HospitalInspections.org

Based on observations, interviews and record review, the hospital failed to meet the Condition of Participation for Medical Record Services by failing to maintain administrative responsibility for the completion and secure storage of medical records as evidenced by:

1) failing to ensure medical records were promptly completed within 30 days after a patients discharge as per hospital policies, Medical Staff Bylaws and Medical Staff Rules and Regulations as evidenced by 4 physicians having 1,731 deficiencies with 283 medical records incomplete greater than 60 days. (See findings Tag Fed-A-0438)

2) failing to ensure over 1000 medical records (2 years ' worth) were protected from water damage in the event the hospital sprinkler system became activated. (See findings Tag Fed-A-0438)

Based on record review and interviews the hospital failed to ensure the medical staff was accountable to the governing body for the quality of the medical care provided to patients as evidenced by:
1) Medical staff did not examine patients in person to pronounce them dead on expiration for 3 (#18, #19, #20) of 3 death records reviewed, and

2) RNs (registered nurse) documenting verbal read back orders for admission without calling the physician for orders. The RN was writing the admission orders based on the orders received from the transferring hospital for 2 of 20 sampled patients (#9, #10) and a preadmission screening for 1 (#8) of 20 sampled patients. Findings:

1) Medical staff did not examine patients in person to pronounce them on expiration

Review of the hospital Medical Staff Rules and Regulations, provided by S1Administrator 4/30/13 as current, revealed in part the following: II. Admission, Transfer and Discharge:, C. Discharge: 4. "In the event of a Hospital patient death, the deceased will be pronounced dead by the attending Physician or his Physician designee within a reasonable time."...

Patient #19
Review of the medical record for Patient # 19 revealed he was an 87 year old male admitted on 11/6/12 for physical therapy from a femur fracture.
Further review of the medical record for Patient #19 revealed the following entries on 11/8/12 with no signatures:
5:10 p.m. - Seizure activity noted in the DR (dining room). Arms flailing, unresponsive in w/c to room.
5:15 p.m. - code called. Chest compressions, CPR began, 911 called, fly (family) called. BG (blood glucose) 232.
5:20 p.m. - CPR continued.
5:25 p.m. - Fire Department B called. Arrived. IV (intravenous catheter) left wrist 22 G (gauge) D51/2 Bolus.
5:30 p.m. - D Fib applied per Fire Department B. No shock advised. CPR continued. IV restarted L wrist 22G.
5:35 p.m. No shock advised. EMS arrived confirmed pt PEA (pulseless electrical activity). ED Physician C notified. Advised to stop CPR. Son called, advised that (no further entry).
5:50 p.m. - LOPA/Coroner called.
Further review of the medical record for Patient #19 revealed no documentation that a hospital physician had examined and pronounced him dead.
An interview was conducted on 5/1/13 at 1:05 p.m. with S3DON. She stated ED Physician C was the doctor on call for EMS services and was not at the facility when CPR for Patient #19 was discontinued. S3DON said ED Physician C pronounced the patient over the phone and no staff physician came to see Patient #19 in person and pronounce him dead. S3DON stated she did not know that a physician had to pronounce the patient dead in person.

In an interview on 5/2/13 at 3:10 p.m. with S6MedicalDirector, he said the process for coding a patient at the hospital should have been to initiate CPR and call 911. S6MedicalDirector said the EMTs (Emergency Medical Technicians) should have taken over CPR when they arrived at the hospital. He said EMS usually took the patients out of the facility and to a local hospital. S6MedicalDirector said when Patient #19 passed away in the hospital and EMS left the body, it was the responsibility of the hospital for a physician to pronounce him dead in person. S6MedicalDirector said he should have come to the hospital and pronounced Patient #19 dead but he did not. When asked if he had seen any problems with any of the medical records for patients that had passed away in the hospital, he replied, " no " . S6MedicalDirector also verified he was on the governing body at the hospital.

Patient #18
Review of the medical record for Patient #18 revealed he was an 83 year old admitted to the hospital 5/16/13 following a Cerebral Vascular Accident (stroke) with right body involvement for rehabilitation therapy. Review of a Physician's Progress note ,dated 5/28/13 at 4:35 p.m., revealed in part, the following: " (Patient #19) was noted to be unresponsive by nursing staff today around 1:20 p.m. Code (resuscitation) initiated with EMS (Emergency Medical Services) assistance in the patient's room. Code was called (called to a stop) by EMS around 1:50 p.m...." and signed by S6Medical Director who was also the patient's admitting physician.

Patient #20
Review of the medical record for Patient #20 revealed she was a 78 year old admitted to the hospital 10/12/13 from an acute care hospital for rehabilitative therapy. Her diagnoses on discharge from the acute care hospital included, in part, Decompenstated Diastolic Heart Failure, Acute Respiratory Failure, Uncontrolled Hypertension, Pulmonary Hypertension, Alkalosis secondary to diuretics, and Erosive Gastritis. Further review revealed a faxed copy (fax date of 11/19/12) of EMS (emergency medical services) paramedics notes of an incident 10/20/13 regarding Patient #20. These notes revealed the following, in part:
Assessment exam: Unresponsive, both eyes fixed and non-reactive, skin cyanotic(bluish discoloration) and warm, absent lung sounds. The Chief Complaint was documented as cardiac arrest. It was documented that resuscitation was initiated and included CPR (Cardiopulmonary Resuscitation), Oxygen via a mask, and advanced cardiac life support medications (Epinephrine 3 times and Sodium Bicarbonate once). Listed under Cardiac Arrest Data was the cardiac arrest was not witnessed, the etiology (cause) was presumed cardiac. CPR discontinued at 5:11 (a.m.). The call disposition was documented as "Dead at Scene".
Review of Nurses notes dated 10-19-12 and timed at 4:30 a.m. (actual date of 10/20/13 after midnight) revealed, in part: "...EMS took over CPR and eventually stopped and 'said they were done.' EMS notified the coroner. I notified (S8Physician), family, ADON (Assistance Director of Nursing), DON(Director of Nursing) and LOPA (Louisiana Organ Procurement Agency)." and was signed by an RN (Registered Nurse). Further review of Patient #20's medical record revealed no documentation that a physician came to the hospital and pronounced the death of Patient #20.




2) RNs (registered nurse) documenting verbal read back orders for admission without calling the physician for orders.

Review of Medical Staff Rules and Regulation, provided by S1Administrator as current, revealed in part: II. Admission, Transfer and Discharge, A. 2. Only Active and Courtesy Medical Staff Members may admit patients to the hospital... 4. Patients may be admitted only on order of a Physician...

Patient #9
Review of Patient #9's medical record revealed she was a 73 year old female admitted on 04/19/13 with diagnoses of Severe Parkinson's Disease and Debility. Review of her "Rehab Admission Orders" revealed S4RN received a verbal order and read it back on 04/19/13 with no documented evidence of the time the verbal order was received. Further review revealed S6Medical Director authenticated the verbal order on 04/19/13 at 7:10 p.m.

Patient #10
Review of Patient #10's medical record revealed he was an 82 year old male admitted on 04/25/13 with a diagnosis of Osteoarthritis. Review of his "Rehab Admission Orders" revealed S4RN received a verbal order and read it back on 04/25/13 with no documented evidence of the time the verbal order was received. Further review revealed S6Medical Director authenticated the verbal order on 04/25/13 at 3:10 p.m.

In a face-to-face interview on 05/02/13 at 12:45 p.m., S4RN indicated she filled in the blanks and selected the orders on the admission standing order form based on the orders received from the transferring hospital for Patients #9 and #10. She further indicated she documented "read back verbal order", but she did not call S6Medical Director to obtain admission orders. When informed that her practice of writing admission orders without calling the physician to obtain orders would be considered practicing medicine without a medical license, S4RN answered "I agree." S4RN indicated they were told to go by the discharge orders from the transferring hospital, and she had always done that. She further indicated she didn't remember who had given those instructions.

In a face-to-face interview on 05/02/13 at 3:00 p.m., S6Medical Director indicated the process for admission began with the nurse liaison evaluating the patient while he/she was in the acute care hospital, copying part of the chart, and sending the information to him for approval or disapproval of the patient's admission for rehab. He further indicated when the patient arrived at the rehab hospital, the nurse would let him know that the patient had arrived, and the nurse would review the patient's medications with him. When S6Medical Director was informed that S4RN said that she didn't call him for admission orders but wrote them based on the discharge orders from the transferring hospital, S6Medical Director indicated that "could be happening at times." He indicated that he times his signature on verbal orders within 30 minutes of when the order was written and not when he actually signed the verbal order. He further indicated he may not see the patient on the day of admit, if he has left the hospital by the time the patient arrived.

