14/15 to the patient and/or family member.

b. Patient #11's medical record lacked documented evidence showing staff provided notification of Patient Rights and Responsibilities upon admission to the hospital on 4/14/15 to the patient and/or patient representative. Documentation showed on 4/14/15 Patient #11's representative gave a verbal consent for admission and treatment. However, documentation showed the patient representative signed the Patient Rights and Responsibilities documents on 4/24/15. (10 days after the patient was admitted)

c. Patient #12's medical record lacked documented evidence showing staff provided notification of Patient Rights and Responsibilities upon admission to the hospital on 4/16/15 to the patient. Documentation showed on 4/16/15 Patient #12 signed the consent for admission and treatment document. However, documentation showed the patient signed the Patient Rights and Responsibilities documents on 4/23/15. (7 days after the patient was admitted)

d. Patient #14's medical record lacked documented evidence staff provided notification of Patient Rights and Responsibilities upon admission on 6/4/15 to the patient and/or patient representative. Documentation showed on 6/4/15 the patient representative signed the consent for admission and treatment document. However, the Patient Rights and Responsibilities document displayed a sticker that read, "Patient expired prior to completing paperwork." Patient expired on 6/7/15 at 6:40 AM. (3 days after admission)

4. Review of personnel files revealed the following:

a. A document titled, "Admissions Coordinator" included in part, ..."Position summary...oversees the timely admission of each patient into the registration system and ensures all other admission forms are explained and signed by the patient/responsible party."

b. Admissions Coordinator X received training and education in general orientation in her position in the Admission Department on hire 10/27/11. The general orientation competency forms documented completion of the training requirements for patient rights on 12/5/11.

5. During a telephone interview on 7/22/15 at 11:25 AM, Patient #8's family member said although informally they were the legal representative for all medical decisions for their mother. The family member said the family was present when [Patient #8] was admitted on the afternoon of 4/14/15 and the family stayed until 4:00 PM that day. The family member reported at the time they arrived [Admissions Coordinator X] informed them they needed to review some admission information and would meet with them in the front lobby. The family member said they waited but [Admissions Coordinator X] never met with them. Patient #8's representative reported they did not receive a copy of the Patient's Rights and Responsibilities.

6. During a telephone interview on 7/27/15 at 3:35 PM, Admissions Coordinator X acknowledged she failed to inform and provide Patient #8 family member with their Patient Rights and Responsibilities information. She said she was planning on completing the paperwork portion with the family the next day but the patient passed away shortly after admission.

7. During an interview on 7/29/15 at approximately 1:45 PM, the Chief Nursing Officer stated the staff are expected to provide the Patient Rights and Responsibilities to patients or their legal representative upon admission in accordance with policy.

Based on review of policies, procedures, Medical Staff Rules and Regulations, personnel records, medical records, staff and patient representative interviews the Long Term Acute Care Hospital (LTACH) admissions staff failed to obtain an consent for admission and treatment upon admission for 1 of 10 patients reviewed (Patient #8). The Chief Nursing Officer (CNO) identified an average daily census of 24 patients.

Failure to obtain an consent for admission and treatment upon admission from the patient or the designated authorized person(s) prior to the patient receiving care and services resulted in patient receiving treatments and services without being fully informed of the nature and risks of the proposed treatments or the possible alternatives by the hospital's nursing and physician staff.

Findings include:

1. Review of policy titled, "Consents for Medical Treatment" revised 1/14 included in part, "...The hospital recognizes that the patient has the right to reasonable and informed participation in decisions involving his/her health care including collaboration with his/her physician in making these decisions...inpatient admissions - the admission consent from shall be signed by each patient seeking admission...whenever the patient's condition prevents the obtaining of the consent, every effort shall be made and documented to obtain the consent of the patient's legal representative prior to the procedure..."

Review of policy titled, "Admission Process" revised 1/8/2010 included in part, "...On the scheduled day of admission, the admission coordinator will be registered as an inpatient in the Hospital Registration system and patient/responsible part will finalize...consent forms..."

2. Review of a document titled, "Admissions Coordinator" revised 1/10, included in part, "...Oversees the timely admission of each patient into the registration system and ensures Consent to treat...are explained and signed by the patient/responsible party..."

Review of a document titled, "Medical Staff Rules and Regulations' dated 4/3/15 included in part, "...A general consent form, signed by or on behalf of every patient admitted to the Hospital, shall be obtained at the time of admission..."

3. Review of Patient #8's medical record showed on 4/14/15 at 12:38 PM, Admissions Coordinator X obtained a verbal consent from the patient's family member for admission and treatment. The document included in part, "...Patient currently has altered mental status and unable to participate in paper work. Spoke with [family member] who provided verbal consent to admit and treat..."

4. During a telephone interview on 7/22/15 at 11:25 AM, Patient #8's representative said the family was present when Patient #8 was admitted on the afternoon of 4/14/15 and that they stayed until 4:00 PM that day. The family member said they were informed when they arrived that the Admissions Coordinator needed to review some admission information and would meet with them in the front lobby. The family member said they waited however, Admissions Coordinator X never met with them. Patient #8's family member denied giving verbal consent for admission and treatment to Admissions Coordinator X. The family member stated, "If it's written in the medical record I did, that's not true."

5. During a telephone interview on 7/27/15 at 3:35 PM, Admissions Coordinator X said she recalled [Patient #8's family member] verbally consented for medical care and treatment on the day the patient was admitted 4/14/15. She reported it was unusually busy that day and thought she may have spoken with [Patient #8's family member] personally around 12:30 PM.

6. During an interview on 7/29/15 at approximately 1:45 PM, the Chief Nursing Officer stated the staff are expected to obtain a consent to admit and treat all patients from the patient or their legal representative upon admission in accordance with policy.

Based on review of policies, medical records, staff and family interviews the Long Term Acute Care Hospital (LTACH) admissions staff failed to review the Advanced Directives/Do Not Resuscitate (DNR) information with the patient and/or the patient's representative for 4 of 10 patients reviewed (Patient #8, #11, #12, and Patient #14). The Chief Nursing Officer (CNO) identified an average daily census of 24 patients.

Failure to inform patients and/or their representative of Advanced Directives and review to affirm the DNR status for patients upon admission to the hospital could potentially result in the staff' initiation of artificial ventilation when the patients respiratory status rapidly declined for those patients that wanted to be DNR status..

