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Based on record review and interview, the facility failed to ensure one patient (Patient #7) of 15 medical records reviewed received informed consent. The facility census was 28.
Findings included:
1. Review of the facility policy titled, "Consents for Medical Treatment", revised 03/24/00, gave direction, in part, to include the following:"The Hospital recognizes that the patient has the right to reasonable and informed participation in decisions involving his/her health care including collaboration with his/her physician in making these decisions. Except for emergencies, 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.""Informed Consent - Consent obtained from the patient after being informed of the nature and risks of the proposed treatment and of the possible alternatives by the attending physician.""Prior to the commencement of each procedure requiring informed consent, the physician will write a note in the patient's chart which states (at a minimum) that the physician has discussed the procedure with the patient and has advised the patient of the risks involved, alternative treatments, and any risks involved in the alternative treatment(s)."
2. Review of current Patient #7's medical record on 01/19/10 at 4:00 p.m. showed a form titled, "Consent for Operative and Invasive Procedures" for a bronchoscopy (procedure where an instrument is taken through the nose, mouth, or tracheostomy into the airway to visualize the airway passages). The consent was signed by the patient on 01/13/10. At the bottom of the consent form it stated, "I have explained the matters indicated above related to the operation and/or procedure and the risk, consequences and alternative. The patient and/or the legally responsible person indicated appeared to understand and consented to the procedures described above." There was a place beside that statement for the physician to sign. There was no physician signature on the consent form.
3. Review of current Patient #7's medical record on 01/19/10 at 4:00 p.m. showed a form titled, "Consent for Operative and Invasive Procedures" for a hemodialysis (method of removing waste products from the blood when the kidneys are not able to perform this function). The consent was signed by the patient on 01/08/10. At the bottom of the consent form it stated, "I have explained the matters indicated above related to the operation and/or procedure and the risk, consequences and alternative. The patient and/or the legally responsible person indicated appeared to understand and consented to the procedures described above." There was a place beside that statement for the physician to sign. There was no physician signature on the consent form.
4. Review of current Patient #7's medical record on 01/19/10 at 4:00 p.m. showed no evidence of the physician(s) informing the patient of the procedures.
5. During an interview on 01/20/10 at 2:00 p.m., Director of Quality, staff B, stated that Patient #7 did receive the bronchoscopy and hemodialysis. Staff B confirmed there was no physician note indicating that the patient was informed of the procedures. Staff B stated that they have noticed this to be a problem.
6. During an interview on 01/20/10 at 2:10 p.m., Health Information Manager, staff I, confirmed there was no evidence of informed consent being completed on Patient #7.

Based on observation and interview, the facility failed to provide storage of confidential patient medical information in a manner to prevent unauthorized access for 28 patients. The facility census was 28.
Findings included:
1. Review of the facility's policy titled, "Confidentiality of Records", issued 12/01/98, gave direction, in part, to include the following:"All record pertaining to both current and former patients, and all other persons who have been involved with Select Specialty Hospitals, shall be considered confidential.""Only authorized personnel shall have access to records.""All departments and sections responsible for retaining information shall exercise suitable precautions to insure that unauthorized individuals cannot gain access to these records."
2. Observation on 01/20/10 at approximately 10:00 a.m. showed Registered Nurse, staff G, administer medication to current Patient #9. Two covered clipboards were noted inside the patient's room located in a wall-mounted file pocket. The clipboards were closed with a Velcro closure and readily available to anyone in the room. Inside the first clipboard were Patient #9's medical record documents to include the "24 Hour Patient Record and Plan of Care", a skin assessment form, and the diabetic flow sheet. Inside the second clipboard were medical record documents related to respiratory care.



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3. Observation on 01/20/10 at approximately 9:30 a.m. showed documents on a clipboard in a wall-mounted file pocket in the room of current Patient #3. The clipboard was closed with a Velcro closure and was readily available to anyone in the room. Documents maintained in the clipboard for Patient #3 were "24 Hour Patient Record and Plan of Care" dated 01/20/10, Nursing Wound Documentation sheets dated 01/13/10 through 01/20/10, and Skin Breakdown Assessments dated 01/07/10 and 01/08/10.

4. Observation on 01/21/10 at 2:30 p.m. showed documents on a clipboard in the anteroom for current Patient #4. The clipboard was closed with a Velcro closure and was readily available to anyone in the anteroom. Documents maintained on a clipboard for Patient #4 were "24 Hour Record and Plan of Care" dated 01/21/10, Diabetic Record dated 01/11/10 - 01/21/10, Skin Breakdown Assessment dated 01/15/10, and Nursing Wound Documentation dated 01/19/10 and 01/20/10.



