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Based on record review and interview the hospital failed to meet the requirements of the Condition of Participation for Governing Body as evidenced by:

1) Failing to ensure contracted services were provided in a safe and effective manner as evidenced by: 1) failure to have QAPI (quality assurance/performance improvement) data collected and reviewed by the governing body for the following contracted services: Pharmacy, Radiology, Laboratory, Dietary, and Respiratory Services. As a result of the lack of monitoring patients failed to receive their medications on time, medications were unavailable from the pharmacy for administration to the patients, lab results were not available to the physician to assist in diagnosing and assessment of patients, and respiratory treatments were to administered as ordered to patients requiring respiratory treatments (See findings at Tag A0384).

Based on record review and interview the hospital failed to meet the requirements of the Condition of Participation for Quality Assurance as evidenced by:

1) Failing to follow the hospital's policy and procedure for performance improvement as evidenced by no documented evidence the hospital developed indicators for medication errors, labs, consents, and confidentiality tracked, measured and/or analyzed resulting in continued problems with unreported medication variances, unavailable medications for patient administration, ordered labs not being performed, lab reports not being obtained, and confidential information being obtained without consent of the patient(s) (See findings at Tag A0267);

2) Failing to monitor the contracted services of pharmacy and laboratory to ensure effectiveness and safety of service and quality of care as evidenced by continued identified and unresolved unavailability of patient medication from the pharmacy resulting in missed medication and results not being sent to the hospital by the contracted lab (See findings at Tag A0275); and

3) Failing to follow the policy and procedure for Performance Improvement as evidenced by failing to have documented evidence of corrective actions implemented for identified problems related to medication errors, unavailability of medications from the contracted pharmacy, labs not performed according to physician orders, and labs results not sent by the contracted lab (See findings at Tag A 0310).

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

1) Failing to ensure a Registered Nurse supervised, assessed, and evaluated the needs of each patient by failing to assess and monitor patient's vital signs when the patient was prescribed prn (as needed) blood pressure medication (#1, #3, #4, #5, #6, #7, #10, #11, #18, #19); failing to assess significant changes in patients' weights (#3, #6, #17); failing to assess patients weights as ordered by the physician (#3, #5, #9, #10, #17, #18, #19); failing to assess patient's allergies prior to the administration of medication(#14); failing to assess the skin integrity of diabetic patients (#14); failing to assess patients after falling in the facility (#18); and failing to assess the need to inform the physician when a patient had a significant change in medical condition (#4, #18) (See findings cited at A0395);

2) Failing to ensure medications were administered according to the orders of the practitioner for 8 of 20 sampled patients (#1,#2, #3, #4, #5, #9, #10, #19), labs were performed as ordered by the practitioner for 8 of 20 sampled patients with orders for labs (#2, #4, #9, #13, #11, #17, #18, #19) from a total of 20 sampled patients, and respiratory treatments were performed as ordered by the patient's physician for 2 of 2 patients with orders for incentive spirometry from a total of 20 sampled patients (#4, #18) (See findings cited at A0396 and A0404)

Based on record review and interview the hospital failed to meet the the requirements of the Condition of Participation for Utilization review as evidenced by:

1) Failing to have a utilization review committee as evidenced by the hospital's inability to produce a list of committee members or submit UR committee meeting minutes as far back as 12 months. (See findings at Tag A0654);

2) Failing to develop written admission criteria and scope of services; revise their Utilization Review (UR) Plan to ensure compliance with State regulations for Medicaid admission; and ensure the UR Plan approved by the Governing Body was implemented (See findings at Tag A0656); and

3) Failing to ensure review of professional services had been included in their Utilization Plan and reviews conducted to promote efficient use of services resulting in lack of availability of pharmaceutical drugs in a timely manner for administration to patients as ordered by his/her physician (See findings at Tag A0658).

Based on record review and interview, the governing body failed to ensure contracted services were provided in a safe and effective manner as evidenced by: 1) failure to have QAPI (quality assurance/performance improvement) data collected and reviewed by the governing body for the following contracted services: Pharmacy, Radiology, Laboratory, Dietary, and Respiratory Services; 2) failure to ensure non-employee licensed nurses working in the hospital were supervised and their clinical activities evaluated by a qualified hospital-employed RN (registered nurse) as evidenced by 3 of 7 contract RNs assigned as the only RN present in the hospital on seven days in October and November 2010 (S6, S14, S15); and 3) failure to ensure contract nurses were evaluated for competency prior to providing patient care at the hospital for 3 of 3 contract nurses reviewed from a total of 7 contract RNs ( S6, S14, S15). Findings:

1) Failure to have QAPI data collected and reviewed by the governing body for the following contracted services: Pharmacy, Radiology, Laboratory, Dietary, and Respiratory Services:
Review of the "Governing Board Minutes" dated 01/29/10 revealed, in part, "...Medical Care Evaluation Committee: The Medical Staff meeting for the 4th QTR (quarter) 2009 was discussed and the PI (performance improvement) and UR (utilization review) reports were accepted as presented. No issues were noted ...". Review of the data submitted for review by the Governing Board, presented by Administrator S9, revealed the data was related to the nursing, therapy, health information management, human resources, and social services departments and utilization data. There was no documented evidence that QAPI data for the Pharmacy, Radiology, Laboratory, Dietary, and Respiratory Services was submitted for review. There was no documented evidence Administrator S9 was in attendance at the meeting as required by the bylaws.

Review of the "Governing Board Minutes" dated 04/29/10 revealed, in part, "...Medical Care Evaluation Committee: The Medical Staff meeting for the 1st QTR 2010 was discussed and the PI and UR reports were accepted as presented. No issues were noted ...". Review of the data submitted for review by the Governing Board, presented by Administrator S9, revealed the data was related to the nursing, therapy, health information management, and human resources departments and utilization data. There was no documented evidence that QAPI data for the Pharmacy, Radiology, Laboratory, Dietary, and Respiratory Services was submitted for review. There was no documented evidence Administrator S9 was in attendance at the meeting as required by the bylaws.

Review of the "Governing Board Minutes" dated 07/29/10 revealed, in part, "...Medical Care Evaluation Committee: The Medical Staff meeting for the 2nd QTR 2010 was discussed and the PI and UR reports were accepted as presented. No issues were noted .. ". Review of the data submitted for review by the Governing Board, presented by Administrator S9, revealed the data was related to the nursing, therapy, health information management, social services, and human resources departments and utilization data. There was no documented evidence that QAPI data for the Pharmacy, Radiology, Laboratory, Dietary, and Respiratory Services was submitted for review. There was no documented evidence Administrator S9 was in attendance at the meeting as required by the bylaws.

Review of the "Governing Board Minutes" dated 10/14/10 revealed only nursing issues and infection control were discussed by the Medical Care Evaluation Committee. There was no documented evidence the PI report for the 3rd Quarter, which included a report on the nursing, therapy, respiratory, health information management, human resources, and social services departments and utilization data, was reviewed by the Governing Board. There was no documented evidence that QAPI data was collected and reviewed by the Governing Board for the Pharmacy, Radiology, Laboratory, and Dietary Services. There was no documented evidence Administrator S9 was in attendance at the meeting as required by the bylaws.

In a face-to-face interview on 01/04/10 at 1:15pm, Administrator S9 provided the data that was submitted to the Governing Board for QAPI. She indicated there was no data that was used to evaluate the Laboratory and Radiology contracted services, and no quality indicators had been established to monitor the effectiveness of the services provided by the contracted providers. She could offer no explanation for her lack of attendance at the board meetings as required by the governing body bylaws.

Review of the "Governing Body Bylaws", submitted by Administrator S9 as their current bylaws, revealed, in part, "...The goals shall be to maintain quality of services being rendered and to continue to update equipment and expand the facility as the needs dictate for the optimum diagnosing and treatment of rehabilitative services. ...The hospital Chief Executive Officer/Administrator is an ex-officio member of the Board. ...The Chief Executive Officer/Administrator shall be given the necessary authority and be held responsible for the administration of the Hospital subject only to policies enacted by the Board. Section 2. Specifically, the authority and duties of the Chief Executive Officer/Administrator shall be: ...f. To submit regularly to the board or its authorized committees, periodic reports of the professional service and financial activities of the hospital ... g. To attend all meetings of the Board and its committees, and serve as ex-officio member thereof ...".

Review of the hospital contract with Agency C (Pharmacy Services), which had never been signed by a representative of Agency C, revealed in part, "(Agency C agrees to deliver to facility all pharmaceuticals, pursuant to physician' orders, and supplies within a reasonable time, except for circumstances and conditions beyond it's control which shall expressly include but not be limited to any back ordered or out of stock items. . . (Agency C) agrees to provide continuous service to facility during the five day workweek. According to this service, (Agency C) agrees to deliver routine pharmaceuticals to facility. In the event of an emergency, (Agency C) agrees to provide emergency pharmacy services to facility twenty four hours per day, seven days per week. . ."

During a telephone interview on 1/04/2011 at 1:55 p.m., Pharmacist S13 indicated the Pharmacy delivered medications to the hospital one time per day, in the evening hours. S13 indicated the usual departure time is between 6:30 and 7:30 p.m. S13 indicated the pharmacy is located approximately 1.5 hours from the facility; however, there are four areas served by the same delivery vehicle which included Metairie, Luling, Kenner, and LaPlace. S13 indicated the pharmacy would make a special delivery but only at the request of the facility. S13 further indicated in emergency situations medications could be obtained by a local pharmacy; however, he was not sure if there were any 24 hour pharmacies in the area.

During a face to face interview on 1/05/2011 at 3:20 p.m., Administrator S9 indicated Hospital Contract Evaluations had been done based on whether she had received any (verbal or written) reports of problems regarding the Contracted Service. S9 further indicated she had no Quality Indicators that she had monitored on the Contracted Services. S9 confirmed that without tracking and trending indicators she would not be able to determine decline or improvement in performance for any identified problems with Contracted Services. S9 further indicated there would be no way to identify problems without monitoring Quality Indicators unless a staff member reported a problem. S9 confirmed the contract for Pharmacy Services (Agency C) did not provide for routine daily services which resulted in instances of medications not being available for administration.

2) Failure to ensure non-employee licensed nurses working in the hospital were supervised and their clinical activities evaluated by a qualified hospital-employed RN as evidenced by 3 of 7 contract RNs assigned as the only RN present in the hospital on seven days in October and November 2010 (S6, S14, S15):
Review of the "Specialty Rehabilitation Hospital Daily Staffing Sheet" revealed RN S15, contract RN from Agency A, was the only RN assigned to the night shift on 10/19/10. Further review revealed RN S6, contract RN with Agency B, was the only RN assigned on the night shift of 10/29/10 and 10/30/10. Further review revealed RN S15, contract RN from Agency A, was the only RN assigned to the night shift on 10/31/10. Further review revealed RN S14, contract RN with Agency A, was the only RN assigned to the night shift on 11/06/10, RN S6 with Agency B was the only RN assigned to the night shift on 11/19/10, and RN S15 with Agency A was the only RN assigned to the night shift of 11/28/10.

In a face-to-face interview on 01/05/11 at 9:40am, Director of Nursing S1 indicated she did not know that contract agency RNs had to be supervised by a hospital-employed RN.

3) Failure to ensure contract nurses were evaluated for competency prior to providing patient care at the hospital for 3 of 3 contract nurses reviewed from a total of 7 contract RNs ( S6, S14, S15):
Review of employee personnel file for contracted (agency) nurse S6 revealed no documented evidence of competency evaluation. S6 worked at the hospital, providing patient care, on 10/29/2010, 10/30/2010, and 11/19/2010.

Review of employee personnel file for contracted (agency) nurse S14 revealed no documented evidence of competency evaluation. S14 worked at the hospital, providing patient care, on 11/06/2010.

Review of the employee personnel file for contracted (agency) nurse S15 revealed no documented evidence of competency evaluation. S15 worked at the hospital, providing patient care, on 10/19/2010, 20/31/2010, and 11/28/2010.

These findings were confirmed by Director of Nursing S1 on 1/05/2011 at 3:20 p.m.

Based on record review and interview the hospital failed to ensure all patients were allowed to make informed decisions about their health care as evidenced by a 63 year old alert and oriented patient (#18) and a 58 year old alert and oriented patient (#19) with an advanced directive, being made a DNR (Do Not Resuscitate) without any documented evidence they had been informed of their condition for 2 of 2 patients with a DNR status out of 20 sampled medical records. Findings:

Review of the hospital's "Specified Resuscitation Orders" revealed an option to check either full code or no code. Further review revealed if no code was selected, the following checklist had to be completed by checking yes or no: A. if cardiopulmonary arrest occurs, call a "Code Blue"; B. initiate chest compressions; C. assist ventilation without intubation; D. intubate the patient; E. administer intravenous drugs; F. cardiovert or defibrillate in the event of life-threatening arrhythmias.

Patient #18
Review of Patient #18's medical record revealed she was admitted on 11/09/10 with diagnoses of staph bacteremia related to right knee arthroscopy, hypertension, diabetes mellitus, bipolar disorder, osteoarthritis, coronary artery disease, obesity, sleep apnea, and anemia. Review of the history and physical revealed she was a 63 year old awake and oriented patient.

Observation of the closed medical record for Patient # 18 revealed an orange DNR sticker on the front cover.

Review of Patient #18's "Specified Resuscitation Orders" revealed no code had been selected and the answers to questions A through F were "no". Further review revealed Patient #18 the RN (registered nurse) witnessing the patient's signature had signed the form on 11/09/10 at 3:00pm. There was no documented evidence whether the order had been received from a physician verbally or by telephone, and there was no verbal read-back confirmation. Further review revealed Physician S16 signed the order on 11/10/10 at 11:55am.
Review of Patient #18's physician progress notes and history and physical dictated by Physician S16 on 11/10/10 at 1:22pm revealed no documented evidence Physician S16 had discussed with Patient #18 her wishes to be a "no code" and the consequences of such an order.

Patient # 19
Review of the H&P for Patient # 19 revealed he was a 58 year old male admitted on 09/17/10 with the diagnosis of TTP (Thrombotic Thrombocytopenic Purpura) with anemia, anasarca, hypertension, generalized weakness, de-conditioning and possible critical illness neuropathy.

Observation of the closed medical record for Patient # 19 revealed an orange DNR sticker on the front cover.

Review of the "Declaration of "Living Will" form dated 09/08/10 which was signed/dated/timed by Patient #19 and appropriately witnessed revealed #19 did not want cardiopulmonary resuscitation implemented when after being examined by two physicians (one of whom is the attending physician) and both physician certify in writing 1) that my conditional is terminal, irreversible, and will likely cause my death in the near future, whether or not life sustaining procedures are utilized, and application of the procedures would serve only to prolong artificially the dying process or 2) That I am in a continual, profound comatose state with no reasonable chance of recovery.

Review of the "Specified Resuscitation Orders" (a hospital-specific form) revealed Patient # 19 signed the form on 09/17/10 (no time documented) and witnessed by the nurse, indicating he was a "NO CODE" but wanted E. "Intravenous Drugs". The form was signed by one physician on 09/17/10 and the second on 09/23/10.

Review of the Physician's Progress Notes dated 09/17/10 through `0/08/10 (admit through discharge) revealed no documented evidence the physician had discussed with the patient his condition before making him a DNR (Do Not Resuscitate).

In a face to face interview on 01/05/10 at 11:25am S16 Medical Director indicated the process for obtaining the code status using the "Specified Resuscitation Orders" form is for the nurse to explain the information to the patient, or if the patient is not able, the family and then get either one to sign. Then the attending signs and gets another MD to co-sign. When the physician was asked if he had determined that Patient # 19, a 58 year old man with the diagnoses of TTP (Thrombotic Thrombocytopenic Purpura), anemia, anasarca, hypertension, generalized weakness, and de-conditioning was at the end of his life, S16 declined to answer. S16 indicated his interpretation of end of life was when the person was coding. Further S16 verified he had not documented any discussion of DNR with the patient or his family. S16 further indicated he could not remember if the nurse called him for a DNR order for Patient #18. After reviewing the medical record of Patient #18, Physician S16 confirmed there was no documentation in the record of his discussion with Patient #18 regarding her health status, diagnosis, and prognosis prior to her having an order for "no code". Physician S16 further indicated he thought the hospital had a policy for DNR. He had no explanation to offer when informed by the surveyor that the hospital did not have such a policy.

Review of Policy Number N 1.013 titled "Advanced Directives" (no documented evidence of the date of implementation or revision) and submitted as the one currently in use revealed...... "Purpose: To ensure patients have the opportunity to express their wishes for acute medical care and to have their wishes adhered to in the event of a terminal illness and/or coma. Procedure: D. Nursing personnel are responsible to follow the patient's Advance Directive".





25065

Based on record review and interview the hospital failed to ensure a patient's Advance Directive was obtained and placed on the Medical Record for 1 of 20 sampled patients (#3). Findings:

Review of Patient #3's Medical Record revealed a check mark on 12/21/2010 indicating "I have executed Advance Directive" and "I have executed an advance directive and have been requested to supply a copy to this facility".

