HospitalInspections.org

Based on 4 of 10 records reviewed, interview with facility staff, interview with patient's family and review of policy the hospital failed to assure therapy services were offered.

Findings include:

Patient #1 was receiving therapy services delegated to certified nursing assistants (CNA's) which consisted of passive range of motion (PROM) exercises to be done twice daily. According to an initial occupational therapy evaluation in patient #1's clinical record dated 10/26/11; "PROM established and to be performed by nursing aide staff 2 X/day." According to "24 Hour Patient Record & Plan of Care" in pt. #1's clinical record these exercises were not done on the following days/shifts; 10/28/11 7 PM - 7 AM, 10/29/11 7 PM -7 AM, 11/7/11 PROM 1 X 7 AM - 7 PM, 11/8/11 no PROM done, 11/9/11 no PROM done, 11/10/11 no PROM done, 11/12/11 no PROM done, 11/13/11 no PROM done, 11/14/11 no PROM done.

Patient #2 was receiving mobility exercises delegated to certified nursing assistants (CNA's) which consisted of repositioning in bed and getting out of bed into a chair. According to "24 Hour Patient Record & Plan of Care" in pt. #2's clinical record these exercises were not done on the following days/shifts; 02/26/12 7 PM - 7 AM, 02/28/12 both shifts, 02/29/12 both shifts, 03/02/12 both shifts, 03/05/12 7 PM - 7 AM, 03/06/12 7 PM - 7 AM.

Patient #3 was receiving mobility exercises delegated to certified nursing assistants (CNA's) which consisted of repositioning in bed and sitting up in a chair and PROM. According to "24 Hour Patient Record & Plan of Care" in pt. #1's clinical record these exercises were not done on the following days/shifts; 01/4/12 7 AM - 7 PM, 01/7/12 7 PM - 7 AM, 01/8/12 7 PM - 7 AM, 01/11/12 7 PM - 7 AM, 01/13/12 7 AM - 7 PM, 01/15/12 7 PM - 7 AM, 01/18/12 7 AM - 7 PM, 01/23/12 both shifts, 01/24/12 7 PM - 7 AM.

Patient #4 was receiving therapy services delegated to certified nursing assistants (CNA's) which consisted of passive range of motion (PROM) exercises to be done twice daily. " According to "24 Hour Patient Record & Plan of Care" in pt. #1's clinical record these exercises were not done on the following days/shifts; 05/06/12 7 PM - 7 AM, 05/07/12 both shifts, 05/08/12 7 AM - 7 PM, 05/11/12 both shifts. Per interview with patient #4's husband on 05/16/12 at 2:50 PM PROM exercises were done solely by him the majority of the time.

According to the hospital's policy # M05-G entitled; "Mobility and weight bearing guidelines". Amongst these guidelines are the following; "Every patient will be assessed by both Nursing and Rehab within 72 hours of admission and placed in a standard Mobility Level." in addition; "There will be a combined effort among Nursing, Rehabilitation Staff, and Respiratory Staff to complete and document the completed level every day for every patient."


The preceding findings were confirmed per interview with Director of Quality Management A on 05/17/12 at 4:00 PM.