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During the on-site investigation several personnel and competency files (4 RN, 1 LPN and 2 GNAs) were reviewed. The files were complete and up-to-date with the exception of one of the GNAs. On review of the GNA's personnel file, the GNA has a disciplinary note in his personnel file regarding roughness and attitude while providing care to a patient. As a result of the behavior the GNA had been taken off of the patient's assignment for a period of time. The GNA was later reassigned to care for the patient; however, after a period of time the patient informed staff at the hospital that it was not working out.

This same GNA was disciplined and recommendation made that the GNA participate in a customer service program. The GNA was to participate in the program by 4/28/11 but as of the survey date 7/11/11, the GNA had not received the customer service training. The surveyor received confirmation that the GNA is scheduled for the training in September 2011.

Based on the hospital's own internal policy titled "Competency Assessment" employees are to update competencies on an annual basis; however, said GNA 's competencies were also outdated since 2/28/11.

Further review of the GNA's personnel file also indicates that on a separate occasion despite being informed by the nurse that no one could leave the patient unit until coverage arrived, the GNA had left the unit and gone home leaving just one GNA on the unit.

Despite this second infraction being related to patient safety the GNA's competencies and customer service training remain incomplete

Based on review of Patient #1's medical record it was determined that entries made in the medical record and dated March 27, 2011 between the hours of 6:00 am and 9:00 am were not accurately written.
Patient #1 is a 34 year old female with a history of unresponsiveness related to Intracranial Hemorrhage due to hypertensive emergency, Chronic Respiratory Failure, Diabetes, and End Stage Renal Disease requiring hemodialysis, and Sacral Decubitus Ulcer.
On review of Patient #1's medical record, specifically a nursing progress note dated March 27, 2011 at 6:00 am the following entry was made : "Patient's temp at 5 am 101.1, Tylenol given as ordered, PA aware, Patient is not on any antibiotic therapy, waiting for blood culture result ."
Following the first entry a second entry dated March 27, 2011 at 9:00 am was made by the physician assistant stating the following in bold lettering : "PA Was Not Called For Temp 101.1@ 0600. "
As a result of the conflicting documentation this surveyor was provided the Physician Assistant's telephone number to obtain her input into the documentation discrepancies. During the telephone interview the PA indicated that she had not been made aware of the patient's temperature elevation at 6:00 am and would not have waited hours to see the patient had she been made aware. Patient # 1 was subsequently seen and assessed by the PA on March 27, 2011 at 9:15 am.
Telephone interview was also conducted with the LPN who made the first entry into the medical record. According to the LPN, she had made the PA aware of Patient #1's temperature elevation in person not via telephone, in the presence of one of the RNs on the unit at 6:00 am .

Based on review of Patient #1's medical record it was determined that an entry made in the medical record by the Physician Assistant on March 27, 2011 at 9:15 am regarding a follow-up assessment for Patient #1 due to a fever of 101.1 was illegible. Despite efforts by the state surveyors, the hospital ' s Long Term Care Director of Nursing, and one of the hospital's RNs multiple portions of the entry could not be determined due to illegibility.
In addition, on review of several of Patient #1's wound order and documentation sheets it was determined that multiple entries made by one of the wound team members were illegible.