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Based on observations, medical record reviews, staff interviews, and facility policy review, it was determined the facility failed to ensure patient rights by not properly executing consent forms with signatures, witnesses, dates and times (A-0117), by not providing patients with correct information regarding the State Agency complaint hotline (A-118), by not documenting and following policy for restraint flow sheet monitoring (A-167), by not ensuring restrained patients had current physician orders (A-0168), and by using trial period/ PRN orders for resuming restraint use (A-0169). The cumulative effect of these systemic practices resulted in the facility's inability to ensure the patients' needs would be met.

Based on observations, medical record review, staff interview, and facility policy review, it was determined the facility failed to ensure nursing staff followed policy and procedures for assessment and documentation of patients' status on the shift in which the patient expired (A-0395), for not administering medications in accordance with policy and procedure and with justification for the medications (A-405), and for frequently using and not following policy and procedure in regards to verbal orders by physicians (A-407). The cumulative effect of these systemic practices resulted in the facility's inability to ensure the patients' needs would be met.

Based on medical record review, policy review, and staff interview, the facility failed to ensure consent forms were properly signed and witnessed. This affected two of ten sampled medical records reviewed (Patients #1 and #6). The facility census was 78.

Findings include:

On 11/25/15 the hospital policy, Consents for Medical Treatment, Number C02-G, revised 01/01/14 and 10/01/15, was reviewed. The policy documented
"The physician should obtain the voluntary, competent and understanding consent of the patient or the consent of his/her legally authorized representative prior to the start of any procedure or treatment. A written consent is required for all patients in the following circumstances: Non-Routine Tests, Treatments and/or Procedures-The patient's consent to medical treatment or surgical procedure and an acknowledgement of receipt of medical information consent form shall be signed at the request of the physician for non-routine test, treatment and/or procedure that the patient receives. Whenever the patient's condition prevents the obtaining of consent, every effort shall be made and documented to obtain the consent of the patient's legal representative prior to the procedure.
Witnesses: Any Hospital employee may sign as a witness to a patient's signature."

Also reviewed on 11/25/15 was the policy titled Blood/Blood Components Administration (Packed Cells, Plasma, Platelets, Cryoprecipitate), Number B04-N, Revised 07/01/12. This policy documented: "Informed consent must be obtained after a physician orders transfusion of blood and/or blood components and before the type and cross-match are obtained."

1. On 11/25/15, a medical record review was conducted for Patient #1. The patient was admitted to the facility on 11/05/15 with diagnoses of acute respiratory failure with hypoxia, pneumothorax with chest tube insertion, chronic obstructive pulmonary disease, pulmonary infection, and atrial fibrillation (a-fib). A nurse practitioner's documentation, dated 11/21/15 at 8:11 AM, revealed the patient complained of pain on surgical site at the right side of chest, was on cardiac monitoring, lungs had fine crackles bilaterally on water seal of chest tube, had pitting edema in bilateral feet, and had experience atrial flutter. According to a physician's progress note and record of death form on 11/22/15, the patient expired at 5:20 AM at the facility.
The patient's medical record contained two consents for a blood transfusion on two different days. One of the consents, signed by the patient, lacked a date and time of when the patient signed the consent. The consent was witnessed by a registered nurse on 11/16/15 at 3:40 PM. The second consent was signed by the patient's significant other on 11/17/15; however, the consent was missing a time this person signed the consent, and was silent to a witness.
This finding was confirmed with Staff B on 11/25/15 at 11:32 AM. Staff B confirmed the consents were incomplete for either a date/time/witness, in accordance with facility policy.



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2. Review of the medical record for Patient #6 revealed a Consent/Refusal to Transfusion of Blood or Blood Products form dated 10/12/15. The physician noted verbal consent was obtained from Patient #6's POA (power of attorney) but failed to document the date and time consent was obtained, and the form lacked the signature of a second witness to the verbal consent.