Patient #8
Review of the medical record for Patient #8 revealed she had been admitted to the hospital for rehabilitation after a coronary artery bypass graft. Review of the " Rehab Admission Orders " for Patient #8 revealed she had been admitted to the hospital on 4/19/13 at 2:30 p.m. The admission orders were signed at the bottom by S4RN that they had been received as a verbal order from S6MedicalDirector on 4/19/13 at 2:30 p.m. S6MedicalDirector signed and authenticated his signature on 4/19/13 at 2:40 p.m.
In an interview on 5/2/13 at 11:00 a.m. with S4RN, she stated when patients were admitted to the hospital, the nurses would fill out the admission order sheet for the patients. S4RN said the orders were based on discharge orders from the previous hospital even when the doctor was not privileged at this hospital. S4RN reviewed the admission orders for Patient #8 and stated she had written the admission orders. S4RN said the patient had been admitted from home, so she wrote the medication orders from a list of home medications. S4RN said the other orders were selected to be done by her based on what was usually done at the hospital for patients on admission and the preadmission screening by a nurse. S4RN said the hospital had no policies and procedures or protocols about how to fill out the admission orders. S4RN stated all of the nurses did the admissions orders the same way and that was how she was instructed to fill the order sheet out, but she could not remember who told her how to complete the admission orders. S4RN said she wrote that she received a verbal order from the physician about the admission orders, but never actually notified the physician. She said the physician would review the orders when he came to the hospital, which was usually in the mornings. S4RN said sometimes S6MedicalDirector would come in the afternoon for staffing. S4RN also said a nurse practitioner was usually in the building, but the admission orders were not presented to or ordered by them.

In an interview on 5/2/13 at 1:00 p.m. with S3DON, she stated the procedure for admissions should have been to fill out the admission order sheet based on the discharge orders from the previous facility, then notify S6MedicalDirector and go over the orders with him. S3DON said the nurses should not have instituted the admission orders without speaking to S6MedicalDirector first and receiving the orders from him. S3DON verified the discharge orders from the previous hospitals almost always came from physicians that were not credentialed at this hospital. S3DON also said S6MedicalDirector did not come to the hospital within 10-30 minutes of receiving admission orders or within 10-30 minutes of receiving telephone orders. S3DON said he came to the hospital approximately an hour in the morning or an hour in the evening and about 2-3 hours a couple of times per week for staffing. S3DON stated the hospital had no policies or protocols to instruct the Registered Nurses on how they should have filled out the admission orders.
In an interview on 5/2/13 at 3:10 p.m. with S6MedicalDirector, he said he approved if the patients were appropriate candidates for admission. When the patients arrived at the hospital, the nurses let him know what medications the patients were on and he would continue or discontinue them. S6MedicalDirector said there must have been instances where the nurses did not call him to go over the admission orders. S6MedicalDirector also stated that he dated and timed verbal orders within 30 minutes of the times the orders had been written, not when he actually authenticated the orders.


30420

In a phone interview 5/2/13 at 12:46 p.m. S10RN verified that she was employed at the hospital as a charge nurse. When asked what procedure was used in the admission of a new patient in regards to admission orders, S10RN reported that the acute care hospital sends discharge orders with the patient. She would then transfer the discharge orders to an admission order sheet and write them out, including pain medications and such. S10RN said that S6Medical Director would come in the morning and evening and sign the orders the nurses had written. She stated, "We don't usually call him each time we take and admit. He'll come by later. We don't know what time he'll be by." When asked to further explain how she initiated admission orders, but did not call the physician S10RN replied, " We write telephone order/S6MedicalDirector, but we don't usually call him unless some order needs to be verified." She verified that although telephone order was documented, the physician was not actually called. She said he would be by later, or in the morning.

Based on record reviews and interviews, the hospital failed to ensure that all patients were admitted to the hospital only on the recommendation of a licensed practitioner as evidenced by RNs (registered nurse) documenting verbal read back orders for admission without calling the physician for orders. The RN was writing the admission orders based on the orders received from the transferring hospital for 2 of 20 sampled patients (#9, #10) and a preadmission screening for 1 (#8) of 20 sampled patients. Findings:

Review of Medical Staff Rules and Regulation, provided by S1Administrator as current, revealed in part: II. Admission,Transfer and Discharge, A. 2. Only Active and Courtesy Medical Staff Members may admit patients to the hospital... 4. Patients may be admitted only on order of a Physician...

Patient #9
Review of Patient #9's medical record revealed she was a 73 year old female admitted on 04/19/13 with diagnoses of Severe Parkinson's Disease and Debility. Review of her "Rehab Admission Orders" revealed S4RN received a verbal order and read it back on 04/19/13 with no documented evidence of the time the verbal order was received. Further review revealed S6Medical Director authenticated the verbal order on 04/19/13 at 7:10 p.m.

Patient #10
Review of Patient #10's medical record revealed he was an 82 year old male admitted on 04/25/13 with a diagnosis of Osteoarthritis. Review of his "Rehab Admission Orders" revealed S4RN received a verbal order and read it back on 04/25/13 with no documented evidence of the time the verbal order was received. Further review revealed S6Medical Director authenticated the verbal order on 04/25/13 at 3:10 p.m.

In a face-to-face interview on 05/02/13 at 12:45 p.m., S4RN indicated she filled in the blanks and selected the orders on the admission standing order form based on the orders received from the transferring hospital for Patients #9 and #10. She further indicated she documented "read back verbal order", but she did not call S6MedicalDirector to obtain admission orders. When informed that her practice of writing admission orders without calling the physician to obtain orders would be considered practicing medicine without a medical license, S4RN answered "I agree." S4RN indicated they were told to go by the discharge orders from the transferring hospital, and she had always done that. She further indicated she didn't remember who had given those instructions.

In a face-to-face interview on 05/02/13 at 3:00 p.m., S6MedicalDirector indicated the process for admission began with the nurse liaison evaluating the patient while he/she was in the acute care hospital, copying part of the chart, and sending the information to him for approval or disapproval of the patient's admission for rehab. He further indicated when the patient arrived at the rehab hospital, the nurse would let him know that the patient had arrived, and the nurse would review the patient's medications with him. When S6Medical Director was informed that S4RN said that she didn't call him for admission orders but wrote them based on the discharge orders from the transferring hospital, S6MedicalDirector indicated that "could be happening at times." He indicated that he times his signature on verbal orders within 30 minutes of when the order was written and not when he actually signed the verbal order. He further indicated he may not see the patient on the day of admit, if he has left the hospital by the time the patient arrived.

Patient #8
Review of the medical record for Patient #8 revealed she had been admitted to the hospital for rehabilitation after a coronary artery bypass graft. Review of the "Rehab Admission Orders" for Patient #8 revealed she had been admitted to the hospital on 4/19/13 at 2:30 p.m. The admission orders were signed at the bottom by S4RN that they had been received as a verbal order from S6MedicalDirector on 4/19/13 at 2:30 p.m. S6MedicalDirector signed and authenticated his signature on 4/19/13 at 2:40 p.m.
In an interview on 5/2/13 at 11:00 a.m. with S4RN, she stated when patients were admitted to the hospital, the nurses would fill out the admission order sheet for the patients. S4RN said the orders were based on discharge orders from the previous hospital even when the doctor was not privileged at this hospital. S4RN reviewed the admission orders for Patient #8 and stated she had written the admission orders. S4RN said the patient had been admitted from home, so she wrote the medication orders from a list of home medications. S4RN said the other orders were selected to be done by her based on what was usually done at the hospital for patients on admission and the preadmission screening by a nurse. S4RN said the hospital had no policies and procedures or protocols about how to fill out the admission orders. S4RN stated all of the nurses did the admissions orders the same way and that was how she was instructed to fill the order sheet out, but she could not remember who told her how to complete the admission orders. S4RN said she wrote that she received a verbal order from the physician about the admission orders, but never actually notified the physician. She said the physician would review the orders when he came to the hospital, which was usually in the mornings. S4RN said sometimes S6MedicalDirector would come in the afternoon for staffing. S4RN also said a nurse practitioner was usually in the building, but the admission orders were not presented to or ordered by them.

In an interview on 5/2/13 at 1:00 p.m. with S3DON, she stated the procedure for admissions should have been to fill out the admission order sheet based on the discharge orders from the previous facility, then notify S6MedicalDirector and go over the orders with him. S3DON said the nurses should not have instituted the admission orders without speaking to S6MedicalDirector first and receiving the orders from him. S3DON verified the discharge orders from the previous hospitals almost always came from physicians that were not credentialed at this hospital. S3DON also said S6MedicalDirector did not come to the hospital within 10-30 minutes of receiving admission orders or within 10-30 minutes of receiving telephone orders. S3DON said he came to the hospital approximately an hour in the morning or an hour in the evening and about 2-3 hours a couple of times per week for staffing. S3DON stated the hospital had no policies or protocols to instruct the Registered Nurses on how they should have filled out the admission orders.
In an interview on 5/2/13 at 3:10 p.m. with S6MedicalDirector, he said he approved if the patients were appropriate candidates for admission. When the patients arrived at the hospital, the nurses let him know what medications the patients were on and he would continue or discontinue them. S6MedicalDirector said there must have been instances where the nurses did not call him to go over the admission orders. S6MedicalDirector also stated that he dated and timed verbal orders within 30 minutes of the times the orders had been written, not when he actually authenticated the orders.




30364

Based on record review and interview the hospital failed to ensure that services performed under contract were provided in a safe and effective manner when the hospital had no process in place that evaluated all contract services.
Findings.

Review of the Quality Assurance documents revealed no evaluation of contracted biomedical services for hospital equipment, contracted environmental cleaning services, or contracted X-ray and ultrasound services.

In an interview on 5/2/13 at 4:15 p.m. S1Administrator reported that there was no documented evaluation of contracted cleaning services or of contracted biomedical services. She reported that radiology services were not evaluated by the facility.

