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Based on the Life Safety Code Validation survey, the Condition for Physical Environment is not met based on the results of the Division of Safety Inspection survey completed on July 8, 2011, at Healthsouth Rehabilitation Hospital of Sewickley. Those deficient practices and associated regulations can be found on the respective Life Safety Code survey (FFP021).

Based on review of facility documents and medical records (MR) and staff interview (EMP), it was determined that the facility failed to ensure that a medical history and physical examination was completed and documented no more than 30 days before or 24 hours after admission for for three of 31 medical records (MR2, MR5 and MR24).

Findings include:

Review of policy "Patient Records and Documentation Requirements " revised April 2010 revealed, "1. Inpatient Records...A Physician documentation on inpatients shall consist of History and Physical Examination....History and physical examinations should be completed within 24 hours of admission. Progress notes should be written for each patient contact..."

1) Review of MR2 on June 8, 2011, revealed admission on June 3, 2011. Further review of MR2 revealed that the History and Physical was dated June 5, 2011.

2) Review of MR5 on June 8, 2011, revealed admission on June 3, 2011. Further review of MR5 revealed that the History and Physical was dated June 5, 2011.

3) Review of MR24 on June 8, 2011, revealed admission on June 1, 2011. Further review of MR24 revealed that the History and Physical was dated June 3, 2011.

Interview on June 8, 2011, at approximately 1:30 PM with EMP 2 confirmed that the History and Physicals were not completed within 24 hours of admission for MR2, MR5, and MR24.

Based on review of facility documents and medical records (MR), and staff interview (EMP), it was determined that the facility failed to ensure the evaluation of patients' pain levels for three of 31 medical records reviewed (MR6, MR22 and MR23).

Findings include:

Review of "Medication Administration 200.21," revised in October 2010, revealed, "Purpose...The purpose of this policy is to establish consistent guidelines to ensure that all facilities treating Healthsouth patients promote patient care and safety by maintaining a system for verification of proper medication administration...J. The licensed or registered staff administering medications should monitor according to the clinical needs of the patient and address the patient's response to his or her medications including response to "as needed" medications. This monitoring should include when appropriate the patient's own perceptions about side effects or received efficacy and relevant patient information.

Review of "Pain Management Assessment, Care and Documentation," revised in October 2010, revealed, "The Purpose of pain management is to provide for pro-active interdisciplinary approach that ensures the highest level of comfort for patients...Procedure...A. Assessment and Documentation...3. If the assessment process indicated issues related to pain, an interdisciplinary treatment plan will be initiated with goals relating to pain management. 4. On a periodic basis, the patient will be assessed by the interdisciplinary team with consideration of the following in regards to pain: c. Interventions utilized, both pharmacological and /or non-pharmacological.

1) Review of MR6 on June 7, 2011, at approximately 2:15 PM revealed a medication was ordered for pain, to be administered as needed. Further review of MR6 revealed that the pain medication was given on June 1, 2011, and June 2, 2011. There was no documentation of a follow-up pain assessment for MR6.

2) Review of MR22, on June 8, 2011, at approximately 3:15 PM revealed an order for a narcotic pain medication to be administered as needed. Further review of MR22 revealed that the narcotic pain medication was given on June 3 and June 4, 2011. There was no follow up pain assessment documented for MR22.

3) Review of MR23, on June 8, 2011, at approximately 3:20 PM revealed an order for a narcotic pain medication to be administered as needed. Further review of MR23 revealed that the narcotic pain medication was given on June 3 and June 4, 2011. There was no follow up pain assessment documented for MR23.

Interview on June 8, 2011, at approximately 3:20 PM with EMP2 confirmed, "No...there is no follow-up assessment [for MR6, MR22, and MR23].

Based on a review of facility documents and medical records (MR) and staff interview (EMP), it was determined that the facility failed to ensure that nursing care plans were developed for three of 31 medical records (MR6, MR22 and MR23).

Findings include:

Review of policy "Interdisciplinary Plan of Care - Inpatient " revised October 2010 revealed, "Procedure...1. The RN will initiate the IPOC within 24 hours of admission on each patient. The evaluating Interdisciplinary Team and rehab physician will complete the IPOC following patient assessment, by day 4...18. Updates to the IPOC are documented in the plan. Any new problem identified are checked. Any new interventions are dated and initiated. Any discontinued interventions are dated and initiated.".

Review of "Pain Management Assessment, Care and Documentation," revised in October 2010, revealed, "The Purpose of pain management is to provide for pro-active interdisciplinary approach that ensures the highest level of comfort for patients...Procedure...A. Assessment and Documentation...3. If the assessment process indicated issues related to pain, an interdisciplinary treatment plan will be initiated with goals relating to pain management. 4. On a periodic basis, the patient will be assessed by the interdisciplinary team with consideration of the following in regards to pain: c. Interventions utilized, both pharmacological and /or non-pharmacological.

1) Review of MR6 on June 8, 2011, revealed a medication was ordered for pain to be administered as needed for pain. Further review of MR6 revealed that the pain medication was given on June 1, 2011, and June 2, 2011. There was no documentation of a plan relating to pain management

2) Review of MR22 on June 8, 2011, revealed an order for a narcotic pain medication to be administered as needed. Further review of MR22 revealed that the narcotic pain medication was given on June 3 and June 4, 2011. There was no documentation of a plan relating to pain management.