During a face to face interview on 1/04/2010 at 10:55 a.m., Case Manager S2 indicated she had been aware that Patient #3 had an Advance Directive. Further S2 indicated Patient #3 had resided at the nursing home in which Specialty Rehabilitation Hospital of Luling was located (facility within a facility) and a copy of the Patient's Living Will/Advanced Directive had been located in the patient's medical record at that facility. S2 indicated she had not been to the Nursing Home (adjacent to the hospital) to obtain a copy of the Living Will/Advanced Directive for Patient #3 until 1/03/2010 (13 days after the patient had been admitted to the hospital) and only after surveyors had inquired about the patient's Advance Directive. S2 confirmed that without a copy of the Advance Directive, the hospital would have not been aware of the patient's wishes if his health had declined.

Review of the hospital policy titled, "Advance Directives: SS 2.004" presented by the hospital as their current policy revealed no documentation of how the hospital was to address patients that indicated they had an advanced directive located at another facility. Review revealed in part, "If the decision is made to complete the Advance Directive, two witnesses. . . will sign the Advance Directive form after observing the patient doing so. . A copy will be placed in the patient's medical record. . ."

Based on record review and interview the hospital failed to ensure safeguards were in place to protect the confidentiality of patient's clinical records as evidenced by: 1) allowing patients to sign incomplete consents authorizing the release of information from their medical record for 4 of 20 sampled patients (#2, #4, #5, #10) and 2) obtaining confidential patient information from outside facilities without having the patient or his/her representative sign a consent authorizing release of information faxed to a referring hospital without the patient's signature for 3 of 20 sampled patients (#9, #13, #19). Findings:

1) allowing patients to sign incomplete consents authorizing the release of information from their medical record
Patient #2
Review of the "Release of Information Authorization" for Patient #2 dated 11/30/10 revealed the consent had been obtained via the telephone from the patient's daughter. Further review revealed no documented evidence of the date or time the consent had been obtained, the information consented to be released, or to whom the information was to be released.

Patient #4
Review of Patient #4's medical record revealed a "Release of Information Authorization" with the Section titled, "Information Requested" blank which afforded the hospital the opportunity of releasing information to a source undisclosed to the patient. Review of the preprinted section contained no information in the blanks, "I hereby authorize Specialty Rehabilitation Hospital to disclose the information described below to: Name of Individual/Institution: ____ (blank contained no documentation). . . Dates of Treatment from ___ to ___ (blanks contained no documentation). . . Information to be disclosed ___ Discharge Summary ___ Physician Orders ___ Nurses Notes ___History and Physical ___ Progress Notes ___ Therapy Notes ___ Radiology Reports ___ Laboratory Reports ___ Laboratory Reports ___ (blanks contained no documentation). . . Authorization expiration date ___ (blank contained no documentation). Further review revealed the signature of the Patient #4 dated 11/05/10.

In a face-to-face interview on 01/05/11 at 2:10pm, Director of Nursing (DON) S1 confirmed the above findings.

Patient #5
Review of Patient #5's medical record revealed a "Release of Information Authorization" with the Section titled, "Information Requested" blank which afforded the hospital the opportunity of releasing information to a source undisclosed to the patient. Review of the preprinted section contained no information in the blanks, "I hereby authorize Specialty Rehabilitation Hospital to disclose the information described below to: Name of Individual/Institution: ____ (blank contained no documentation). . . Dates of Treatment from ___ to ___ (blanks contained no documentation). . . Information to be disclosed ___ Discharge Summary ___ Physician Orders ___ Nurses Notes ___History and Physical ___ Progress Notes ___ Therapy Notes ___ Radiology Reports ___ Laboratory Reports ___ Laboratory Reports ___ (blanks contained no documentation). . . Authorization expiration date ___ (blank contained no documentation). Further review revealed the signature of the patient dated 12/28/2010.

This finding was confirmed in a face to face interview with Director of Nursing S1 on 1/03/2010 at 4:00 p.m.

Patient #10
Review of Patient #10's medical record revealed a "Release of Information Authorization" with the Section titled, "Information Requested" blank which afforded the hospital the opportunity of releasing information to a source undisclosed to the patient. Review of the preprinted section contained no information in the blanks, "I hereby authorize Specialty Rehabilitation Hospital to disclose the information described below to: Name of Individual/Institution: ____ (blank contained no documentation). . . Dates of Treatment from ___ to ___ (blanks contained no documentation). . . Information to be disclosed ___ Discharge Summary ___ Physician Orders ___ Nurses Notes ___History and Physical ___ Progress Notes ___ Therapy Notes ___ Radiology Reports ___ Laboratory Reports ___ Laboratory Reports ___ (blanks contained no documentation). . . Authorization expiration date ___ (blank contained no documentation). Further review revealed the signature of the patient and his daughter-in-law dated 12/15/2010.

This finding was confirmed in a face to face interview with the Director of Nursing S1 on 1/04/2010 at 8:30 a.m.

2) obtaining confidential patient information from outside facilities without having the patient or his/her representative sign a consent authorizing release of information faxed to a referring hospital without the patient's signature
Patient #9
Review of the "Release of Information Authorization" for Patient # 9 dated 10/18/10 revealed the consent had been faxed to obtain an ortho note or consult from another hospital without documented evidence of the patient (#9) or his representative's signature

Patient #13
Review of Patient #13's "Release Of Information Authorization" revealed radiology reports, laboratory reports, MRI (magnetic resonance imaging), echocardiogram, and urine culture and sensitivity reports were being requested from the referring hospital. Further review revealed the form was dated 10/07/10 and was faxed with no documented evidence of the signature of Patient #13.

Patient # 19
Review of the "Release of Information Authorization" for Patient #19 dated 10/04/10 revealed the consent had been faxed to obtain a colonoscopy biopsy result without documented evidence of the patient (#19) or his representative's signature.

In a face to face interview S9 Administrator indicated all information should be completed and all signatures, dates and times obtained before the form is sent to another facility.

Review of the hospital policy titled, "Release of Information, HIM 17.001" presented by the hospital as their current policy revealed in part, "All information in the health record is confidential with the exception of admission and discharge dates for rehabilitation patients. . . The release of information shall be closely controlled. . . In keeping with the tenet of informed consent, a properly completed and signed authorization to release patient health information shall include at least the following data: a. Name of the institution that is to release the information. b. Name of the institution or individual that is to receive the information. c. Patient's full name, date of birth and other info needed to identify the patient. d. Purpose or need for the information. e. Extent or nature of information to be released, including inclusive dates of treatment. f. Specific date, event or condition upon which consent will expire unless revoked earlier. g. Date that the authorization is signed. h. Signature of the person witnessing the patient or legal representative's signature. The signature of at lease (least) two witnesses shall be required when obtaining verbal consent. . ."



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25065

Based on record review and interview the hospital failed to ensure all History & Physicals
were available in the patient's medical record within 24 hours of admission for 2 of 20 sampled medical records (#2, #9). Findings:

Patient #2
Review of the History & Physical (H&P) for Patient #2 revealed she was admitted to the hospital on 11/30/10 with a significant functional decline. Further review revealed the physician dictated the H&P on 12/01/10 but was not dictated until 12/02/10 which was greater than 24 hours after #2 was admitted.

Patient #9
Review of the History & Physical (H&P) for Patient # 9 revealed she was admitted to the hospital on 10/15/10 with debility due to neuropathy and chronic left hip and knee pain. Further review revealed the the H&P was dictated and typed on 10/17/10 which was greater than 24 hours after #9 was admitted.

In a face to face interview on 01/05/10 at 4:00pm S9, Administrator, indicated she thought that as long as the MD dictated the H&P within 24 hours of admit, it was acceptable. Further S9 indicated the facility had just had a Joint Commission survey and this practice was acceptable according to their standards.

Review of the "Medical Staff Bylaws" , with no documented evidence of the date of adoption, revealed, in part, "...A medical history and physical examination must be completed no more than 30 days before or 24 hours after admission for each patient by a physician, or other qualified individual in accordance with the Hospital, State of Louisiana, Medicare/Medicaid or other third-party agency. The medical history and physical examination must be placed in the patient ' s medical record within 24 hours after admission. When the medical history and physical examination are completed within 30 days before admission, the hospital must ensure that an updated medical record entry documenting an examination for any changes in the patient ' s condition is completed. This updated examination must be completed and documented in the patient's medical record within 24 hours after admission ...".

Based on record review and interview the hospital failed to ensure the Registered Nurse supervised and evaluated the nursing care for each patient by:
1) Failing to ensure patients' medical needs were assessed and reassessed by nursing staff with interventions as evidenced by:
a) Failing to monitor vital signs to determine if patients required administration of Blood Pressure Medication (Clonidine) ordered by the physician as needed every 6 hours 10 of 20 sampled patients (#1,#3, #4, #5, #6, #7, #10, #11, #18, #19);
b) Failing to ensure patients' weights were reassessed upon having documentation indicating substantial changes in the patient's weight for 3 of 20 sampled patients (#3, #6, #17);
c) Failing to ensure weights were assessed as per physician's orders for 7 of 20 sampled patients (#3, #5, #9, #10, #17, #18, #19);
d) Failing to ensure the Pharmacist was notified after assessing a patient's allergies which resulted in a patient being prescribed and administered medications that she was allergic to for 1 of 20 sampled patients assessed for allergies out of a total sample of 20 (Patient #14);
e) Failing to ensure Apical Pulses were monitored according to the hospital's Drug Resource Book (Nursing 2011 Drug Handbook) for 1 of 1 patients reviewed on Metoprolol out of a total sample of 20 (Patient #8);
f) Failing to ensure the RN accurately assessed and documented the skin of a diabetic patient with impaired skin integrity for 1 of 1 diabetic patient with impaired skin integrity reviewed out of a total sample of 20 ( Patient #1);
g) Failing to ensure the RN assessed patients with a change in condition for 2 of 2 patients reviewed with a change in condition from a total sample of 20 patients (#4, #18) and after a fall for 1 of 1 patient reviewed with a fall from a total of 20 sampled patients (#18);
2) Failing to ensure that blood glucometer machines used to determine blood glucose readings for the administration of oral and/or injectable insulin to patients were determined accurate as evidenced by the failure of nursing staff to perform quality controls on the glucometer machines according to hospital policy and manufacturer's recommendations.
3) Failing to clarify physician's orders regarding absence of parameters for multiple routes of medication administration for 2 of 2 patients reviewed with more than one route of administration ordered out of a total sample of 20 (#8, #17).
Findings:

1a) Failing to monitor vital signs to determine if patients required administration of Blood Pressure Medication (Clonidine) ordered by the physician as needed every 6 hours (#1,#3, #4, #5, #6, #7, #10, #11, #18, #19):
Review of physician's admission orders revealed "Clonidine 0.1 mg (milligrams) PO (by mouth) Q6 (Every 6 hours) for SBP (systolic blood pressure) > (Greater Than) 180 or DBP (diastolic blood pressure) > 110 mm Hg (millimeter mercury) and notify MD (physician)" for the following patients:
Patient #1 dated 12/17/2010 at 1930 (7:30 p.m.)
Patient #3 dated 12/21/2010 at 1900 (7:00 p.m.)
Patient #4 dated 11/05/10 at 1830 (6:30pm)
Patient #5 dated 12/27/2010 at 0630 (6:30 a.m.)
Patient #6 dated 12/29/2010 at 1530 (3:30 p.m.)
Patient #7 dated 12/30/2010 at 1230
Patient #10 dated 12/15/2010 at 1550 (3:50 p.m.)
Patient #11 dated 11/03/2010 at 1430 (2:30 p.m.)
Patient #18 dated 11/09/10 at 1400 (2:00pm)
Patient #19 dated 09/19/10 at 1806 (6:06pm)
Further review revealed no documented evidence that the blood pressure for Patients #1,#3, #4, #5, #6, #7, #10, #11, #18 and #19 had been monitored every six hours to determine if the patient's blood pressure met the parameters requiring the administration of prn (as needed) Clonidine as ordered by the patient's physician.

Record review revealed Patient #1's Vital Signs to include blood pressure had been taken every 12 hours (rather than every 6 hours) from the dates 12/17/2010 to 1/3/2011.
Record review revealed Patient #3's Vital Signs to include blood pressure had been taken every 12 hours (rather than every 6 hours) from the dates of 12/21/2010 to 1/02/2011.
Record review revealed Patient #4's Vital Signs, to include blood pressure, had been taken every 12 hours (rather than every 6 hours) from the dates of 11/06/10 to 1/02/2011.
Record review revealed Patient #5's Vital Signs to include blood pressure had been taken every 12 hours (rather than every 6 hours) from the dates of 12/27/2010 to 1/02/2011.
Record review revealed Patient #6's Vital Signs to include blood pressure had been taken every 12 hours (rather than every 6 hours) from the dates of 12/29/2010 to 1/03/2011.
Record review revealed Patient #7's Vital Signs to include blood pressure had been taken every 12 hours (rather than every 6 hours) from the dates of 12/30/2010 to 1/03/2011
Record review revealed Patient #10's Vital Signs to include blood pressure had been taken every 12 hours (rather than every 6 hours) from the dates of 12/15/2010 to 12/21/2010.
Record review revealed Patient #11's Vital Signs to include blood pressure had been taken every 12 hours (rather than every 6 hours) from the dates of 11/10/2010 to 11/19/2010.
Record review revealed Patient # 18's Vital Signs, to include blood pressure, had been taken every 12 hours (rather than every 6 hours) from the dates of 11/09/10 to 11/25/10.
Record review revealed Patient # 19's Vital Signs to include blood pressure had been taken every 12 hours (rather than every 6 hours) from the dates of 09/17/10 to 10/08/10. .

This finding was confirmed by Director of Nursing S1 on 1/04/2011 at 11:30 a.m.

1b) Failing to ensure patients' weights were reassessed upon having documentation indicating substantial changes in the patient's weight (#3, #6, #17):
Patient # 3
Review of Patient #3's Graphic Sheet revealed the patient's weight was 167.2 pounds on 11/28/2010 and the following day (12/29/2010) the patient was documented as 136.6 pounds (a weight loss of 30.6 pounds in one day). Further review revealed no documented evidence of re-weighing or assessing Patient #3's 30.6 pound documented weight loss on 12/29/2010.

Patient # 6
Review of Patient #6's Graphic Sheet revealed the patient's weight was 182.4 pounds on 10/11/10, 180 something pounds (no documented evidence of the entire weight written out) on 10/12/10, and 206.6 pounds on 10/13/10. Further review revealed no documented evidence of re-weighing or assessing Patient #6's weight gain of 24 or more pounds in one day.

Review of Patient #17's Graphic Sheet revealed the patient's weight was 99.1 pounds on 10/09/2010 and 2 days later was 127.4 pounds (a weight gain of 28.3 pounds in two days). Further review revealed Patient #17 was documented as weighing 123.2 pounds on 10/15/2010 and the following day (10/16/2010) weighing 130.2 pounds (a weight gain of 7 pounds in one day). Review of Patient #17's medical record revealed the patient weighed 131.6 on 10/21/2010 and the following day 10/22/2010 the patient was documented as weighing 120.4 (a weight loss of 11.2 pounds in 1 day). The following day (10/23/2010) Patient #17 was documented as weighing 109.4 pounds (a weight loss of 11 pounds in one day/ 22.2 pounds in two days).

During a face to face interview on 1/05/2011 at 3:30 p.m., Director of Nursing S1 confirmed abrupt weight losses and/or gains for Patients #3, #6, and #17. S1 indicated it appeared as if the nursing staff had either forgotten to subtract the weights of wheelchairs or had not calibrated the scale prior to weighing the patients; however, in the case of abrupt weight changes she would expect the nurse providing care to the patient to re-weight the patient to ensure accuracy of the weight.


1c) Failing to ensure weights were assessed as per physician's orders for 7 of 20 sampled patients (#3, #5, #9, #10, #17, #18, #19):
Review of Patient #3's medical record revealed a physician's order dated 12/21/2010 at 1900 (7:00 p.m.) for "Weight, on admit, daily". Further review revealed no documented weight on the date of 12/31/2010.

Review of Patient #5's medical record revealed a physician's order dated 12/27/2010 at 0630 a.m. for "Weight, on admit, daily". Further review revealed no documented weight on the date of 12/28/2010.

Review of Patient #9's medical record revealed a physician's order dated 10/19/2010 at 9:55am "Daily weight". Further review revealed no documented weight for the date of 10/26/10.

Review of Patient #10's medical record revealed a physician's order dated 12/15/2010 at 1550 (3:50 p.m.) for "Weight, on admit, daily". Further review revealed no documented weight for the dates of 12/18/2010, 12/19/2010, and 12/20/2010.

Review of Patient #17's Graphic Sheet revealed a physician's order dated 10/06/2010 at 12:00 noon for "Weight, on admit, daily". Further review revealed no documented weight for the dates of 10/08/2010 and 10/10/2010.

Patient # 18
Review of Patient #18's medical record revealed she was admitted on 11/09/10 with diagnoses of staph bacteremia related to right knee arthroscopy, hypertension, diabetes mellitus, bipolar disorder, osteoarthritis, coronary artery disease, obesity, sleep apnea, and anemia. Review of the "Standing Admission Orders" dated 11/09/10 at 2:00pm revealed an order to weigh the patient on admit and daily.
Review of the "7 Day Graphic Sheet" revealed no documented evidence Patient #18 was weighed on 11/19/10.