Based on interviews and record reviews, the hospital failed to ensure the medical staff enforced bylaws for delinquent medical records for 4 (S6MedicalDirector, S7Physician, S8Physician, S9Physician) of 4 physicians medical record delinquencies reviewed.
Findings:
Review of the Hospital Medical Staff Bylaws presented as current by S5MRDirector revealed the following in part:
Members of the medical staff are required to complete medical records according to the time periods set forth in the rules and regulations. A temporary suspension in the form of withdrawal of admitting and other related privileges until medical records are completed shall be imposed by the Medical Director, or his or her designee, after notice of delinquency for failure to complete medical records within such period. For the purpose of this section, "related privileges" means voluntary on-call service for consulting on Hospital cases and providing professional services within the Hospital for future patients.

Review of the Medical Staff Rules and Regulations provided by S5MRDirector as current revealed in part:
9. Medical records must be completed in all respects within 30 days of patient discharge.
5. If the medical records are not thereafter completed within the seven-day period, then Medical Records/HIM Department shall issue a Notice of Temporary Suspension for Medical Record Deficiencies, which may have the effect of temporarily suspending the affected members privileges in accordance with the terms and procedures in the Medical Staff Bylaws.

Review of the Deficiency Report by Physician list provided by S5MRDirector revealed the following number of medical record delinquencies:
S6MedicalDirector- The total number of delinquent records was listed as 1,420. 147 medical records were delinquent greater than 60 days. The oldest delinquency was dated 4/29/12.
S7Physician- The total number of delinquent records was listed as 17.3 medical records were delinquent greater than 60 days.
S8Physician- The total number of delinquent records was listed as 250. 126 medical records were delinquent greater than 60 days. The oldest deficiency was dated 5/2/12.
S9Physician- The total number of delinquent records was listed as 44.7 medical records were delinquent greater than 60 days. The oldest deficiency was dated 9/25/12.

In an interview on 5/1/13 at 8:30 a.m. with S5MRDirector, she stated she sent certified letters to the physicians every month with a list of their delinquencies. S5MRDirector stated the physician's then had 7 days to complete their charts. S5MRDirector also said she notified the Administrator and DON of the delinquencies. She also said none of the physicians have been suspended as per the policy or Medical Staff Bylaws.
In an interview on 5/2/13 at 3:15 p.m. with S6MedicalDirector, he stated he was aware of the large number of delinquent medical records at the hospital. He said he had discussed suspensions, but had not enforced any of the Bylaws related to suspension of physician privileges
In an interview on 5/3/13 at 2:10 p.m. with S1Administrator, she stated she was aware of the large numbers of delinquent medical records and it had been an ongoing problem at the hospital. She stated the hospital has not enforced its suspension policy for delinquencies because a hospital could not function without any physicians.

Based on record reviews and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care for each patient.

1) The RN failed to assess patients with a change in condition as per hospital policy. The patients with changes in condition required transfer to an emergency department for evaluation, had bloody stools while on Coumadin, and changes in vital signs that resulted in the LPN (licensed practical nurse) holding the antihypertensive medication for 3 of 7 current patient records reviewed for an RN assessment with a change in condition from a total sample of 27 patient records (#2, #9, #10).

2) The RN failed to ensure a patient's blood pressure and pulse were assessed prior to administering antihypertensive medications to ensure safe administration. The RN also failed to assess a patient's breath sounds, respirations, and pulse before and after nebulizer treatments as recommended on the MAR (medication administration record) by the pharmacist for 1 of 8 current patient records reviewed for medication administration (#9) and 1 of 1 patient record reviewed with orders for nebulizer treatments (#10) from a total of 27 patient records.

3) The RN failed to ensure physician orders were implemented for weights (#2, #7, #10), labs (#5, #9), in and out catheterization (#2) and respiratory treatments (#10) for 5 of 20 current patients' records reviewed for implementation of physician orders from a total sample of 27 patients.
Findings:


1) The RN failed to assess a patient with a change in condition related to pain requiring transfer to an emergency department for evaluation, bloody stool, and changes in vital signs that resulted in the LPN holding the antihypertensive medication:

Review of the hospital's policy titled "Admission Assessment", policy number I.G.3.0 revised 04/12, revealed reassessment is based on continued desire for care, response to care, and change in patient status. Further review revealed each patient is reassessed when a significant change occurs in the patient's condition and when a significant change occurs in the patient's diagnosis.

Review of the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII" revealed the assessment performed by the RN shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. Further review revealed the registered nurse may delegate to licensed practical nurses the major part of the nursing care needed by individuals in stable nursing situations, i.e. (that is), when the following three conditions prevail at the same time in a given situation: 1) nursing care ordered and directed by R.N./M.D. (medical doctor) requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable; 2) change in the patient's clinical conditions is predictable; and 3) medical and nursing orders are not subject to continuous change or complex modification.
Patient #2
Review of Patient #2's medical record revealed he was a 32 year old male admitted on 03/05/13 with diagnoses of Idiopathic Transverse Myelitis, Burkitt's Lymphoma, Hernia, and Herpes Zoster Virus Ophthalmicus.

Review of Patient #2's nurses' notes for 03/17/13 revealed S20LPN documented that she was called to his room, and he was crying and stating his eye pain was worse. Further review revealed he was transferred to the emergency department at an acute care hospital for evaluation. There was no documented evidence of an assessment performed by an RN. Further review revealed Patient #2 returned from the emergency department on 03/18/13 at 1:15 a.m. and assessed by S20LPN. There was no documented evidence of documentation by the RN until 4:00 a.m. (2 hours and 45 minutes after Patient #2's return from the emergency department) on 03/18/13 that consisted of "agree (with) above assessment and flowsheet. no acute distress noted."

Patient #9
Review of Patient #9's medical record revealed she was a 73 year old female admitted on 04/19/13 with diagnoses of Severe Parkinson's Disease and Debility. Review of the physician admit medication orders dated 04/19/13 at 7:10 p.m. revealed an order for Lisinopril 40 mg (milligrams) by mouth daily and Metoprolol ER (extended release) 50 mg by mouth BID (twice a day).

Review of Patient #9's MARs revealed Metoprolol was held at 7:00 p.m. on 04/26/13 with a blood pressure of 110/64 and 122/80 documented. Further review revealed Lisinopril and Metoprolol were held at 7:00 a.m. on 04/29/13 with a blood pressure of 101/60 and pulse of 70, and Metoprolol was held at 7:00 p.m. on 04/28/13 with a blood pressure of 106/67 and 97/68. Review of the nurses' notes for the above dates when Lisinopril and Metoprolol were held revealed no documented evidence that an RN assessed Patient #9 and that an order was received to hold the medication from the physician.

In a face-to-face interview on 05/02/13 at 12:45 p.m., S4RN indicated the LPN was supposed to inform the RN of the patient's blood pressure, and the physician was to be contacted to obtain an order to hold the antihypertensive medication.

Patient #10
Review of Patient #10's medical record revealed he was an 82 year old male admitted on 04/25/13 with a diagnosis of Osteoarthritis.

Review of Patient #10's history and physical signed by S6Medical Director on 04/26/13 revealed he had a history of transient ischemic attack (when blood flow to a part of the brain stops for a brief period of time and felt to be a warning sign that a true stroke may happen in the future if something is not done to prevent it). He was prescribed Coumadin and was to be assessed for complications such as deep vein thrombosis, pulmonary embolus (blood clot in the lung), pressure decubitus, infections, bleeding, and falls.

Review of Patient #10's nurses' notes for 04/30/13 revealed an entry by S27LPN at 11:30 a.m. that Patient #10 had a large, hard, bright red stool. Further review revealed S27LPN asked him if he hemorrhoids, to which Patient #10 answered "yes." Further review revealed S27LPN documented that she reported the change in condition to S4RN at the time of the observance and to S26Nurse Practitioner at 2:00 p.m. (2 hours and 30 minutes after the stool was observed to be bright red). There was no documented evidence of an assessment by an RN of Patient #10 who was at risk for bleeding due to being on Coumadin.

In a face-to-face interview on 05/02/13 at 12:45 p.m., S4RN confirmed that she did not document an assessment of Patient #10 after she was notified by S24LPN of his having a large, hard, bright red stool.

2) The RN failed to ensure a patient's blood pressure and pulse were assessed prior to administering antihypertensive medications and a patient's breath sounds, respirations, and pulse were assessed before and after nebulizer treatments as recommended on the MAR by the pharmacist to ensure safe administration:
Patient #9
Review of Patient #9's medical record revealed she was a 73 year old female admitted on 04/19/13 with diagnoses of Severe Parkinson's Disease and Debility. Review of his physician admit medication orders dated 04/19/13 at 7:10 p.m. revealed an order for Lisinopril 40 mg by mouth daily and Metoprolol ER 50 mg by mouth BID (twice a day).

Review of Patient #9's MARs revealed a note of "check blood pressure" was typed below the Lisinopril dose, and a space below the time of 7:00 a.m. had "B/P" (blood pressure) typed for the blood pressure to be written. Further review revealed a note of "check blood pressure, check apical pulse" was typed below the Metoprolol dose. Further review revealed a line for the blood pressure and apical pulse was typed below the 7:00 a.m. time, but there was no line for the blood pressure and apical pulse to be entered for the 7:00 p.m. dose of Metoprolol.

