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Based on record review and interview, the physician failed to follow Medical Staff Rules and Regulations by not documenting the evaluation and effectiveness of treatment for 1 of 1 sampled patients in a total sample of 5. (Patient #1)

Findings:

Review of the medical record revealed patient #1 was admitted from Hospital A to Healthsouth Specialty Hospital of North Louisiana, Homer campus on 5/31/2011 at 9:56 AM. Review of the History and Physical dated 5/31/11 revealed patient #1 had a history of fibromyalgia, anxiety and depression, traumatic brain injury, and hyperlipidemia and was recently hospitalized at Hospital A for evaluation and treatment of multiple superficial ulcers with gastrointestinal (GI) bleeding, as well as anemia due to blood loss and secondary to NSAID use.

Review of the 5/31/11 physician admission orders to Healthsouth revealed Normal Saline with 40 mEq (miliequivalent) potassium chloride @ 50 cc/hr; Rocephin 1 gram IVPB (intravenous piggy back) every 24 hrs, Protonix 40 mg IVP (intravenous push) every 24 hours, Carafate 1 gram by mouth before meals and at bedtime, Hydroxazine 50 mg by mouth at bedtime, Trazadone 100 mg at bedtime, Colace 100 mg at bedtime, Fluroxetine 20 mg twice a day, Tricor 145 by mouth at bedtime, Klonopin 1 mg by mouth twice a day, Bentyl 10 mg by mouth 4 times a day, Morphine 2 mg IVP every 4 hours PRN (as needed) , Zofran 4 mg IVP every 4 hours for nausea, Chromagen 1 by mouth every day, consult PT/OT, CBC (complete blood count), BMP (basic metabolic panel), U/A (urinalysis) in the morning (6/01/11), and oxygen 2 liters per nasal cannula PRN.

Review of the 6/02/2011 (no time documented) physician progress notes dictated by the nurse practitioner revealed patient #1 reported that she was nauseated at the " beginning of the night and they gave her some medications; however, she did not vomit, but she states she did " . Further review revealed her temperature was 98.8 degrees F.(1.8 degrees higher than the NP documented on 6/01/2011) heart rate 102 beats per minute (10 beats per minute more than documented by the NP on 6/02/2011) and respirations 20 breaths per minute. The NP documented that the patient " bowel sounds were positive " and " had a bowel movement yesterday (6/01/2011) " and that her abdomen was slightly distended. Further review revealed there failed to be documented evidence the elevated white count reported on 6/01/11 was addressed.

Review of the 6/03/2011 nurses notes revealed at 7:10 AM patient #1 reported to S7 that she had a " gassy feeling " . Further review revealed the patient got up to the bedside commode and had a watery green stool. S7 documented at that time, the patient had an apical heart rate of 108 beats per minute, the rhythm was irregular, denies being SOB and oxygen was in place at 2 liter per nasal cannula. Documentation in the nurses ' notes at 8:30 AM revealed the patient ' s sitter was there when patient #1 complained of nausea after eating her breakfast and S7 RN administered Zofran 4 mg by mouth. S7 also documented at 9:15 AM patient #1 went to therapy and " no distress was noted but at 12:00 noon she had 3 dark green " very loose stools " . S7 documented that at 1:50 PM that the patient bowel sounds were active and her abdomen was still " distended and firm " . At 3:30 PM, S7 documented that the patient was very drowsy, abdomen tight and distended and her apical heart rate increased to 114 beats per minute. Review of the medical record revealed the last temperature, respiration and blood pressure was obtained on 6/03/2011 at 8:00 AM: temperature 97 degrees F., respirations 22 breaths per minute and blood pressure 154/69. According to the nurse notes, S2 MD ' s office was notified at 3:30 regarding the change of condition and S2 spoke to the NP. Further review revealed the ambulance was called and the family was " informed of OK to transfer " . Documentation revealed the patient was transferred at 5:35 PM by ambulance to Hospital B. There failed to be documented evidence that the nurse assessed patient #1 between 3:30 PM on 6/03/2011 and the time the patient was transferred to Hospital B (6/03/2011 at 5:35 PM). Review of the 6/03/2011 (no time documented) " Daily Nursing Documentation/Physical Assessment " revealed patient #1 ' s abdomen was firm and distended.

On 6/13/2011 a telephone interview was held with S2 MD who stated he was patient #1 ' s primary physician. S2 MD confirmed the NP (nurse practitioner) made rounds every day while he made only one visit (6/02/2011). S2 MD reported that during that visit he examined patient #1 ' s abdomen and talked to her daughter but he did not document his findings. S2 MD also said the lab results showed that the patient ' s WBCs were elevated due to the urinary tract infection and from having several catherizations during her hospitalization at Hospital A. The survey team asked S2 MD about the increase in temperature and abnormal WBC even though she had been on Rocephin at Hospital A and for 9 days at Healthsouth and he replied " I thought it was the urinary tract infection " .