3) Review of MR23 on June 8, 2011, revealed an order for a narcotic pain medication to be administered as needed. Further review of MR23 revealed that the narcotic pain medication was given on June 3 and June 4, 2011. There was no documentation of a plan relating to pain management.

Interview on June 8, 2011, at approximately 3:20 PM with EMP2 confirmed, "No...there is no care plan for pain [for MR6, MR22, and MR23].

Based on a review of facility documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure staff documented pertinent and complete information for six of 31 medical records ( MR7, MR9, MR15, MR26, MR30 and MR31).

Findings include:

Review of "Medication Administration " policy revised October 2010 revealed, "VII. Documentation of Medical Record... A. All entries noting administration of medication must be entered properly in the medical record. All entries must include: Name of the medication, Dosage administered, Route of administration and site of administration for intra-musculare (IMP only , Time of administration, Individual who administered medication, Patient response of all as needed (prn) medications. B. All entries must be signed and dated and include time of administration. C. Refused or held medications shall be documented int he medical record as well as the reason for holding medication."

Review of "Interdisciplinary Daily Documentation" policy revised January 2009, revealed, "...Procedure...3. Professional caregivers are responsible for the accuracy and completion of documentation, even when supported by non-licensed staff."

Review of "Administration of Influenza and Pneumococcal Vaccines" policy reviewed October 2010 indicated "...Procedure...4. The admitting nurse shall be responsible for determining the patient's vaccination status if not yet determined. This will be documented on the Influenza and Pneumococcal Vaccine Verification/Refusal/Consent Form."

Review of "Emergency Discharge of a Patient to a Hospital" policy reviewed July 2009 revealed "Purpose: To provide for continuity of patient care. ...Procedure:...7...Document in Nursing Notes." Attached to the policy is a form called "Acute Care Transfer Checklist" which indicates "original - chart; copy - receiving facility."

Review of "Wound Assessment, Prevention and Documentation" policy reviewed September 2010 revealed, "...Assessment All patients will have integument and wound inspections daily, weekly and as often as indicated. 1. Assess all patients for risk of skin breakdown using the Braden scale..."

1) Review of MR7 on June 7, 2011, at approximately 3:10 PM revealed the Medication Administration Record (MAR) for June 2, 2011, indicated Ambien to be administered at hour of sleep and Clotrimazole cream and Xenaderm ointment to be applied twice daily. Further review of MR7 revealed that the Ambien, Clotrimazole and the Xenaderm was not documented as administered on June 2, 2011, from 1501 through 2259, the evening shift, as per order.

2) Review of MR15, on June 8, 2011, at approximately 1:00 PM revealed the Medication Administration Record (MAR) for June 6, 2011, indicated Urecholine was to be administered three times a day. Further review of MR15 revealed that the Urecholine was not documented as administered on June 6, 2011, at 8:00 AM, as per order.

3) Review of MR9 revealed that the Interdisciplinary Assessment Braden Scale was not completed.

During an interview on June 8, 2011, at approximately 3:15 PM, EMP2 indicated, "There is no documentation that the medication was given [for MR7 or MR15]. I really do not know why it was not documented." EMP2 further indicated, "The Braden Scale is not completed[MR9].

4) On June 7, 2011, at approximately 2:00 PM, documentation review indicated that MR26 was admitted to the facility on May 27, 2011. Review of the 'Daily Flowsheet/Treatment Record' for the date of admission indicated the patient had a foley catheter. The 'Daily Progress/Narrative' notes for the same date state, "...4:30 PM ...foley draining clear amber urine."

On June 7, 2011, at 2:20 PM EMP13 stated "I don't recall MR26 ever having a foley...that must have been documented on the wrong patient."

5) Review of the MAR for MR26 dated May 28, 2011, revealed an order for Flomax 0.4 mg daily. The scheduled time of administration of 0800 was circled.

On June 7, 2011, at 2:15 PM EMP1 stated, "If it's circled it wasn't given, but there should be a reason documented somewhere. I don't see anything documented to say why this wasn't given."

6) On June 9, 2011, at approximately 10:00 AM, a review of the MAR dated August 18, 2010, for MR31 revealed an order for Cipro 500 mg twice a day (8 AM/8 PM). There was no documentation on the MAR that the patient received the 8:00 PM dose on this date.

On June 9, 2011, at approximately 10:30 AM EMP2 confirmed the above information, stating "If it's not signed we don't know if they received it or not."

7) On June 8, 2011, at 11:30 AM, a review of MR30 revealed an "Influenza and Pneumococcal Vaccine Verification/Refusal/Consent" form which was signed by the POA on the date of admission indicating request and consent for the patient to receive the pneumococcal vaccine during this hospitalization. Further review of the MR, revealed there was no physician order to administer the pneumococcal vaccine.

On June 8, 2011, at approximately 11:55 AM, EMP1 confirmed the above information and stated "There should be a physician order for the vaccine and it would be documented on the MAR. We confirmed with pharmacy that they never dispensed the vaccine for this patient."