Review of Patient #9's MARs revealed no documented evidence that his apical pulse was assessed prior to administering Metoprolol at 7:00 p.m. on 04/25/13, at 7:00 a.m. and 7:00 p.m. on 04/27/13, at 7:00 p.m. on 04/29/13, and at 7:00 p.m. on 04/30/13.

In a face-to-face interview on 05/02/13 at 12:45 p.m., S4RN indicated the pharmacist puts a reminder on the MAR for the blood pressure to be checked prior to administering Lisinopril and the blood pressure and apical pulse prior to administering Metoprolol. She further indicated that although the physician doesn't order the blood pressure and apical pulse to be checked, it was the expected practice that the nurse would check the vital signs as directed on the MAR. After reviewing Patient #9's MARs, S4RN confirmed the blood pressure and apical pulse were not documented prior to the Lisinopril and Metoprolol being administered on the above listed days and times.

Patient #10
Review of Patient #10's medical record revealed he was an 82 year old male admitted on 04/25/13 with a diagnosis of Osteoarthritis.

Review of Patient #10's "Rehab Admission Orders" dated 04/25/13, with no documented evidence of the time the order was received, revealed an order for Albuterol/Ipratropium Solution 0.5/3.0 (1 vial) per nebulizer every 6 hours. Review of the MAR revealed a note by the pharmacist to check Patient #10's breath sounds, respirations, and pulse before and after each treatment. Further review revealed no documented evidence that his breath sounds, respirations, and pulse were checked before and after each treatment on 04/26/13, 04/27/13, 04/28/13, and 04/29/13 as evidenced by either no documentation on the MAR or only one untimed documentation (unable to determine if the assessment was prior to or after administration of the treatment).

In a face-to-face interview on 05/02/13 at 12:45 p.m., S4RN confirmed an assessment of Patient #10's breath sounds, respirations, and pulse was not documented for each time he received his nebulizer treatment, and the assessment should have been performed by the nurse who administered the treatment.

3) The RN failed to ensure physician orders were implemented for weights, labs, in and out catheterization, orthostatic blood pressure checks,and respiratory treatments:
Weights:
Patient #2
Review of Patient #2's medical record revealed he was a 32 year old male admitted on 03/05/13 with diagnoses of Idiopathic Transverse Myelitis, Burkitt's Lymphoma, Hernia, and Herpes Zoster Virus Ophthalmicus. Review of his admit physician orders on 03/05/13 at 6:40 p.m. revealed an order to weigh on admit and every week. Further review of his orders revealed an order on 03/06/13 at 9:15 a.m. to weigh patient due to no admit weight. Further review revealed an order on 03/26/13 at 5:25 p.m. to weigh patient today and record in the MAR.

Review of Patient #2's admit physician orders dated 03/05/13 at 6:40 p.m. revealed the line next to "wt" (weight) was blank. Review of the nurses' notes and MARs revealed no documented evidence of Patient #2's weight as ordered by the physician.

Review of the weight logs revealed all patients were listed on the log. Review of the weight log for 03/09/13 to 03/10/13 revealed no documented evidence of a weight for Patient #2, and Patient #2's name was not listed on the log. Further review revealed Patient #2 refused to be weighed on 03/16/13 to 03/17/13, on 03/31/13, on 04/13/13 to 04/14/13, and on 04/28/13. Further review of the weight logs revealed no documented evidence of a weight or that Patient #2 refused to be weighed on 03/23/13 to 03/24/13, 04/06/13 to 04/07/13, and 04/21/13.

In a face-to-face interview on 04/30/13 at 2:15 p.m., S3DON (director of nursing) confirmed there was no documented weight at admit and when ordered by the physician for Patient #2. She indicated the weight log was kept on the unit, but the weights do not become part of the patient's clinical record after discharge.

In a face-to-face interview on 05/03/13 at 10:10 a.m., S3DON indicated a nurse should report to the physician when a patient continually refuses to be weighed, and it should be care planned as non-compliant with treatment.

Patient #7
Review of Patient #7's medical record revealed he was a 59 year old male admitted on 03/21/13 with a diagnosis of Paraplegia.

Review of Patient #7's physician orders revealed an order on 04/22/13 at 9:00 a.m. to weigh him and document his weight in the MAR. Review of Patient #7's MAR for 04/22/13 revealed no documented evidence of Patient #7's weight.

In a face-to-face interview on 05/03/13 at 10:10 a.m., S3DON confirmed there was no documented evidence that Patient #7 was weighed on 04/22/13 as ordered by the physician.

Patient #10
Review of Patient #10's medical record revealed he was an 82 year old male admitted on 04/25/13 with a diagnosis of Osteoarthritis.

Review of Patient #10's physician orders revealed a telephone order from S6Medical Director on 04/26/13 at 10:40 a.m. to weigh him and place his weight on the MAR. Review of the MAR revealed no documented evidence that Patient #10's weight was performed and placed on the MAR as ordered.

In a face-to-face interview on 05/02/13 at 12:45 p.m., S4RN confirmed Patient #10's weight was not documented on his MAR on 04/26/13 as ordered by S6Medical Director.

Labs:
Patient #5
Review of the medical record for Patient #5 revealed she was an 84 year old female admitted on 4/10/13 with diagnosis which included CVA with effects including dysphagia.
Review of the Physician's Admission Orders for Patient #5 dated 4/10/13 revealed an order for a U/A (urinalysis).
Review of the lab results for Patient #5 revealed a Urinalysis had not been collected and sent to lab until 4/19/13 at 7:38 a.m.
In an interview on 5/1/13 at 12:45 p.m. with S14, LPN, she stated Patient #5 had a U/A ordered on admission on 4/10/13, but a U/A had not been drawn until 4/19/13. S14LPN stated she could not locate an order for a U/A to be done except on admission. S14LPN said the admission U/A should have been drawn on 4/11/13. S15LPN stated Patient #5 could have had an abnormal urinalysis that would not have been detected for 8 days.

Patient #9
Review of Patient #9's medical record revealed she was a 73 year old female admitted on 04/19/13 with diagnoses of Severe Parkinson's Disease and Debility. Review of the physician admit orders dated 04/19/13 at 6:45 p.m. revealed an order for a urinalysis and a culture and sensitivity if indicated by the results of the urinalysis.

Review of Patient #9's lab reports revealed the urinalysis was collected on 04/21/13, 2 days after it was ordered.

In a face-to-face interview on 05/02/13 at 12:45 p.m., S4RN confirmed the urinalysis was not collected timely. She indicated the nurse should document when a urine specimen was not collected at least by the morning after it was ordered and the reason for it not being collected timely.

In and out catheterization:
Patient #2
Review of Patient #2's medical record revealed he was a 32 year old male admitted on 03/05/13 with diagnoses of Idiopathic Transverse Myelitis, Burkitt's Lymphoma, Hernia, and Herpes Zoster Virus Ophthalmicus.

Review of Patient #2's physician orders revealed an order on 04/08/13 at 12:40 p.m. to discontinue his catheter and teach in and out catheterization every 6 hours.

Review of the nurses' notes for 04/08/13 revealed Patient #2 had his catheter in place at 10:00 p.m., and he was informed that the catheter would be removed in the morning (9 hours and 20 minutes after the physician had ordered the catheter to be removed). Further review revealed Patient #2 was instructed on self-catheterization on 04/09/13, 04/10/13, 04/11/13, and 04/12/13, and he refused to self-catheterize. There was no documented evidence that this was reported by the LPN to the RN and subsequently to the physician.

In a face-to-face interview on 05/03/13 at 10:10 a.m., S3DON indicated she could not offer an explanation for Patient #2's catheter not being discontinued on 04/08/13 as ordered by the physician.

Respiratory treatments:
Patient #10
Review of Patient #10's medical record revealed he was an 82 year old male admitted on 04/25/13 with a diagnosis of Osteoarthritis.

Review of Patient #10's "Rehab Admission Orders" dated 04/25/13, with no documented evidence of the time the order was received, revealed an order for Albuterol/Ipratropium Solution 0.5/3.0 (1 vial) per nebulizer every 6 hours.

Review of Patient #10's MARs revealed no documented evidence that he had nebulizer treatments as ordered on 04/27/13 at 12:00 a.m. and 6:00 a.m.

In a face-to-face interview on 05/02/13 at 12:45 p.m., S4RN confirmed Patient #10 did not have a nebulizer treatment documented for 12:00 a.m. and 6:00 a.m. on 04/27/13.