On 11/24/15 at 2:15 PM, Staff D (RN house supervisor) and Staff E (infection control RN) confirmed the consent for blood was not complete per policy.

¿Based on medical record review, admission packet information review, staff interview, and policy review, the facility failed to ensure patients were informed of the Ohio Department of Health complaint hotline telephone number. This affected the 10 medical records reviewed and had the potential to affect all patients who receive hospital services from the facility. The census was 78 at the time of the survey.

Findings include:

On 11/25/15, the hospital policy #C06-A, Complaint and Grievance Process, revised on 10/01/13 was reviewed. The policy documented patient's would be notified of the right to make a complaint or grievance during the admission process by admitting personnel.
On 11/25/15 at 9:15 AM, the patient relations representative, Staff C, provided a patient admission packet and stated the complaint information was contained in the admission materials; Patient's Bill of Rights and the Patient/Family Handbook. The admission materials however, lacked information on the State agency's complaint hotline or the State agency's mailing address.
On 11/25/15 at 10:15 AM, the Admission Coordinator, Staff F, confirmed there was no documentation patients were notified or given information on how to file a complaint or grievance with the State agency.

Based on medical record review, staff interview, and policy review, the hospital failed to ensure documentation followed hospital policy for restraint use. This affected four of ten medical records reviewed including Patient's #9, #10, #5, and #3. The hospital census was 78.

Findings include:

On 11/25/15, hospital policy #R02-N, Restraints and Seclusion, revised 06/2012 was reviewed. The policy documented minimum documentation must include evidence of monitoring of the patient's condition during restraint use every two hours including safety, comfort, mobility, skin integrity, food/hydration, toileting, and removal of restraints at least 10 minutes every two hours.

1. On 11/25/15, the medical record for Patient #9 was reviewed. Bilateral soft wrist restraints were started on 11/23/15 at 4:00 AM per the nursing log. The two hour monitoring log for interventions for restrained patients lacked documentation of safety checks for the 6:00 AM hour on 11/23/15. The two hour monitoring log for interventions for restrained patients also lacked documentation of safety checks for the 6:00 PM checks on 11/23/15.

2. On 11/25/15, the medical record for Patient #10 was reviewed. Bilateral soft wrist restraints were started on 10/30/15 at 8:00 PM per the nursing log. The two hour monitoring log for interventions for restrained patients lacked documentation of safety checks 17 times from 10/30/15 through 11/24/15 including the 3:00 AM, 5:00 AM, and 7:00 AM hours on 11/02/15, the 10:00 PM hour on 11/03/15, the 3:00 AM and 5:00 AM hours on 11/11/15, the 12:00 AM, 2:00 AM, 4:00 AM, and 6:00 AM hours on 11/12/15, the 5:00 AM hour on 11/22/15, the 1:00 AM, 3:00 AM, and the 5:00 AM hours on 11/23/15, and the 7:00 PM hour on 11/24/15.

On 11/25/15 at 11:30 AM, the Chief Nursing Officer, Staff B, confirmed the lack of two hour monitoring for the restrained patients reviewed per hospital policy.



















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3. On 11/24/15, the medical record for Patient #5, including 12 days (11/12/15 to 11/23/15) of restraint documentation, was reviewed. Bilateral soft wrist restraints were in place on 11/12/15 beginning at 7:00 AM per the nursing log. There was no documentation staff re-assessed the need and alternatives to restraints, skin integrity, offered food/fluids or removed the restraints between the hours of 9:00 PM on 11/12/15 and 6:00 AM on 11/13/15.

On 11/13/15, there was no documentation Patient #5's skin integrity was assessed or the restraints were removed between the hours of 1:00 PM and 6:00 PM. On 11/16/15, there was no documentation food/fluids were offered between the hours of 9:00 PM and 6:00 AM on 11/17/15. On 11/18/15, there was no documentation staff re-assessed the need and alternatives to restraints, skin integrity or restraint removal between the hours of 2:00 AM and 6:00 AM. There was also no documentation food/fluids or a urinal/bedpan were offered between the hours of 7:00 PM on 11/18/15 and 6:00 AM on 11/19/15.