Findings include:

1. Review of policy titled, "Patient Rights" revised 5/13 included in part, "...The following Patient Rights Policy specifically applies to those patient admitted to the hospital in accordance with federal and state regulations...as the patient, must be informed of and understand what you may expect...Advanced Directives. You have the right to formulate advance directives and to have those directives followed. Forms are available in admissions and are reviewed with you prior to admission..."

Review of policy titled, "Admission Process" revised 1/10 included in part, ..."On the scheduled day of admission, the Admissions Coordinator will be registered as an inpatient in the Hospital Registration system and patient/responsible party will finalize any admission forms...other relevant documentation..."

Review of policy titled, "DNR, Cardiopulmonary Arrest, Directive for Care" revised 10/11 included in part, "...Any hospital staff member who receives information regarding the code status...of or about a patient at hospital must report that information to the physician caring for the patient..."

2. Review of Patient #8's medical record revealed the patient admitted to the LTACH on 4/14/15 at 12:30 PM. The medical record lacked documented evidence for the acknowledgment of advance directives. The form stated in part, "...Patient admitted 4/14/15 at 1:05 PM and expired 4/15/15 at 1:17 AM. Patient had altered mental status and was unable to participate in paperwork...." The document showed Admissions Coordinator X signed the form on 4/15/15 at 3:30 PM.

Further review of Patient 8's medical record revealed on 4/15/15 at 1:15 AM, the patient's breathing suddenly changed. Documentation showed the nursing and respiratory services staff used artificial means of resuscitation in the form of an Ambu bag (a manual resuscitator/self inflating bag that is commonly used to provide positive pressure ventilation to patients who are not breathing) for 2 minutes.

3. During a telephone interview on 7/22/14 at 11:25 AM, Patient #8's family member said the family was present when [Patient #8] was admitted on the afternoon of 4/14/15 and that they stayed until 4:00 PM that day. Patient #8's family member reported they informed nursing staff at the time of admission Patient #8 was a DNR. The family member said critical information was missing from Patient #8's medical record that resulted in a phone call on the morning of 4/15/15 from a nurse at the hospital asking what [Patient 8's] DNR status was. The family member stated because the staff were unaware of [Patient 8's] DNR status, they used an artificial means of resuscitation when [Patient #8's] breathing suddenly changed.

4. During a telephone interview on 7/27/15 at 3:35 PM, Admissions Coordinator X acknowledged she failed to inform and provide Patient #8's representative with the Advanced Directives information. She said she was planning on completing the paperwork portion with the family the next day but the patient passed away shortly after admission.

5. Review of Patient #11's medical record revealed the patient admitted to the LTACH on 4/14/15 at 1:00 PM. The document titled, "Acknowledgement for Advance Directives" signed by the patient's spouse on 4/24/15 (10 days after admission).

6. Review of Patient #12's medical record revealed the patient admitted to the LTACH on 4/16/15 at 3:03 PM. The document titled, "Acknowledgement for Advance Directives" signed by the patient on 4/23/15 (7 days after admission).

7. Review of Patient #14's medical record revealed the patient admitted to the LTACH on 6/4/15 at 5:05 PM. The medical record lacked documented evidence for the acknowledgment of advance directives. Documentation showed on 6/4/15 the patient representative signed the consent for admission and treatment document. However, the document titled, Acknowledgement for Advance Directive" displayed a sticker that read, "Patient expired prior to completing paperwork." Patient expired on 6/7/15 at 6:40 AM. (3 days after admission)

Based on review of policies, documents, and staff interview the Administration staff at the Long Term Acute Care Hospital (LTACH) failed to ensure staff submitted mandatory requests to the Iowa Department of Human Services (DHS) for clearance to hire 19 of 89 employees with a history of criminal conviction prior to their date of hire. (Staff A, B, C, D, E, F, G, H, I , J, K, L, M, N, O, P, Q, R, and S). The Chief Nursing Officer (CNO) identified an average daily census of 24 patients.

Failure to ensure staff submitted the mandatory requests and received clearance of convictions for 19 of 89 employees hired from 8/29/09 through 12/15/14 with a history of criminal conviction prior to their hire date could potentially result exploitation of dependent patients by staff who have a known history of a criminal conviction.

Findings include:

1. Review of policy titled, "Abuse, Neglect" revised 7/12 included in part, ..."employee screening: this involves background checks...for all employees...this will be completed during the hiring process by the human resources.

Review of policy titled, "References and Background Checks" revised 5/03 included in part, ..."any applicant who discloses they have been convicted of, or pleaded quilty or no contest to a felony or who's background check reveals a criminal history may not be hired without the review and approval of the Senior Vice President of Human Resources."

Review of a Iowa Administrative Code at 481-51.41 "Chapter 51 Criminal, dependent adult abuse, and child abuse record checks 481-51.41" dated 2/5/14 stated in part, "...51.41(2) Requirements for employer prior to employing an individual...Prior to employment of a person in a hospital...request that the department of public safety perform a criminal history check...perform child and dependent adult abuse record checks of the person in this state...If a person considered for employment has been convicted of a crime...the department of public safety shall notify the hospital that upon request of the hospital the department of human services will perform an evaluation to determine whether the founded child or dependent adult abuse warrants prohibition of employment in the hospital..."

Both policies lacked the state and federal guidelines for submitting mandatory requests to the Iowa Department of Human Services (DHS) for clearance to hire personnel with a history of criminal conviction prior to employment.


2. Review of personnel files on 7/28/15 at 11:00 AM showed the following:

a. On 7/21/13 staff completed a criminal and dependent adult abuse background check for Staff A. The background check returned on 7/31/13 with a positive criminal history. Staff A's personnel file lacked documented evidence that showed staff submitted a mandatory request to DHS for a clearance to hire prior to Staff A's hire date 8/19/13.

b. On 5/09/12 staff completed a criminal and dependent adult abuse background check for Staff B. The background check returned on 5/10/12 with a positive criminal history. Staff B's personnel file lacked documented evidence that showed staff submitted a mandatory request to DHS for a clearance to hire prior to Staff B's hire date 5/15/12.

c. On 7/09/14 staff completed a criminal and dependent adult abuse background check for Staff C. The background check returned on 12/11/12 with a positive criminal history. Staff C's personnel file lacked documented evidence that showed staff submitted a mandatory request to DHS for a clearance to hire prior to Staff C's hire date 12/15/14.

d. On 7/19/12 staff completed a criminal and dependent adult abuse background check for Staff D. The background check returned on 7/24/12 with a positive criminal history. Staff D's personnel file lacked documented evidence that showed staff submitted a mandatory request to DHS for a clearance to hire prior to Staff D's hire date 8/13/12.