30364

Based on interview and record review, the hospital failed to ensure the Registered Nurses (RN) developed and kept current complete care plans for all patients.
1) The RNs failed to accurately review care plans for appropriateness for 16 (#1- #16) of 16 rehabilitation inpatients' care plans reviewed from a sample of 27 patients.
2) The RNs failed to ensure each patient's care plan was individualized, patient-specific, included all medical problems, revised as needed to meet the changing needs of the patient,and included goals that stated the expected behavioral outcome for 6 of 6 (#1, #2, #3, #5, #6, #7) patients' records reviewed for care plans from a sample of 27 patients.
Findings:

Review of the hospital policy titled Patient Care Plan/Treatment Plan, Policy I.G.12.0, approved 12/12 revealed in part:
A nursing care plan is initiated by the admitting RN or designated RN within 24 hours of admission. The plan of care should be goal oriented, patient specific, and updated to meet patient's needs. The RN is responsible for reviewing and revising the care plan as needed.
B. Steps to Formulating the Nursing Care Plan ...3) Goals are developed that state the behavioral outcome expected. 4) The plan of care is individualized and formulated or validated with the patient. The plan will reflect the patient's current condition and needs and will be modified, as appropriate, to meet the changing needs of the patient. C. How to Identify Needs and Problems of Nursing Care 1) The statement must be specific to the patient, not a repetition of the general aim of care for every patient.
2) Needs are concerned with the process necessary for life and with individual's response to this environment (i.e., oxygenation, elimination, rest and activity, safety, nutrition). 3) The objective is stated in terms of overt behavior which can be evaluated.
F. How to Keep Nursing Care Plans Up to Date: 1) The RN is responsible for keeping the care plan up-to-date by evidence of the daily assessment verified by signature.

1) The RNs failed to accurately review care plans for appropriateness:
Review of the Care Plan book on 4/30/13 for the 16 Rehabilitation patients revealed the plans of care for the patients had been signed off as having been reviewed for appropriateness on 5/1/13.
In an interview on 4/30/13 at 2:40 p.m. with S4RN, she stated the care plans were reviewed every day for appropriateness. S4RN also stated she signed all of the patients' care plans as having been reviewed for 5/1/13 on 4/30/13.
In an interview on 4/30/13 at 2:50 p.m. with S3DON, she stated the care plans for the patients were signed off daily after being reviewed by the Registered Nurse. S3DON said the care plans should not have been signed off on 4/30/13 as being reviewed on 5/1/13.

2) The RNs failed to ensure each patient's care plan was individualized, patient-specific, included all medical problems, revised as needed to meet the changing needs of the patient,and included goals that stated the expected behavioral outcome:

Patient #1
Review of the medical record for Patient #1 revealed she had been admitted to the hospital on 4/18/13 with diagnosis which included hip fracture status post hemiarthroplasty, Parkinson's disease, Hypertension, Pain Management, and Anxiety.
Review of the medical record for Patient #1 revealed the following orders in part:
4/16/13 at 1730-O2 (oxygen) at 2L/nc 2 liters per nasal cannula) to keep sat (saturation)greater than or equal to 94%.
4/19/13 at 12:00 a.m.- CXR "Hypoxemia"
4/23/13 at 1400- Stat CXR (chest x-ray). PT (physical therapy) to wean O2 during therapy.
Review of the Nurse's Notes for Patient #1 dated 4/24/13 at 1100 revealed in part:
Rtn (return) from therapy, tech (technician) states sats (saturations) dropped in gym, sat checked 86%, dropped to 82% when talking.
Review of the care plans for Patient #1 revealed no care plans for Oxygen use or alteration in tissue perfusion.
In an interview on 4/30/13 at 2:50 p.m. with S3DON, she stated the patients' care plans should have included all medical and rehabilitation diagnosis. S3DON verified Patient #1's care plans did not include a care plan for Oxygen usage. S3DON also stated care plans should have been initiated for the medical problems for Patient #1.

Patient #2
Review of Patient #2's medical record revealed he was a 32 year old male admitted on 03/05/13 with diagnoses of Idiopathic Transverse Myelitis (a neurologic disorder caused by inflammation across both sides of one level or segment of the spinal cord), Burkitt's Lymphoma, Hernia, and Herpes Zoster Virus Ophthalmicus.

Review of Patient #2's "Interdisciplinary Initial Evaluation" performed on 03/06/13 revealed Patient #2 was a paraplegic (complete paralysis of the lower half of the body including both legs) and presented with decreased self-care performance, decreased bilateral upper strength, and decreased functional mobility.

Review of Patient #2's admit physician orders on 03/05/13 at 6:40 p.m. revealed an order to weigh on admit and every week. Further review of his orders revealed an order on 03/06/13 at 9:15 a.m. to weigh patient due to no admit weight. Further review revealed an order on 03/26/13 at 5:25 p.m. to weigh patient today and record in the MAR.

Review of the weight logs revealed all patients were listed on the log. Review of the weight log for 03/09/13 to 03/10/13 revealed no documented evidence of a weight for Patient #2, and Patient #2's name was not listed on the log. Further review revealed Patient #2 refused to be weighed on 03/16/13 to 03/17/13, on 03/31/13, on 04/13/13 to 04/14/13, and on 04/28/13.

Review of Patient #2's physician orders revealed an order on 04/08/13 at 12:40 p.m. to discontinue his catheter and teach in and out catheterization every 6 hours.

Review of the nurses' notes for 04/08/13 revealed Patient #2 was instructed on self-catheterization on 04/09/13, 04/10/13, 04/11/13, and 04/12/13, and he refused to self-catheterize. There was no documented evidence that his care plan was revised to include non-compliance with treatment and interventions to be implemented.

Review of Patient #2's "Interdisciplinary Plan Of Care" revealed the following care plans were initiated: altered tissue perfusion,impaired physical mobility, potential for injury, activity intolerance, self-care deficit, bowel incontinence, altered urinary elimination, actual infection, pain, constipation, and airway clearance. Further review revealed the interventions selected for each plan had no documented evidence of written additions that individualized it for Patient #2. The care plans initiated for bowel incontinence, altered urinary elimination, self-care deficit, impaired physical mobility, potential for injury, constipation, and pain had the same selected interventions as Patient #7's care plan with no additions to assure it was patient-specific and individualized. Further review revealed the goals were not stated in measurable, behavioral terms that could be used to determine when the goal was met.

In a face-to-face interview on 05/03/13 at 10:10 a.m., S3DON indicated a nurse should report to the physician when a patient continually refuses to be weighed, and his care plan should have been revised to include non-compliance with treatment.

Patient #3
Review of the medical record for Patient #3 revealed she was an 87 year old admitted 4/22/13 for continuation of rehabilitation services after returning from an acute care hospital where she was diagnosed with CHF (Congestive Heart Failure) exacerbation and pneumonia. Her admitting diagnosis was Polyarthritis Secondary to Osteoarthritis. Her comorbidities included Atrial Fibrillation, CHF, GERD (Gastroesophageal Reflux Disease), Hypertension, and Dysphagia (difficulty swallowing). Further review of a history and physical by an APRN (Advanced Practice Registered Nurse) and cosigned by a physician revealed the patient was receiving oxygen at 2 liters/minute by nasal cannula. Her physical also indicated that Patient #3 had impaired cognition. The patient had multiple medication allergies that included, in part, latex, Doxycycline, Atenolol, Minipress, Morphine, Lopressor, Levaquin, Hydrodiuril, Digoxin, Codeine, and Ativan. Patient #3 was assessed to have pain as a barrier to progress.
Review of Patient #3's care plans revealed no care plans related to her diagnosis of GERD, her need for or use of oxygen, her latex or medication allergies, her impaired cognition, or her current or potential for pain.

In an interview 5/1/13 at 11:00 a.m. S3DON, after review of Patient #3's medical record verified that the patient did not have care plans related to her diagnoses of GERD, use/need of oxygen and respiratory function, her allergies, impaired cognition, or pain. S3DON verified that patient care plans are to be individualized to the patient's needs, but not limited to their rehabilitation diagnoses.

Patient #5
Review of the medical record for Patient #5 revealed she was an 84 year old female admitted to the hospital on 4/10/13 with diagnosis which included CVA with effects including dysphagia.
Review of the Physician's Admission Orders dated 4/10/13 for Patient #5 revealed an order for an ADA (American Diabetic Association) - Pureed diet.
Review of the Physician Orders for Patient #5 dated 4/18/13 at 12:55 p.m. revealed the following order: Change diet consistency to mechanical soft and with finely chopped meats. Continue thin liquid. Verbal cues to alternate liquids/solids, slow rate, clear oral cavity after each bite. Supervision with meals.
Review of the care plans for Patient #5 revealed no care plans addressing swallowing or eating difficulties or interventions.
In an interview on 5/1/13 at 10:00 a.m. with S3DON, she stated Patient #5 should have had a care plan for impaired swallowing, but she did not.

Patient #6
Review of the medical record for Patient #6 revealed he was a 67 year old who was admitted to the hospital 4/22/13 for rehabilitation services to improve his ability to assist with his ADLs (activities of daily living) and his functional mobility to decrease his caregiver's burden. A history and physical revealed Patient #6 had a history of a Cervical fracture with incomplete Quadriplegia. A physician's progress note noted that the patient had a history of a sacral decubitus, but the physical and history assessed to patient of no longer having a sacral ulcer on admission. The patient was reported to have recently started to regain some sensation and movement. His medical history also included Hypertension, Spastic Dystonia, Depression, Chronic pain, and Neurogenic Bowel and Bladder. Admission orders for Patient #6 included a Regular diet and assistance with all meals- needs to be fed.

Further review of Patient #6's care plans revealed a care plan for self-care deficit but no care plan or intervention was specific to the patient's need to be fed or his potential alteration to nutrition related to his inability to feed himself. Review of the care plans for Patient #6 did not reveal care plans for his Neurogenic bowel and bladder, resulting in incontinence.

In an interview 5/1/13 at 11:00 a.m. S3DON, after review of Patient #6's medical record verified that he did not have a care plan that addressed his need to be fed or the potential nutritional alteration that could occur, or a care plan for his care related to his incontinence of bowel or bladder.