On 11/21/15, there was no documentation staff re-assessed the need and alternatives to restraints, skin integrity or restraint removal between the hours of 12:00 AM and 6:00 AM. And between the hours of 4:00 PM and 9:00 PM there was no documentation a urinal/bedpan was offered or comfort measures were provided.

On 11/23/15, there was no documentation staff re-assessed the need and alternatives to restraints, skin integrity or restraint removal between between the hours of 1:00 PM and 6:00 PM.

On 11/24/15 at 2:15 PM, Staff D and Staff E confirmed the lack of two hour monitoring for Patient #5 while restrained.





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4. On 11/25/15, the medical record for Patient #3 was reviewed. Bilateral soft wrist restraints were started on 06/02/15 at 10:30 AM per physician's orders for pulling at tracheostomy and tubes. The two hour monitoring log for interventions for restrained patients lacked documentation of safety checks for the 7:00 PM hour on 06/05/15, and on 06/06/15 between the hours of 3:00 AM and 6:00 7:00 AM. The two hour monitoring log for interventions for restrained patients also lacked documentation of safety checks for bilateral wrist restraints on 06/08/15 at 10:30 PM. The nursing documentation was silent to how long the bilateral wrist restraints were in place on 06/08/15.

This medical record was confirmed with Staff B on 11/25/15 at 2:00 PM.

Based on medical record review, staff interview, and policy review, the facility failed to ensure patients placed in restraints had physician orders. This affected four of ten medical records reviewed including Patient #9, #10, #5, and #3. The hospital census was 78 at the time of the survey.

Findings include:

On 11/25/15, the hospital policy R02-N, Restraints and Seclusions, revised 06/2012 was reviewed. The policy documented a written physician order would be obtained prior to the application of a restraint and entered into the patient's medical record on a daily basis when the restraint use was clinically appropriate.

1. On 11/25/15, the medical record for Patient #9 was reviewed. Bilateral mitten restraints were started on 11/23/15 at 4:00 AM, however the medical record lacked a physician order for the restraint. A physician order was obtained on 11/23/15 at 9:45 AM, five hours and 45 minutes after Patient #9 was placed in restraints.

2. On 11/25/15, the medical record for Patient #10 was reviewed. Bilateral soft wrist restraints were started 10/30/15 at 8:00 PM, however the medical record lacked a physician order for the restraint. Bilateral soft wrist restrains were again started on 11/02/15 at 1:00 AM, but the medical record lacked a physician order for the restraint. Bilateral soft wrist restraints were again started on 11/07/15 at 3:00 AM, but the medical record lacked a physician order for the restraint. Bilateral soft wrist restraints were again started on 11/19/15 at 4:00 AM, but the medical record lacked a physician order for the restraint.

On 11/25/15 at 11:30 AM, the Chief Nursing Officer, Staff B, confirmed the lack of physician orders for restraint use per hospital policy.





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3. Patient #5's medical record contained a Restraint Order/Assessment Sheet dated 11/12/15 indicating the need for bilateral soft wrist restraints. Although signed by the physician, the order was not dated or timed.

On 11/13/15 at 10:00 AM, the physician signed a Restraint Order/Assessment Sheet, however, the type of restraint to be used was not indicated and the Comprehensive Assessment by the RN was incomplete.

A Restraint Order/Assessment Sheet dated 11/16/15 was not signed by the physician until 11/17/15 at 10:35 AM, more than 48 hours after the prior order for restraints was obtained on 11/15/15 at 8:30 AM.

A Restraint Order/Assessment Sheet dated 11/19/15 was not signed by the physician until 11/20/15 at 9:00 AM, more than 48 hours after the prior order for restraints was obtained on 11/18/15 at 8:45 AM.