Review of the Medical Staff Rules and Regulations section titled " Reassessments Process " revealed " pertinent progress notes shall be recorded at the time of observation, sufficient to permit continuity of care and transfer ability. Whenever possible, each of the patient ' s clinical problems should be clearly identified in the progress notes and correlated with specific orders and well as results of test and treatments " .

Based on record review and interview, the hospital failed to evaluate the nursing care for each patient on an ongoing basis for 1 of 1 patients (Patient #3) and failed to notify the physician of a change in condition for 2 of 2 patients (Patient #1, #3) in a total sample of 5.Findings:

1. Review of the medical record revealed patient #1 was admitted from Hospital A to Healthsouth Specialty Hospital of North Louisiana, Homer campus on 5/31/2011 at 9:56 AM. Review of the History and Physical dated 5/27/11 revealed patient #1 had a history of fibromyalgia, anxiety and depression, traumatic brain injury, and hyperlipidemia and was recently hospitalized at Hospital A from 5/22/11-5/31/11 for evaluation and treatment of multiple superficial ulcers with gastrointestinal (GI) bleeding, a urinary tract infection, as well as anemia due to blood loss and secondary to NSAID use.

Review of the 5/31/11 physician admission orders to Healthsouth Hospital revealed Normal Saline with 40 mEq (miliequivalent) potassium chloride @ 50 cc/hr; Rocephin 1 gram IVPB (intravenous piggy back) every 24 hrs (initiated 5/26/11 for UTI), Protonix 40 mg IVP q 24 hours, Carafate 1 gram by mouth before meals and at bedtime, Hydroxazine 50 mg by mouth at bedtime, Trazadone 100 mg at bedtime, Colace 100 mg at bedtime, Fluroxetine 20 mg twice a day, Tricor 145 by mouthat bedtime, Klonipin 1 mg by mouth twice a day, Bentyl 10 mg by mouth 4 times a day, Morhine 2 mg IVP every 4 hours PRN, Zofran 4 mg IVP every 4 hours for nausea, Chromagen 1 by mouth every day, consult PT/OT, CBC (complete blood count), BMP (basic metabolic panel), U/A (urinalysis) in the morning (6/01/11), and oxygen 2 liters per nasal cannula PRN.

Review of the 6/02/2011 nurses notes revealed at 12:00 noon a family member was at the bedside and at 1:40 PM the patient complained of nausea and requested to be medicated. Documentation in the 6/02/2011 nurses notes revealed S5 administered Zofran (antiemetic) at 1:50 PM for nausea and at 4:03 PM the nausea was better. Further review revealed the patient daughter asked that S2 MD be informed that " her mother has a very high anxiety level & needs PRN (as needed) Klonopin (used to treat panic disorders) in addition to routine Klonopin ". Review of physician orders dated 6/2/11 at 6:00 PM revealed Klonopin .5 mg was ordered every 6 hours PRN. The 6/02/2011 nurses notes revealed S5 administered Klonopin 0.5 mg by mouth and Maalox Plus 30 milliliters (ml) to patient #1 at 6:00 PM for anxiety and indigestion. Further review revealed at 7:30 PM patient #1 was awake and confused to time and place and abdomen was distended but denied having discomfort. Further review revealed patient # 1's confusion and abdominal distention were not reported to the physician.

Review of the 6/03/2011 nurses notes revealed at 7:10 AM patient #1 reported to S7 that she had a " gassy feeling " . Further review revealed the patient got up to the bedside commode and had a watery green stool. S7 documented at that time, the patient had an apical heart rate of 108 beats per minute, the rhythm was irregular, denies being SOB and oxygen was in place at 2 liter per nasal cannula. Documentation in the nurses' notes at 8:30 AM revealed the patient's sitter was there when patient #1 complained of nausea after eating her breakfast and S7 RN administered Zofran 4 mg by mouth. S7 also documented at 9:15 AM patient #1 went to therapy and " no distress was noted but at 12:00 noon she had 3 dark green " very loose stools " . S7 documented that at 1:50 PM that the patient bowel sounds were active and her abdomen was still " distended and firm " . At 3:30 PM, S7 documented that the patient was very drowsy, abdomen tight and distended and her apical heart rate increased to 114 beats per minute. Review of the medical record revealed the last temperature, respiration and blood pressure was obtained on 6/03/2011 at 8:00 AM: temperature 97 degrees F., respirations 22 breaths per minute and blood pressure 154/69. According to the nurse notes, S2 MD ' s office was notified at 3:30 regarding the change of condition and S2 spoke to the NP. Further review revealed the ambulance was called and the family was " informed of OK to transfer " . Documentation revealed the patient was transferred at 5:35 PM by ambulance to Hospital B. There failed to be documented evidence that the nurse assessed patient # 1 between 3:30 PM on 6/03/2011 and the time the patient was transferred to Hospital B (6/03/2011 at 5:35 PM). Review of the 6/03/2011 (no time documented) " Daily Nursing Documentation/Physical Assessment " revealed patient #1 ' s abdomen was firm and distended.