Patient #7
Review of Patient #7's medical record revealed he was a 59 year old male admitted on 03/21/13 with a diagnosis of Paraplegia.

Review of Patient #7's history and physical signed by S6Medical Director on 03/26/13 revealed he was a complete thoracic paraplegic with impaired ambulation and transfers and was at high risk for skin breakdown and falls. Further review revealed he had a history of Hypertension, Diabetes Mellitus, and Hyperlipidemia.

Review of Patient #7's physician admit orders on 03/21/13 at 3:00 p.m. revealed an order for capillary blood glucose checks before meals and at bedtime with a sliding scale for regular Insulin if indicated by the results. Further review of the physician orders revealed an order on 03/25/13 for orthostatic blood pressure checks times 3.

Review of Patient #7's care plans revealed a care plan was initiated for bowel incontinence, altered urinary elimination, self-care deficit, impaired physical mobility, potential for injury, constipation, pain, fluid volume excess, anxiety, potential for hemorrhage, and electrolyte/metabolic abnormality. Further review revealed no documented evidence of a care plan for his medical conditions of Diabetes Mellitus and Hypertension. The care plan was not revised on 03/25/13 when Patient #7 was being assessed for orthostatic hypotension.
Patient #7's care plans initiated for bowel incontinence, altered urinary elimination, self-care deficit, impaired physical mobility, potential for injury, constipation, and pain had the same selected interventions as Patient #2's care plan with no additions to assure it was patient-specific and individualized. Further review revealed the goals were not stated in measurable, behavioral terms that could be used to determine when the goal was met.

In a face-to-face interview on 05/03/13 at 10:10 a.m., S3DON confirmed that the patients' care plans were not individualized and patient-specific but a repetition of the same care for every patient. She offered no explanation for each patient having the same care plan without any additions made to individualize it to meet the needs of each patient.


30364





30420

Based on record reviews and interviews, the hospital failed to ensure that the nursing care of each patient was assigned by the registered nurse (RN) according to patient need and the qualifications and competence of the available nursing staff. The hospital failed to ensure the competency assessment performed included whether the skills competency evaluation had been met, not met, or was not applicable for 3 of 6 nurses' personnel files reviewed for competency from a total of 48 employed nurses (S10, S21, S22). Findings:

Review of the hospital policy titled "Staff Competency", policy number I-B.2.18, issued 11/11, and presented as the current policy for staff competency by S3DON (director of nursing), revealed that an evaluation of a staff member's competence is conducted during the orientation process, three months after hire, and annually thereafter. Further review revealed all nursing department employees are oriented to their duties, responsibilities, and work environment on nursing units through a preceptorship program. Further review revealed the nursing unit competency tool is utilized by the preceptor and provides competency-based guidelines relative to specific nursing units, skills, and job responsibilities, nursing care, equipment, and procedures. The competency of employees are re-evaluated annually by the appropriate Department Director with the specified unit competency tool.

Review of the "Skills Competency Assessment" tool revealed 7 columns labeled as follows: self-assessment; performance standard that included the clinical responsibilities such as vital signs, Foley catheter care, oxygen administration, neuro checks, medication administration, infection control, wound care; competency evaluation with a box to check for met, not met, or not applicable; evaluation method that included demonstration, test, observation, simulation/skills lab, and verbal recall; date; initials; and action plan/comments.

S10RN
Review of S10RN's personnel file revealed her initial competency evaluation performed on 11/22/11 had no documented evidence that she had been evaluated by the therapist on patient transport, back injury prevention program, and certified nursing assistant training on therapy practices such as therapy precautions, wheelchair management, bed mobility, transfer training, proper positioning, pressure relief, application of orthotics, and dressing techniques. Review of her annual competency evaluation performed on 11/21/12 by S3DON revealed no documented evidence whether S10RN had met, not met, or if the skill was not applicable for the skills listed on pages 2 through 5. Further review revealed no documented evidence that she had been evaluated by the therapist on the above-listed skills.

S21RN
Review of S21RN's personnel file revealed she was hired on 07/21/12. Further review revealed no documented evidence of the date she was evaluated for competency by S10RN (who had not been evaluated for competency by the therapist for therapy practices). Further review of the entire "Skills Competency Assessment" tool revealed no documented evidence whether S21RN had met, not met, or if the skill was not applicable for the skills listed.

S22LPN (licensed practical nurse)
Review of S22LPN's personnel file revealed she was hired on 03/15/12. Review of her "Skills Competency Assessment" performed by S3DON on 05/01/13 revealed no documented evidence whether S22LPN had met, not met, or if the skill was not applicable for the skills listed.

In a face-to-face interview on 05/03/13 at 1:20 p.m., S28Human Resource Manager indicated the nurses' skills competency assessments were done upon hire and annually. She further indicated that after it was reviewed by the manager with the employee, the form was sent to her (S28Human Resource Manager). She further indicated that she assumed it was correct and just signed off on it. S28Human Resource Manager indicated she did not review the evaluations to assure that the evaluations revealed whether the skills competency had been met, not met, or was not applicable.

In a face-to-face interview on 05/03/13 at 1:30 p.m., S3DON indicated the competency evaluations were done upon hiring and annually. She confirmed that competency evaluations for S10RN, S21RN, and S22LPN had not been completed appropriately and did not indicate whether the nurses' skills competency had been met, not met, or was not applicable.

Based on observation, interview and record review, the hospital
1) failed to ensure medical records were promptly completed within thirty days after a patients discharge as per hospital Policies, Medical Staff Bylaws and Medical Staff Rules and Regulations for 4 of 4 physicians (S6MedicalDirector, S7Physician, S8Physician, S9Physician) medical record delinquencies reviewed. The 4 physicians had 1,731 total medical record deficiencies with 283 of those medical records being incomplete greater than 60 days from the patients' discharge..
2) failed to ensure over 1000 medical records (2 years worth) were protected from water damage in the event the hospital sprinkler system became activated.
Findings:
1) Failing to ensure medical records were promptly completed
Review of the Hospital Medical Staff Bylaws presented as current by S5MRDirector revealed the following in part:
Members of the medical staff are required to complete medical records according to the time periods set forth in the rules and regulations. A temporary suspension in the form of withdrawal of admitting and other related privileges until medical records are completed shall be imposed by the Medical Director, or his or her designee, after notice of delinquency for failure to complete medical records within such period. For the purpose of this section, " related privileges " means voluntary on-call service for consulting on Hospital cases and providing professional services within the Hospital for future patients.

Review of the Medical Staff Rules and Regulations provided by S5MRDirector as current revealed in part:
9. Medical records must be completed in all respects within 30 days of patient discharge.
5. If the medical records are not thereafter completed within the seven-day period, then Medical Records/HIM Department shall issue a Notice of Temporary Suspension for Medical Record Deficiencies, which may have the effect of temporarily suspending the affected members privileges in accordance with the terms and procedures in the Medical Staff Bylaws.

Review of the Policy titled Delinquent Records, Policy Number III.B.24.0, Revised 12/12 revealed in part:
The medical record will be considered complete when the required contents are accurately assembled, completed, and authenticated, by the appropriate personnel, within 30 days from discharge. If a record is not completed by the physician within 30 days of discharge, it will be considered delinquent ...
A. A deficiency list is generated monthly or more frequently as advised by administration for physicians and staff.
B. Medical records that are not completed by the physician within 30days following discharge may result in possible suspension of the physician ' s admitting or consulting privileges.
C ...If the physician has delinquent charts, these charts must be completed within 7 days, privileges may be suspended.
D. The suspension list is distributed by the Health Information Management Department to Administration, Admitting, and Nursing Service.

Review of the hospital policy presented as current titled Physician Chart Deficiency Notification/Medical Staff Suspension, Policy Number: I.F.3.0, Revised 3/12 stated in part:
A physician will be suspended from staff for any record that is not completed 25 days post discharge.
4. If any record is not completed within the 25 day period, suspension will be initiated by the HIM Director or Designee who will contact the physician ' s office to notify him/her that he/she is suspended until records are completed.

Review of the Deficiency Report by Physician list provided by S5MRDirector revealed the following number of medical record delinquencies:
S6MedicalDirector- The total number of deficiencies was listed as 1,420. 147 medical records were delinquent greater than 60 days. The oldest delinquency was dated 4/29/12.
S7Physician- The total number of deficiencies was listed as 17. 3 medical records were delinquent greater than 60 days.
S8Physician- The total number of deficiencies was listed as 250. 126 medical records were delinquent greater than 60 days. The oldest deficiency was dated 5/2/12.
S9Physician- The total number of deficiencies was listed as 44. 7 medical records were delinquent greater than 60 days. The oldest deficiency was dated 9/25/12.

In an interview on 5/1/13at 8:30 a.m. with S5MRDirector, she stated she sent certified letters to the physicians every month with a list of their delinquencies. S5MRDirector stated the physician ' s then had 7 days to complete their charts. S5MRDirector also said she notified the Administrator and DON of the delinquencies. She also said none of the physicians have been suspended as per the policy or Medical Staff Bylaws.
In an interview on 5/2/13 at 3:15 p.m. with S6MedicalDirector, he stated he was aware of the large number of delinquent medical records at the hospital. He said he had discussed suspensions, but had not enforced any of the Bylaws related to suspension of physician privileges
In an interview on 5/3/13 at 2:10 p.m. with S1Administrator, she stated she was aware of the large numbers of delinquent medical records and it had been an ongoing problem at the hospital. She stated the hospital has not enforced its suspension policy for delinquencies because a hospital could not function without any physicians.