8) Continued review of MR30 revealed a physician order on September 4, 2010, at 5:10 AM to transfer the patient to an acute care facility for evaluation of rectal bleeding. There was no nursing documentation on the above date to indicate whether the patient was transferred to an outside facility.

On June 9, 2011, at 12:10 PM EMP2 confirmed "In an acute care transfer there is a specific form that should be completed but I don't see it on this record."

Based on review of facility documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure all entries in the record are dated, timed and authenticated per policy for ten of 31 medical records (MR1, MR3, MR4, MR6, MR7, MR13, MR15, MR23, MR30 and MR31).

Findings include:

The "HealthSouth Rehabilitation Hospital of Sewickley Medical Staff rules and Regulations", reviewed February 24, 2010 indicated, "...Organizational Functions...G...1. All clinical entries in the patient's medical record shall be accurately dated, time and authenticated by the persons authorized to assess, write orders and treat patients. The medical record must be clear, concise, complete and accurate"

1) A review of MR1 on June 7, 2011, at approximately 10:25 AM revealed a Therapy Request sticker dated May 24, 2011, with no time the entry was placed into the record.

2) A review of MR3 on June 7, 2011, at approximately 11:30 AM revealed a Therapy Request sticker dated June 5, 2011, with no time the entry was placed into the record.

3) A review of MR6 on June 7, 2011, at approximately 2:15 PM revealed a Therapy Request sticker dated June 3, 2011, with no time the entry was placed into the record.

4) A review of MR7 on June 6, 2011, at approximately 3:10 PM revealed a Therapy Request sticker dated June 1, 2011, with no time the entry was placed into the record.

5) A review of MR4, MR13, MR15, and MR23 on June 7, 2011, at approximately 2:00 PM revealed Therapy Request stickers dated June 6, 2011, with no time the entry was placed into the records.

Interview on June 7, 2011, at approximately 2:00 PM, EMP2 confirmed, "Yes, there should be a time entered [for the therapy stickers for MR1, MR3, MR4, MR6, MR7, MR13, MR15, MR23].

6) A review of MR30 on June 8, 2011, at approximately 10:00 AM revealed Progress Notes and Therapy Request stickers dated between August 25, 2010 and September 1, 2010, with no time the entry was placed into the record.

7) A review of MR31 on June 8, 2011, at approximately 11:15 AM revealed Progress Notes and Therapy Request stickers dated between August 18, 2010 and August 25, 2010, with no time the entry was placed into the record.

On June 8, 2011 at approximately 11:45 AM, EMP1 confirmed there was no time on the above identified entries stating, "We're working hard on this issue."

Based on a review of facility documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure Medical Staff compliance with Medical Staff Rules and Regulations relative to the authentication of verbal orders within 24 hours for five of 31 medical records (MR1, MR7, MR10, MR15 and MR17).

Findings include:

Review of the Medical Staff Rules and Regulations, reviewed February 24, 2010, revealed, "D. Treatment of Patients 1. Medical Staff Responsibilities...b. A verbal order shall be considered to be in writing if dictated to a duly authorized personnel functioning with his sphere of competence and signed by the responsible ordering practitioner. All orders dictated over the telephone shall be signed by the appropriately authorized person to who dictated with the name of the ordering practitioner, the date and the time the order was given and full signature of person taking the order. The responsible ordering practitioner shall authenticate such orders, within 24 hours...Organizational Functions G. Management of Information 1. All clinical entries in the patient's medical record shall be accurately dated, time, and authenticated by persons authorized to assess, write orders and treat patients. The medical record must be clear, concise, complete, and accurate."

1. Review of MR1 and MR7, on June 7, 2011, at approximately 11:30 AM and review of MR10, MR15 and MR17 on June 8, 2011, at approximately 12:00 PM revealed verbal orders that were not authenticated with the time the verbal order was countersigned by the physician.

During an interview on June 9, 2011 at approximately 12:00 PM, EMP2 confirmed that the verbal orders for MR1, MR7, MR10, MR15, and MR17 were not timed when countersigned by the physician.

Based on a tour of the facility and staff interviews (EMP) it was determined that the facility failed to maintain supplies to ensure an acceptable level of safety and quality.

Findings include:

1) A tour of the medication room on the second floor on June 8, 2011, at approximately 3:00 PM revealed IV catheters with January 2011 and March 2011 expiration dates.

2) A tour of the nursing supply room on June 8, 2011, at approximately 3:30 PM revealed urethral catheters with May 2010 and April 2010 expiration dates.

Interview with EMP23 on June 8, 2011, at approximately 3:00 PM confirmed that the autoguard catheters located on the second floor nursing medication room were expired.

Interview on June 8, 2011, at approximately 3:30 PM, EMP2 confirmed that the urethral catheters were expired. Further interview on June 9, 2011, at approximately 9:30 AM EMP2 confirmed that the facility did not have a policy regarding expired patient care items.

Interview on June 9, 2011, at approximately 9:30 AM, EMP17 indicated, " No, we just know to rotate items. I don't think there is a policy specific for that [expired patient care items]."