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5. During observation of medication administration to current Patient #14 on 01/20/10 at 9:50 a.m., two covered clipboards were noted inside the patient room located in a wall-mounted file pocket. The clipboards were closed with a Velcro closure and readily available to anyone in the room. The first clipboard contained Patient #14's medical record documents to include the "24 Hour Patient Record and Plan of Care", and a diabetic flow sheet. The second clipboard contained Respiratory Care Mechanical Ventilator Flow Sheets.
6. During observation of medication administration to current Patient #13 on 01/20/10 at 9:55 a.m., one covered clipboard was noted inside the patient's room located in a wall-mounted file pocket. The clipboard was closed with a Velcro closure and readily available to anyone in the room. The clipboard contained Patient #13's Respiratory Oxygen Treatment Records.
7. During observation of medication administration to current Patient #10 on 01/20/10 at 10:30 a.m., two covered clipboards were noted inside the patient's room located in a wall-mounted file pocket. The clipboards were closed with a Velcro closure and readily available to anyone in the room. The first clipboard contained Patient #10's medical record documents to include the "24 Hour Patient Record and Plan of Care", the Diabetic Record, and a "Patient History and Tracking Form" from another facility which contained all the patient's diagnosis. The second clipboard contained "Respiratory Care Mechanical Ventilator Flow Sheets".
8. During an interview with Registered Nurse, staff G, he/she stated that one clipboard contained nursing documentation and the second clipboard contained documents used by respiratory therapy. Staff G stated that all patients have these clipboards in their room.
9. During an interview with CEO, staff D, he/she stated that the ability of the staff to chart while in the room assists the staff in documenting findings.

10. During an interview with Registered Nurse, staff A, he/she stated that medical record materials kept in the patient rooms were covered so that individuals who entered the room were not readily aware that medical information was in the room, but agreed that it was difficult to ascertain whether the chart was reviewed without patient permission.

Based on record review and interview, the facility failed to obtain physician orders prior to the application of physical restraints for two patients (Patient #15 and Patient #13) of two patient's records reviewed for restraint use. The facility census was 28.
Findings included:
1. Review of the facility policy titled, "Restraints and Seclusion", revised 07/09, gave direction, in part, to include the following:"A physical restraint is further defined as, 'any manual method or physical or mechanical device, material or equipment attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body.'""Obtain a physician's order prior to the application of any restraint.""If a patient is removed from restraint before the current order expires and must be returned to restraints a new physician order is required.""Every use of restraint is to be documented in the patient's record. At a minimum, documentation must include:" "The justification for restraint". "A time-limited order by a physician".
2. Review of current Patient #15's medical record on 01/21/10 at 8:20 a.m. showed the following physician orders for restraints missing:- On 01/13/10, the type of restraint used was documented by nursing as a lap belt and wrist restraints. The physician's order on 01/13/10 was for wrist restraints only. There was no documentation that the nurses notified the physician of the need for a lap belt. There was no order obtained for a lap belt.- On 01/15/10, the physician's order was for wrist restraints only. A physician's progress note written 01/15/10 at 8:50 a.m. stated, "Up in chair in hallway, smiles, cooperative but restrained by belt". There was no order for the lap belt.- On 01/16/10, the physician's order did not document the justification for the restraints.- On 01/16/10, nursing documentation showed that the restraints were removed at 10:00 p.m. and placed back on the patient at 5:00 a.m. on 01/17/10. There was no physician's order for restraints until 2:00 p.m. (01/17/10). After that physician's order was written, documentation showed that the restraints were not applied until 9:00 p.m. There is no physician's order for restraints at 9:00 p.m. (01/17/10).
3. During an interview on 01/21/10 at 9:30 a.m., Registered Nurse, charge nurse, staff J, stated that a lap belt is considered a restraint if the patient's wrists are restrained and the patient can't easily remove the lap belt. Staff J stated that Patient #15 could not remove his/her lap belt with wrists restrained. Staff J confirmed that for Patient #15 there was no order obtained for restraints on 01/17/10 at 9:00 p.m. when the restraints were re-applied. Staff J stated that a new order should be obtained if the restraints are re-applied after being off the patient for a period of time.



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4. Review of current Patient #13's medical record on 01/20/10 at 10:00 a.m. showed a physician order dated 01/15/10 at 8:00 p.m. for left and right wrist restraints. The order also showed right and left mitten restraints checked, but with a line drawn though it with error written.
The nursing notes dated 01/15/10 at 10:00 a.m. state, "Mitts placed on patient and patient managed to get mitts off; wrist restrains placed on patient with good results".
There was no physician order in the medical record for bilateral mitten restraints.
5. Staff J, Registered Nurse (RN) charge nurse said in an interview on 01/20/10 at 11:00 a.m. that it appears that the nurse changed the type of restraint to wrist restraints when the mittens did not work, but can't be sure. The nurse should not have changed the type of restraint on the order. A new order should have been received from the physician for wrist restraints, or an order should have been received from a physician for the mitten restraints prior to placing them on the patient.