There was no documental order for restraints on 11/21/15, although review of the nursing log revealed Patient #5 was restrained between the hours of 3:00 PM and 11:00 PM. The next order for restraints was not obtained until 11/22/15 at 9:30 AM, more than 18 hours after he was placed in restraints.

On 11/24/15 at 2:15 PM, Staff D and Staff E confirmed the orders for restraints regarding Patient #5 were not obtained and/or completed per policy.


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4. On 11/25/15, the medical record for Patient #3 was reviewed. Bilateral soft wrist restraints were started on 06/02/15 at 10:30 AM per physician's orders for pulling at tracheostomy and tubes. A 24 hour physician's order was obtained on 06/14/15 at 9:20 AM, and was not renewed on 06/15/15. However, a review of the nursing documentation flow sheet for restraints revealed documentation these bilateral wrist restraints were used without a physician's order on 06/15/15 at 11:00 AM and 1:00 PM.

This medical record was confirmed with Staff B on 11/25/15 at 2:00 PM.

This substantiates complaint OH00080625

Based on medical record review and staff interview, the facility failed to ensure patients placed in restraints had physician orders that were not written as a standing order or on an as needed basis. This affected one of ten medical records reviewed (Patient #5). The hospital census was 78.

Findings include:

1. Patient #5's medical record was reviewed on 11/24/15. Per the nursing log documentation, Patient #5 was in restraints on 11/12/15 until 7:00 PM, at which time they were removed. The restraints were then re-applied 12 hours later, at 7:00 AM on 11/13/15. There was no order to re-apply the restraints.

The restraints were removed again at 12:00 PM on 11/13/15, and then re-applied seven hours later at 7:00 PM. There was no order to re-apply the restraints. On 11/18/15 the restraints were removed from Patient #5 at 2:00 AM and then re-applied at 7:00 AM, five hours later. There was no order to re-apply the restraints.

On 11/20/15, Patient #5 was removed from restraints at 11:00 PM, and they were then re-applied at 3:00 PM on 11/21/15. There was no order to re-apply the restraints some 16 hours after they were removed.

On 11/23/15 the restraints were removed at 12:00 PM and then re-applied at 7:00 PM. There was no order to re-apply the restraints some seven hours after they were removed.

On 11/24/15 at 2:15 PM Staff D and Staff E confirmed orders were not obtained to re-apply the restraints as per policy.

This substantiates complaint OH00080625

Based on medical record review, policy review, and staff interview, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for two of ten sampled patients (Patients #1 and #8) out of a total census of 78.

Findings include:

1. On 11/25/15, a review was conducted of the the facility policy titled Guidelines and Protocols, Clinical, Number S05-G, revised 10/01/15 regarding Signatures. This policy documented:
"Documentation of staff signature (full name) with credentials and initials" minimum frequency "every shift by all staff who provide care for the patient; on all pages with documentation by the staff member."
"Performed by all disciplines. Purpose: To provide clinical personnel with requirements for documentation that will provide a current, complete and concise description of the patient's status with minimal duplication of information."
"Documentation should be done throughout the shift and not left until the end of the shift. If there is no observed change in the patient's condition, it is acceptable to chart in the narrative, No change in patient condition since (date/time)."
"Dating and Timing entries: All entries must be dated and timed. Each separate entry must have a corresponding time of occurrence in the time column. Each dated and timed entry must be followed by the signature or initials of the person making the entry. When initials appear on any permanent part of the medical record, a corresponding signature (first initial, last name, and title) must also appear on the document or form. The documentation must reflect that the patient has been assessed by an RN every 12 hours and every time there is a significant change in condition."