e. On 3/24/10 staff completed a criminal and dependent adult abuse background check for Staff E. The background check returned on 3/25/10 with a positive criminal history. Staff E's personnel file lacked documented evidence that showed staff submitted a mandatory request to DHS for a clearance to hire prior to Staff E's hire date 4/5/10.

f. On 7/11/14 staff completed a criminal and dependent adult abuse background check for Staff F. The background check returned on 7/11/14 with a positive criminal history. Staff F's personnel file lacked documented evidence that showed staff submitted a mandatory request to DHS for a clearance to hire prior to Staff F's hire date 7/28/14.

g. On 9/16/11 staff completed a criminal and dependent adult abuse background check for Staff G. The background check returned on 9/19/11 with a positive criminal history. Staff G's personnel file lacked documented evidence that showed staff submitted a mandatory request to DHS for a clearance to hire prior to Staff G's hire date 10/17/11.

h. On 10/30/13 staff completed a criminal and dependent adult abuse background check for Staff H. The background check returned on 11/6/13 with a positive criminal history. Staff H's personnel file lacked documented evidence that showed staff submitted a mandatory request to DHS for a clearance to hire prior to Staff H's hire date 12/9/13.

i. On 3/15/11 staff completed a criminal and dependent adult abuse background check for Staff I. The background check returned on 3/18/11 with a positive criminal history. Staff I's personnel file lacked documented evidence that showed staff submitted a mandatory request to DHS for a clearance to hire prior to Staff I's hire date 4/11/11.

j. On 12/13/09 staff completed a criminal and dependent adult abuse background check for Staff J. The background check returned on 12/18/09 with a positive criminal history. Staff J's personnel file lacked documented evidence that showed staff submitted a mandatory request to DHS for a clearance to hire prior to Staff J's hire date 12/22/09.

k. On 5/7/13 staff completed a criminal and dependent adult abuse background check for Staff K. The background check returned on 5/17/13 with a positive criminal history. Staff K's personnel file lacked documented evidence that showed staff submitted a mandatory request to DHS for a clearance to hire prior to Staff K's hire date 5/21/13.

l. On 8/27/09 staff completed a criminal and dependent adult abuse background check for Staff L. The background check returned on 8/28/09 with a positive criminal history. Staff L's personnel file lacked documented evidence that showed staff submitted a mandatory request to DHS for a clearance to hire prior to Staff L's hire date 8/29/09.

m. On 8/31/11 staff completed a criminal and dependent adult abuse background check for Staff M. The background check returned on 9/4/11 with a positive criminal history. Staff M's personnel file lacked documented evidence that showed staff submitted a mandatory request to DHS for a clearance to hire prior to Staff M's hire date 9/19/11.

n. On 2/11/13 staff completed a criminal and dependent adult abuse background check for Staff N. The background check returned on 2/28/13 with a positive criminal history. Staff N's personnel file lacked documented evidence that showed staff submitted a mandatory request to DHS for a clearance to hire prior to Staff N's hire date 3/4/13.

o. On 3/15/13 staff completed a criminal and dependent adult abuse background check for Staff O. The background check returned on 3/21/13 with a positive criminal history. Staff O's personnel file lacked documented evidence that showed staff submitted a mandatory request to DHS for a clearance to hire prior to Staff O's hire date 4/1/13.

p. On 3/14/14 staff completed a criminal and dependent adult abuse background check for Staff P. The background check returned on 3/20/14 with a positive criminal history. Staff P's personnel file lacked documented evidence that showed staff submitted a mandatory request to DHS for a clearance to hire prior to Staff P's hire date 3/24/14.

q. On 2/6/12 staff completed a criminal and dependent adult abuse background check for Staff Q. The background check returned on 2/7/12 with a positive criminal history. Staff Q's personnel file lacked documented evidence that showed staff submitted a mandatory request to DHS for a clearance to hire prior to Staff Q's hire date 2/6/12.

r. On 11/9/10 staff completed a criminal and dependent adult abuse background check for Staff R. The background check returned on 11/10/10 with a positive criminal history. Staff R's personnel file lacked documented evidence that showed staff submitted a mandatory request to DHS for a clearance to hire prior to Staff R's hire date 12/2/10.

s. On 5/19/10 staff completed a criminal and dependent adult abuse background check for Staff S. The background check returned on 5/24/10 with a positive criminal history. Staff S's personnel file lacked documented evidence that showed staff submitted a mandatory request to DHS for a clearance to hire prior to Staff S's hire date 6/21/10.

3. During an interview on 7/28/15 at 11:10 AM, Human Resources (HR) Director T, acknowledged Staff A's personnel file lacked the mandatory request for clearance from DHS. HR Director T said when she began her position as HR Director in June of 2015 she identified they had not completed the required clearance checks for employees prior to employment and they had not completed them for several years. HR Director T said when she discovered the error she began submitting mandatory requests to DHS for clearance for all new employees with a history of criminal conviction prior to employment.

During a follow up interview on 7/29/15 at 2:15 PM, HR Director T provided a document that identified an 17 additional staff who lacked a mandatory request to DHS for clearance prior to employment.

4. Review of documents dated 7/30/15 included in part, ..."An audit was performed on 7/29/15 (during the survey) of...current employees of the hospital...18 were identified as having a criminal background that was not submitted to the Iowa Department of Human Services for clearance....while Select does have a policy that requires criminal background checks for all new hires, this policy will be amended to require that any personnel seeking employment in our hospital who has a criminal conviction other that a simple misdemeanor will be submitted to the Iowa Department of Human Services for clearance...[Chief Executive Officer (CEO) signature]..."

5. During an interview on 7/29/15 at 3:00 PM, the CEO reported she was unaware of requirement for the mandatory requests to DHS for clearance prior to staff's employment. The CEO the 18 current employees without the mandatory clearance request to DHS for clearance would not be working at the hospital until the clearance was received.

Based on review of policies, medical records, documents, and staff interview the Long Term Acute Care Hospital (LTACH) Administration staff lacked a plan of delineation of licensed staff responsibilities for patient admissions to the LTACH to ensure licensed staff were aware of their responsibilities during patient admissions. The Chief Nursing Officer (CNO) identified an average daily census of 24 patients.

Failure to have a plan of delineation of responsibilities for licensed staff's responsibilities to ensure all licensed staff were aware of their responsibilities during each patient's admission to the LTACH resulted in the disregard of physician transfer orders for patients could potentially result in severe illness and/or death.