Based on record review facility policy review and interview, the facility failed to follow their policy to ensure appropriate monitoring and nursing documentation was completed for two patients (Patient #15 and Patient #13) of two patient's records reviewed for restraint use. The facility census was 28.
Findings included:
1. Review of the facility policy titled, "Restraints and Seclusion", revised 7/09, gave direction, in part, to include the following:"A physical restraint is further defined as, 'any manual method or physical or mechanical device, material or equipment attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body.'""Obtain a physician's order prior to the application of any restraint.""Obtain a physician's order prior to the application of any restraint.""If a patient is removed from restraint before the current order expires and must be returned to restraints a new physician order is required.""Every use of a restraint is to be documented in the patient's record. At a minimum, documentation must include:" "The patient assessment that demonstrates the need for restraint as part of the patient's treatment". "Evidence of monitoring of the patient's condition during restraint"."Interdisciplinary Team Member documentation must:" "State type of device applied and patient response (shift & prn [as needed])"; "State observations/interventions/findings from periodic observations, to include: safety, comfort, mobility, skin integrity, food/hydration and toileting - to include removal of restraints at least 10 minutes every 2 hours or more often (observations every two hours for medical restraints").
2. Review of current Patient #15's medical record on 01/21/10 at 8:20 a.m. showed the following nursing documentation was incomplete:- On the form titled, 24 Hour Patient Record and Plan of Care", dated 01/12/10, the type of restraint used was not documented;- On the form titled, 24 Hour Patient Record and Plan of Care", dated 01/13/10 from 3:00 a.m. until 7:00 a.m. (1/14/09), the following blocks under "Hourly Rounding (These items also apply to restrained pts [patients])" were not checked: "Direct Observations every hour Offer food/fluids every 2 h (hours) and prn (as needed) Offer urinal/bedpan q (every) 2 h and prn Provide comfort measures q 2 h and prn R=Reposition, E=Exercise, O=OOB (out of bed), B=Back to Bed, q 2 h and prn";- On 01/13/10, the type of restraint used was documented by nursing as a lap belt and wrist restraints. The physician's order on 01/13/10 was for wrist restraints only. There was no documentation that the nurses notified the physician of the need for a lap belt. There was no order obtained for a lap belt.- On the form titled, 24 Hour Patient Record and Plan of Care", dated 01/14/10, the type of restraint used was not documented;- On the form titled, 24 Hour Patient Record and Plan of Care", dated 01/15/10, the type of restraint used was not documented by nursing; - On the form titled, 24 Hour Patient Record and Plan of Care", dated 01/16/10, the type of restraint used was not documented. From 3:00 p.m. until 9:00 p.m. the following blocks under "Interventions for Restrained Patients (Includes all items below and all items under 'Hourly Rounding')" were not checked: "Re-Assess Need and Alternatives q (every) 2 h (hour) and prn (as needed) Assess Skin Integrity and circ (circulation) check q 2 h and prn Removed Restraints for 10 mins (minutes) q 2 h";- On 01/16/10, the "Interventions for Restrained Patients" section was marked out between 10:00 p.m. and 5:00 a.m. (01/17/10). Documentation of restraint use was resumed on 01/17/10 at 6:00 a.m. There was no order written for restraint use until 01/17/10 at 2:00 p.m. After that physician's order was written, documentation showed that the restraints were not applied until 9:00 p.m (01/17/10). There is no documentation that the nurse notified the physician and obtained a new physician's order.- On the form titled, 24 Hour Patient Record and Plan of Care", dated 01/17/10 from 10:00 p.m. through 6:00 a.m. (01/18/10), the following block under "Interventions for Restrained Patients (Includes all items below and all items under 'Hourly Rounding')" was not checked: "Removed Restraints for 10 mins (minutes) q 2 h";- On the form titled, 24 Hour Patient Record and Plan of Care", dated 01/20/10 showed no documentation of restraint use or if the restraints were no longer indicated. - A physician's order was written on 01/18/10 at 10:40 a.m. for bilateral wrist restraints and mittens. On 01/18/10, a nurse documented that the restraints were "not needed". There was no documentation that the nurse notified the physician that restraints were not indicated.- A physician's order was written on 01/19/10 at 11:00 a.m. for bilateral wrist restraints. On 01/19/10, a nurse documented that there were "no restraints". There was no documentation that the nurse notified the physician that restraints were not indicated.- A physician's order was written on 01/20/10 at 10:20 a.m. for bilateral wrist restraints and a lap belt. On 01/20/10, there was no documentation of the restraints being used or no documentation of the restraints not being used. There was no documentation that nurse notified the physician if the restraints were not indicated.
3. During an interview on 01/21/10 at 9:30 a.m., Registered Nurse, charge nurse, staff J, stated that a lap belt is considered a restraint if the patient's wrists are restrained and the patient can't easily remove the lap belt. Staff J stated that Patient #15 could not remove his/her lap belt with wrists restrained. Staff J confirmed that for Patient #15 there was no order obtained for restraints on 01/17/10 at 9:00 p.m. when the restraints were re-applied. Staff J stated that a new order should be obtained if the restraints are re-applied after being off the patient for a period of time.