Review of Patient #19 medical record revealed a physician's order dated 09/17/10 at 1800 (6:00pm) for "Weight, on admit, daily". Further review revealed no documented weight for the dates of 09/17/10, 09/20/10, 09/24/10, and 10/04/10.

In a face-to-face interview on 01/05/11 at 2:10pm, DON S1 indicated she had not been auditing charts to assure that weights were checked as ordered by the physician.

These findings were confirmed in a face to face interview on 1/05/2011 at 3:30 p.m. with the Director of Nursing S1. S1 further indicated the error could be that the staff failed to transcribe the weights onto the patient's charts; however, she further indicated all staff should make sure that patient weights were present on the medical record for review by the patient's physician, the Registered Dietician, and the oncoming nursing staff.

1d) Failing to ensure the Pharmacist was notified after assessing a patient's allergies which resulted in a patient being prescribed and administered medications that she was allergic to (Patient #14):
Review of Patient #14's medical record revealed the patient was assessed as having an allergy to Cipro, Doxycycline, and Naprosyn on 9/24/2010 as documented on the patient's Medication Administration Record. Further review revealed a physician's order dated 10/12/2010 at 11:50 a.m. for Doxycycline 100 milligrams by mouth two times per day for 5 days. Review of Patient #14's Medication Administration Record revealed the patient had received Doxycycline on 10/12/2010 at 8:00 p.m. and also on 10/13/2010 at 8:00 a.m.

During a telephone interview on 1/04/2011 at 1:55 p.m., Pharmacists S13 indicated that there had been no notification of Pharmacy regarding the assessment of Patient #14's allergies to Cipro, Doxycycline, or Naprosyn. S13 indicated when a medication order was received at the Pharmacy, the first step prior to filling the medication was to review the patient's allergies. S13 further indicated if the pharmacy had known the patient had reported an allergy to Doxycycline, he would have called the physician for verification prior to filling the medication.

During a face to face interview on 1/05/2011 at 11:40 a.m., Physician S16 indicated he had not been aware that Patient #14 had reported to the nursing staff that she was allergic to Doxycyline or he would not have ordered the medication. Physician S16 indicated it was his practice to check the top of the physician's order sheet where allergies were documented and Doxycline had not been listed as an allergy for Patient #14 on the Physician's order sheet (confirmed with record review).

During a face to face interview on 1/05/2010 at 2:10 p.m., Director of Nursing S1 indicated any nurse that assesses a patient as having a medication allergy, that had not been disclosed at the time of admission, should ensure the pharmacy was notified so the patient's record would be updated. S1 further indicated all allergies were to be documented on the top of the physician's order sheet in the patient's medical record.

1e) Failing to ensure Apical Pulses were monitored according to the hospital's Drug Resource Book (Nursing 2011 Drug Handbook) (Patient #8):
Review of Patient #8's medical record revealed the patient was admitted to the hospital on 11/19/2010 with diagnoses that included Hypertension, Diabetes, and Chronic Low Back Pain. Further review revealed physician's orders for Metoprolol 50 milligrams by mouth twice daily, dated 11/19/2010 at 1400 (2:00 p.m.).

Review of Patient #8's Medical Record revealed no documented evidence of the patient's Apical Pulse being assessed prior to the administration of Metoprolol on 11/18/2010 at 8:00 p.m., 11/20/2010 at 8:00 a.m., 11/21/2010 at 8:00 a.m., 11/22/2010 at 8:00 a.m., 11/23/2010 at 8:00 a.m., 11/24/2010 at 8:00 a.m., 11/25/2010 at 8:00 a.m. and 8:00 p.m., 11/26/2010 at 8:00 a.m. and 8:00 p.m., and 11/27/2010 at 8:00 p.m.

This finding was confirmed by the Director of Nursing on 1/03/2010 at 4:00 p.m. who further indicated nursing staff should obtain and record apical pulses as per drug reference prior to the administration of Metoprolol.

Review of Drug Reference Handouts provided by the Director of Nursing as current (taken from Nursing 2011 Drug Handbook) revealed the following:
Metoprolol Succinate/ Metoprolol Tartrate: Nursing Considerations- Always check patient's apical pulse rate before giving drug. If it's slower than 60 beats/minute, withhold drug and call prescriber immediately. . . Monitor blood pressure frequently; drug masks common signs and symptoms of shock.

1f) Failing to ensure the RN accurately assessed and documented the skin of a diabetic patient with impaired skin integrity ( Patient #1)

Review of the medical record for Patient #1 revealed he was admitted to the hospital on 12/17/2010 was diagnoses that included diabetes, parkinson ' s disease, neuropathy with paresis, and gait dysfunction.
Review of the admission patient assessment under skin/integumentary dated 12/17/10 revealed this to be a normal assessment for the day and evening shifts. Review of the nurse's notes on 12/17/10 at 5:00 PM revealed the patient had a PEG tube, and that his skin was intact except for a small dime sized area on the inner aspect of the left heel.
Review of the patient assessment under skin/integumentary dated 12/18/10 revealed this to be an abnormal assessment on the day shift and a normal assessment for the evening shift. Review of the nurse's notes on 12/18/10 revealed no documentation of the location of the abnormal skin assessment.
Review of the patient assessment under skin/integumentary dated 12/19/10 revealed this to be an abnormal assessment for both shifts. Review of the nurse's notes on 12/19/10 revealed documentation of a scab to the area of the medial aspect of the left foot.
Review of the patient assessment under skin/integumentary dated 12/20/10 revealed this to be an abnormal assessment on the evening shift. Review of the nurse's notes on 12/20/10 revealed documentation of a scab to the right elbow.
Review of the patient assessment under skin/integumentary dated 12/21/10 revealed this to be a normal assessment of the day shift and an abnormal assessment on the evening shift. Review of the evening nurse's notes on 12/21/10 revealed documentation of scabbed areas to the left medial foot X2.
Review of the patient assessment under skin/integumentary dated 12/22/10, 12/23/2010, 12/24/2010, 12/25/10, 12/26/10, 12/27/2010, 12/28/10, 12/29/10, 12/30/10, and 12/30/10 revealed this to be an abnormal assessment for both shifts. Review of the nurse's notes on these days revealed no documentation of the assessment to the patient's left medial foot.
Review of the patient assessment under skin/integumentary dated 1/1/11 revealed a normal skin assessment on the day shift and an abnormal scan assessment on the evening shift with no documentation of the location of the abnormal scan assessment.
Review of the patient assessment under skin/integumentary dated 1/2/11 revealed a normal skin assessment on the day shift and evening shifts.
Review of the photographic documentation dated 12/19/10, which was 2 days after the patient ' s admission to the hospital, revealed a skin tear to the right elbow and scabbed areas noted to the medial aspect of the left foot. Further review revealed no documentation that these wounds were staged by a registered nurse or that the assessment included the width and depth of the areas on the left foot and right elbow. Review of the entire medical record revealed no additional photographic wound documentation since 12/19/10.
An interview was held with S1DON on 1/3/11 at 2:05 pm. After review of the Patient #1's medical record she indicated that photographic wound documentation had only been completed on 12/19/2010 and added that it should have been taken every week when the Braden scale was completed. She further indicated there was poor documentation as well as no documentation of the daily assessments of the patient ' s foot and elbow.
An observation was made of a skin assessment performed on Patient #1 by S1DON on 1/3/2011 at 2:30 pm. This observation revealed that one of the area's on the patient's left foot was healed and the DON indicated the healing area on the left foot was a Stage 1. The peg site was within normal limits. S1DON indicated at this time that she had no explanation why the wounds had never been staged. She reported that she could not find in the documentation when the second area on the left foot and right elbow had healed or why the last photographic wound documentation completed on Patient #1 had been 12/19/10.
1g) Failing to ensure the RN assessed patients with a change in condition (#4, #9, #18) and after a fall (#18):
Patient #4
Review of Patient #4's medical record revealed she was admitted on 11/05/10 with a diagnosis of debility secondary to multiple sclerosis.
Review of the "Nurses Notes" for 11/18/10 at 6:20pm revealed documentation by LPN (licensed practical nurse) S22 of "bs (bowel sounds) distended without + (positive) bs. pt. (patient) has a hx (history) of constipation. Will call the physician for Mag (magnesium) citrate in A.M. (morning), this is the only med (medication) that seems to help". Review of the entire shift of documentation for 11/18/10 revealed no documented evidence LPN S22 reported the absence of bowel sounds to the RN for assessment and the physician.
Review of the "Nurses Notes" for 11/22/10 at 6:20pm revealed an entry by RN S5 of "noted small, pink, open area to rt (right) inner thigh, barrier cream applied". Further review revealed no documented evidence of measurement of the open area and the appearance of surrounding tissue and the presence or absence of drainage.

Patient # 9
Review of the H&P for Patient #9 revealed she was admitted to the hospital on 10/15/10 with debility related to neuropathy and chronic left hip and knee pain. Further review she had a history of COPD (Chronic Obstructive Lung Disease), DM (Diabetes Mellitus), Diastolic Dysfunction and CHF (Congestive Heart Failure.

Review of the Physician's Orders dated 10/16/10 at 1830 (6:30pm) Patient #9 had orders for Cardiac Precautions in therapy, heart rate not to exceed 105bpm (beats per minute).

Review of the Nurses ' Narrative Notes dated 10/17/10 revealed the following: "0830 (8:30am) Patient up in w/c (wheelchair) HR 134 (Heart rate), BP 101/52 (Blood Pressure). Patient non-symptomatic at this time. Patient propelling w/c denies pain at this time. 0845 (8:45am) Patient assist to bed. Lying in bed HR 104 @ (at) rest. Will continue to monitor. 1100 (11:00am) Patient lying in bed HR 112. Continue to be asymptomatic. Will continue to monitor 1300 (1:00pm) Patient up in w/c BP 124/98, HR 140. Patient diaphoretic. Denies chest pain. MD notified. Instruct to transfer to ER (Emergency Room)" .
Further review of the nurses ' notes revealed no documented evidence the LPN assigned to the care of the patient had communicated to the RN the change in Patient #9 ' s condition and no assessment was performed by an RN.

Review of the Nurses' Narrative Notes dated 10/1810 revealed the following: "1430 (2:30pm) Patient lying in bed eating potatoes, corn, crabs, turkey neck. Educated patient on diabetic diet - the importance of maintaining her diet. States she understands. .1630 (4:30pm) Blood sugar 407 Observed patient. No signs or symptoms of hyperglycemia - states she feels fine. MD called. Made aware of BS (Blood Sugar) - instruct to follow hyperglycemia protocol and notify him of change. Regular insulin 10 units sq (subcutaneously) given in the LUA (Left Upper Arm). 1830 (6:30pm) Blood Sugar 359. No signs and symptoms of hyperglycemia. Patient states she feels OK" . Further review of the Nurses' Notes revealed no documented evidence the LPN assigned to the care of #9 communicated to the RN the change in the patient's condition and no assessment by the RN was performed. In addition there was no documentation in the Nursing Notes that the nurse informed the MD concerning Patient #9's dietary non-compliance prior to the increase in her blood sugar or the patient ' s blood sugar of 359 2 hours after administering 10 units of regular insulin.

Patient #18
Review of Patient #18's medical record revealed she was admitted on 11/09/10 with diagnoses of staph bacteremia related to right knee arthroscopy, hypertension, diabetes mellitus, bipolar disorder, osteoarthritis, coronary artery disease, obesity, sleep apnea, and anemia.
Review of Patient #18's "Admit Nursing Assessment" performed by RN S23 on 11/09/10 revealed no documented evidence of pressure ulcers.
Review of Patient #18's "Photographic Wound Documentation" dated 11/14/10 by LPN S8, with no documented evidence of the time of the assessment, revealed a Stage I pressure ulcer to the left upper thigh and the right upper thigh. Further review revealed no documented evidence of the measurement of the pressure ulcers to include length, width, and depth. Review of the nurses' notes for 11/14/10 revealed no documented evidence that a RN was notified of the change in Patient #18's skin with a resulting assessment by the RN.
Review of the nurses' notes for 11/19/10 at 9:45am revealed an entry by LPN S24 of "called to patient's bathroom per PT (physical therapist) ... patient sitting on the floor close to the toilet ...unable to cooperate with transfer from toilet to w/c (wheelchair), pt (patient) eased to floor ...". Review of the entire nursing notes for the shift revealed no documented evidence a RN was notified and had performed an assessment of Patient #18.

In a face-to-face interview on 01/05/11 at 2:10pm, DON S1 indicated she had not performed chart reviews related to RN assessment with a change in condition, assessment and measurement of alteration in skin integrity, and assessment of patient problems identified by the LPN.

2) Failure of nursing staff to perform quality controls on the glucometer machines according to hospital policy and manufacturer's recommendations:
Review of the Package Insert for "McKesson Truetrack" revealed in part, "Match Code in Display with Code on Test Strip vial label being used. . . Compare result to Control range printed on Test Strip vial label: If result is in range, System can be used for testing blood. If result does not fall within range, repeat test using a new Test Strip. Caution! If Control Test result continues to be outside range, system should not be used for testing blood."

Review of the hospital policy titled, "Glucometer Quality Control Testing, N 2.060 date 07/10" presented by the hospital as their current policy revealed in part, "Registered Nurses and Licensed Practical Nurse are the staff members identified to perform quality control. . . . . If result is within range, system can be used for testing blood. If result does not fall within range, repeat test using a new Test Strip. If Control Test result continues to be out of range, System should not be used for testing."

Review of the hospital's "Glucometer Quality Control Log" for the month of December 2010 revealed the preprinted acceptable range for low controls to be "88 - 118 mg/dl (milligrams per deciliter)" and the acceptable range for high controls to be "183 - 247 mg/dl". Further review of the Glucometer Quality Control Log revealed new Test Strips were initiated on 12/05/2010 with the Lot number of #RL3461, 12/15/2010 with the lot number of #RL3387, and 12/26/2010 with the lot number of #RL3434 for Machine #1 and 12/06/2010 with the lot number of #RL3461 and 12/22/2010 with the lot number of #RL3434 for Machine #2. There was only one bottle of Test Strips available for review by the surveyor: Lot Number 3434. Review of the Test Strip label for Lot # 3434 revealed the acceptable testing range for 0 (Lo) was 88 - 118, and 1 (Hi) was 181-245 (differs from the preprinted acceptable range of 183-247 for hi on the hospital form Glucometer Quality Control Log). None of the other bottles were available for review: #RL3461, #RL3387, or #RL3461. Review of the Quality Test results for High Controls on the date of 12/09/2010 revealed a level of 254.

3) Clarify physician's orders regarding absence of parameters for multiple routes of medication administration:
Review of Patient #8's medical record revealed an order dated 11/23/2010 at 2:00 p.m. for Cefazolin 1.5 Grams Intravenously or Intramuscularly every 8 hours for 7 days. Further review revealed no documented parameters to indicate when nursing staff should administer the medication by mouth versus intramuscularly versus intravenously.

Review of Patient #17's medical record revealed an order dated 10/07/2010 at 12:25 p.m. for Ativan 1 milligram IV (intravenous)/IM (intramuscular)/ or PO (by mouth) as needed every four hours for seizure or tremor. Further review revealed no documented parameters to indicate when nursing staff should administer the medication by mouth versus intramuscularly versus intravenously.

This finding was confirmed by Director of Nursing S1 on 1/04/2010 at 2:35 p.m. S1 indicated there were no parameters or indicators instructing the nursing staff as to when they should administer the medication by mouth versus intramuscularly versus intravenously. S1 further indicated the hospital did not have a policy specifying parameters/indicators when physician's wrote orders for multiple routes of administration.


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Based on record review and interview the hospital failed to: 1) ensure the patient's plan of care was implemented as ordered by the patient's physician as evidenced by: a. failing to ensure labs were drawn as ordered by the patient's physician for 8 of 20 sampled patients with orders for labs (#2, #4, #9, #13, #11, #16, #17, #18) of 20 total sampled patients; failing to ensure incentive spirometry was performed as ordered for 2 patients with orders for incentive spirometry (#4, #18) from a total of 20 sampled patients; c. failing to assess weights as ordered for 3 of 20 sampled patients (#9, #16, #18); and 2) to ensure the patient's care plan was developed to meet the needs of the patient and/or revised for a change in condition for 6 patients out of a total sample of 20 patients were revised when the patients had a change in condition. (#2, #4, #12, #13, #18, #19). Findings:

a. failing to ensure labs were drawn as ordered by the patient's physician
Patient #2
Review of the History & Physical (H&P) for Patient # 2 revealed she had a positive history for C- Diff. Review of the Physician ' s Orders dated 12/17/10 and 12/22/10 revealed an order for stool for C-Diff toxin and antibody.

Review of the "Specimen Lab Tracking" form revealed on 10/18/10 and 10/23/10 a stool for C-Diff toxin and antibody was sent to the lab. Further review of the form revealed no documented evidence the results of the tests had been received by the hospital as of 01/05/11. Review of the Physician's Orders dated 12/22/10 revealed a request from the physician to obtain the results of the stool culture from 12/18/10 for Patient #2. Review of the entire medical record revealed no documented evidence the results had been sent from the contracted lab to the hospital.

Review of the Physician's Orders for Patient # 2 for the time period of 10/30/10 through 01/03/11 revealed no documented evidence of an order for a CBC with Differential and a BMP to be done on 01/02/11.