Findings include:

1. Review of hospital document titled, "Job Description House Supervisor" Revised 7/25/15 included in part, "...Ensures documentation meets Select standards including shift assignments,restraints, pain, care planning, medications, and graphics..." The document failed to include the responsibility of processing patient admissions.

Review of hospital document titled, Job Description Registered Nurse" Revised 2/10/2014 included in part, "...Receives admissions and/or transfers to the unit...Assures that medical orders are transcribed and processed accurately...Assures that documents in the medical record are complete, factual, accurate and timely.

2. During a telephone interview on 7/27/15 at 1:50 PM when asked who was responsible to complete patient admission orders, Practitioner A, a physician, stated, "The House Supervisor writes the orders, the doctor reviews the order and co-signs the orders."

3. During an interview on 7/28/15 at 9:50 AM, the House Supervisor RN U reported it is not his responsibility to complete the patient admission orders for a patient that is transferred and admitted to the LTACH. RN U stated, "I am doing this more for the medications. I don't know the rest of the stuff. If I find other stuff I just help out and fill them in." RN U stated, "It's not in my job description. I did this to help out. I want to make sure we have the patient medications available when the patient arrives." The House Supervisor was unaware he should maintain the faxed discharge summary with physician orders in the patients' medical records. House Supervisor RN U reported he shredded all faxed discharge summaries that contained physician orders. (Refer to A 438 and A 467)

4. During an interview on 7/28/15 at 3:35 PM Registered Nurse (RN) Y reported the admission orders were completed prior to patient's arrival at the LTACH. RN Y stated, "Generally the admission orders are filled out by the House Supervisor from the information faxed over before the patient comes."

During an interview on 7/28/15 at 3:50 PM House Supervisor RN BB reported staff used the admission orders to take care of the patient. House Supervisor RN BB agreed they fill out the admission orders for the nurses before the patient arrives.

During an interview on 7/29/15 at 1:35 PM the Chief Executive Officer (CEO) reported the LTACH had policies and procedures in place however, she acknowledged the lack of documented evidence of a system in place to ensure staff were aware of their responsibilities during patient admissions. The CEO reported the House Supervisor is responsible to complete the admission orders for patients.

I. Based on review of hospital documents, medical records and staff interview the Long Term Acute Care Hospital (LTACH) Administrative staff failed to ensure the nursing staff supervised and evaluated the nursing care services provided to 1 of 1 patient dependent on nasogastric (NG) feedings (The delivery of nutrients from the nasal route into stomach via a feeding tube.) to ensure the patient maintained nutrition (Patient #8). The Chief Nursing Officer (CNO) identified an average daily census of 24 patients.

Failure to ensure the nursing staff supervised and evaluated nursing care services for all patients resulted in a lack of nutrition/sustenance for Patient #8 for a total of 12 hours. The patient was unable to receive food or fluids by mouth and was dependent on the NG feedings to maintain fluid and nutrition status.

Findings include:

The CNO identified a census of 24 patients on 4/14/14 and a total of 6 patients receiving NG tube feedings and a monthly average of 10 patients receiving NG feedings.

1. Review of a document titled, "Job Description House Supervisor" revised 7/25/15 included in part, ..."The House Supervisor's main purpose is to administer and supervise the clinical care provided on the assigned shift and ensure all clinical services policies, procedures, and objectives are maintained...effectively manages resources during assigned shift...constantly manages work place to ensure all company policies and procedures are being maintained...performs rounds on all patients to ensure adherence to standards...assists with monitoring staff performance."

2. Review of a document titled, "Scope and Services" included in part, ..."Our patients tend to be chronically ill with multiple medical concerns. We provide extended acute hospital care and therapy to medically complex patients who need more time to meet their recovery goals...We specialize in...Medically Complex Treatment...the following list is a sample of medically necessary treatment/interventions to consider when referring a patient for potential admission...enteral feedings."

3. Review of the hospital document titled, "LTACH Plan for the Provision of Patient Care" revised 2/13 revealed the following in part, ..."Patient Care Goals...to continue the healing process of the catastrophically ill patient in a safe environment where a comprehensive clinical team approach will provide care."

4. Review of Patient #8's medical record revealed the following:

a. A document titled, "Nutrition Visit Summary" from the transferring hospital dated 4/6/15 included in part, "...Nothing by mouth (NPO) since about 3/31/15 with admission locally, not responsive since 4/3/15. Jevity (high-protein, fiber-fortified formula that provides complete, balanced Nutrition for tube feeding) feedings started today. She is now hypernatremic (an electrolyte imbalance and is indicated by a high level of sodium in the blood)...."

b. A document titled, "History and Physical" dated 4/14/15 Physician A's documentation included in part, ..."The patient was transferred here to continue...plan of care....very frail-looking... has tube feeding in place...is malnourished...is not eating...might have some dysphasia (difficulty or discomfort in swallowing)...

c. A document titled, "Admission Orders" dated 4/14/15 included in part, "...Tube feeding and rate: Jevity at 40 milliliters (ml) per hour with 25 cubic centimeters) cc flush after feeding..."

d. A document titled, "24 Hour Patient Record and Plan of Care" dated 4/14/15 included in part, "...diet NPO, enteral (by way of the gastrointestinal tract) feedings of jevity at 40 ml per hour..." Documentation showed Patient #8 received a total of 68 ml (milliliters) of jevity enteral feeding via the NG during a 12 hour period of time instead of jevity enteral feeding at 40 ml every hour in accordance with the physician's order. Nursing staff failed to document why they failed to provide the physician ordered NG feedings or how the patient responded to no nutritional services for an extended period of time. The medical record lacked documented evidence of physician notification or reason why the feedings were withheld from the patient.

5. During an interview on 7/24/15 at 7:40 AM, RN Z said she received report form RN Y at approximately 7:30 PM on 4/14/15 regarding Patient #8. She said she remembered Patient #8 was a complex patient with severe malnutrition. RN Z said when she started the shift the patient's NG feedings were not running because there were no feeding pumps available. RN Z reported she planned on starting the feedings later on in the shift when she located a working feeding pump. RN Z said she told House Supervisor RN BB and the Certified Nursing Assistant (CNA) staff to "keep an eye out" for a feeding pump. RN Z said when Patient #8 pulled out her NG tube at 11:00 PM is when she realized they did not administer the jevity tube feedings and the patient had not received any fluids.