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4. Review of current Patient #13's medical record on 01/20/10 at 11:00 a.m. showed a physician order for wrist restraints dated 01/15/10 at 8:00 p.m.. Nursing notes on page eight (8) of the "24 Hour Patient Record and Plan of Care" dated 01/15/10 at 10:00 p.m. state the patient is in restraints. The following nursing documentation was incomplete:- On the form titled, 24 Hour Patient Record and Plan of Care", dated 01/15/10, at 10:00 p.m. the following blocks under "Hourly Rounding (These items also apply to restrained pts [patients])" were not checked: Direct Observations every hour Offer food/fluids every 2 h (hours) and prn (as needed) Offer urinal/bedpan q (every) 2 h and prn Provide comfort measures q 2 h and prn R=Reposition, E=Exercise, O=OOB (out of bed), B=Back to Bed, q 2 h and prn";
- At 11:00 p.m. the following block was not checked:
Offer food/fluids every 2h (hours) and prn (as needed)
- At 12:00 pm the following blocks were not checked: Offer food/fluids every 2h (hours) and prn
Provide comfort measures q 2 h and prn
R=Reposition, E=Exercise, O=OOB (out of bed), B=Back to Bed, q 2 h and prn";
- At 1:00 a.m. on 01/16/10 the following block was not checked:
Offer food/fluids every 2h (hours) and prn (as needed)
- At 2:00 a.m. the following blocks were not checked:
Direct Observations every hour Offer food/fluids every 2 h (hours) and prn (as needed) Offer urinal/bedpan q (every) 2 h and prn Provide comfort measures q 2 h and prn R=Reposition, E=Exercise, O=OOB (out of bed), B=Back to Bed, q 2 h and prn";
- At 3:00 a.m. the following block was not checked:
Offer food/fluids every 2h (hours) and prn (as needed)
- At 4:00 a.m. the following blocks were not checked:
Direct Observations every hour Offer food/fluids every 2 h (hours) and prn (as needed) Offer urinal/bedpan q (every) 2 h and prn Provide comfort measures q 2 h and prn R=Reposition, E=Exercise, O=OOB (out of bed), B=Back to Bed, q 2 h and prn";
- At 5:00 a.m. the following block was not checked:
Offer food/fluids every 2 h (hours) and prn (as needed)
- At 6:00 a.m. the following blocks were not checked:
Direct Observations every hour Offer food/fluids every 2 h (hours) and prn (as needed) Offer urinal/bedpan q (every) 2 h and prn Provide comfort measures q 2 h and prn R=Reposition, E=Exercise, O=OOB (out of bed), B=Back to Bed, q 2 h and prn";

On the 24 Hour Patient Record and Plan of Care, dated 01/15/10 the following blocks under "Interventions for Restrained Patients (Includes all items below and all items under 'Hourly Rounding')" were not checked:
- At 10:00 p.m. the following blocks were not checked:
Reorient prn (as needed)
Person at Bedside prn
Line of View prn
Removed Restraints for 10 minutes q (every) 2 hours
- At 11:00 p.m. the following blocks were not checked:
Reorient prn (as needed)
Person at Bedside prn
Line of View prn
Removed Restraints for 10 minutes q (every) 2 hours
- At 12:00 p.m. the following blocks were not checked:
Reorient prn (as needed)
Person at Bedside prn
Line of View prn
- At 1:00 a.m. on 01/16/10 the following blocks were not checked:
Patient/Family Education prn (as needed)
Reorient prn
Person at Bedside prn
Line of View prn
Removed Restraints for 10 minutes q (every) 2 hours
- At 2:00 a.m. the following blocks were not checked:
Patient/Family Education prn (as needed)
Reorient prn
Person at Bedside prn
Line of View prn
Removed Restraints for 10 minutes q (every) 2 hours
- At 3:00 a.m. the following blocks were not checked:
Re-Assess Need & Alternatives q (every) 2h (hours) & prn (as needed)
Patient/Family Education prn
Reorient prn
Person at Bedside prn
Line of View prn
Removed Restraints for 10 minutes q (every) 2 hours
- At 4:00 a.m. the following blocks were not checked:
Patient/Family Education prn (as needed)
Reorient prn
Person at Bedside prn
Line of View prn
Removed Restraints for 10 minutes q (every) 2 hours
- At 5:00 a.m. the following blocks were not checked:
Re-Assess Need & Alternatives q (every) 2h (hours) & prn (as needed)
Patient/Family Education prn
Reorient prn
Person at Bedside prn
Line of View prn
Removed Restraints for 10 minutes q (every) 2 hours
- At 6:00 a.m. the following blocks were not checked:
Patient/Family Education prn (as needed)
Reorient prn
Person at Bedside prn
Line of View prn
Removed Restraints for 10 minutes q (every) 2 hours