Review of the Laboratory Report for Patient #2 revealed a specimen was sent and received on 01/02/11 at 0635 (6:35am) for a CBC with Differential and a BMP to be done on 01/02/11.

Review of the Physician's Orders dated 01/03/11 for Patient # 2 revealed a third order for C-Diff toxin and antibody with the results to be obtained by the RN.

Patient #4
Review of Patient #4's medical record revealed she was admitted on 11/05/10 with a diagnosis of debility secondary to multiple sclerosis. Review of the H&P (history and physical) of 11/06/10 revealed Patient #4 had a prior history of depression and anxiety, anemia, and constipation with recent fecal impaction.
Review Patient #4's "Physician Orders" revealed the following orders for labs:
11/05/10 at 6:30pm - CBC (complete blood count), CMP (complete metabolic profile), UA (urinalysis) and C&S (culture and sensitivity);
11/06/10 at 11:33am - stool for occult blood times 3;
11/11/10 at 11:25am - Sed (sedimentation) rate today; stool for occult blood times 3; and
11/16/10 with no documented evidence of the time the order was written - right eye swab culture.
Review of Patient #4's "Laboratory Report" revealed the following:
1) prealbumin was drawn on 11/06/10 with no documented evidence of a physician's order to check Patient #4's prealbumin level;
2) no documented evidence of stool for occult blood until 11/19/10 and 11/22/10 when Patient #4 had bowel movements on 11/13/10, 11/14/10, 11/15/10, 11/19/10, 11/21/10, 11/22/10, 11/23/10, 11/24/10, and 11/25/10; no documented evidence of a third stool specimen for occult blood as ordered;
3) sed rate ordered to be drawn 11/11/10 was drawn on 11/12/10; and
4) right eye swab culture ordered on 11/16/10 was performed on 11/17/10 after Patient #4 had received 2 doses of the ordered anti-infective medication.

In a face-to-face interview on 01/05/11 at 2:10pm, DON S1 indicated she had not been auditing charts to assure that labs were being drawn as ordered. She confirmed the above findings.

Patient #9
Review of the H&P for Patient #9 revealed she was admitted to the hospital on 10/15/10 with debility related to neuropathy and chronic left hip and knee pain.

Review of the medical record revealed results for a urinalysis which lab documentation indicated was ordered on 10/17/10 and a preliminary report on a urine culture and a Chem 8 dated 10/18/10 for Patient #9. Review of the Physician ' s Admit Orders dated 10/15/10 and orders written through 10/18/10 revealed no documented evidence a urinalysis, culture/sensitivity or Chem 8 had been ordered by the physician.

Patient #11:
Review of Patient #11's medical record revealed physician's orders dated 11/03/2010 at 1430 (2:30 p.m.) which included "Admit Labs: CMP, Pre-Albumin". Further review revealed Physician's orders dated 11/05/2010 for "CMP/Pre-albumin from admit to chart."
Review of Patient #11's entire medical record revealed no documented evidence that the admission CMP and Pre-Albumin were drawn until 11/05/2010 when the patient's physician ordered that the admit CMP and Pre-Albumin were to be placed in the chart (2 days after the physician ordered the labs to be drawn upon admission).

This finding was confirmed by Director of Nursing S1 in a face to face interview on 1/04/2011 at 11:30 a.m. S1 indicated Admit Labs were to be drawn at the time the patient was admitted to the hospital.

Patient #13
Review of Patient #13's medical record revealed she was admitted on 10/06/10 with a diagnosis of CVA with right-sided hemiparesis. Review of the H&P documented on 10/07/10 revealed Patient #13 was status post acute CVA with right upper extremity, plegia, right lower extremity paresis, decreased sensation and gait dysfunction, and had a history of hypertension, hyperlipidemia, bipolar disorder, seizure disorder, prior question of gastroesophageal reflux disease/peptic ulcer disease, bacteremia with critical illness neuropathy, and recent urinary tract infection.
Review of Patient #13's "Physician Orders" revealed an order on 10/13/10 at 12:47pm for a urinalysis and culture and sensitivity "today" and an order on 10/22/10 at 2:17pm for a CBC, sed rate, and urinalysis and culture and sensitivity "today". Review of Patient #13's "Laboratory Report" revealed the UA ordered to be done on 10/13/10 was done on 10/14/10. Further review revealed the CBC, sed rate, and CMP ordered to be done on 10/22/10 was done on 10/23/10, and the UA ordered to be done on 10/22/10 was done on 10/24/10.

In a face-to-face interview on 01/05/11 at 2:10pm, DON S1 indicated she had not been auditing charts to assure that labs were being drawn as ordered. She confirmed the above findings.

Patient #16
Review of the History & Physical (H&P) for Patient #16 revealed he was admitted to the hospital with diagnoses of a blister/ulceration on the right foot, respiratory failure, COPD (Chronic Obstructive Pulmonary disease), and Diabetes. Review of the Physicians' Orders dated 10/29/10 revealed an order for a CBC and BMP to be performed on 10/30/10. Review of the Lab Log revealed no documented evidence the ordered labs had been drawn and sent to the lab. Review of the results of the BMP sent from the contracted lab revealed the BMP for #16 had not been drawn and sent to the lab until 11/01/10 (2 days past the date ordered by the physician) and the CBC had not been drawn and sent to the lab until 11/02/10 (3 days past the date ordered by the physician.

Patient #17:
Review of Patient #17's medical record revealed a physician's order dated 10/06/2010 at 12:00 noon for Admission Labs to include Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Prothrombin Time/ International Normalized Ratio (PT/INR), and Pre-Albumin. Review of Patient #17's entire medical record revealed no documented evidence that these labs were drawn upon admission to the hospital (as ordered by the physician).

Further review revealed a physician's order for Patient #17 dated 10/05/2010 (no documented time) for BMP (Basic Metabolic Panel) every other day. Review of Patient #17's entire medical record revealed no documented evidence of a BMP being drawn on 10/11/2010, 10/15/2010, 10/19/2010, 10/21/2010, 10/23/2010, or 11/01/2010.
Further review revealed a physician's order for Patient #17 dated 10/18/2010 at 11:16 a.m. for a BMP and PT/INR to be drawn on 10/22/2010 and 10/25/2010. Review of the entire medical record revealed no documented evidence that Patient #17 had a BMP and/or INR drawn on 10/22 or 10/25/ 2010.

These findings were confirmed during a face to face interview on 11/04/2010 at 2:35 p.m. with Director of Nursing S1. S1 indicated she had not been aware that Patient #17 had not had labs drawn as ordered by the patient's physician. S1 indicated nursing staff should have drawn the labs as ordered and if there had been a problem in obtaining blood for the labs, the patient's physician should have been notified.

Patient #18
Review of Patient #18's medical record revealed she was admitted on 11/09/10 with diagnoses of staph bacteremia related to right knee arthroscopy, hypertension, diabetes mellitus, bipolar disorder, osteoarthritis, coronary artery disease, obesity, sleep apnea, and anemia.

Review of the "Physician Orders" revealed an order on 11/15/10 at 11:55am for a depakote level "today" and a UA with C&S "today". Further review revealed an order on 11/23/10 at 2:50pm to obtain a UA with C&S "today". Review of the "Laboratory Report" revealed the UA ordered to be obtained on 11/15/10 was obtained on 11/16/10, and the depakote level ordered to be drawn on 11/15/10 was drawn on 11/17/10. Further review revealed the UA with C&S ordered to be obtained on 11/23/10 was obtained on 11/24/10.

In a face-to-face interview on 01/05/11 at 2:10pm, DON S1 indicated she had not been auditing charts to assure that labs were being drawn as ordered.

Review of Policy Number N 2.016 titled "Lab Ordering" (documented date of implementation) submitted as the one currently in use by the hospital, revealed.... "A. When lab is ordered by a physician, the noting nurse will complete a lab request slip for the lab and file it under the date to be drawn and report to the oncoming shift". Further review of the policy revealed no documented evidence requiring staff to use a lab log.

b. failing to ensure incentive spirometry was performed as ordered
Patient #4
Review of Patient #4's medical record revealed she was admitted on 11/05/10 with a diagnosis of debility secondary to multiple sclerosis. Review of the H&P (history and physical) of 11/06/10 revealed Patient #4 had a prior history of depression and anxiety, anemia, and constipation with recent fecal impaction.
Review of Patient #4's "Physician Orders" revealed an order on 11/06/10 at 11:33am for incentive spirometry every two hours while awake when not in therapies. Review of the entire medical record revealed no documented evidence that incentive spirometry was ever performed from the date it was ordered until the date of chart review on 01/01/11.

Patient #18
Review of Patient #18's medical record revealed she was admitted on 11/09/10 with diagnoses of staph bacteremia related to right knee arthroscopy, hypertension, diabetes mellitus, bipolar disorder, osteoarthritis, coronary artery disease, obesity, sleep apnea, and anemia.
Review of Patient #18's "Physician Orders" revealed an order on 11/10/10 at 12:35pm for incentive spirometry every two hours while awake when not in therapies. Review of the entire medical record revealed no documented evidence that incentive spirometry was ever performed during Patient #18's hospital stay from the order date of 11/10/10 through discharge on 11/25/10.

In a face-to-face interview on 01/05/11 at 2:10pm, DON S1 indicated she had not been auditing charts to assure that incentive spirometry was performed as ordered.

c. Failing to assess weights as ordered for 3 of 20 sampled patients
Patient #9
Review of the H&P for Patient #9 revealed she was admitted to the hospital on 10/15/10 with debility related to neuropathy and chronic left hip and knee pain. Review of the Physicians' Orders dated 10/19/10 revealed an order for daily weights.
Review of the "7 Day Graphic Sheet" revealed no documented evidence Patient #9 was weighed on 10/26/10.

Patient #16
Review of the History & Physical (H&P) for Patient #16 revealed he was admitted to the hospital with diagnoses of a blister/ulceration on the right foot, respiratory failure, COPD (Chronic Obstructive Pulmonary disease), and Diabetes.
Review of the "Standing Admission Orders" dated 10/22/10 at 2300 (11:00pm) revealed an order to weigh the patient on admit and daily.
Review of the "7 Day Graphic Sheet" revealed no documented evidence Patient #16 was weighed on 10/26/10.

Patient # 18
Review of Patient #18's medical record revealed she was admitted on 11/09/10 with diagnoses of staph bacteremia related to right knee arthroscopy, hypertension, diabetes mellitus, bipolar disorder, osteoarthritis, coronary artery disease, obesity, sleep apnea, and anemia. Review of the "Standing Admission Orders" dated 11/09/10 at 2:00pm revealed an order to weigh the patient on admit and daily.
Review of the "7 Day Graphic Sheet" revealed no documented evidence Patient #18 was weighed on 11/19/10.

In a face-to-face interview on 01/05/11 at 2:10pm, DON S1 indicated she had not been auditing charts to assure that weights were checked as ordered by the physician.

The hospital could not submit a policy on weights.

2) Failing to ensure the patient's care plan was developed to meet the needs of the patient and/or revised for a change in condition
Patient # 2
Review of Nursing Care Plan dated 11/30/10 revealed the following:
Nursing Diagnosis # 2, Decline in ADLs (Activities of Daily Living) bathing, grooming, eating, dressing had no documented interventions.
Nursing Diagnosis #13, Altered Urine Elimination, Patient # 2 had a Foley catheter on admit which was discontinued on 12/01/10. Further review revealed no documented evidence the plan of care was updated to reflect the physician's order to monitor the patient to ensure voiding every 6 hours and toileting every two hours. Review of Nursing Diagnosis #22, Risk for Spread of Infection, revealed the patient was on contact precautions which were discontinued on 12/27/10. Further review revealed no documented evidence the plan of care was updated to reflect the physician's order on 01/03/11 to place the patient on contact isolation.

Patient #4
Review of Patient #4's medical record revealed she was admitted on 11/05/10 with a diagnosis of debility secondary to multiple sclerosis. Review of the medical record revealed Patient #4 had a right eye swab culture performed on 11/16/10, and she was referred for an ophthalmology consult with no documented evidence her care plan was updated to reflect the change in condition. Further review revealed Patient #4 had a stool specimen submitted on 12/03/10 to check for Clostridium Difficile Toxin A and B with no documented evidence of her care plan updated to reflect the potential risk for spread of infection. On 11/22/10 at 6:20pm an opened area to the right inner thigh was documented with no documented evidence of the care plan being updated to reflect the change in skin integrity.

Patient #12
Review of the medical record for Patient #12 revealed he was admitted to the hospital on 11/16/2010 with diagnosis that included debility with osteoarthritis and dementia. Further review of the medical record revealed the patient had a urinalysis with culture and sensitivity collected on 11/17/2010. The final results dated 11/19/2010 revealed a diagnosis of enterococcus faecalis. The patient was started on Ampicillin 500 mg every 6 hours for seven days on 11/23/2010 after the hospital received a faxed copy from the laboratory.

Review of the care plan for Patient #12 revealed that it had not been been updated since 11/16/2010 to reflect the urinary tract infection from 11/19/2010.

An interview was held with S1 DON on 1/4/2011 at 11:00 am. After review of the care plan for Patient #12, she indicated the care plan had not been revised by the nursing staff to reflect the patient's urinary tract infection.

Patient #13
Review of Patient #13's medical record revealed she was admitted on 10/06/10 with diagnoses of CVA (cerebral vascular accident), right-sided hemiparesis, hypertension, hyperlipidemia, urinary tract infection, seizure disorder, and bipolar disorder.
Review of Patient #13's "Nursing Plan Of Care" revealed her care plan was initiated for impaired mobility, decline in activities of daily living, ineffective airway clearance, altered urine elimination, high risk for injury (fall), high risk for impaired skin, and discharge planning needs. Further review revealed no documented evidence of Patient #13's care plan including high risk for infection (patient was admitted with urinary tract infection) and potential for injury related to seizures (patient was diagnosed with seizure disorder). Further review revealed no documented evidence whether the established goals had been met at the time of discharge on 10/27/10.

Patient # 18
Review of Patient #18's medical record revealed she was admitted on 11/09/10 with diagnoses of staph bacteremia related to right knee arthroscopy, hypertension, diabetes mellitus, bipolar disorder, osteoarthritis, coronary artery disease, obesity, sleep apnea, and anemia. A urinalysis with culture and sensitivity was performed on 11/16/10 with the final report revealing Escherichia coli and Pseudomonas aeruginosa present. Further review of the medical record revealed elevated protime and INR (international normalized ratio) results from lab performed on 11/18/10.
Review of Patient #18's care plan revealed no documented evidence a plan of care was initiated upon admit for high risk for infection related to the admit diagnosis of staph bacteremia related to right knee arthroscopy, and the care plan was not updated with the urinary tract infection of 11/16/10. Further review of the care plan revealed it was not updated to reflect the elevated protime and INR.

Patient # 19
Review of the H&P for Patient # 19 revealed he was admitted on 09/17/10 with the diagnosis of TTP (Thrombotic Thrombocytopenic Purpura) with anemia, anasarca, hypertension, generalized weakness, de-conditioning and possible critical illness neuropathy. Further review revealed Patient #19 was at risk of developing pneumonia, urinary tract infection, bed sores, deep venous thrombosis and was finishing treatment for fungus in the stool. Patient #19 had complained of some breakdown on his bottom.

Review of the Physician's Orders for Patient # 19 revealed the following orders: 09/17/10 pressure relieving wheelchair cushion for relief every 20 minutes and Calmoseptine ointment to buttocks qid (four times a day) and prn (as needed); 09/19/10 130cc of liquid Promod in 2 ounces of beverage po (by mouth) bid (twice a day); and 09/22/10 2L fluid restriction per day..

Review of the Plan of Care for Patient # 19 revealed no documented evidence Nursing Diagnosis #16, High Risk for Impaired Skin and intervention of pressure relieving device or ordered ointment had been identified and included. Further review revealed no documented evidence the care plan had been updated during the patient ' s hospital admission and according to the care plan documentation had met none of the established goals upon discharge on 10/08/10.

In a face-to-face interview on 01/05/11 at 2:10pm, DON S1 indicated the nursing staff was supposed to revise patients' care plans with changes in condition.






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25452

Based on record review and interview, the hospital failed to ensure: 1) non-employee licensed nurses working in the hospital were supervised and their clinical activities evaluated by a qualified hospital-employed RN (registered nurse) as evidenced by 3 of 7 contract RNs assigned as the only RN present in the hospital on seven days in October and November 2010 (S6, S14, S15) and 2) contract nurses were evaluated for competency prior to providing patient care at the hospital for 3 of 3 contract nurses reviewed from a total of 7 contract RNs ( S6, S14, S15). Findings:

1) Non-employee licensed nurses working in the hospital were supervised and their clinical activities evaluated by a qualified hospital-employed RN:
Review of the "Specialty Rehabilitation Hospital Daily Staffing Sheet" revealed RN S15, contract RN from Agency A, was the only RN assigned to the night shift on 10/19/10. Further review revealed RN S6, contract RN with Agency B, was the only RN assigned on the night shift of 10/29/10 and 10/30/10. Further review revealed RN S15, contract RN from Agency A, was the only RN assigned to the night shift on 10/31/10. Further review revealed RN S14, contract RN with Agency A, was the only RN assigned to the night shift on 11/06/10, RN S6 with Agency B was the only RN assigned to the night shift on 11/19/10, and RN S15 with Agency A was the only RN assigned to the night shift of 11/28/10.