6. During an interview on 7/24/15 at 9:00 AM, House Supervisor RN BB said when a patient is admitted with an order for NG tube feedings they should be started within an hour after admission. She said she did not recall if staff informed her the feeding did not run during the shift because nursing staff could not locate another feeding pump. During a follow up telephone interview on 7/28/15 at 3:55 PM, House Supervisor RN BB confirmed the hospital had an ample supply of feeding pumps in house and it shouldn't of been a problem to replace a feeding pump that was not working. She acknowledged as the house supervisor she is responsible for assisting nursing staff throughout the hospital to ensure continuity of care and services to all patients.

7. During an interview on 7/24/15 at 9:40 AM, House Supervisor RN U, confirmed he completed the admission orders for Patient #8 on 4/14/15. He said he was aware the nursing staff were having problems with the NG pump shortly after the patient was admitted. RN U reported he had assigned the patient to RN Y and "assumed" she took care of the problem. House Supervisor RN U said he knew the hospital had additional feeding pumps in the facility that were available to nursing staff. He said "ultimately" he is responsible to make sure things are "running smoothly" and he should have "followed" up with RN Y.

8. During an interview on 7/27/15 at 10:15 AM, RN Y said after House Supervisor RN U completed the admission orders and she "hurriedly" noted the orders. She said she remembered Patient #8 being extremely emaciated (abnormally thin or weak, especially because of illness or a lack of food) and cachexic (weakness and wasting of the body due to severe chronic illness). RN Y said "There were problems with the feeding pump however, I was so inundated with a heavy load of patients and I was pulled thin." RN Y reported she told CNA N to locate another feeding pump. She said until the CNO spoke with her the next day she didn't realize that the patient had only received 68 ml of jevity during her shift. She said she gave a verbal report to RN Z when the shift ended but did not remember if she told her that the feeding pump wasn't working. RN Y acknowledged she failed to follow up with the CNA staff to ensure another feeding pump was found. RN Y agreed she failed to follow the physician's orders for jevity feedings for Patient #8, and failed to document why the feedings were withheld from the patient for an extended period of time.

9. During an interview on 7/27/15 at 11:10 AM, Registered Dietician (RD) ZZ said from a dietician's standpoint "we never like to see a tube feeding held or not given."

10. During an interview on 7/27/15 at noon, CNA N said she did not recall wether or not RN Z told her to locate a feeding pump on 4/14/15 for Patient #8.

11. During an interview on 7/24/15 at approximately 10:00 AM, the CNO reported there were feeding pumps available for patient use on 7/14/15. The CNO provided a document titled, "Equipment Detail" dated 7/24/15 that showed there were a total of 19 feeding pumps available for use on 4/14/15.

II. Based on review of policies, documents, medical records, and staff interview Long Term Acute Care Hospital (LTACH) nursing staff failed to follow physicians orders for telemetry monitoring for 1 of 1 physician ordered telemetry monitoring (A remote cardiac monitoring system to monitor a persons heart rate, pulse, and respirations.) patients reviewed.(Patient #27). The Chief Nursing Officer (CNO) identified an average daily census of 24 patients.

Failure to ensure licensed staff followed physicians orders to provide telemetry monitoring for patients could potentially result in staff's failure to identify and report patient's cardiac rhythm changes if needed. Failure to monitor patient's cardiac status for any significant change in the patient's cardiac rhythm could potentially result in the delay of treatment and/or medical intervention if needed and could result in severe illness and/or a patient's death.

Findings include:

1. Review of policy titled, "Orders, Physician" revised 1/14 included in part, "...to provide a systematic method of...implementing physician's orders...all physician's orders will be written...reviewed and carried out appropriately by facility staff..."

Review of policy titled, "Telemetry, Alarms, Prioritization" revised 10/14 included in part, "...to clarify telemetry monitoring requirements, ensure patient safety...indications for telemetry: absolute (must be on telemetry monitoring)...a physician order...analysis, documentation and notification...a rhythm strip will be analyzed and posted a minimum of every shift. All rhythm interpretations will be validated by a monitor competent Registered Nurse (RN)...rhythm changes...are considered a significant change and require further assessment, documentation, and notification of the physician at a minimum..."

Review of policy titled, "Documentation Standards" revised 4/11 included in part, "...Patients on telemetry will have a telemetry strip documented at the beginning of each shift and any time during the shift when a change in the heart rhythm is noted..."

2. Review of Patient #27's medical record revealed the following:

a. Patient #27 admitted on 5/7/15 with an acute exacerbation of bronchiectasis,(A syndrome of chronic cough and daily viscid (covered with sticky or clammy coating) sputum production associated with airway dilatation and bronchial wall thickening. severe protein-calorie malnutrition, and muscle weakness. The patient's other pertinent diagnosis are coronary artery disease, (A narrowing or blockage of small blood vessels that provide oxygen and nutrients to the heart.) neuropathy,( A result of damage to the peripheral nerves often casing weakness, numbness, and pain, usually in your hands and feet.) to the hyperlipidemia, (The presence of excess fats or lipids in the blood.) and pulmonary sarcoldosis. (An inflammatory disease that affects multiple organs in the body, but mostly the lungs and lymph glands.)

b. A physician's admission order for telemetry monitoring dated 5/7/15 when the patient admitted to the LTACH.

c. Patient #27's medical record lacked documented evidence staff provided telemetry monitoring from date of admission on 5/7/15 to 5/12/15 (5 days) and from 5/29/15 to 7/12/15.

d. During an interview on 7/29/15 at 11:50 AM, the CNO acknowledged staff failed to follow the physician's order to provide telemetry monitoring for Patient #27.


III. Based on review of policies, medical record, staff and family interviews, the Long Term Acute Care Hospital (LTACH) licensed staff failed to obtain a Do Not Resuscitate (DNR) physician's order upon admission for 1 of 10 patients reviewed. (Patient #8).

Failure to ensure staff obtained a physician's order for a patient's DNR status resulted in staff initiating artificial means of respirations when the patient's respiratory status suddenly changed.

Findings include:

1. Review of policy titled, "Orders, Physician" revised 1/14 included in part, "...the licensed nurse will notify the attending physician within one hour of the arrival of a new patient regarding the need for orders...the licensed nurse will contact the Licensed Independent Practitioner if an order is in any way incomplete or questionable..."

2. Review of Patient #8's LTACH medical record revealed the following:

a. A document titled, "Physician's Orders" revealed admission orders, dated 4/14/15 at 3:50 PM, lacked documented evidence of a DNR order.

b. A document titled, "Resuscitation Orders" dated 4/15/15 at 00:15 stated in part, "...telephone order...[family member]...Limited Resuscitation...Resuscitation efforts should be limited as indicated below...Ventilation with "Ambu Bag" (A self reinflating manual resuscitator bag used to deliver oxygen)...Practitioner A signature dated 4/17/15 (2 days after Patient #8 passed away)..."