Review of current Patient #13's medical record on 01/20/10 at 11:00 a.m. showed a physician order dated 01/16/10 and timed at 2:15 p.m. for wrist restraints. The following nursing documentation was incomplete:
On the 24 Hour Patient Record and Plan of Care, dated 01/15/10 from 7:00 a.m. until 01/16/10 at 6:00 a.m. the following blocks under "Interventions for Restrained Patients (Includes all items below and all items under 'Hourly Rounding')" were not checked:
- At 7:00 a.m. until 6:00 p.m., there are no items checked
- At 7:00 p.m. there is a zero with a line through it in the Re-Assess Need & Alternatives q (every) 2 hours prn (as needed), and initials in the Removed Restraints for 10 minutes q (every) 2 hours block. There is no further documentation on the form. (From 8:00 p.m. through 01/17/10 at 6:00 a.m.).

Based on observation, facility policy review and interview, the facility staff failed to follow standard of practice and facility policy with regard to securing indwelling foley catheter tubing to reduce the possibility of tissue injury for three out of three patient's observed with indwelling foley catheters. (Patient #10, #13, #14). The census at the time of the survey was twenty-eight (29) patients.

Findings include:

Staff A, Director of Clinical Services stated on 01/21/10 that the facility policy for maintenance of indwelling foley catheters comes from The Lippincott Manual of Nursing Practice which states, "Secure the indwelling catheter to the patient's thigh using tape, strap, adhesive anchor, or other securement device. Allow some slack of the tubing to accommodate the patient's movements. Properly securing the catheter prevents catheter movement and traction on the urethra".
1. During observation of nursing care to current Patient #10 on 01/20/10 at 10:30 a.m., showed the patient with an indwelling foley catheter (rubber tubing introduced into the bladder to provide for a continuous flow of urine from the bladder). The foley tubing was not secured to the patient.

2. During observation of nursing care to current Patient #13 on 01/20/10 at 9:55 a.m., showed the patient with an indwelling foley catheter. The foley tubing was not secured to the patient.

3. During observation of nursing care to current Patient #14 on 01/20/10 at 9:50 a.m., showed the patient with an indwelling foley catheter. The foley tubing was not secured to the patient.

4. Staff A, Director of Clinical Services confirmed during an interview on 01/21/10 at 11:00 a.m. confirmed that indwelling foley catheter tubing should be secured.

Based on observation, facility policy review and interview, facility staff failed to follow facility policy with regard to administering medication via nasogastric (NG) tubes for two out of two patients observed receiving medications via NG. (Patient #10, #14). The census at the time of the survey was 28 (twenty-eight) patients.

Findings include:

The facility policy titled, Gastric/Duodenal Tube Guidelines: Peg, Gastrostomy Tube, Small-Bore Nasal Tube, Nasogastric Tube, policy number G01-N and last revised 04/07/09 states, "Special Considerations for Specific Intubations, Nasogastric Tubes (NG, small bore tubes), Flush tubing with 20 milliliters (ml) of tap water before and after every medication administered via tube".

1. During observation of medication administration to current Patient #10 on 01/20/10 at 10:30 a.m. through a nasogastic feeding tube (a plastic tube inserted through the nose, past the throat, and down into the stomach used for feeding, administering medications and fluid) showed staff K, Registered Nurse (RN) turn off the patient's tube feeding, and administer medications without flushing the tube prior to administration of the medications.

2. During observation of medication administration to current Patient #14 on 01/20/10 at 9:30 a.m. through a nasogastic feeding tube, showed staff M, Registered Nurse (RN) turn off the patient's tube feeding, and administer medications without flushing the tube prior to administration of the medications.

3. Staff A, Director of Clinical Services confirmed during an interview on 01/21/10 at 11:30 a.m. confirmed that prior to administering medications through a nasogastric tube, the tube should be flushed with water.

Based on medical record review, facility policy review and interview, facility staff failed to follow their internal policy with regard to administration of blood products for one patient (Patient #12) out of two patient medical records reviewed having received blood products while in the facility. The census at the time of the survey was 28 (twenty-eight) patients.

Findings included:

Facility Policy number BO4-N titled, Blood/Blood Components Administration (Packed Cells, Plasma, Platelets, Cryoprecipitate) with revision date of 05/13/09 states, "10. Only a RN (Registered Nurse) can hang blood. Blood is to be started within 30 minutes of receipt from Blood Bank. Under NO circumstances is blood to be stored in refrigerator on the nursing units. Only one unit of blood is released per patient at one time. If unable to give within 30 minutes, return blood to Blood Bank with transfusion form".