In a face-to-face interview on 01/05/11 at 9:40am, Director of Nursing S1 indicated she did not know that contract agency RNs had to be supervised by a hospital-employed RN.

2) Contract nurses were evaluated for competency prior to providing patient care at the hospital:
Review of employee personnel file for contracted (agency) nurse S6 revealed no documented evidence of competency evaluation. S6 worked at the hospital, providing patient care, on 10/29/2010, 10/30/2010, and 11/19/2010.

Review of employee personnel file for contracted (agency) nurse S14 revealed no documented evidence of competency evaluation. S14 worked at the hospital, providing patient care, on 11/06/2010.

Review of the employee personnel file for contracted (agency) nurse S15 revealed no documented evidence of competency evaluation. S15 worked at the hospital, providing patient care, on 10/19/2010, 20/31/2010, and 11/28/2010.

These findings were confirmed by Director of Nursing S1 on 1/05/2011 at 3:20 p.m.




25065








25452

Based on record review and interview the hospital failed to ensure medication orders were complete as evidenced by failing to ensure parameters were written when orders contained more than one choice of routes for administration for 2 of 2 patients with multiple routes ordered for medication administration out of a total sample of 20 ( #8, #17). Findings:

Review of Patient #8's medical record revealed an order dated 11/23/2010 at 2:00 p.m. for Cefazolin 1.5 Grams Intravenously or Intramuscularly every 8 hours for 7 days. Further review revealed no documented parameters to indicate when nursing staff should administer the medication by mouth versus intramuscularly versus intravenously.

Review of Patient #17's medical record revealed an order dated 10/07/2010 at 12:25 p.m. for Ativan 1 milligram IV (intravenous)/IM (intramuscular)/ or PO (by mouth) as needed every four hours for seizure or tremor. Further review revealed no documented parameters to indicate when nursing staff should administer the medication by mouth versus intramuscularly versus intravenously.

This finding was confirmed by Director of Nursing S1 on 1/04/2010 at 2:35 p.m. S1 indicated there were no parameters or indicators instructing the nursing staff as to when they should administer the medication by mouth versus intramuscularly versus intravenously. S1 further indicated the hospital did not have a policy specifying parameters/indicators when physician's wrote orders for multiple routes of administration.

Based on record review and interview the hospital failed to ensure that the medical record for each inpatient was complete by failing to ensure Discharge Summaries were accurately written for 2 of 20 sampled patients (#17, #18). Findings:

Patient #17
Review of Patient #17's Discharge Summary dictated on 11/03/2010 at 12:51 p.m, transcribed on 11/03/2010 and signed by Physician S16 on 11/08/2010 at 12:00 noon revealed the following, "(page 2) In occupational therapy, patient is minimal assistance with using _____ for feeding, minimal assistance grooming, maximum assistance bathing, moderate assistance upper body dressing, minimal assistance toilet transfers, maximum assistance lower body dressing and toileting." and "(page 3) Medicines include. . . Ensure one can t.i.d. (three times per day) between meals, ______ 0.77% cream to feet b.i.d. (two times per day), Ensure ____ ounces b.i.d. with lunch and supper." There was no documentation in the blanks left by the transcriptionist.

Patient #18
Review of Patient #18's "Discharge Summary" dictated on 11/25/10 at 1:47pm, transcribed on 11/26/10, and signed by Physician S16 on 11/29/10 at 11:30am, revealed, in part, "... 7. Alavesta fungal ointment to buttocks and peri- ____ q.i.d. (four times a day)...". Further review revealed no documented evidence the blanks left by the transcriptionist were completed by Physician S16 when he signed the discharge summary.

These findings were confirmed by Administrator S9 and Director of Nursing S1 on 1/04/2011 at 1:20 p.m. and also by Physician S16 on 1/05/2011 at 11:55 a.m. Physician S16 indicated that he should have ensured that the transcription was complete by filling in the blanks or else marking through the documentation with a line and his initials.

Review of the "Medical Staff Bylaws", with no documented evidence of the date of adoption, revealed, in part, "...The Medical Staff shall adopt such rules and regulations as may be necessary to implement more specifically the general principles found within these bylaws. The rules and regulations shall regulate the proper conduct of Medical Staff organizational activities and will embody the specific standards and level of practice that are required to each Medical Staff Member and other designated individuals who exercise clinical privileges or provide designated patient care services in the hospital...". Further review revealed no documented evidence of rules and regulations for the medical staff.

In a face-to-face interview on 01/05/11 at 10:30am, Administrator S9 confirmed the hospital had no Medical Staff Rules and Regulations.








25065

Based on record review and interview the hospital failed to ensure medical record entries were timed, dated, and/or authenticated as evidenced by: 1) 13 of 20 sampled patients who were assessed using the Braden Scale (#1,#3, #4, #5, #6, #7, #8, #10, #11,#12, #13, #16,#18) out of 20 total sampled medical records. Findings:

Graphic Sheet Entries:
Patient #1
Review of Patient #1 medical record revealed he was admitted on 12/17/2010 with diagnoses that included neuropathy with paresis and gait dysfunction. Further review of the
"7 Day Graphic Sheet" revealed no documented evidence of the time the patient's vital signs were obtained on the dates of 12/18/10 (x2), 12/19/10 (x2), 12/20/10(x1), 12/21/10 (x1),12/23/10 (x2), 12/24/10 (x1), 12/25/10 (x1), 12/29/10 (x1), 1/1/11 (x2), 1/2/11 (x1).

Patient #3
Review of Patient #3's medical record revealed no documented evidence of the time the patient's vital signs were obtained on the dates of 12/29/10 (x1), 1/01/11 (x1), and 1/02/2011 (x2).

Patient #4
Review of Patient #4's medical record revealed she was admitted on 11/05/10 with a diagnosis of debility secondary to multiple sclerosis.
Review of Patient #4's "7 Day Graphic Sheet" revealed no documented evidence of the times the vital signs were taken on the day shift for 11/07/10, 11/11/10, 11/14/10, 11/19/10, 11/20/10, 11/21/10, 11/26/10, 11/28/10, 11/29/10, 11/30/10, 12/02/10, 12/03/10, 12/08/10, 12/10/10, 12/11/10, 12/15/10, 12/16/10, 12/17/10, 12/23/10, 12/24/10, and 01/02/11. Further review revealed no documented evidence of the times the vital signs were taken for on the night shift for 11/016/10, 11/07/10, 11/08/10, 11/09/10, 11/14/10, 11/15/10, 11/16/10, 11/17/10, 11/18/10, 11/20/10, 11/21/10, 11/26/10, 11/27/10, 11/29/10, 11/30/10, 12/01/10, 12/02/10, 12/05/10, 12/08/10, 12/09/10, 12/14/10, 12/15/10, 12/16/10, 12/18/10, 12/19/10, 12/23/10, 01/01/11, and 01/02/11.

Review of Patient #5's medical record revealed no documented evidence of the time the patient's vital signs were obtained on the dates of 12/27/2010 (x2), 12/28/2010 (x1), 12/31/2010 (x1) and 1/01/11 (x1).

Review of Patient #6's medical record revealed no documented evidence of the time the patient's vital signs were obtained on the dates of 12/29/2010 (x1), 12/30/2010 (x1), 12/31/2010 (x1), 1/01/2011 (x1), and 1/02/.2011 (x1).

Review of Patient #7's medical record revealed no documented evidence of the time the patient's vital signs were obtained on the dates of 12/30/10 (x1), 1/01/11 (x2), and 1/02/2011 (x2).

Review of Patient #8's medical record revealed no documented evidence of the time the patient's vital signs were obtained on the dates of 11/19/2010 (x1), 11/20/2010 (x2), 11/21/2010 (x2), 11/24/2010 (x2), 11/25/2010 (x1), 11/26/2010 (x2), and 11/29/2010 (x1).

Review of Patient #10's medical record revealed no documented evidence of the time the patient's vital signs were obtained on the dates of 12/15/2010 (x1), 12/17/2010 (x1), 12/18/2010 (x2), 12/19/2010 (x2), 12/20/2010 (x1) and 12/21/2010 (x1)..

Review of Patient #11's medical record revealed no documented evidence of the time the patient's vital signs were obtained on the dates of 11/13/2010 (x1), 11/14/2010 (x2), 11/14/2010 (x1), 11/16/2010 (x1), 11/17/2010 (x1), and 11/18/2010 (x1).

Patient #13
Review of Patient #13's medical record revealed she was admitted on 10/06/10 with a diagnosis of CVA with right-sided hemiparesis.
Review of Patient #13's "7 Day Graphic Sheet" revealed no documented evidence of the times the vital signs were taken on the day shift for 10/07/10, 10/08/10, 10/13/10, 10/14/10, 10/15/10, 10/16/10, 10/17/10, 10/21/10, 10/22/10, and 10/26/10. Further review revealed no documented evidence of the times the vital signs were taken on the night shift for 10/07/10, 10/13/10, 10/14/10, 10/15/10, 10/18/10, 10/19/10, 10/20/10, 10/21/10, 10/23/10, and 10/24/10.

Patient #16
Review of the History & Physical (H&P) for Patient #16 revealed he was admitted to the hospital with diagnoses of a blister/ulceration on the right foot, respiratory failure, COPD (Chronic Obstructive Pulmonary disease), and Diabetes.
Review of Patient #16's "7 Day Graphic Sheet" revealed no documented evidence of the times the vital signs were taken on the day shift for 10/22/10, 10/26/10, 10/27/10, 10/31/10 and 11/01/10. Further review revealed no documented evidence of the times the vital signs were on the night shift for 10/23/10, 10/24/10, 10/28/10, 10/29/10, 10/30/10, 10/31/10, and 11/01/10.

Patient #18
Review of Patient #18's medical record revealed she was admitted on 11/09/10 with diagnoses of staph bacteremia related to right knee arthroscopy, hypertension, diabetes mellitus, bipolar disorder, osteoarthritis, coronary artery disease, obesity, sleep apnea, and anemia.
Review of Patient #18's "7 Day Graphic Sheet" revealed no documented evidence of the times the vital signs were taken on the day shift for 11/09/10, 11/12/10, 11/13/10, 11/14/10, 11/19/10, 11/20/10, and 11/21/10. Further review revealed no documented evidence of the times the vital signs were taken for on the night shift for 11/09/10, 11/10/10, 11/11/10, 11/14/10, 11/15/10, 11/16/10, 11/19/10, 11/20/10, 11/21/10, 11/22/10, 11/23/10, and 11/24/10.

These findings were confirmed by Director of Nursing S1 on 11/04/2010.

In a face-to-face interview on 01/05/11 at 2:10pm, Director of Nursing (DON) S1 indicated she had not audited medical records for timing of vital signs. She confirmed the above findings of lack of dates and/or times for vital signs.

Review of the "Medical Staff Bylaws", with no documented evidence of the date of adoption, revealed no documented evidence of rules and regulations that addressed that all medical record entries needed to be timed, dated, and authenticated.
Braden Scale Entries:
Review of the "Braden Scale for Predicting Pressure Sore Risk" form revealed no documented evidence the signature of the person performing the assessment or the time the assessment was performed was required.

Patient # 1
Review of Patient #1's "Braden Scale for Predicting Pressure Sore Risk" revealed no documented evidence authenticating who performed the assessment or the time the assessment was performed for the dates of 12/17/2010, 12/19/2010, and 1/02/2011.

Patient # 3
Review of Patient #3's "Braden Scale for Predicting Pressure Sore Risk" revealed no documented evidence authenticating who performed the assessment or the time the assessment was performed for the dates of 12/21/2010 and 1/02/2011.

Patient #4
Review of Patient #4's medical record revealed she was admitted on 11/05/10 with a diagnosis of debility secondary to multiple sclerosis.
Review of Patient #4's "Braden Scale For Predicting Pressure Sore Risk" revealed the assessment was performed on 11/7/10, 11/21/10, 12/05/10, 12/12/10, 12/19/10, 12/21/10, and 01/02/11. Further review revealed no documented evidence of the signature and title of the nurse performing the assessment or the time the assessment was performed.

Patient #5
Review of Patient #5's "Braden Scale for Predicting Pressure Sore Risk" revealed no documented evidence authenticating who performed the assessment or the time the assessment was performed for the dates of 12/24/2010.

Review of Patient #6's "Braden Scale for Predicting Pressure Sore Risk" revealed no documented evidence authenticating who performed the assessment or the time the assessment was performed for the dates of 1/02/2011.

Review of Patient #8's "Braden Scale for Predicting Pressure Sore Risk" revealed no documented evidence authenticating who performed the assessment or the time the assessment was performed for the dates of 11/21/2010.

Review of Patient #10's "Braden Scale for Predicting Pressure Sore Risk" revealed no documented evidence authenticating who performed the assessment or the time the assessment was performed for the dates of 12/15/2010 and 12/19/2010..

Review of Patient #11's "Braden Scale for Predicting Pressure Sore Risk" revealed no documented evidence authenticating who performed the assessment or the time the assessment was performed for the dates of 11/09/2010.

Patient #13
Review of Patient #13's medical record revealed she was admitted on 10/06/10 with a diagnosis of CVA with right-sided hemiparesis.
Review of Patient #13's "Braden Scale For Predicting Pressure Sore Risk" revealed the assessment was performed on 10/06/10, 10/10/10, 10/17/10, and 10/24/10 with no documented evidence of the time the assessment was performed and the signature and title of the nurse performing the assessment .

Patient #18
Review of Patient #18's medical record revealed she was admitted on 11/09/10 with diagnoses of staph bacteremia related to right knee arthroscopy, hypertension, diabetes mellitus, bipolar disorder, osteoarthritis, coronary artery disease, obesity, sleep apnea, and anemia.
Review of Patient #18's "Braden Scale For Predicting Pressure Sore Risk" revealed the assessment was performed on 11/12/10 and 11/21/10 with no documented evidence of the time the assessment was performed and the signature and title of the nurse performing the assessment.

In a face-to-face interview on 01/05/11 at 2:10pm, DON S1 confirmed the Braden Scale assessments performed did not include the time the assessment was performed nor the signature and title of the nurse performing the assessment.

Review of Policy Number N 2.008 titled "Skin Care: Risk Assessment and Skin Assessment" (no date of implementation or revision) and submitted as the one currently in use revealed no documented evidence the name, signature the name, signature of the person performing the assessment or the time the assessment was performed was required.

Timed consents:
Patient #2
Review of the "Conditions of Admission" (Consent for Treatment), "Patient Rights", and " Advanced Directives" dated 11/30/10 revealed no documented evidence the time the forms had been signed.

Patient #4
Review of Patient #4's "Conditions Of Admission" revealed no documented evidence of the time the consent was signed by the patient and witnessed by the nurse.

Patient # 9
Review of the "Conditions of Admission" (Consent for Treatment), "Patient Rights" , and " Advanced Directives" dated 10/15/10 revealed no documented evidence the time the forms had been signed.

Patient #12
Review of Patient #12's "Conditions Of Admission" and "Acknowledgement Of Receipt Of Information" (regarding advance directives, patient rights, privacy rights, grievance procedure, Medicare message)on 11/16/2010 revealed no documented evidence of the time the patient and witness signed the consents.

Patient #13
Review of Patient #13's "Conditions Of Admission" and "Acknowledgement Of Receipt Of Information" (regarding advance directives, patient rights, privacy rights, grievance procedure, Medicare message) revealed no documented evidence of the time the patient and witness signed the consents.

In a face-to-face interview on 01/05/11 at 2:10pm, DON S1 indicated she had not audited medical records for completion of consents.

Review of the "Medical Staff Bylaws", with no documented evidence of the date of adoption, revealed no documented evidence of rules and regulations that addressed that all medical record entries needed to be timed, dated, and authenticated.
Inaccurate Medical Records
EKG
Review of the H&P for Patient #9 revealed she was admitted to the hospital on 10/15/10 with debility related to neuropathy and chronic left hip and knee pain. Review of the Physician's Orders dated 10/17/10 at 1510 (3:10pm).

Review of the medical record for Patient # 9 revealed the results of one EKG documented as performed on 08/29/1970 at 10:28PM.

In a face to face interview on 01/05/10 at 2:30pm S9 Administrator indicated EKGs are a contracted service. S1 DON indicated she had not noticed the date and time printed on the EKGs before and was not aware it was not the date and time performed.

Review of the Fall Risk Assessment form used to assess Patient #2 during her hospital stay of 11/30/10 to 01/04/11 revealed no documented evidence the time or signature of the nurse performing the assessment was required and therefore none had been documented.


Review of the Admit Nursing Assessment for Patient # 2 revealed no documented evidence of the time and signature of the nurse performing the assessment.


Patient # 19
Review of the " Braden Scale Assessment " form for Patient # 19 revealed no documented evidence a signature of the person performing the assessment was required; therefore on 09/18/10 there was no signature of the nurse performing the assessment.


Review of Policy Number N 2.066 titled " Informed Consent for Medical Treatment " adopted 11/10 and submitted as the one currently in use revealed no documented evidence a date and time is required.

Inaccurate Assessments
Patient # 2
Review of the History & Physical for Patient # 2 revealed she was admitted on 11/30/10 for dehydration, hypotension, and a severe functional decline. Further review revealed she had a history of previous hospitalizations for diabetes complications and decubitus ulcers.