2) Failure to protect medical records from water damage.
An observation on 4/30/13 at 11:00 a.m. of the medical records department with S5MRDirector revealed the following:
10 shelves 3 feet by 7 feet with exposed medical records.
48 medical records on a rolling cart with shelves.
55 medical records stacked on a table.

In an interview on 4/30/13 at 2:20p.m.with S5MRDirector, she stated she had approximately 2 years or 1066 paper medical records on the shelves in the medical record room that were not protected from the sprinkler system. S5MRDirector stated she had tarps to cover the records, but they were not in use. S5MRDirector also stated she did not have electronic copies of the paper records.

Based on interview and record review, the hospital failed to administer the pharmacy in accordance with accepted professional principles by failing to have a current CDS (Controlled Dangerous Substance) license.
Findings:
Review of the CDS license posted in the medication room on 4/30/13 revealed an expiration date of 4/28/13.

In an interview on 4/30/13 at 4:00 p.m. with S1Administator, she said the hospital had applied for their CDS license and sent the application on 4/26/13. S1Administrator said the application was delivered to the Louisiana State Board of Pharmacy on 4/29/13, one day after the expiration of the CDS license on 4/28/13. S1Adninistrator said the Pharmacy had to perform a site inspection before issuing a new license because the hospital had changed ownership. S1Administrator verified she did not have a current CDS license in the hospital.

Based on observation, record review, and interview, the hospital failed to ensure drugs listed as Schedule II, IV, and V of the Comprehensive Drug Abuse Prevention and Control Act of 1970 were kept locked within a secure area as evidenced by failing to ensure the lock on the medication room functioned correctly and failing to ensure the keys to an unsecured narcotic box in the medication room were held by the Registered Nurse in charge of the unit.
Findings:
A review was made of the hospital policy provided as current titled Medication Management, Policy Number: II.E.1.0, Revised 8/11. The policy stated in part:
The security of the Pharmaceuticals will be maintained in accordance with federal, state and local laws. All personnel on duty will protect pharmaceuticals and guard against theft and drug diversion.
All drugs stored in the hospital will be accessed only by authorized personnel.
Security of Medication Areas:
All drugs will be stored in lockable containers, automated dispensing machines or locked medication areas.
Controlled drugs will be secured at all times.
The medication room door will be locked at all times.

An observation was made on 4/30/13 at 11:45 a.m. of the entrance to the medication room at the hospital. Observation of the door to the medication room revealed it had a keypad lock to control unauthorized entrance. Further observation revealed the door was able to be opened and closed 3 times by a surveyor without accessing the keypad.
Observation of the interior of the medication room revealed a portable tackle box that with a single lock. Review of a list of contents of the box revealed it contained the following:
4 Tamazepam 7.5mg (milligrams) (a schedule IV drug)
1 Oxycodone 5mg (a schedule II drug)
2 Lorcet 10/650 (a schedule II drug)
2 Allegra D 240 (a schedule V drug)

In an interview with S10RN, she stated she was the charge nurse for the day shift. S10RN stated she was not aware the door to the medication room had a lock that did not work all of the time. S10RN also verified the tackle box in the medication room contained scheduled drugs. When asked for a key to the drug box, S10RN went to the nurse's station and removed the keys from an unlocked drawer. S10RN verified she should have had the keys to the scheduled drugs box on her person and unauthorized persons could have had access to the keys in the desk drawer.
In an interview on 5/3/13 at 9:20 a.m. with S1Administrator, she stated she was not aware the keypad to the medication room was not working correctly. S1 Administrator also stated the keys to the box in the medication room containing scheduled drugs should have been on the charge nurse and not in a drawer at the nurse's station.

Based on observations, record reviews, and interviews, the hospital failed to ensure that equipment was maintained to assure an acceptable level of safety and quality as evidenced by failing to conduct biomedical inspections of patient care equipment according to the hospital's policy. Findings:

Review of the hospital policy titled "Medical Equipment Management Plan" (no documented evidence of a policy number, effective date, and approval date) presented by S1Administrator as a current policy revealed that all equipment shall be inspected on a regular basis determined by the level of equipment requirements by an outside contractor. Further review revealed the plan would identify and maintain a preventative maintenance program for all equipment used in the hospital.

Review of the hospital's contract with Company A revealed the maintenance and electrical safety inspections of all general patient care equipment, unless maintained by third parties, examples of which are listed in the Exclusion Section, or unless consistently maintained by previous vendors on a lesser frequency, would be performed by Company A semi-annually. Further review revealed that exclusions consisted of certain specialized equipment groups such as anesthesia machines, respiratory ventilators, x-ray machines, nuclear cameras, laboratory analyzers, chillers, refrigerators, sterilizers, boilers, elevators, computer networks, and nursing call and dictation equipment that require various levels of specialized support by manufacturers and other vendors.

Observation of the therapist's storage closet on 04/30/13 at 10:50 a.m. revealed an Intelect Ultrasonic treatment machine that had a tag indicating the biomedical inspection was due 05/10. There was no evidence presented during the survey that the ultrasonic machine had been inspected since 05/10. This observation was confirmed by S2Assistant Administrator.

Observation of the crash cart located on the nursing unit on 04/30/13 at 11:40 a.m. revealed the AED (automated external defibrillator) biomedical inspection was due 04/13.

Observation on 05/02/13 at 12:45 p.m. revealed the AED located on the crash cart had a biomedical inspection sticker indicating the inspection was due 04/13.

In a face-to-face interview on 05/02/13 at 12:45 p.m., S4RN (registered nurse) confirmed the AED had not been biomedically inspected by 04/30/13 as required by hospital policy.


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Observation of the Central Supply room 4/30/13 at 11:15 a.m. revealed a red portable suction machine with a biomedical inspection sticker with a last date inspected documented as 10/12 and inspection due 4/13. A second larger suction machine was observed to have a biomedical inspection sticker that indicated it was inspected 8/11 with an inspection due date of 8/12.

In an interview 4/30/13 at 11:15 S19SupplyClerk verified that the biomedical sticker on a red portable suction machine had an inspection date of 10/12 and an inspection due date of 4/13. He also verified a second larger suction machine had a biomedical inspection sticker with an inspection date of 8/11 and an inspection due date of 8/12.

An observation on 5/3/13 at 3:30 p.m. revealed a red portable suction machine with a biomedical inspection sticker with an inspection date of 10/12 and an inspection due date of 4/13. A second larger suction machine was observed to have a biomedical inspection sticker that indicated it was inspected 8/11 and had an inspection due date of 8/12.

In an interview 5/3/13 at 3:30 p.m. S19SupplyClerk verified that the biomedical sticker on the red suction machine indicated it was inspected 10/12 and the inspection due date was 4/13. He also verified that a second larger suction machine had a biomedical sticker that indicated it was inspected 8/12 and had an inspection due date of 8/12. S19SupplyClerk confirmed that he was responsible for seeing that patient care equipment in central supply was inspected as per policy. He reported that there was no list of equipment with the date the inspection was due for each. He stated that he would call to have equipment inspected when he saw something was due to be inspected. He confirmed that he had not notified anyone of the suction machines that were past due for inspection.

Based on observations, record reviews, and interviews, the infection control officer
1) failed to identify that the system for cleaning bedside commodes after use presented a potential breach in controlling infections and communicable diseases. The Rehabilitation Tech (S12) cleaned a soiled bedside commode in the gym used to provide physical and occupational therapy to rehabilitation patients,
2) failed to maintain the sanitary storage of supplies by failing to ensure the floor and working surface of a wound care cart in a clean supply room were properly cleaned by staff,
3) failed to ensure dirty equipment was not stored with clean equipment and supplies as evidenced by a soiled feeding pump being stored in the main central supply room, and
4) failed to ensure patient rooms were cleaned after use and before a patient was admitted to the room.

Findings:

Review of the hospital policy titled "Clean Storage Area", presented by S1Assistant Administrator as a current policy, revealed that a designated area for only items deemed clean would be the clean storage rooms located in the therapy gym and central supply. Further review revealed that all equipment that had been cleaned can be temporarily stored in the clean storage rooms. Further review revealed any item taken out of the clean storage rooms and used in patient care would be placed in the dirty utility room and cleaned within 72 hours before returning the item to the clean storage area.

1)Failed to identify that the system for cleaning bedside commodes after use presented a potential breach in controlling infections and communicable diseases.

Observation in the gym used for occupational and physical therapy provided to rehabilitation patients on 04/30/13 at 11:30 a.m. revealed S12 Rehabilitation (Rehab) Tech cleaning a bedside commode with Cavi-Wipes (cleaner and disinfectant used on non-porous surfaces). Further observation revealed S12Rehab Tech, while gloved, picked a Cavi-Wipe off the floor (had fallen from his hand) and continued to wipe the bedside commode. Continuous observation revealed S12Rehab Tech picked up the container of Cavi-Wipes with his same gloved hands (after having cleaned a soiled bedside commode) to remove another Cavi-Wipe and then placed the container of Cavi-Wipes on the floor, while wearing the same gloves. Continuous observation revealed that at 11:35 a.m. S12Rehab Tech carried the container of Cavi-Wipes with the same gloved hands and placed the container that had been placed on the floor on the counter in the gym. He then removed his gloves and opened the door to the therapy office without first washing his hands.