3. During an interview on 7/23/15 at 3:45 PM, the CNO acknowledged nursing staff failed to obtain a physician's order for patient #8's code status upon admission to the LTACH on 4/14/15. The CNO stated, "The nursing staff presumed the patient was a full code since the physician failed to fill in the code status on the admission order set." She said this was missed by 2 House Supervisors (Registered Nurse (RN) U and RN BB) and 2 RN's (RN Y and Z) and unfortunately it wasn't discovered until the patient's respiratory status suddenly changed prior to the time Patient #8 passed away.

4. During a telephone interview on 7/24/15 at 9:50 AM, Patient #8's family member said they told [RN Y] that their parent was a DNR upon admission on 4/14/15. The family member said when [House Supervisor BB] contacted them by telephone on 4/15/15 at 1:15 AM the family member told House Supervisor BB the patient's code status was DNR and not to use an Ambu Bag.

5. During an interview on 7/24/15 at 7:40 AM, RN Z said she recalled being told the patient was a DNR but on 4/15/15 at 12:15 AM when the patient's respiratory status changed suddenly the staff reviewed the patient's medical record chart and did not find a physician order for the patient's code status. RN Z acknowledged the licensed staff are responsible to obtain or clarify a patient's code status from the primary physician if the physician failed to provide a code status order in the patient's medical record. She stated, "When the patient became unresponsive and did not have a pulse or respirations I called a rapid response (an emergency for staff to immediately respond to the patient's room) and began to "bag" (Manual administration of oxygen to a person via a Ambu bag.) the patient while House Supervisor BB contacted the [family member] to see if she was a DNR."

6. During an interview on 7/24/15 at 9:00 AM, House Supervisor BB said on 4/14/15 around midnight RN Z called her to Patient #8's room to assist her with insertion of an NG (nasogastric) tube. She said within minutes of attempting to insert the NG tube the patient's respiratory status declined abruptly. She left the room to review the patient's chart and discovered they did not have a physician's order for DNR. House Supervisor BB agreed the nursing staff failed to obtain a physician's order for DNR upon admission in accordance with the LTACH policy. Although nursing staff did document DNR on the 24 hour flowsheet, House Supervisor BB stated, "There really wasn't an order and they needed to clarify this because they were dealing with an emergent situation." House Supervisor RN BB said she contacted the patient's family member and informed them that the patient's respiratory status had changed abruptly and asked what was the code status. House Supervisor RN BB said the patients family member informed her the patient was DNR but was "ok" with an Ambu bag. House Supervisor RN BB acknowledged she failed to document the conversation in the nurses notes and confirmed this was hospital policy and standard nursing practice. The efforts to resuscitate the patient with the Ambu bag were unsuccessful and the patient passed away.

7. During an interview on 7/27/15 at 10:15 AM, RN Y acknowledged she failed to obtain a physician's order for code status for patient #8 upon admission on 4/14/15. She said this was an oversight on her part and it is the LTACH policy to obtain the code status upon admission because it is vital information for continuity of care. RN Y said she recalled hearing in oral report from the transferring hospital that the patient was DNR. RN Y reported she documented the DNR on the admission database and 24 hour patient record and plan of care sheets.

8. During an interview on 7/24/15 at 10:00 AM, House Supervisor RN U acknowledged he failed to follow hospital policies and standard nursing practice when Patient #8 was admitted to their hospital and the DNR orders were not completed. He said it was his responsibility to clarify the patient's code status order. RN U said he received [Patient 8's] faxed discharge summary from the transferring hospital. RN U said he transferred the physician orders from the discharge summary onto the patient's admission orders and then discarded the faxed discharge summary in a shred bin.

9. During an interview on 7/27/15 at 1:45 PM, Practitioner A acknowledged he failed to provide nursing staff with a DNR order and stated he should have done so. Practitioner A stated, "The importance of ordering code status is it explains to all staff at the hospital whether or not the patient should be coded in a crisis situation."

IV. Based on review of policy, medical records, and staff interview nursing staff failed to obtain a physician diet order to administer oral fluids to 1 of 1 patient on NPO (nothing by mouth) status. (Patient #8)

Failure to ensure staff obtained a physician order to administer fluids to a patient on an NPO diet resulted in staff administering sips of water to the patient that resulted in the patients coughing, gagging, and potentially caused the patient's respiratory distress and death.

Findings include:

1. Review of policy titled, "Orders, Physician" revised 1/14 included in part, "...To provide a systematic method of receiving, noting and implementing physicians orders...all...therapeutic diets...must have a Licensed Independent Practitioner (LIP) order..."

Review of policy titled, "Non-Routine Circumstances" revised 3/14 included in part, "...Patients on NPO will remain NPO until Food and Nutrition Services is notified with written documentation of updated diet prescription...Enteral (A way to provide food through a tube placed in the nose, stomach, or small intestine.) formulas and nutritional supplements will be provided by Materials Management..."

2. Review of Patient 8's document titled, "Discharge Summary" dated 4/14/15 received from the transferring hospital included in part, "...Diet: NPO. NG feeds with Jevity at 40 ml per hour with 25 ml of water per hour...Verbal report given to Practitioner A (at the LTACH)..."

3. Review of Patient #8's LTACH medical record revealed:

a. A document titled, "Nutrition Progress Note" dated 4/5/15 from the transferring hospital stated in part, "...NPO since about 3/31/15, not responsive since 4/3/15..."

b. A document titled, "History and Physical" dated 4/14/15 Physician A's documentation included in part, "...very frail...tolerating tube feeding without difficulty...extremely frail and weak...does not have an appetite. has not been eating...had a tough time speaking, due to severe weakness... malnourished...might have some dysphasia (difficulty or discomfort in swallowing)...the patient will be evaluated by our dietician..."

c. A document titled, "24 Hour Patient Record and Plan of Care" dated, 4/14/15 included in part. "...diet NPO with NG tube feeding of Jevity at 40 ml per hour with a 25 ml flush..."

d. A document titled, "Nurses Progress Notes" included the following:

On 4/14/15 at 11:50 PM, [RN Z] notified this nurse [House Supervisor RN BB] that the patient had removed NG."