Review of the Nursing Admit Assessment dated 11/30/10 for Patient # 2 revealed the following Skin Breakdown Assessment .... " Is pressure ulcer present? Yes. Buttock Reddened. Type of Wound: Yes. Pressure Ulcer " . Further review of the admit assessment, section for wound photographs and measurements revealed " NO WOUNDS " . Further review of the medical record revealed no documented evidence Patient #2 had a pressure ulcer to the buttocks.

Observation of a skin audit for Patient # 2 on 01/03/11 at 3:15pm revealed no evidence of any skin breakdowns.

Patient #19
Review of the H&P for Patient # 19 revealed he was admitted on 09/17/10 with the diagnosis of TTP (Thrombotic Thrombocytopenic Purpura) with anemia, anasarca, hypertension, generalized weakness, de-conditioning and possible critical illness neuropathy. Further review revealed Patient #19 was at risk of developing pneumonia, urinary tract infection, bed sores, deep venous thrombosis and was finishing treatment for fungus in the stool. Patient #19 had complained of some breakdown on his bottom. Review of the Physician' s Orders dated 09/17/10 revealed orders for a pressure reliving wheelchair cushion for relief every 20 minutes and Calmoseptine ointment to buttocks qid (four times a day) and prn (as needed).

Review of the Braden Scale Assessment for Patient # 19 revealed he had no sensory impairment, his skin was rarely moist, he walked occasionally, no mobility limitation, had adequate nutrition and had potential problems for friction or shear which indicated a low risk for pressure ulcer development.

Falls Assessments
Patient #2
Review of the History & Physical for Patient # 2 revealed she was admitted on 11/30/10 for dehydration, hypotension, and a severe functional decline. Further review revealed she had a history of previous hospitalizations for diabetes complications and decubitus ulcers.

Review of the Fall Risk Assessment Scale for Patient #2 dated 11/30/10 through 01/05/11 revealed no documented evidence the time or person performing the assessment.

Patient # 16
Review of the H&P for Patient #9 revealed she was admitted to the hospital on 10/15/10 with debility related to neuropathy and chronic left hip and knee pain.

Review of the Fall Risk Assessment Scale for Patient #9 dated 10/17/10 through 01/05/11 revealed no documented evidence the time or person performing the assessment.







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25452

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

1. failing to ensure a pharmacist supervised and evaluated the pharmacy services to ensure that patient medications were available for administration in a timely manner and as ordered by the physician; (See findings cited at A0492)

2. failing to ensure medication errors were reported to the patient's physician and tracked through the Quality Assurance Performance Improvement Committee for review to determine root causes and for implementation of corrective action as needed. (See findings cited at A0492 and A0508)

Based on record review and interview the hospital failed to ensure a pharmacist supervised and evaluated the services provided by pharmacy to ensure the quality of services as evidenced by:
1. Failing to ensure that patient medications were available for administration in a timely manner and as ordered by the physician for 2 of 20 sampled patients (#2, #4);
2) Failing to ensure medication errors were reported to the patient's physician and the Quality Assurance Performance Improvement Committee for review to determine root causes and implementation of corrective action as needed for 7 of 8 patients with medication errors reviewed (Patient #1, #2, #3, #4, #9, #10, #19) out of a total sample of 20. (Refer to findings cited a A0404 and A0508): Findings:


1)
Review of the hospital contract with Agency C (Pharmacy Services), which had never been signed by a representative of Agency C, revealed in part, "(Agency C) agrees to deliver to facility all pharmaceuticals, pursuant to physician' orders, and supplies within a reasonable time, except for circumstances and conditions beyond it's control which shall expressly include but not be limited to any back ordered or out of stock items. . . (Agency C) agrees to provide continuous service to facility during the five day workweek (hospital is open 24 hours a day/7 days per week). According to this service, (Agency C) agrees to deliver routine pharmaceuticals to facility. In the event of an emergency , (Agency C) agrees to provide emergency pharmacy services to facility twenty four hours per day, seven days per week. . ." Further review revealed no documented evidence defining "emergency" in relation to the contracts provision of "emergency pharmacy services" in the "event of an emergency".

During a telephone interview on 1/04/2011 at 1:55 p.m., Pharmacist S13 indicated the Pharmacy delivered medications to the hospital one time per day, in the evening hours. S13 indicated the usual departure time was between 6:30 and 7:30 p.m. S13 indicated the pharmacy was located approximately 1.5 hours from the facility; however, there were four areas served by the same delivery vehicle which included Metairie, Luling, Kenner, and LaPlace. S13 indicated the pharmacy would make a special delivery upon request of the facility, as needed. S13 further indicated medications could be obtained by a local pharmacy; however, he was not sure if there were any 24 hour pharmacies in the area. S13 indicated the Pharmacist that typically handled problems for the hospital was out of town and unable to be reached.

During a face to face interview on 1/05/2011 at 3:20 p.m., Administrator S9 confirmed the contract for Pharmacy Services provided by (Agency C) did not provide for routine daily services, 7 days per week, which resulted in instances of medications not being available for administration. S9 indicated the hospital's contracted Pharmacy (Agency C) delivered medications to the hospital one time daily during weekdays and Saturday.

Review of Medical Records revealed the following medications were not available for administration:
Patient #2 failed to receive Restoril 30 milligrams by mouth on 12/15/10 at 2045 (8:45pm), as ordered by the patient's physician on 11/30/2010, due to medication not being available (as documented in the patient's Medication Administration Record).

Patient #4 failed to receive Gentamycin 0.3% eye drops on 11/15/2010 at 8:00 p.m., as ordered by the patient's physician on 11/15/2010 at 5:30 p.m. , due to the medication not being available as documented in the patient's Medication Administration Record. The medication was ordered on 11/15/2010 at 1:00 p.m. for administration every four hours while awake times 4 days.

2)
Review of Patient Medical Records and Hospital Medication Occurrence Reports revealed no documented evidence that the following medication errors were reported to the patient's physician and that occurrence reports had been completed for review by the hospital's Quality Assurance Performance Improvement Committee and the hospital's Pharmacy and Nutrition Committee to ensure problems were identified and corrective action taken as needed:

Patient #1 failed to have documented evidence of receiving Lantus 5 units on the evening of 12/21/2010 (ordered by the patient's physician on 12/17/2010 to be administered subcutaneously every evening). Further review revealed no documented evidence that the patient's physician was notified of the omission and no documented evidence of an occurrence report.

Patient #2 failed to have documented evidence that Restoril 30 milligrams (ordered by the patient's physician on 11/30/2010 to be administered every hour of sleep) was administered on 12/15/2010 at 8:45 p.m. and Nexium 40 milligrams (ordered by the patient's physician on 11/30/2010 to be administered daily) was administered on 12/31/2010 and 1/01/2011. Further review revealed no documented evidence that the patient's physician was notified of the omission and no documented evidence of an occurrence report.

Patient #3 failed to have documented evidence of receiving Lantus 24 units (ordered 12/21/2010 to be administered every evening) subcutaneously on the evening (5:00 p.m. scheduled dose) of 12/24/2010 or 12/25/2010. Further review revealed no documented evidence that the patient's physician was notified or an occurrence report was documented.

Patient #4 failed to have documented evidence of receiving Gentamycin eye drops on 11/15/2010 at 8:00 p.m. (ordered 11/15/2010 at 5:30 p.m. for administration to right eye every four hours while awake), Ampicillin 50 milligrams (ordered on 12/06/2010 at 12:35 p.m. for administration every 6 hours for 7 days) on 12/06/2010 , and Medrol dose pack on 11/11/10 and 11/12/2010 (ordered on 11/11/2010 at 11:25 p.m. and not started until 11/13/2010). Further review revealed no documented evidence that the patient's physician was notified of the omissions and no documented evidence of an occurrence report.

Patient #9 failed to have documented evidence of receiving Lactulose 30 cc on 10/28/2010 at 8:00 a.m. and 8:00 p.m. (ordered by the patient's physician on 10/19/2010 to be administered twice per day), MagCitrate 150 milliliters (ordered on 10/26/2010 to be administered two times per day and held for loose stools) on 10/27/2010 at 5:00 p.m., and Robaxin 750 milligrams (ordered on 10/15/2010 to be administered by mouth three times per day) on 10/15/2010 at 8:00 p.m., 10/16/2010 at 8:00 a.m. and 10/16/2010 at 2:00 p.m.. Further review revealed no documented evidence that the patient's physician was notified of the omission and no documented evidence of an occurrence report.

Patient #10 failed to have documented evidence of receiving Travantan Z 0.004 (ordered on 12/16/2010 at 9:50 a.m. to be administered every hour sleep) or Artificial Tears (ordered 12/16/2010 at 9:50 a.m. to be administered three times per day) eye drops on 12/16/2010 at the 8:00 p.m. scheduled dose. Further Patient #10 failed to have documented evidence of receiving Cipro (ordered by the patient's physician on 12/17/2010 at 2:15 p.m. for 500 milligrams by mouth two times per day) or Florinex 1 tablet (ordered by the patient's physician on 12/17/2010 at 2:15 p.m. to be administered by mouth two times per day) on 12/17/2010 at the 8:00 p.m. scheduled dose. Further review revealed no documented evidence that the patient's physician was notified of the omissions and no documented evidence of an occurrence reports.

Patient #19 failed to have documented evidence of receiving Proventil HFA (ordered by the patient's physician on 9/17/2010 for 2 puffs every six hours) on 09/17/10 at 12noon and 1800 (6:00pm); 09/20/10 at 1800 (6:00pm); 09/21/10 12 at midnight, 12 noon and 1800 (6:00pm); 09/22/10 at 12 midnight, 0600 (6:00am) and 1800 (6:00pm); 09/23/10 12 at midnight 0600 (6:00am) and 12 noon; 09/25/10 at 12 midnight 0600 (6:00am), 12 noon and 1800 (6:00pm); 09/26/10 at 0600 (6:00am); 09/28/10 12 midnight; and 10/02/10 12 midnight. Further Patient #19 failed to have documented evidence of receiving Colace 100 milligrams on 9/25/2010 at 8:00 p.m., 10/02/2010 at 8:00 a.m., 10/05/2010 at 8:00 a.m., and 10/05/2010 at 8:00 p.m. Further Patient #19 failed to have documented evidence of receiving Normal Saline Spray (ordered by the patient's physician on 9/17/2010 to be administered one to two sprays to each nostril twice a day) on 9/25/2010 at 8:00 a.m. and 8:00 p.m. Further review revealed Patient #19 failed to have documented evidence of receiving Prednisone 40 milligrams (ordered by the patient's physician on 9/17/2010 to be administered 1 tablet daily) on 10/02/2010 at 8:00 a.m. Additional review revealed Patient #19 failed to receive Azathioprine 50 milligrams (ordered on 9/17/2010 to be administered daily) on 10/03/2010 at 9:00 p.m. Further review revealed no documented evidence that the patient's physician was notified of the omissions and no documented evidence of an occurrence reports.

Medication errors as listed above were reviewed with Director of Nursing S1 on 1/05/2011 who confirmed there were no occurrence reports and no documented evidence that the patent's physician had been notified. S1 indicated that Occurrence reports would be needed for Pharmacy and Nutrition Meetings and Quality Assurance Performance Improvement to be able to identify problems and develop corrective action as needed. S1 indicated the hospital had been depending on self report by nursing staff for identification of medication errors. S1 indicated there had been no chart audits by either pharmacy staff or nursing staff that identified the above errors.

During a face to face interview on 1/03/2010 at 11:00 a.m., Registered Nurse S5 indicated the practice at the hospital for ordering medications on the day shift was to wait for the newly admitted patient to arrive and then to order their medication. S5 further indicated staff would send in orders to pharmacy for patients that were expected to arrive on evening shift prior to their arrival. S5 indicated the Pharmacy was located in Mandeville and delivered medications in the evening hours. S5 further indicated there were times when medications were not available for administration to patients and in those instances nursing staff would document in the medical record that the medications were not available and also should document on an occurrence report.
Review of the hospital policy titled, "Medication Errors, N 3.007, last revised 10/18/2010" presented by the hospital as their current policy revealed in part, "A Medication Variance Report is completed on all medication administration errors. . . The error and patient assessment data are communicated to the attending physician and DON (Director of Nursing) immediately if the situation is potentially life threatening. If the error has no serious effect on the patient, the physician and DON are notified as soon as possible. . . A Medication Variance Report is completed. . . The charge nurse investigates the error to determine the cause. The charge nurse is responsible for completing the Medication Variance Form and forwarding it to the Director of Nursing/Director of Pharmacy."

Review of the hospital's Pharmacy and Nutrition Committee Meeting Minutes dated December 8, 2010 revealed in part, "Recommendations: All orders are to be faxed ASAP (as soon as possible) to the pharmacy. If a patient is admitted after pharmacy hours, orders will be faxed and the pharmacist in charge will be paged to confirm receipt of orders. Medications can be sent by courier if necessary." Further review revealed no documented evidence to define the protocol/plan for requesting medications to be delivered by a courier and no documented evidence that a pharmacist was represented at the meeting or participated in the meeting.

Based on observation, interview, and record review the hospital failed to ensure a patient's medication was kept in a secure area as evidence by having a tube of murirocin ointment and an open/unlabeled medicine cup containing a thick white substance on the bedside table. Findings:

An observation was made on 1/3/2011 at 10:50am in the room of Patient #12 of a tube of murirocin ointment and an open/unlabeled medicine cup containing a thick white substance on the bedside table.

An interview was held with S5RN on 1/3/2011 at 10:50am. She confirmed the tube of murirocin ointment and an open/unlabeled medicine cup containing a thick white substance on the bedside table. S5RN reported that medications should not be left at the patient's bedside.

Review of Policy Number N 3.001 titled "Medications" (no date of implementation) and submitted by the hospital as the one currently in use, revealed no documented evidence medications at the bedside was addressed in the policy. Further review revealed... "III. Procedure: 11. Give patient the medication. 12. Remain with the patient to ensure medication is swallowed".

Based on record review and interview the hospital failed to ensure medication errors were reported to the patient's physician and tracked through the Quality Assurance Performance Improvement Committee for review to determine root causes and for implementation of corrective action as needed for 7 of 8 patients with medication errors reviewed (Patient #1, #2, #3, #4, #9, #10, #19). . Findings:



Patient #1
Review of Patient #1's medical record revealed a physician's order on 12/17/2010 for Lantus 5 units subcutaneously every evening. Further review revealed no documented evidence that Patient #1 received the scheduled dosage of Lantus 5 units on the evening of 12/21/2010. This finding was confirmed by Director of Nursing S1 on 1/03/2011 at 2:20 p.m. Further review revealed no documented evidence that Patient #1's physician had been notified of the medication omission. Review of hospital occurrence reports failed to reveal any documented evidence of a report regarding the medication error for Patient #1 on 12/21/2010.

Patient # 2
Review of the History & Physical for Patient # 2 revealed she was admitted on 11/30/10 for dehydration, hypotension, and a severe functional decline. Review of the Physician ' s Orders revealed the following medication orders: 11/30/10 Lortab 5/500mg po (by mouth) Q8? (every eight hours) prn (as needed) for pain;, Restoril 30mg po QHS (every hour of sleep) prn insomnia; Nexium 40mg po daily; and Levemir 18 units SQ (subcutaneously) daily at 0800 (8:00am).

Review of the MAR (Medication Administration Record) for Patient # 2 revealed no documented evidence the following medications had been administered:
12/15/10 at 2045 (8:45pm) Restoril 30mg po not given due to drug not available.
12/16/10 at 0700 (7:00am) Lortab 5/500mg po circled indicating medication not given.
12/31/10 and 01/01/11 0600 (6:00am) Nexium 40mg po not given.
Levemir 25 units SQ 1630 (4:30pm) not given.

Review of the MAR and the Nurses' Narrative Noted revealed no documented evidence the reason the medications had not been administered. Further review revealed no documented evidence of notifying the patient's physician of the medication omissions.
Review of hospital occurrence reports failed to reveal any documented evidence of a report regarding the medication errors for Patient #2 on 12/15/2010, 12/16/2010, 12/31/2010, and 1/01/2011.

Patient #3:
Patient #3 was admitted to the hospital on 12/21/2010 with diagnoses that included Left Hip Fracture, Diabetes and Cerbral Vascular Accident. Review of Patient #3's medical record revealed a physician's order dated 12/21/2010 for Lantus 24 units subcutaneously every evening. Further review revealed no documented evidence that Patient #3 received the scheduled dosage of Lantus on the evening of 12/24/2010 or 12/25/2010. This finding was confirmed by Director of Nursing S1 on 1/04/2011 at 8:00 a.m., who further indicated that if a medication had not been charted that it could not be assured that it had been administered. Further review of Patient #3's medical record revealed no documented evidence that Patient #3's physician had been notified of the medication omission.
Review of hospital occurrence reports failed to reveal any documented evidence of a report regarding the medication error for Patient #3 on 12/24/2010 or 12/25/2010.