2. On 11/25/15, a medical record review was conducted for Patient #1. The patient was admitted to the facility on 11/05/15 with diagnoses of acute respiratory failure with hypoxia, pneumothorax with chest tube insertion, chronic obstructive pulmonary disease, pulmonary infection, and atrial fibrillation (a-fib). A nurse practitioner's documentation, dated 11/21/15 at 8:11 AM, revealed the patient complained of pain on surgical site at the right side of chest, was on cardiac monitoring, lungs had fine crackles bilaterally on water seal of chest tube, had pitting edema in bilateral feet, and had experienced atrial flutter. According to a physician's progress note and record of death form on 11/22/15, the patient expired at 5:20 AM at the facility on that same date.
The 24 hour patient record and plan of care review of Patient #1 revealed two recordings of body temperature of 97.6 and respiration rate of 7 (very low) and 26 on 11/21/15; however, there was no documented time of the vital signs. This 24 hour flow record lacked a signature by the registered nurse for the 7:00 PM-7:00 AM shift beginning on 11/21/15. The following documentation was missing from this shift on 11/21/15 as follows: Sepsis Screen documented as + without specifics, hourly rounding for restraints at 4:00 PM and 6:00 PM, or nursing notes regarding the patient's status after 8:00 PM on 11/21/15. The medical record was silent to nursing documentation regarding the patient's status after 11/21/15 at 8:00 PM, with the exception of hourly rounding which included direct observations, offering urinal/bedpan and providing comfort measures every two hours and as needed. The last documented repositioning of the patient was at 2:00 PM on 11/21/15. The patient was pronounced dead by the physician on 11/22/15 at 5:20 AM. There was no documentation of notification of the physician regarding the patient's status with the exception of the physician's note pronunciation of the patient's death. The hourly rounding nursing flow sheet revealed the nurse documented a direct observation of the patient at 6:00 AM on 11/22/15; however, the patient expired at 5:20 AM that same date.
This medical record was confirmed with Staff B on 11/25/15 at 2:00 PM. Staff B stated the facility policy was for nursing to write narrative notes describing the patient's status at least once a shift, and stated this medical record was incomplete for the time of the vital signs, evaluation and monitoring of the patient hourly at 4:00 PM and 6:00 PM on 11/21/15, and notification of the physician at the time of the patient's death. Staff B confirmed the facility policy Number S05-G was not followed for documentation of this patient.



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On 11/25/15, the hospital policy #D05-G, Documentation Standards, revised on 07/01/15 was reviewed. The policy documented "all entries must be dated and timed".

3. On 11/25/15, the medical record for Patient #8 was reviewed including a surgical/procedural site verification checklist completed by the nurse.

The surgical/procedural site verification checklist form had six items to be checked off for the surgical/procedure verification. The instructions at the top of the form documented to initial, date, and time each entry. Each of the six items were initialed by a staff member under the column heading "RN", however the entries lacked documentation of a date or time for the procedure checklist.

On 11/25/15 at 11:30 AM, the Chief Nursing Officer, Staff B, confirmed the checklist lacked dates or times for any of the six checklist entries.

Based on medical record review, staff interview, and policy review, the facility failed to ensure one of ten sampled patients (Patient #3) received medications in accordance with facility policy and with justification for the medications. The census was 78.

Findings include:

On 11/25/15, a review of facility policy titled Medication Administration, Number M01-N, revised 07/01/15 revealed "Follow the 6 rights of medication administration (right medication, right time, right dose, right patient, right route, right circumstance). When a medication is ordered with two or more options for the route, the least invasive will be used if possible. Monitor patient clinical response as appropriate for the medication given. Any subjective response the patient shares should be noted in the nursing notes."

Patient #3's medical record was reviewed on 11/24/15 and 11/25/15. The patient was admitted to the facility on 06/02/15 status post surgery for pituitary adenoma and ongoing encephalopathy. The patient was admitted with a ventilator and tracheostomy, and was receiving an abdominal tube feeding (PEG). At the time of admission the patient was able to communicate by nodding their head for yes or no answers. This patient was discharged to an acute care hospital on 06/20/15 with a diagnosis of septic shock.