On 4/15/15 at 1:00 AM, "...went into patient's room to reinsert NG tube. Patient alert, confused. First attempt unsuccessful...patient then started breathing differently. Code status was questioned just in case...This nurse called [patient's family member] at 1:15 AM to clarify code status...double verification with [RN Z] Patient's BiPap (a machine used to gently push air into the lungs) only nothing else...Patient's color changed, shallow breathing with long periods of apnea (temporary cessation of breathing)...patient Ambu bagged (Manual administration of oxygen to a person via a Ambu bag.)...called for BiPap after getting off the phone with [patient's family member].

On 4/15/15 at 1:00 AM, "...Attempt to replace NG tube..unsuccessful, patient slightly combative when NG attempted to be placed. Patient encouraged to try and swallow tube with small amounts of water. Patient pulling against NG and placement not adequate. Patient reassured of procedure and agreed to wait a little bit before another attempt made..." The patient was NPO.

On 4/15/15 at 1:15 AM, "...Patient breathing changes suddenly, respirations become shallow but not labored. Patient seems to be staring off into space. Patient responds to name but slowly loses consciousness. Respiratory therapist called for stat breathing treatment...patient not responding to voice."

On 4/15/15 at 1:17 AM, "...Patient rapidly declined. Respiratory therapy unable to obtain oxygen saturation. (The measurement of how much oxygen the blood is carrying as a percentage of the maximum it could carry.) Patient with brief period of gulping respirations noted, unresponsive to stimuli, apical pulse absent...patient expired. Family and MD notified per nursing supervisor [House Supervisor BB]..."

4. During an interview on 7/23/15 at 3:45 PM, the CNO said the insertion of an NG tube is very traumatic to patients. The CNO stated the nursing staff are advised to call the physician before they put the patient through the trauma. The CNO said if the patient is NPO the nursing staff is trained to not offer any types of fluids or ice because the patient would be at risk for aspiration. The CNO stated the patient could potentially choke on the fluids. or if they were a silent aspirator (occurs in people that have swallowing problems, which is known as dysphagia) they would not even cough. The CNO said during orientation and then annually, all nursing staff are trained and educated on how to insert an NG tube. In addition, the CNO reported the staff received training and education if an NG insertion is ordered for an NPO patient the staff should apply extra lubricating jelly on the NG tube instead of administering sips of water to a NPO patient. The CNO acknowledged RN Z failed to follow the LTACH NG insertion policy for the NPO patient regarding the notification of the physician and to obtain a physician order to administer water and for the reinsertion of Patient 8's NG tube. She reported that although RN Z documented she would notify the physician the medical record lacked documented evidence that the physician notification was done.

5. During an interview on 7/24/15 at 7:40 AM, RN Z said after completing the initial nursing assessment for Patient #8 she noted on the transfer orders the patient was NPO and documented that on the patient's medical record. RN Z the order for NPO was a "default" order since Practitioner A failed to write a diet order for the patient upon admission. RN Z said at midnight on 4/14/15 she noted the NG tube had moved from the measured position. (From the tip of the patient's nose to the patient's stomach.) RN Z reported she removed Patient #8's NG and notified House Supervisor BB she was going to insert another feeding tube. She reported the patient was awake and cooperative and after she gathered supplies and measured the NG tube for correct placement she began to insert the tube into the patients nose. RN Z said when she was half way down she was met with resistance and the patient began "gagging." RN Z stated the patient flexed her head forward, began rocking back and forth and started fighting against the insertion of the NG tube. RN Z said when the patient started gagging, in an attempt to make it easier for the patient, RN Z administered a "few" sips of water to [Patient #8]. RN Z began inserting the NG tube further down the patient's nose after the sips of water and again met resistance. RN Z stated she decided to pull the NG tube and give the patient a few minutes to relax before she attempted to reinsert the NG tube again. RN Z acknowledged she failed to contact the physician although she documented that she did. RN Z said, "After a few minutes the patient's status instantly changed, her breathing was labored, and it looked like she was passing out. The patient then became unresponsive and a couple of minutes later she/he was gone." She said when the patient's breathing changed she called a rapid response and "flipped" through the chart because they weren't able to find a DNR order. RN Z agreed Patient #8 did not receive Jevity feedings for 12 hours because they were having problems with the feeding pump.

6. During an interview on 7/24/15 at 9:00 AM, House Supervisor RN BB said RN Z called her around 10:00 PM on 4/14/15 to let her know Patient #8 pulled the NG tube out. She said she told RN Z they would need to reinsert another NG tube and went to the patient's bedside around midnight to assist with the procedure. She said when they attempted to reinsert the NG tube the patient was coughing and RN Z met resistance. House Supervisor RN BB said she was unaware of any problems with the feeding pump and that the patient had not received any NG feedings for the past 12 hours at that point. House Supervisor RN BB acknowledged she failed to review the patient's medical record to determine wether or not the patient was NPO and confirmed if the patient was NPO nursing staff are trained not to administer fluids because the patient could potentially aspirate. House Supervisor RN BB said the patient's breathing became labored (15 minutes after the sips of water and RN Z's attempt to reinsert the NG tube). House Supervisor RN BB said she called a rapid response and the respiratory therapist arrived. She said she left the room to "look through" the patient's chart and saw the nursing staff had documented DNR on the 24 Hour Patient Record and Plan of Care but she could not find a physician's order for the patient's code status. House Supervisor RN BB stated she called Patient #8's family member to inform them what was happening and they told her the patient was dependent on BiPap for breathing problems and verified the patient was DNR. House Supervisor RN BB acknowledged she failed to document the conversation with the patients family member or code status and agreed this was standard nursing practice and she should have. She said she summarized what occurred on a progress note after the event. House Supervisor RN BB stated, "Nursing and respiratory staff Ambu bagged the patient but after 2 minutes the patient died."

7. During an interview on 7/27/15 at 1:45 PM, Practitioner A said when a patient is admitted to their hospital, normally the House Supervisor writes the admission orders and then verbally confirms the order with him. He then reviews the orders and signs them. Practitioner A acknowledged he failed to write an order for DNR for Patient #8 and was "very surprised."
He said he would expect since the patient was NPO nursing staff should not have administered sips of fluid. Practitioner A acknowledged nursing staff failed to obtain a physician's order for sips of water and that this was a "concern."

V. Based on review of hospital policies, procedures, medical record, and staff interview, staff failed to follow physician admission orders for 3 of 10 patients.(Patient #8, #23 and Patient #26) The Chief Nursing Officer (CNO) identified an average daily census of 24 patients.

Failure to ensure staff followed all physician admission orders resulted in the delay of the patient's treatment.