2. Review of current Patient #12's medical record showed the patient was admitted to the facility on 01/10/10 and received two units of packed red blood cells on 01/10/10. One Transfusion Record dated 01/10/10 showed no staff signature, date or time when the blood was received from the Blood Bank. The transfusion form showed the blood was initiated at 2:30 p.m., but there would be no way to determine if the blood product was initiated within thirty (30) minutes of receipt from the Blood Bank.

3. Staff A, Director of Clinical Services confirmed during an interview on 01/20/10 at 10:00 a.m. the Transfusion Form had not been completed. (The signature, date and time when the staff person received the blood). Staff A said that without this information there would be no way to confirm the blood was given in the time frame according to the facility policy.

Based on record review, the medical staff failed to document the date and time of signatures for History and Physicals for ten current patients (Patient #5, #6, #8, #9, #15, #13, #2, #1, #4 and #10), failed to document the date and time of signatures for Discharge Summaries for four discharged patients (Patient #5, #6, #2, and #1), failed to document the date and time of signature for one current patient (Patient #4) of 15 patient's medical records reviewed. The facility census was 28.
Findings included:
1. Review of discharged Patient #5's medical record on 01/19/10 at 2:10 p.m. showed that he/she was admitted on 11/19/09 and discharged on 12/05/09. The history and physical was signed by the physician but the signature was not dated and timed. The discharge summary was signed by the physician but the signature was not dated and timed.
2. Review of discharged Patient #6's medical record on 01/19/10 at 3:15 p.m. showed that he/she was admitted on 11/20/09 and discharged on 11/30/09. The history and physical was signed by the physician but the signature was not dated and timed. The discharge summary was signed by the physician but the signature was not dated and timed.
3. Review of current Patient #8's medical record on 01/20/10 at 9:15 a.m. showed that he/she was admitted on 01/08/10. The history and physical was signed by the physician but the signature was not dated and timed.
4. Review of current Patient #9's medical record on 01/20/10 at 11:05 a.m. showed that he/she was admitted on 01/14/10. The history and physical was signed by the physician but the signature was not dated and timed.
5. Review of current Patient #15's medical record on 01/21/10 at 8:20 a.m. showed that he/she was admitted on 01/08/10. The history and physical was signed by the physician but the signature was not dated and timed.



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6. Review of current Patient #13's medical record on 01/20/10 at 3:00 p.m. showed that he/she was admitted on 01/14/10. The history and physical was signed by the physician but the signature was not dated and timed.
7. Review of discharged Patient #2's medical record on 01/19/10 at 2:30 p.m. showed that he/she was admitted on 12/10/09 and discharged on 12/08/10. The history and physical was signed by the physician but the signature was not dated and timed. The discharge summary was signed by the physician but the signature was not dated and timed.
8. Review of discharged Patient #1's medical record on 01/19/10 at 4:30 p.m. showed that he/she was admitted on 12/07/09 and discharged on 12/11/10. The history and physical was signed by the physician but the signature was not dated and timed. The discharge summary was signed by the physician but the signature was not dated and timed.



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9. Review of current Patient #10's medical record on 01/21/10 showed that he/she was admitted on 01/18/10. The history and physical was signed by the physician but the signature was not dated and timed.
10. Review of current Patient #4's medical record on 01/20/10 showed that he/she was admitted on 12/23/09. The history and physical was signed by the physician but the signature was not dated and timed. The consultation took place on 12/30/09 but was not authenticated with signature, date or time.