During the patient's hospitalization in this facility, the patient was placed on multiple medications including narcotic pain medications (Oxycodone and Dilaudid), insomnia medications of Benadryl, an antidepressant medication of Trazadone, and antipsychotic medications of Seroquel and Haldol per physician orders.

A review of the medication administration record and nursing documentation revealed the following on 06/24/15 through 06/26/15:

The medication administration record on 06/24/15 revealed the patient was administered Seroquel at 10:23 PM for sleep, a narcotic pain medication of Oxycodone 5 milligrams (mg) at 1:09 AM, a second narcotic pain medication of Trazadone 50 mg at 1:10 AM along with a bensodiazepine medication of Klonopin 0.25 mg by mouth (used for panic).

The Oxycodone and Trazadone was ordered to be given either by mouth (po) or by gastric feeding tube (PT). The medication administration record was silent to the route the medications were administered. The Trazadone medication was ordered to be given at bedtime; however, was given at 1:10 AM on 06/24/15. On 06/24/15 at 1:00 AM, nursing notes documented (by a registered nurse) "Patient resting in bed, denies any pain. Alert and oriented x 1. Family at bedside. Vital Signs stable. No distress noted. Will continue to monitor." On 06/24/15 at 1:30 AM (after receiving the three medications) the nursing note documented the patient was trying to get out of bed and the patient was medicated.

On 06/25/15, the patient was administered Trazadone at 1:39 AM (was ordered at bedtime), Haldol 1 mg intravenously at 4:28 AM on 06/25/15 at 9:03 AM and Oxycodone 5 mg at 9:04 AM (no route listed on the medication administration record).

A physical therapy note dated 06/26/15 at 10:25 AM documented the patient was difficult to wake up. An occupational therapy note on 06/26/15 at 10:22 AM documented the patient displayed somnolent (drowsy) behaviors and decreased level of alertness which required maximum stimulation to improve level of alertness slightly.

On 06/30/15, a physician discharge summary revealed family requesting elimination of Seroquel, Haldol, and Trazadone and use Benadryl for sleep.
Throughout the patient's stay, the patient exhibited low heart rate on 06/07/15 at which time the physician ordered an intravenous medication to raise the patient's heart rate. The patient continued to exhibit a lower heart rate (53) overnight of 06/08/15 to 06/09/15. On 06/26/15 a CT scan of the patient's head for mental status changes was ordered by the physician. A physician's order was written on 06/30/15 at 12:05 AM to give the patient Narcan 0.4 mg intravenous push one time now (to reverse effects of narcotic medications). Low heart rate and dizziness are side effects related to the medications the patient was receiving.

On 11/25/15 at 2:00 PM, Staff B confirmed this patient's medical record contained multiple medications, the patient's status, and the medication administration policy.

Based on medical record review, policy review, and staff interview, the facility failed use verbal orders infrequently for two of ten sampled patients (Patient #1 and #7) out of a total census of 78.

Findings include:

On 11/25/15, a review was conducted of facility policy titled Physician Orders, Number O02-G, revised 01/01/14, stated the following: "Verbal directives for writing orders (verbal orders) should be used as infrequently as possible."