Findings Include:

1. Review of policy titled, "ORDERS, PHYSICIAN" Revised 10/1/13 included in part, "...To provide a systematic method of receiving, noting and implementing physician's orders....All physician's orders will be written or verbally stated by a Licensed Independent Practitioner (LIP)...Orders will be reviewed and carried out appropriately by facility staff. A patient...diet/therapeutic diet, testing and or invasive procedure must have a LIP's order...The licensed nurse will notify the attending physician within one hour of the arrival of a new patient regarding the need for orders...Each order will be verified as having all necessary information entered into the computer, any necessary requisitions are complete and accurate..."

Review of policy titled, "Transcription/Notification of Diet Orders" Revised 4/1/2014 included in part, "Active diet prescriptions are required for all patients...The patient's admission diet prescriptions ordered in the patient's medical record by the physician...The dietician...should be consulted for diet clarification when a question arises concerning interpretation of a diet order..."

2. During an interview on 7/28/15 at 1:35 PM, the surveyor requested the patient discharge summary's from the transferring hospitals that House Supervisor Registered Nurse (RN) U reported he shredded. The Chief Executive Officer (CEO) reported she would request a copy of those documents from the transferring hospitals. The CEO did provide a copy of the patient's discharge summary from the transferring hospitals.

3. Review of 3 of 5 documents received from the CEO revealed physician orders that staff failed to transcribe to the patient admission orders:

a. Documentation showed staff admitted Patient #8 on 4/14/15 with a primary diagnosis of chronic respiratory failure with hypercapnia (A condition where there is an increase level of carbon dioxide in the blood.), pneumonia, (An inflammatory condition (infection) of the lungs. An infection in one or both lungs caused by fungi, bacteria, or viruses.) severe deconditioning, (To diminish physical strength and be weaken.) and mycoplasma. (A bacteria found in the urinary and reproductive organs.) A document titled, "Discharge Summary" dated 4/14/15 included in part "...Respiratory NIPPV (Noninvasive positive pressure ventilation is a procedure when the patient wears a mask delivering continuous oxygen to keep their airway open and their oxygen level up to an acceptable level.)10/5 cm (centimeters) H20 (water) with 02 (oxygen) at 5 L/min (liters per minute) or flow rate needed to keep Sp02 (Blood Saturation level, it is the measurement of the amount of oxygen carried in the blood.) 88% or greater..." Documentation on the admission orders failed to show the above orders and staff failed to monitor and document Patient #8's oxygen level upon admission and throughout the patient's first 3 hours and 20 minutes at the LTACH (at that time the patient's oxygen level was 86%) to ensure the patient's oxygen level was at 88% or greater or if the patient required the NIPPV.

b. Documentation showed staff admitted Patient #23 on 3/27/15 with a primary diagnosis of severe coronary artery disease, (A narrowing or blockage of the arteries and vessels that carry oxygen and nutrients to the heart.) Coronary Artery Bypass Surgery, (A surgical procedure that restores blood flow to the patient's heart muscle by diverting the flow of blood around a section of a blocked artery in the patient's heart.) diabetes, and hypertension (elevated blood pressure). Patient 23's document titled, "Discharge Summary" dated 3/27/15 included in part "...Speech therapy completed an OPMS (a study how food and liquids are controlled by the mouth and throat) with recommendations for Pureed diet, thin liquids with 100% supervision...Diet Speech pathology/OPMS cleared patient for Pureed diet, thin liquids and 100% supervision...continue with incentive spirometry (A manual device used to perform breathing exercises and to measure how much air is inhaled in the person's lungs)..." Documentation on the admission orders failed to show the patient was to continue on an incentive spirometry. Documentation on the admission orders dated 3/27/15 showed staff placed Patient #23 on an NPO diet until the LTACH speech therapist evaluated the patient on 3/30/15. The patient was denied the opportunity to receive PO (by mouth) pureed diet for 3 days 3/27/15 to 3/30/17.

c. Documentation showed staff admitted Patient #26 on 7/23/15 with a primary diagnosis of prosthetic joint infection, (An inf

Based on review of policies, medical records, documents, and staff interview the Long Term Acute Care Hospital (LTACH) Administrative staff failed to have a system in place to ensure staff maintained all patient admission documents in the patient medical record. The Chief Nursing Officer (CNO) identified an average daily census of 24 patients.

Failure to ensure the Administrative staff had a system in place to ensure staff maintained all patient admission documents in the patient's medical record resulted in physician orders being discarded.

Findings include:

1. Review of a policy titled, "Document Retention" Revised Date 7/30/14 included in part, "...Records are retained in accordance with all applicable laws and regulations...Records shall not be destroyed before prescribed retention period...Any unauthorized destruction, removal...is strictly prohibited..."

2. During an interview on 7/28/15 at 9:50 AM, the House Supervisor RN U reported when a patient is transferred to the LTACH the transferring facility generally faxed a discharge summary with physician orders to the LTACH prior to the patient's arrival. When asked what RN U did with the original faxed discharge summaries with the physician orders. RN U stated, "I shredded it." RN U reported he had a stack of patient's faxed transfer orders on his desk and didn't know what to do with them so he shredded them.

3. During an interview on 7/28/15 at 1:35 PM, the surveyor requested the patient discharge summary's from the transferring hospitals that House Supervisor Registered Nurse (RN) U reported he shredded. The Chief Executive Officer (CEO) reported she would request a copy of those documents from the transferring hospitals. The CEO did provide a copy of the discharge summary from the transferring hospitals for Patient #8, #23, #24, #25, and #26.

4. Review of 5 of 10 patient's medical records transferred from other hospitals revealed the following:

a. Patient #8 admitted on 4/14/15 lacked the faxed document titled, "Discharge Summary" dated 4/14/15.

b. Patient #23 admitted on 3/27/15 lacked the faxed document titled, "Discharge Summary" dated 3/27/15.

c. Patient #24 admitted on 7/15/15 lacked the faxed document titled, "Discharge Summary" dated 7/15/15.

d. Patient #25 admitted on 7/21/15 lacked the faxed document titled, "Discharge Summary" dated 7/21/15.

e. Patient #26 admitted on 7/23/15 lacked the faxed document titled, "Discharge Summary" dated 7/23/15.

5. During an interview on 7/28/15 at 12:30 PM, the Chief Executive Officer (CEO) acknowledged the House Supervisor RN U had destroyed all faxed transfer physician orders for patients admitted to LTACH. The CEO stated, "That is not a preferred practice. I am not sure why that happened."