Based on the facility's Rules and Regulations and record review, the facility failed to ensure telephone and verbal orders were signed by a physician within 48 hours for five patients (Patient #7, #9, #5, #6, and #3) of 15 medical records reviewed. The facility census was 28.
Findings included:
1. Review of the facility's Rules and Regulations, approved 02/06/09, gave direction, in part, to include the following:"All orders dictated over the telephone shall be dictated by the practitioner and shall be signed by the appropriately authorized person to whom dictated with the name of the practitioner. The responsible practitioner shall authenticate such order within the time frame specified by state law or if no state law applies the responsible practitioner shall authenticate such order within forty-eight (48) hours". "For the five (5) year period following January 26, 2007, all orders, including verbal orders, must be dated, timed and authenticated by the prescribing practitioner or another practitioner responsible for the care of the patient".
2. Review of the facility policy titled, " Physician Orders, " issued 12/01/98 gave direction, in part, to include the following:
" All physicians' orders will be written by a credentialed physician, signed by the physician and carried out appropriately. "
" All written orders are to be dated and timed. "
3. Review of current Patient #7's medical record on 01/19/10 at 4:00 p.m. showed the following physician telephone/verbal orders were not signed/dated/timed.- Telephone order written on 01/7/10 included:"Dialysis (procedure to remove waste products and fluid from the body when the kidneys aren't functioning) orders 4 hours 200 DializedRoutine Heparin (medication used to prevent blood clots). Follow acetate protocol."This order was not signed by a physician.- Verbal order written on 01/11/10 included:"Change accucheck (blood sugar test) to AC (before meals) / HS (at bedtime) on diet"This order was not signed by a physician.- Verbal order written on 01/15/10 included:"Dialysis today"This order was not signed by a physician.
4. Review of current Patient #9's medical record on 01/20/10 at 11:05 a.m. showed the following physician telephone/verbal orders were not signed/dated/timed.- Verbal order written on 01/14/10 included:"Percocet (pain medication) 5/325 2 tabs q (every) 4 hrs (hours) PRN (as needed)"This order was signed by a physician but the signature was not dated/timed.- Verbal order written on 01/15/10 included:"Drug order clarificationChange Tricor (medication used to treat high cholesterol) to Gemfibrozil (medication used to treat high cholesterol) 600 mg (milligrams) PT (per tube [method of administering through a tube]) BID (twice a day).Change Detrol LA (medication used to treat overactive bladder) to Detrol (medication used to treat overactive bladder) 2 mg PT BID.Change Calcium Carbonate (calcium dietary supplement) to 500 mg 1 to 2 tab (tablets) q 6 hrs PRN.D/C (discontinue) Nexium."These orders were signed by a physician but the signature was not dated/timed.- Verbal order written on 01/16/10 included:"Clarification of orderIncrease Hydralazine (medication used to treat high blood pressure) by 10 mg (milligrams). Total dose to be given 20 mg IV q 4 hours PRN SBP (systolic blood pressure) above 160."This order was signed by a physician but the signature was not dated/timed.
5. Review of discharged Patient #5's medical record on 01/19/10 at 2:10 p.m. showed the following physician telephone/verbal orders were not signed/dated/timed.- Verbal orders written on 11/20/09 included:"Fosphenytoin (medication used to treat seizures) 1500 mg (milligrams) IV (intravenous [administered through a tube inserted into a vein]) nowFosphenytoin 100 mg IV q (every) 8 hrs (hours)CT (cat scan) of head without contrastAM (morning) Dilantin (medication used to treat seizures) level"These orders were signed not signed by a physician.- Verbal orders written on 11/20/09 included:"D5 ? NS (fluid administered through an IV) at 100 ml (milliliters)/hr (hour)Labetalol (medication used to treat high blood pressure) 5 mg IV now"These orders were signed by a physician but the signature was not dated and timed.- Verbal orders written on 11/20/09 included:"Blood cultures X (times) 2Urine cultureSputum culture"These orders were signed by a physician but the signature was not dated and timed.
6. Review of discharged Patient #6's medical record on 01/19/10 at 3:15 p.m. showed the following physician telephone/verbal orders were not signed/dated/timed.- Verbal order written on 11/27/09 included:"D/C (discontinue) PICC (peripherally inserted central catheter [type of intravenous access])"This order was signed by a physician but the signature was not dated and timed.- Verbal order written on 11/28/09 included:"Upgrade to mechanical soft/thin (diet order). Straws okay."This order was signed by a physician but the signature was not dated and timed.- Verbal order written on 11/28/09 included:"Leave dobhoff (feeding tube inserted through the nose) out"This order was signed by a physician but the signature was not dated and timed.



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7. Review of current Patient #3's medical record on 01/20/10 at 2:15 p.m. showed the following physician telephone/verbal order was not signed/dated/timed.
- An order dated 01/13/10 with no time for Vasolex (ointment) to ulceration on penis daily as needed.



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8. Review of current Patient #3's medical record on 01/20/10 showed the following physician telephone/verbal orders were not signed/dated/timed.

- Orders written on 01/07/10 included:

Lovenox (an anticoagulant used to prevent deep vein blood clots in inactive patients) 40 mg (milligrams) subcutaneous daily

Vancomycin (a powerful antibiotic used in the treatment of drug resistant bacteria) 1 g (gram) IV (intravenous) every 12 hours

Morphine Sulfate (a narcotic analgesic) 100 CR (continuous release) po (by mouth) TID (three times daily)