1. On 11/25/15, a medical record review was conducted for Patient #1. The patient was admitted to the facility on 11/05/15 with diagnoses of acute respiratory failure with hypoxia, pneumothorax with chest tube insertion, chronic obstructive pulmonary disease, pulmonary infection, and atrial fibrillation (a-fib). A nurse practitioner's documentation, dated 11/21/15 at 8:11 AM, revealed the patient complained of pain on surgical site at the right side of chest, was on cardiac monitoring, lungs had fine crackles bilaterally on water seal of chest tube, had pitting edema in bilateral feet, and had experienced atrial flutter. According to a physician's progress note and record of death form on 11/22/15, the patient expired at 5:20 AM at the facility on that same date.
The patient's medical record contained verbal orders on 11/17/15 and 11/18/15 as follows:Three verbal orders were obtained on 11/17/15 (two at 2:15 PM and one at 3:50 PM). On 11/18/15 one at 3:10 PM, one at 3:40 PM, and one at 10:00 PM. These orders contained directions to use a nasogastric tube, allow patient to have one cup of ice daily, anti-anxiety and narcotic pain medications intravenously one time now. The verbal orders for the anti-anxiety and narcotic pain medication lacked a reason for the medications. A physician's order for Morphine 2 milligrams intravenously every two hours as needed lacked a reason for the medication. At least four different physicians issued these aforementioned verbal orders.
This medical record was confirmed with Staff B on 11/25/15 at 11:32 AM. Staff B stated the facility policy was to use verbal orders infrequently. Staff B stated this facility policy was not followed for Patient #1 as there were multiple verbal orders issued on 11/17/15 and 11/18/15, stating that was "too many". Staff B confirmed the anti-anxiety and pain medications were missing a reason for why they were ordered.





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2. The medical record for Patient #7 was reviewed on 11/24/15. Physician's Orders for the period of time 11/15/15 to 11/23/15 revealed 13 handwritten orders, of which 10 were noted to be telephone or verbal orders.

One telephone order at 12:00 PM and one verbal order at 1:00 PM were obtained on 11/15/15. The physician then signed off the orders on 11/24/15 but failed to document the time he/she did so.

One verbal order was obtained on 11/16/15 at 11:00 AM, and the physician signed off on 11/241/5 but failed to document the time.

One verbal order was obtained 11/17/15 at 1:55 PM and remained unsigned by the physician as of 11/24/15.

One order obtained 11/18/15 at 11:15 AM didn't indicate whether it was verbal or telephone. The physician signed off on 11/24/15 but failed to document the time.

Based on medical record review, staff interview, and policy and procedure review, the hospital failed to ensure changes in the plan of care were implemented in accordance with hospital policies and procedures. This affected three of ten sampled medical records reviewed (Patients #9, #2, and #6). The hospital census was 78.

Findings included:

1. On 11/25/15, the hospital's speech therapy protocol documented a physician may discontinue or limit speech therapy services at any time by writing an order to that effect in the chart. The speech therapy protocol lacked documentation of a speech therapist limiting or "holding" speech therapy services for a patient.

2. On 11/25/15, the medical record for Patient #9 was reviewed including speech therapy notes. The speech therapy notes dated 10/30/15, 11/03/15, 11/11/15, and 11/20/15 documented the speech therapist placed the plan of care for speech therapy on "hold". The medical record lacked documentation of physician notification of altering the speech therapy plan of care or of a physician order "limiting" speech therapy services.

On 11/25/15 at 11:30 AM, the Chief Nursing Officer, Staff B confirmed the lack of physician orders for holding Patient #9's speech therapy services per the hospital's speech therapy protocol.



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3. The medical record for Patient #2 was reviewed on 11/23/15. Admission Orders dated 09/30/15 revealed ST (speech therapy) was to consult, evaluate and treat the patient. ST did not complete an initial evaluation of Patient #2 until 10/09/15, as evidenced by a Speech Pathology Clinical Dysphagia Evaluation And Discharge Summary form. This was 10 days after ST was initially ordered, and there was no documentation as to why the evaluation was not completed prior.

4. The medical record for Patient #6 was reviewed on 11/24/15. Admission Orders dated 10/07/15 revealed ST was to consult, evaluate and treat the patient. ST did not complete an initial evaluation of Patient #6 until 11/03/15, as evidenced by a Speech/Language Initial/Discharge Evaluation form. This was 27 days after ST was initially ordered, and there was no documentation as to why the evaluation was not completed prior.

On 11/24/15 at 2:15 PM, Staff D and Staff E confirmed the initial evaluations were not completed within 72 hours as per policy.

This substantiates complaint OH00081628