Patient #4
Review of Patient #4's medical record revealed she was admitted on 11/05/10 with a diagnosis of debility secondary to multiple sclerosis. Review of the H&P (history and physical) of 11/06/10 revealed Patient #4 had a prior history of depression and anxiety, anemia, and constipation with recent fecal impaction.
Review of Patient #4's "Standing Admission Orders" of 11/05/10 at 6:30pm revealed orders for Nexium 40 mg by mouth every day and Gabapentin 300 mg by mouth three times a day. Review of the "Physician Orders" revealed the following medication orders:
11/06/10 at 11:33am - discontinue Nexium; start Prilosec 20 mg one by mouth daily;
11/11/10 at 11:25am - Medrol dose pack times one;
11/15/10 at 1:00pm - Effexor XR 37.5 mg one by mouth every day times 5 days then increase to 75 mg one by mouth every day;
11/15/10 at 5:30pm - Gentamycin 0.3 % (per cent) eye drops two drops to right eye every four hours while awake times 4 days; and
12/06/10 at 12:35pm - Ampicillin 500 mg one by mouth every 6 hours times 7 days.
Review of Patient #4's MARs (medication administration records) revealed Nexium was not administered at the scheduled time of 6:00am on 11/06/10 (documentation by nurse of medication being unavailable). Further review revealed Nexium was administered at 2:00pm on 11/06/10, when an order had been received on 11/06/10 at 11:33am to discontinue Nexium. Further review revealed no documented evidence Prilosec was administered on 11/06/10 and 11/07/10 (order received on 11/06/10 at 11:33am). Further review of the MAR revealed Medrol (ordered 11/11/10 at 11:25am) was not administered until 11/13/10 at 8:00pm, two days after it had been ordered. Effexor, which was ordered on 11/15/10 at 1:00pm, was not given 11/15/10 with a note by the nurse that it was unavailable. Review of the MAR revealed Gentamycin eye drops which were ordered on 11/15/10 at 5:30pm were not instilled until 8:00pm on 11/16/10 with a note on the MAR that it was unavailable. Further review revealed Ampicillin, which was ordered on 12/06/10 at 12:35pm, was not begun until midnight on 12/07/10, 12 hours after it had been ordered. Review of the entire medical record revealed no documented evidence that the above listed medication errors had been promptly reported to the patient's physician.
Review of hospital occurrence reports failed to reveal any documented evidence of a report regarding the medication errors for Patient #4 on 11/06/2010, 11/07/2010, 11/11/2010, 11/12/2010, and 11/15/2010.

Patient # 9
Review of the H&P for Patient #9 revealed she was admitted to the hospital on 10/15/10 with debility related to neuropathy and chronic left hip and knee pain. Review of the Physician ' s Orders revealed the following medication orders: 10/15/10 Robaxin 750mg po (by mouth) TID (three times a day); 10/19/10 Lactulose 30cc po BID (twice a day) and 10/26/10 MagCitrate 150ml po BID three days hold for loose stools.

Review of the MAR (Medication Administration Record) for Patient #9 revealed no documented evidence the following medications had been administered:
Lactulose 30cc 10/28/10 0800 (8:00am) and 2000 (8:00pm);
MagCitrate 150ml 10/27/10 1700 (5:00pm);
Robaxin 750mg 10/15/10 2000 (8:00pm); 10/16/10 0800 (8:00am) and 1400 (2:00pm);
Further review revealed no documented evidence that Patient #9's physician had been notified of the medication omissions.

Review of hospital occurrence reports failed to reveal any documented evidence of a report regarding the medication errors for Patient #9 on 10/15/2010, 10/16/2010, 10/27/2010, and 10/28/2010.

Patient #10:
Patient #10 was admitted to the hospital on 12/15/2010 with diagnoses that included Left Patellar fracture, Hypertension, and Osteoporesis. Review of Patient #10's medical record revealed a physician's order dated 12/16/2010 at 9:50 a.m. for Travantan Z 0.004% i (one) drop both eyes every hour sleep and Artificial Tears two drops both eyes three times per day. Further review revealed no documented evidence that Travantan Z was administered at the 8:00 p.m. scheduled dose for 12/16/2010 and documentation revealed "not available" for the 8:00 p.m. scheduled dose of Artificial Tears on 12/16/2010. Further review revealed no documented evidence that Patient #10's physician had been notified of the medication omission on 12/16/2010.
Review of Patient #10's medical record revealed a physician's order dated 12/17/2010 at 2:15 p.m. for Cipro 500 milligrams by mouth two times per day for 5 days and Florinex one tablet by mouth two times per day for 10 days. Further review revealed no documented evidence that Cipro or Florinex was administered at the 8:00 p.m. scheduled administration time on 12/17/2010. Further review revealed no documented evidence that Patient #10's physician had been notified of the medication omission on 12/17/2010.
Review of hospital occurrence reports failed to reveal any documented evidence of a report regarding the medication error for Patient #10 on 12/16/2010 and 12/17/2010.

During a face to face interview on 1/03/2010 at 11:00 a.m., Registered Nurse S5 indicated the practice at the hospital for ordering medications on the day shift was to wait for the newly admitted patient to arrive and then to order their medication. S5 further indicated staff would send in orders to pharmacy for patients that were expected to arrive on evening shift prior to their arrival. S5 indicated the Pharmacy was located in Mandeville and delivered medications in the evening hours. S5 further indicated there were times when medications were not available for administration to patients and in those instances nursing staff would document in the medical record that the medications were not available and also document on an occurrence report.
Patient # 19
Review of the H&P for Patient # 19 revealed he was admitted on 09/17/10 with the diagnosis of TTP (Thrombotic Thrombocytopenic Purpura) with anemia, anasarca, hypertension, generalized weakness, de-conditioning and possible critical illness neuropathy. Review of the Physician ' s Orders revealed the following medication orders: 09/17/10 Proventil HTA ii (two) puffs Q6? (every six hours), Colace 100mg po I BID, Calmoseptine Ointment to buttocks qid and prn (four times a day and as needed), Prednisone 40mg I (one) po (by mouth) daily, Azathioprine 50mg po daily at 9:00pm, Toprol XL 50mg I po daily, and 09/24/10 Normal Saline Spray I to ii (one to two) sprays to each nostril BID (twice a day).

Review of the MAR (Medication Administration Record) for Patient #19 revealed no documented evidence the following medications had been administered:
Proventil HFA 2 puffs; 09/17/10 12noon and 1800 (6:00pm); 09/20/10 1800 (6:00pm); 09/21/10 12 midnight, 12 noon and 1800 (6:00pm); 09/22/10 12 midnight, 0600 (6:00am) and 1800 (6:00pm); 09/23/10 12 midnight 0600 (6:00am), 12 noon; 09/25/10 12 midnight 0600 (6:00am), 12 noon and 1800 (6:00pm); 09/26/10 0600 (6:00am; 09/28/10 12 midnight; 10/02/10 12 midnight;
Colace 100mg 09/25/10 2000 (8:00pm); 10/02/10 0800 (8:00am); 10/05/10 0800 (8:00am) and 2000 (8:00pm);
Calmoseptine Ointment 09/17/10 12 noon and 1800 (6:00pm); 09/21/10 12 midnight, 0922/10 12 midnight, 09/26/10 12 midnight and 0600 (6:00am);
Normal Saline Spray 09/25/10 0800 (8:00am) and 2000 (8:00pm);
Prednisone 40mg 10/02/10 0800 (8:00am);
Azathioprine 50mg 10/03/10 2100 (9:00pm).
Further review revealed no documented evidence that Patient #19's physician had been notified of the medication omissions.

Review of hospital occurrence reports failed to reveal any documented evidence of a report regarding the medication errors for Patient #19 on 9/17/2010, 9/20/2010, 9/21/2010, 9/22/2010, 9/23/2010, 9/25/2010, 9/26/2010, 9/28/2010, 10/02/2010, 10/03/2010, and 10/05/2010.

During a face to face interview Director of Nursing S1 confirmed that nursing staff had not been consistently reporting drug errors through Occurrence Reports/Incident Reports. S1 indicated that all medication errors, to include omissions due to unavailability of medications should be reported to the patient's physician and an occurrence report should be generated.

Review of the hospital policy titled, "Medication Errors, N 3.007, last revised 10/18/2010" presented by the hospital as their current policy revealed in part, "A Medication Variance Report is completed on all medication administration errors. . . The error and patient assessment data are communicated to the attending physician and DON (Director of Nursing) immediately if the situation is potentially life threatening. If the error has no serious effect on the patient, the physician and DON are notified as soon as possible. . . A Medication Variance Report is completed. . . The charge nurse investigates the error to determine the cause. The charge nurse is responsible for completing the Medication Variance Form and forwarding it to the Director of Nursing/Director of Pharmacy."

















25452

Based on record review and interview the hospital failed to ensure a radiologist credentialed by the hospital and determined to be qualified was supervising and interpreting radiological tests for the hospital. Findings:

Review of Credentialing files revealed no documented evidence of a credentialed Radiologist on staff at the hospital.

This findings was confirmed by Administrator S9 on 1/05/2011 at 3:20 p.m. during a face to face interview. S9 indicated the hospital had a contract for Radiology Services and had never Credentialed the Contracted Radiologist.

Based on record review and interview the hospital failed to ensure the Dietary Manager was evaluated as competent for 1 of 1 Dietary Manager at the facility (S2). Findings:

Review of the employee personnel folder for Dietary Manager S2 revealed no documented evidence of being evaluated as competent in the performance of her job duties.

This finding was confirmed by Registered Dietician S17 during a telephone interview on 1/05/2011 at 2:00 p.m. S17 further indicated that he had plans to evaluate S2 for competency in the near future; however, he had not yet evaluated her in the role of Dietary Manager. S17 indicated she (S2) was new to the position.

Based on interview the hospital failed to have a utilization review committee as evidenced by the hospital's inability to produce a list of committee members or committee meeting minutes. Findings:

Review of the Utilization Review Plan (no documentation of the date of implementation) and submitted as the one currently in use by the hospital, revealed..... "Authority: Having been delegated responsibility for implementation of the Utilization Management Program, the Performance Improvement Committee has the authority to facilitate actions, as deemed appropriate, based on the findings of the program".

In a face to face interview on 01/04/11 at 2:15pm S2, Case Manger/Utilization Review, In a face to face interview on 01/04/11 at 2:15pm S2, Case Manger/Utilization Review,
In a face to face interview on 01/05/11 at S2, Care Manager/Utilization Review verified that only statistical data is collected consisting of admissions, discharges, denials, and length of stay.
During the same interview, S9 the Administrator, indicated UR information is included as a report in the Performance Improvement Committee and the "Committee of the Whole".

Based on record review and interview the hospital failed to: 1) develop written admission criteria and scope of services; 2) revise their Utilization Review (UR) Plan to ensure compliance with State regulations for Medicaid admission review; and 3) ensure the UR Plan approved by the Governing Body was implemented related to utilization review documentation. Findings:

1) develop written admission criteria and scope of services
The hospital could not submit written admission criteria or the scope of services provided at the hospital.

In a face to face interview on 01/04/11 at 2:20pm S9, Administrator, indicated she thought the hospital had written admission criteria; however after given the time to look, returned to the survey team and verified she could not find any written criteria. Further she indicated not all patients with rehabilitation needs are eligible for admit because the hospital does not take ventilators, renal patients requiring dialysis or cardiac patients requiring advanced monitoring.

In a face to face interview on 01/05/11 at 11:25am S16, Medical Director indicated he reviews all patients and makes the decision on whether or not the patient is eligible for admit on a case by case basis. Further he indicated all patients must be able to tolerate at least three hours of physical therapy per day to qualify. S16 indicated he is very knowledgeable concerning the criteria of Medicaid and Medicare when determining admission.

2) revise their Utilization Review (UR) Plan to ensure compliance with State regulations for Medicaid admission review
Review of Policy Number UM 1.022 titled "Medicaid Reviews" (no documented evidence of the date implemented) submitted as the one currently in use by the hospital revealed.... Procedure: 1. At the time of Admission, within 72 hours, the utilization review person reviews each rehab Medicaid patient".

In a face to face interview on 01/04/11 at 2:20pm S9, Administrator, indicated the hospital was aware that the UR Plan needed to be updated.

In a face to face interview on 01/04/11 at 2:15pm S2, Case Manger/Utilization Review, indicated the Medical Director reviews all admissions and makes the decision on whether or not the patient can be accepted. For continuing reviews for Medicaid patients she copies the Physician's Orders, Physician Progress Notes and Physical Therapy notes and faxes to the agency who determines approval of continued stay. S2 indicated when the days assigned are almost up, she sends current information to obtain additional days.

3) ensure the UR Plan approved by the Governing Body was implemented.
Review of Policy # UM 1.020 titled "Type of Records Maintained" (no documented date implement or last revised) submitted as the one currently in use by the hospital revealed each patient had a utilization review chart which contained a copy of the following: the face sheet, pre-screen assessment, and a list of units performed on each patient during his/her stay. Further review revealed a utilization review worksheet would be maintained on each which included the patient's rehabilitative status functional scores, and continued stay review information.

In a face to face interview on 01/04/11 at 2:15pm S2, Case Manger/Utilization Review, indicated documentation of continuing stay is now being done on the multidisciplinary staff meeting forms. Further she indicated the team documents the patient's status and the physician determines the additional days needed.

Based on record review and interview the hospital failed to ensure review of professional services had been included in their Utilization Plan and reviews conducted to promote efficient use of services resulting in lack of availability of pharmaceutical drugs in a timely manner for administration to patients as ordered by his/her physician: Findings:

Review of the Utilization Management Plan and Utilization Review (UR) Policies and Procedures (no date of implementation or revision documented) revealed.....Records and Reports: ........These reports will include, but are not limited to: ......Activities related to implementation of Medical Care Evaluation Studies, including the date for implementation and conclusion, criteria, results, recommendations and actions".

Review of the documentation submitted by S2, Case Manager/Utilization Review, in the form of Quality Assurance/Performance Improvement (QA/PI) meeting minutes revealed no documented evidence professional services had been reviewed or medical care evaluation performed.

In a face to face interview on 01/05/11 at S2, Care Manager/Utilization Review verified that only statistical data is collected consisting of admissions, discharges, denials, and length of stay.
During the same interview, S9 the Administrator, indicated UR information is included as a report in the Performance Improvement Committee and the "Committee of the Whole".

Based on record review and interview the hospital failed to 1) ensure an Emergency Preparedness Plan was in place that included a comprehensive evacuation plan which detailed how patients would be evacuated according acuity and needs, transportation of equipment, medication, medical records and staff to provide care; 2) ensure coordination with Federal, State, and local emergency preparedness and health authorities to identify likely risks for their area related to hurricanes as evidenced by a lack of coordination with the phases used to determine landfall and the appropriate preparations; and 3) have documentation the safety officer had training in Emergency Preparedness. Findings:

1) ensure an Emergency Preparedness Plan was in place that included a comprehensive evacuation plan which detailed how patients would be evacuated according acuity and needs, transportation of equipment, medication, medical records and staff to provide care;
Review of the Emergency Preparedness manual revealed no evidence the evacuation plan contained how patients would be evacuated taking into consideration the acuity of the patient and the equipment and/or personnel needed to assistance in the evacuation or how the equipment, medication and medical records would be transported with the patients. Further review revealed no documented evidence on who was to accompany the patient to provide ongoing care.

2) ensure coordination with Federal, State, and local emergency preparedness and health authorities to identify likely risks for their area related to hurricanes as evidenced by a lack of coordination with the phases used to determine landfall and the appropriate preparations
Review of the Emergency Preparedness manual revealed no documented reference to Federal, State, or local authorities. Further review revealed no documented evidence of inclusion of the phases of hurricanes used in order to determine time of landfall and decision-making for evacuation which is universally used by all levels of authorities. There is no documented evidence that the local OEP (Office of Emergency Preparedness) is consulted before any decisions are made.

3) have documentation the safety officer had training in Emergency Preparedness
Review of the personnel file for S10 revealed no documented evidence of emergency preparedness training on the local, State or federal level.

An interview was held on 1/5/2011 at 3:25 p.m. with S9 Administrator who confined the findings.

Based on observation and interview the facility failed to ensure an acceptable level of safety for patients as evidence by having loose handrails in the patient halls. Findings:

An observation in the presence of S10 Maintenance and Safety was made on 1/3/2011 at 10:45 a.m. of loose handrails by rooms a,b, and c. In an interview held with S10 at this time he verified that the handrails were loose and indicated they should be tightened.

20638

Based on record reviews and interview the hospital failed to ensure all physicians and staff received annual Tuberculin screening (TB) as evidenced by 5 of 5 physicians reviewed from a total of 5 credentialed physicians (S16, S18, S19, S20, S21) and 3 of 3 contract nurses (S6, S14, S15) not having documentation of annual TB testing. Findings:

Review of the credentialing files of Physicians S16, S18, S19, S20, and S21 revealed no documented evidence of TB screening having been performed.

In a face-to-face interview on 01/05/11 at 1:30pm, Director of Health Information Management S3 indicated she was responsible for the credentialing process at the hospital. She further indicated the hospital did not require the physicians to have TB screening.

Review of the personnel file for S6RN (Registered Nurse) revealed she had worked at the hospital 10/29/2010, 10/30/2010, and 11/19/2010. Further review revealed no documentation that S6RN had received annual TB screening prior to working with patients in the hospital.

Review of the personnel file for S14RN revealed she had worked at the hospital on 11/06/2010. Further review revealed no documentation that S14RN had received annual TB screening prior to working with patients in the hospital.