Based on observation, record review, and interview, the facility failed to ensure medication orders were clarified with the ordering physician prior to dispensing to one patient (Patient #9) of four patients observed for medication administration. The facility census was 28.
Findings included:
1. Review of the facility policy titled, "Drug Orders", revised 08/08, gave direction, in part, to include the following:"1) In order for a drug order to be valid it must include the following elements: a) The intended patient; b) The drug name (Generic or Brand name accepted); c) The dose to be administered; d) The frequency with which the drug is to be administered ...; e) The intended route of administration"
Review of the facility policy titled, "Orders, Physician", revised 03/09/09, gave direction, in part, to include the following:"1. A complete medication order consists of: a. Name of medication b. Dose of medication c. Frequency of administration d. Route of administration""2. Medication name, dose and frequency must be written by physician. Route may be entered by nurse or pharmacist if known. For example, medication only available in one form or physician stated route, but did not write it. Otherwise, physician must be contacted and clarification order written on order sheet."
2. Observation on 01/20/10 at 9:30 a.m. showed Registered Nurse, staff G, administer medications to current Patient #9. Included in those medications, the following medications were given orally:- Clonidine (medication used to treat high blood pressure) 0.1 mg (milligrams)- Acidophilus (medication used to help prevent diarrhea while on antibiotics) two capsules
3. Review of current Patient #9's medical record on 01/20/10 at 11:05 a.m. showed the following incomplete medication orders:- On 01/14/10, the following orders were written: "Percocet (pain medication) 5/325 2 (two) tabs (tablets) q (every) 4 hrs (hours) prn (as needed)"This order was missing the route.- On 01/16/10, the following orders were written: "Clonidine (medication used to treat high blood pressure) 0.1 mg (milligrams) bid (twice a day) - start now"This order was missing the route.- On 01/17/10, the following orders were written: "Acidophilus (medication used to help prevent diarrhea while on antibiotics) 2 cap (capsules) bid"This order was missing the route.
Review of Patient #9's medication administration record (MAR) on 01/20/10 at 11:05 a.m. showed the route of medication administration for the above medications was transcribed as "po (by mouth)/pt (per tube)".
4. During an interview on 01/20/10 at 1:40 p.m., Director of Pharmacy, staff H, confirmed that the above orders were incomplete. He/she stated that if the order is incomplete, they (pharmacist) go with the default route.

Based on interview, record review and review of the facility's education curriculum for nursing staff, the facility failed to monitor and document the nutritional status of one (Patient #3) of 15 medical records reviewed. The facility census was 28.
Findings included:
1. Review of current Patient #3's medical record on 01/21/10 showed the following physician order written 01/19/10:
- Add Ensure Plus TID with meals and TID as snacks
2. Review of the " 4 Hour Patient Record & Plan of Care" failed to provide documentation that staff had issued the dietary supplement to Patient 3, as ordered.
3. During an interview with Registered Nurse, staff A on 01/21/10 at approximately 10:00 a.m., he/she stated the supplement was sent to the patient on each meal tray and consumption was documented on the "24 Hour Patient Record & Plan of Care."
4. During an interview with Registered Nurse, staff B on 01/21/10 at approximately 1:00 p.m., he/she stated that documentation of dietary supplements was not specified by policy. Rather, staff were trained how to properly document supplements by writing the name of the supplement as well as administration times on the " 24 Hour Patient Record & Plan of Care. "

Based on observation, facility policy review, and interview, the facility failed to implement appropriate infection control policies and procedures to prevent the risk of transmission of infections. This had the potential to impact all 28 patients. The facility census was 28.
Findings included:
1. Review of the facility policy titled, "Enhanced Contact Precautions", gave direction, in part, to include the following:"The policy of Select Specialty Hospital is to prevent transmission of highly transmissible or epidemiologically important infections by direct or indirect contact."
2. Observation on 01/20/10 at approximately 10:00 a.m. showed Registered Nurse, staff G, administer medication to current Patient #9. Posted on the doorway to Patient #9's room stating that the patient was on contact isolation precautions and gave directions to wear a gown and gloves when entering the room. Staff G gowned and gloved and carried the medication administration record (MAR) into the patient's room and set in down on the patient's bedside table without cleaning the table. Staff G administered the medications by putting each pill into the patient's mouth and then holding the patient's cup and straw for the patient to drink water. After administering the medications, staff G opened a clipboard with with contaminated gloves in the patient's room that held several medical record documents to include the "24 Hour Patient Record and Plan of Care", a skin assessment form, and the diabetic flow sheet. Staff G made notations on the documents necessary and returned the clip board to the wall holder. Staff G removed his/her gloves, performed hand hygiene and then carried the MAR out of the room.
3. During an interview on 01/20/10 at approximately 10:10 a.m., staff G stated the medical record documents are kept in the patient's room until completed and then moved to the patient's chart. Staff G stated that he/she always has taken the MAR into the patient rooms, even if they're on isolation.
4. During an interview on 01/20/10 at 2:15 p.m., Registered Nurse, staff F, stated that they do take the MAR to the patient's bedside because of the emphasis on correctly identifying the patient.
5. During an interview on 01/20/10 at 2:40 p.m., Director of Quality, staff B, stated that corporate wants nursing staff to take the MAR into isolation rooms but that the nurse should wipe down the bedside table before laying the MAR on the table. Staff B said that there is no policy specific to this practice.