In a face-to-face interview on 04/30/13 at 11:35 a.m., S12Rehab Tech indicated he had taken the bedside commode from the soiled storage room and brought it to the gym to clean it, so it could be used for another patient. He further indicated that was the process that he usually followed for cleaning bedside commodes.


2) Failed to maintain the sanitary storage of supplies by failing to ensure the floor and working surface of a wound care cart in a clean supply room were properly cleaned by staff.
An observation of the clean supply room on 4/30/13 at 10:55 a.m. with the S2AsstAdministrator revealed the following:
A cart with wound care supplies had an opened pack of petrolatum jelly, 3 cotton swabs, and a temperature probe cover on top of the cart. The top of the cart also had a layer of a brown substance in the corners.
The 3 bins where 1000 ml (milliliter) bags of IV (Intravenous) fluids were kept had a white, powdery substance in them.
On the floor underneath the shelves and the supply cart was 8 lancets, 16 paper medicine cups, 2 mouth swabs, 9 cotton swabs, 3 razors, a crumpled up blue pad, a suction canister liner, hair, and pieces of paper and plastic.

In an interview on 4/30/13 at 10:57 a.m. with S2AsstAdministrator, she stated the brown substance on the top of the wound supply cart appeared to be dirt. She also stated the floors should have been cleaned on the same schedule as the rest of the hospital and they were filthy and had trash on them.

3) Failed to ensure dirty equipment was not stored with clean equipment and supplies as evidenced by a soiled feeding pump being stored in the central supply room.

In an observation on 4/30/13 at 11:20 a.m. in the central supply room, an Alcor feeding pump was observed to have a brown, dried substance on the base. The substance was easily removed with an alcohol pad.

In an interview on 4/30/13 at 11:25 a.m. with S19SupplyClerk, he stated the brown substance on the base of the feeding pump appeared to be dried feeding that had spilled. He also stated the dirty pump should have been cleaned before being stored in the same room as clean supplies.

In an interview on 4/30/13 at 2:30 p.m. with S1Administrator, she stated she could not locate a hospital policy on the separation of clean and dirty supplies.


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4) failed to ensure patient rooms were cleaned after use and before a patient was admitted to the room.

An observation was made on 05/02/13 at 1:50 p.m. with S2AsstAdministrator of a patient room at the beginning of the rehabilitation patient hall. Observation revealed in the first patient area on top of a chest of drawers was a layer of dust and a single black sock. Further observation revealed dried streaks of light, whitish lines down the wall on the lower 1/3 of wall next to the wall where the closet was located. Two blue mattresses were on laying on the floor, one which contained a tear in the middle approximately 2-2 1/2 inches long. There was a gritty dark substance on the baseboard of the wall which contained the streaks. There was no patient bed in the room, but contained two armchairs. A patient was exiting the back of the room via wheelchair, where the second patient area was located. A common bathroom was located between the patient areas. The patient was reported by S4RN to have been admitted the night before and was on her way to therapy. Further observation of the second patient area, occupied by a newly admitted patient, revealed vertical streaks or lines of a dried light white substance and some of dried light brown substance on the wall on which the patient's headboard rested. There was a gritty medium brown particulate substance against the baseboard beside and behind the patient bed headboard.

In an interview 5/2/13 at 1:50 p.m. S2AsstAdministrator verified the above findings. She reported that the mattresses were dirty, that one should have been cleaned and stored somewhere else, and the one with the tear should have been removed for repair or replacement. S2AsstAdministrator said that a room should be cleaned and disinfected upon a patient discharge, and a patient should not be admitted to a room that is not clean.

In an interview on 5/2/13 at 4:15 p.m. S1Administrator reported that the hospital had changed cleaning services about 3-4 months ago because she had not been pleased with the work of the previous franchise. She stated that the hospital maintained their contract with the cleaning company, but retained a different franchise. When asked who monitors the cleaning and how that process occurred, she stated that there is a checklist for patient room cleaning that the cleaning staff fills out and a nurse approves and signs the checklist, then returns it to the cleaning company. When asked if the hospital evaluated the cleaning services she reported that they had no documentation of that.


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Based on record reviews and interviews, the hospital failed to ensure that the nursing staff was educated on donation issues for 7 of 7 nurses' personnel files reviewed for education on donation issues from a total of 49 employed nurses (S1, S3, S4, S10, S21, S22, S23). Findings:

Review of the hospital's "Orientation Checklist" and "Skills Competency Assessment" revealed no documented evidence that organ, eye, and tissue donation was included in the education presented to the staff.

Review of the personnel files of S1Administrator (who is a registered nurse), S3DON (director of nursing), S4RN (registered nurse), S10RN, S21RN, S22LPN (licensed practical nurse), and S23RN revealed no documented evidence that they received education related to organ, eye, and tissue donation.

In a face-to-face interview on 05/03/13 at 1:30 p.m., S3DON indicated the hospital had not provided training to the staff on organ, eye, and tissue donation.

Based on record reviews and interview, the hospital failed to ensure therapy services were provided according to orders of the physician and the therapist who evaluated the patient as evidenced by failure to re-evaluate and order therapy services after the original order had expired for 2 of 6 patients' records reviewed for therapy services from a sample of 27 patients (#2, #9). Findings:

Review of the hospital policy titled "Therapy Documentation", effective 12/12 and presented by S29PT (physical therapist), Director of Inpatient Therapy Services, revealed a patient would be evaluated to determine the level of functioning and establish goals and objectives to be addresses while on the rehabilitation unit. Further review revealed the OT (occupational therapist) should complete toilet, tub, and shower transfers and activities of daily living, and the PT should complete bed mobility and bed transfers. Further review revealed the Interdisciplinary Plan of Care must be completed and include the identification of problems, long-term goals, short-term goals, and treatment interventions. Review of the entire policy revealed no documented evidence of what was to happen when the patient's original frequency and duration of services had been met.

Patient #2
Review of Patient #2's medical record revealed he was a 32 year old male admitted on 03/05/13 with diagnoses of Idiopathic Transverse Myelitis (a neurologic disorder caused by inflammation across both sides of one level or segment of the spinal cord), Burkitt's Lymphoma, Hernia, and Herpes Zoster Virus Ophthalmicus.

Review of Patient #2's "Interdisciplinary Initial Plan of Care" completed on 03/06/13 revealed he was to receive physical therapy 4 to 6 times a week for approximately 90 minutes a day for 6 weeks to address bed mobility, wheelchair training, education, transfer training, safety training, equipment training, and therapeutic exercises. Further review revealed he was to receive occupational therapy at least 5 times a week for approximately 90 minutes a day for 6 weeks to address education, neuro re-education, visual-perceptual, activities of daily living training, transfer training, therapeutic exercises, cognitive training, safety training, community re-entry, equipment training, positioning, independent activities of daily living, and a home safety evaluation.

Review of Patient #2's therapy notes revealed he continued to receive physical therapy services after 04/17/13 through the time of the survey 04/30/13 with no documented evidence of a revision to the Interdisciplinary Plan of Care that included the identification of problems, long-term goals, short-term goals, and treatment interventions with a frequency and planned duration.

Patient #9
Review of Patient #9's medical record revealed she was a 73 year old female admitted on 04/19/13 with diagnoses of Severe Parkinson's Disease and Debility.

Review of Patient #9's "Interdisciplinary Initial Plan of Care" completed on 03/22/13 revealed she was to receive physical and occupational therapy 5 times a week for 90 minutes a day for 4 weeks (through 04/19/13). Further review revealed the physical therapist would address bed mobility, wheelchair training, education, transfer training, safety training, equipment training, positioning, and therapeutic exercises. Further review revealed the occupational therapist would address activities of daily living training, transfer training, therapeutic exercises, orthotic/prosthetic, safety training, equipment training, and positioning.

Review of Patient #9's therapy notes revealed she continued to receive physical and occupational therapy services after 04/19/13 through the time of the survey 04/30/13 with no documented evidence of a revision to the Interdisciplinary Plan of Care that included the identification of problems, long-term goals, short-term goals, and treatment interventions with a frequency and planned duration.

In a face-to-face interview on 05/03/13 at 12:00 p.m., S29PT, Director of Inpatient Therapy Services, indicated that at the end of the duration for therapy ordered on the initial evaluation the therapist was supposed to re-evaluate the patient to determine if he/she needed continued therapy services, and if so, a new plan of care that included the frequency, duration, and interventions was to be completed. He confirmed a re-evaluation and completion of a new plan of care was not done by PT for Patient #2 and by PT and OT for Patient #9. S29PT confirmed that the hospital's policy did not address the process to be followed when a patient's ordered duration for therapy services had expired.

Based on interview and record review, the hospital failed to have a doctor who was the director of respiratory care services on a full-time or part-time basis.
Findings:
Review of the Organizational Chart provided by the hospital as the most current revealed no respiratory services listed.

In an interview on 5/2/13 at 10:15 a.m. with S1Administrator, she stated the hospital had no Medical director of Respiratory Services.