Review of the personnel file for S15RN revealed she had worked at the hospital on 10/19/2010, 10/31/2010, and 11/28/2010. Further review revealed no documentation that S14RN had received annual TB screening prior to working with patients in the hospital.

An interview was held with S1DON on 1/5/2011 at 10:30 am. After review of the personnel files for S6RN, S14RN, and S15 RN she indicated there was no documentation the contracted employees had received annual TB screening prior to working with patients in the hospital.

Review of the hospital policy titled, "Employee Health Assessments, IC 6/001" presented by the hospital as the current policy revealed in part, "It is the policy of Specialty Rehabilitation Hospital that a health assessment be performed on all employees and then (TB/tuberculosis) annually thereafter. . . to ensure that prospective and current employees are in sufficiently good health to perform the job duties of the position for which they are employed and reduce the likelihood of spreading infectious diseases. . ."

Review of the "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005", presented by the CDC (Centers for Disease Control), revealed, in part, "... HCWs (health care workers) Who Should Be Included in a TB Surveillance Program HCWs refer to all paid and unpaid persons working in health-care settings who have the potential for exposure to M. tuberculosis through air space shared with persons with infectious TB disease. Part time, temporary, contract, and full-time HCWs should be included in TB screening programs. All HCWs who have duties that involve face-to-face contact with patients with suspected or confirmed TB disease (including transport staff) should be included in a TB screening program. The following are HCWs who should be included in a TB screening program: ...Nurses ... Physicians ...".











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25452

Based on record review and interview the hospital failed to Failing to follow the hospital's policy and procedure for performance improvement as evidenced by no documented evidence the hospital's developed indicators for medication errors, labs, consents, and confidentiality tracked, measured and/or analyzed resulting in continued problems with unreported medication variances, unavailable medications for patient administration, ordered labs not being performed, lab reports not being obtained, and confidential information being obtained without consent of the patient(s). Findings:


Review of the Department Head Meeting Minutes dated 10/15/10 revealed the following committee assignment of indicators for each department:
Pharmacy & Nutrition - medication variances/adverse reaction; use of high risk medications; coumadin/anticoagulant log, education, diet; use of pain medications/initial pain assessments and follow-up assessments; 1st dose medications identified/education and documentation; stock/formulary change requests; Pharmacy performance Improvement (their monthly findings); educational material presented; multidose vial monitoring; and insulin administration monitoring.
Utilization Review- Number of patients receiving blood, physical therapy, Occupational Therapy, Speech Therapy, Labs, x-rays, ultrasounds, dialysis, other diagnostic testing, and marketing.
Social Services- Consents, Patient Satisfaction surveys, Informed consents for treatments, DNR and Advanced Directives.
Health Information Management - History & Physical within 24 hours, HIPPA compliance, Discharge Summary
Nursing - Open Chart reviews -(Rapid Response, codes, mortality, transfers, invasive procedures, hyperglycemia.

Review of the Performance Improvement Committee Meeting Minutes for the last quarter dated 12/07/10 revealed no documented evidence the assigned indicators were being tracked by the hospital.

Based on record review and interview the hospital failed to monitor the contracted services of pharmacy and laboratory to ensure effectiveness and safety of service and quality of care as evidenced by continued identified and unresolved unavailability of patient medication from the pharmacy resulting in missed medication and results not being sent to the hospital by the contracted lab. Findings:

Review of the Performance Improvement Committee Meeting Minutes dated 12/07/10 for the last quarter of 2010 (October, November, December) revealed no documented evidence services provided by the pharmacy and laboratory had been evaluated.

In a face to face interview on 01/04/11 at 2:20pm S9 Administrator was asked how the laboratory and pharmacy contracted services were being evaluated. In response she indicated all contracted services were evaluated annually by a standard form asking questions about the quality of service. Further S9 indicated these services are not part of the monthly QA.

Based on record review and interview the hospital failed to implement corrective actions for identified problems related to medication variances, following physician orders for lab testing, obtaining lab results, compliance for TB testing annually for all staff providing patient care,
obtaining patient weights as ordered and confidentiality of medical records. Findings:

Review of the Performance Improvement Committee Meeting Minutes for the 4th Quarter of 2010 dated December 7, 2010 revealed no documented evidence any corrective action had been taken to make improvements in medication variances, following physician orders for lab testing, obtaining lab results, compliance for TB testing annually for all staff providing patient care, obtaining patient weights as ordered and confidentiality of medical records.

Based on record review and interview the hospital failed toFailing to follow the policy and procedure for Performance Improvement as evidenced by no documented evidence of corrective actions implemented for identified problems related to medication errors, unavailability of medications from the contracted pharmacy, labs not performed according to physician orders, and labs results not sent by the contracted lab. Findings:

Review of the Performance Improvement Committee Meeting Minutes for the last quarter of 2010 (October, November, December) dated December 07, 2010 revealed no documented evidence corrective actions had been implemented or identified problems monitored.

In a face to face interview on 01/04/11 at 2:20pm S9 Administrator indicated we just started gather statistical data since the survey of our accreditation body. Further S9 indicated the DON had spoken to the lab about not getting results; however nothing was documented and the problem was not being monitored to determine if any improvements had been made. S9 was not aware that the terms of the pharmacy contract provided coverage for medication orders five days a week and seven days a week for emergency medication. Further S9 indicated availability of medication is not being monitored.

Based on record review and interview the hospital failed to ensure medications were administered according to the orders of the practitioner for 8 of 20 sampled patients (#1,#2, #3, #4, #5, #9, #10, #19). Findings:

During a face to face interview on 1/03/2010 at 11:00 a.m., Registered Nurse S5 indicated the practice at the hospital for ordering medications on the day shift was to wait for the newly admitted patient to arrive and then to order their medication. S5 further indicated staff would send in orders to pharmacy for patients that were expected to arrive on evening shift prior to their arrival. S5 indicated the Pharmacy was located in Mandeville and delivered medications in the evening hours. S5 further indicated there were times when medications were not available for administration to patients and in those instances nursing staff would document in the medical record that the medications were not available and should also document on an occurrence report.

Patient #1
Review of Patient #1's medical record revealed a physician's order on 12/17/2010 for Lantus 5 units subcutaneously every evening. Further review revealed no documented evidence that Patient #1 received the scheduled dosage of Lantus 5 units on the evening of 12/21/2010. This finding was confirmed by Director of Nursing S1 on 1/03/2011 at 2:20 p.m.

Patient # 2
Review of the History & Physical for Patient # 2 revealed she was admitted on 11/30/10 for dehydration, hypotension, and a severe functional decline. Review of the Physician ' s Orders revealed the following medication orders: 11/30/10 Lortab 5/500mg po (by mouth) Q8? (every eight hours) prn (as needed) for pain;, Restoril 30mg po QHS (every hour of sleep) prn insomnia; Nexium 40mg po daily; and Levemir 18 units SQ (subcutaneously) daily at 0800 (8:00am).

Review of the MAR (Medication Administration Record) for Patient # 2 revealed no documented evidence the following medications had been administered:
12/15/10 at 2045 (8:45pm) Restoril 30mg po not given due to drug not available.
12/16/10 at 0700 (7:00am) Lortab 5/500mg po circled indicating medication not given.
12/31/10 and 01/01/11 0600 (6:00am) Nexium 40mg po not given.
Levemir 25 units SQ 1630 (4:30pm) not given.

Review of the MAR and the Nurses ' Narrative Noted revealed no documented evidence the reason the medications had not been administered.

Patient #3:
Patient #3 was admitted to the hospital on 12/21/2010 with diagnoses that included Left Hip Fracture, Diabetes and Cerebral Vascular Accident. Review of Patient #3's medical record revealed a physician's order dated 12/21/2010 for Lantus 24 units subcutaneously every evening. Further review revealed no documented evidence that Patient #3 received the scheduled dosage of Lantus on the evening of 12/24/2010 or 12/25/2010. This finding was confirmed by Director of Nursing S1 on 1/04/2011 at 8:00 a.m., who further indicated that if a medication had not been charted that it could not be assured that it had been administered.

Patient #4
Review of Patient #4's medical record revealed she was admitted on 11/05/10 with a diagnosis of debility secondary to multiple sclerosis. Review of the H&P (history and physical) of 11/06/10 revealed Patient #4 had a prior history of depression and anxiety, anemia, and constipation with recent fecal impaction.
Review of Patient #4's "Standing Admission Orders" of 11/05/10 at 6:30pm revealed orders for Nexium 40 mg by mouth every day and Gabapentin 300 mg by mouth three times a day. Review of the "Physician Orders" revealed the following medication orders:
11/06/10 at 11:33am - discontinue Nexium; start Prilosec 20 mg one by mouth daily;
11/11/10 at 11:25am - Medrol dose pack times one;
11/15/10 at 1:00pm - Effexor XR 37.5 mg one by mouth every day times 5 days then increase to 75 mg one by mouth every day;
11/15/10 at 5:30pm - Gentamycin 0.3 % (per cent) eye drops two drops to right eye every four hours while awake times 4 days; and
12/06/10 at 12:35pm - Ampicillin 500 mg one by mouth every 6 hours times 7 days.
Review of Patient #4's MARs (medication administration records) revealed Nexium was not administered at the scheduled time of 6:00am on 11/06/10 (documentation by nurse of medication being unavailable). Further review revealed Nexium was administered at 2:00pm on 11/06/10, when an order had been received on 11/06/10 at 11:33am to discontinue Nexium. Further review revealed no documented evidence Prilosec was administered on 11/06/10 and 11/07/10 (order received on 11/06/10 at 11:33am). Further review of the MAR revealed Medrol (ordered 11/11/10 at 11:25am) was not administered until 11/13/10 at 8:00pm, two days after it had been ordered. Effexor, which was ordered on 11/15/10 at 1:00pm, was not given 11/15/10 with a note by the nurse that it was unavailable. Review of the MAR revealed Gentamycin eye drops which were ordered on 11/15/10 at 5:30pm were not instilled until 8:00pm on 11/16/10 with a note on the MAR that it was unavailable. Further review revealed Ampicillin, which was ordered on 12/06/10 at 12:35pm, was not begun until midnight on 12/07/10, 12 hours after it had been ordered.

In a face-to-face interview on 01/05/11 at 2:10pm, DON S1 indicated she had audited charts to check that two nurses were documenting insulin administration, but she had not checked for all medications being administered as ordered.

Patient #5:
Patient #5 was admitted to the hospital on 12/27/2010 with diagnoses that included Left Medial Tibial fracture with Left Knee fracture, Diabetes Hypertension and Right Hemiparesis. Review of Patient #5's medical record revealed a physician's order dated 12/27/2010 at 6:30 a.m. for Lovastatin 10 milligrams by mouth every hour sleep, Gabapentin 300 milligrams by mouth every hour sleep, Nasal Miacalcin Nasal Spray 1 spray alternate each nare every other day, and Oscal D 500 milligrams by mouth two times per day. Further review of Patient #5's medical record revealed no documented evidence that Patient #5 was administered Lovastatin 10 milligrams, Gabapentin 300 milligrams, Miacalcin Nasal Spray, or Oscal D 500 milligrams as scheduled on 12/27/2010 at 8:00 p.m. This finding was confirmed by Director of Nursing S1 on 1/03/2011 at 4:00 p.m.

Patient # 9
Review of the H&P for Patient #9 revealed she was admitted to the hospital on 10/15/10 with debility related to neuropathy and chronic left hip and knee pain. Review of the Physician ' s Orders revealed the following medication orders: 10/15/10 Robaxin 750mg po (by mouth) TID (three times a day); 10/19/10 Lactulose 30cc po BID (twice a day) and 10/26/10 MagCitrate 150ml po BID three days hold for loose stools.

Review of the MAR (Medication Administration Record) for Patient # 2 revealed no documented evidence the following medications had been administered:
Lactulose 30cc 10/28/10 0800 (8:00am) and 2000 (8:00pm);
MagCitrate 150ml 10/27/10 1700 (5:00pm);
Robaxin 750mg 10/15/10 2000 (8:00pm); 10/16/10 0800 (8:00am) and 1400 (2:00pm);

Patient #10:
Patient #10 was admitted to the hospital on 12/15/2010 with diagnoses that included Left Patellar fracture, Hypertension, and Osteoporosis. Review of Patient #10's medical record revealed a physician's order dated 12/16/2010 at 9:50 a.m. for Travantan Z 0.004% i drop both eyes every hour sleep and Artificial Tears two drops both eyes three times per day. Further review revealed no documented evidence that Travantan Z was administered at the 8:00 p.m. scheduled dose for 12/16/2010 and documentation revealed "not available" for the 8:00 p.m. scheduled dose of Artificial Tears on 12/16/2010.

Review of Patient #10's medical record revealed a physician's order dated 12/17/2010 at 2:15 p.m. for Cipro 500 milligrams by mouth two times per day for 5 days and Florinex one tablet by mouth two times per day for 10 days. Further review revealed no documented evidence that Cipro or Florinex was administered at the 8:00 p.m. scheduled administration time on 12/17/2010.

These findings were confirmed by Director of Nursing S1 on 1/04/2011 at 8:30 a.m.

Patient # 19
Review of the H&P for Patient # 19 revealed he was admitted on 09/17/10 with the diagnosis of TTP (Thrombotic Thrombocytopenic Purpura) with anemia, anasarca, hypertension, generalized weakness, de-conditioning and possible critical illness neuropathy. Review of the Physician ' s Orders revealed the following medication orders: 09/17/10 Proventil HTA ii (two) puffs Q6? (every six hours), Colace 100mg po I BID, Calmoseptine Ointment to buttocks qid and prn (four times a day and as needed), Prednisone 40mg I (one) po (by mouth) daily, Azathioprine 50mg po daily at 9:00pm, Toprol XL 50mg I po daily, and 09/24/10 Normal Saline Spray I to ii (one to two) sprays to each nostril BID (twice a day).

Review of the MAR (Medication Administration Record) for Patient #19 revealed no documented evidence the following medications had been administered:
Proventil HFA 2 puffs; 09/17/10 12noon and 1800 (6:00pm); 09/20/10 1800 (6:00pm); 09/21/10 12 midnight, 12 noon and 1800 (6:00pm); 09/22/10 12 midnight, 0600 (6:00am) and 1800 (6:00pm); 09/23/10 12 midnight 0600 (6:00am), 12 noon; 09/25/10 12 midnight 0600 (6:00am), 12 noon and 1800 (6:00pm); 09/26/10 0600 (6:00am; 09/28/10 12 midnight; 10/02/10 12 midnight;
Colace 100mg 09/25/10 2000 (8:00pm); 10/02/10 0800 (8:00am); 10/05/10 0800 (8:00am) and 2000 (8:00pm);
Calmoseptine Ointment 09/17/10 12 noon and 1800 (6:00pm); 09/21/10 12 midnight, 0922/10 12 midnight, 09/26/10 12 midnight and 0600 (6:00am);
Normal Saline Spray 09/25/10 0800 (8:00am) and 2000 (8:00pm);
Prednisone 40mg 10/02/10 0800 (8:00am);
Azathioprine 50mg 10/03/10 2100 (9:00pm).

During a face to face interview on 1/04/2011 at 11:20 a.m., Pharmacist S12 indicated medications should be delivered on the day the physician orders the medication offering the example that if medication was ordered on Monday, the medication should be delivered on Monday.

During a telephone interview on 1/04/2011 at 1:55 p.m. Pharmacists S13 indicated the hospital delivered medications to the hospital one time per day in the evening hours; however, he further indicated that for emergencies, the hospital would be able to pick up medications from a local pharmacy. S13 indicated he did not think there were local pharmacies that had 24 hour services that were located near the hospital. Pharmacist S13 confirmed that patient's should receive medications at the next scheduled dose once ordered by the patient's physician.

During a face to face interview on 1/05/2011 at 3:30 p.m., Director of Nursing S1 indicated the hospital had problems with medication only being delivered one time per day due patients not always having their prescribed medications administered due to unavailability of the medication. S1 further indicated the hospital had discussed medication occurrences in the Pharmacy and Nutrition meetings. S1 indicated Nursing Staff had been instructed to promptly fax medication orders to the pharmacy to ensure delivery and that local pharmacies could be used to obtain medications ordered by the patient's physician outside of delivery times; however, there continued to be problems with patients receiving medications due to being unavailable.




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25452

Based on observation and interview the hospital failed to maintain the confidentiality and safety of all patient medical records as evidenced by storing medical records on open shelving with a ceiling fire sprinkler system and in boxes located on the floor and allowing the door to the medical records storage closet located in a hallway utilized by staff to be kept open. Findings:

Observation on 01/03/11 at 3:45pm revealed medical records were stored in a closet located on the hallway with Administration and Maintenance. Further observation revealed the door was not locked and the surveyor was able to enter the closet, observe the contents and walk out un-noticed by any personnel.

Observation on 01/03/11 at 3:45pm of the contents of the medical records storage closet revealed medical records being stored on open shelving located on three sides of the space. Further there were 4 card board boxes stored directly on the floor with additional boxes stored on top.

In a face to face interview on 0103/11 at 3:50pm S3 HIM Director indicated the medical records are stored in the closet and should be locked at all times. Further she indicated she was no aware of the possibility of water damage by the sprinkler system.