An interview was held on 6/20/2011 with S9 DON who stated there is no set time during the shift for a nurse to perform assessments and document the findings on the daily nursing assessment form. S9 confirmed that the nurse should have documented the time nursing assessments were performed for patient #1. S9 also confirmed the nurse failed to time the assessments and there failed to be documented evidence the nurse assessed patient #1 prior to an emergent transfer to Hospital B.

Review of the Daily Nursing Assessments policy and procedures reviewed and approved 2/2011 revealed " the shift assessment is completed by an RN/LPN and should be documented toward the end of the shift to include events of the entire shift. The time and initials should recorded in the first of boxes as indicated by ' Time/initials ' . " Further review of the policy revealed the procedure addressed that for " Any indication of the identified problems after the initial assessment and noted during stay will be documented and relayed to the proper authority and the physician " .

2. Review of the medical record revealed patient #3 was admitted on 5/04/11 for surgical aftercare following a laparoscopic cholecystectomy on 4/26/11. Review of the admitting physician orders revealed diagnoses that included malnutrition, chronic pulmonary obstructive disease, hypertension, gastroesophageal reflux disease, depression, arthritis, Bi-polar disorder and frequent falls. Further review revealed Klonopin 0.5 mg TID (3 times a day) (classified as a benzodiazapine with gastrointestinal adverse effects that include constipation), Zofran 4 mg every 4 hours as needed for nausea (agent used to prevent nausea and vomiting with gastrointestinal adverse effects of constipation) were ordered 5/4/11 on admission. On 5/5/11, Ultracet 2 tablets (analgesic with gastrointestinal adverse effects of constipation) every 4 hours as needed for pain was ordered by the Nurse Practitioner. On 5/5/11, Toradol (non-steriodal antiinflammatory analgesic with gastrointestinal adverse effects of constipation) 30 mg IM (intramuscular) was ordered every 6 hours as needed for pain.

Review of the initial nursing assessment revealed the nurse failed to document in the blank on the assessment form, the last bowel movement for patient #1(the blank was empty). Review of Daily Nursing Documentation/Physical Assessment Records dated 5/4/11-5/10/11 revealed patient #1 had normal bowel sounds and noted the last reported bowel movement was 5/3/11 (source of information unable to determine). The nurse notes also indicated the abdomen was soft/non-distended. Review of the Graphic Flow Record revealed patient #3 did not have a bowel movement 5/4, 5/5, 5/6, 5/7, 5/8,/5/9, or 5/10/11. Further review revealed all attempts to facilitate a bowel movement failed, and an X-ray was ordered and obtained on 5/12/11.

Review of the X-Ray (KUB- kidneys, ureters, bladder area) of the abdomen report dated 5/12/11 revealed "There is dense retained oral contrast in the rectosigmoid and in the descending colon".

Review of the Physician Progress Notes from 5/5/11-5/12/11 revealed documentation that patient #3's abdomen was soft/non-tender. Physician Progress notes dated 5/13/11 revealed her abdomen was soft, non-tender, positive bowel sounds mostly in upper quadrants. Further review revealed the KUB identified the cause of patient #3 not being able to have a bowel movement and her nausea and vomiting was due to barium given in April prior to her laparoscopic cholecystectomy and apparently is still there and blocking her bowels.

Review of the Care Plan initiated 5/4/11 revealed constipation was identified as a problem and that the intervention would be to administer a laxative if the patient did not have a bowel movement in 3 days. Review of the May 2011 MAR (medical administration record) revealed a laxative was not administered after patient #3 had not had a bowel movement in 3 days and the physician was not notified.

Interview on 6/9/11 at 10:45 AM with S1 DON confirmed the record reflected patient #3 had not had a bowel movement in 9 days and the hospital did not followed the plan of care to administer a laxative. S1 also stated the hospital had standing orders to address constipation but there was not a signed copy to initiate the standing orders for patient #3. Patient #3 developed a high impaction from a Barium Swallow study performed prior to admission to Health South.

Review of the History and Physical from Hospital B dated 5/13/11 revealed patient #3 was admitted for treatment of an obstruction with barium in the colon. Further review revealed upon physical examination patient #3 had bowel sounds mostly in the upper quadrants and the abdomen was soft and non-tender but occasionally would complain of some tenderness in the epigastrium but mostly denies tenderness at all.