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Based on record review and interview, the hospital failed to ensure that the medical staff was accountable to the governing body for the quality of care provided to Patient #2. This was evidenced by a breakdown in the reporting of a physician (S12) who failed to respond timely to nursing personnel's attempts to contact S12 on 10/30/10 regarding Patient #2. Findings:

The medical record of Patient #2 was reviewed. This review revealed that Patient #2 is a 49 year old male who was hospitalized at LTAC of Louisiana from 10/27/10 through 10/31/10. Review of the admission orders revealed that Patient #2's admission diagnoses included Severe Dehydration, Atrial Fibrillation, Pain, and C6 Quadriplegia. Documentation revealed that S12 (cardiologist) was consulted for cardiology services for Patient #2. Nursing documentation dated 10/30/10 at 7:40 a.m. revealed that Patient #2's heart rate was 127 and blood pressure was 82/58 and that a telephone call was made to the cardiologist (S12). Documentation dated 10/30/10 at 10:45 a.m. revealed that Patient #2's heart rate remained in the 120's and his blood pressure was in the 90's / 60's, and that the cardiologist (S12) has not called back (3 hours and 5 minutes after being called). Nursing documentation dated 10/31/10 at 1:50 p.m. revealed that the attending physician (S8) gave orders to call the cardiologist (S12) relating to Patient #2. Documentation dated 10/31/10 at 3:15 p.m. revealed that the cardiologist (S12) had not called back (1 hour and 20 minutes after a message was left with the answering service exchange) and that a message was left notifying S12 of Patient #2's transfer to Hospital A.

S4 (RN) was interviewed on 12/06/10 at 1:15 p.m. S4 reviewed the medical record of Patient #2 and reported that she did remember the patient. S4 reported that her initial involvement with Patient #2 was on 10/30/10 at approximately 6:45 a.m. S4 reported that Patient #2's heart rate was elevated and his blood pressure was low and that a call was placed to the cardiologist (S12) at 7:40 a.m. on 10/30/10. S4 reported that the cardiologist did not respond to initial attempts to contact him and was not reached until 11:00 a.m. at which time he reported that he would be rounding shortly.

The hospital's policy/procedure titled "Contacting Necessary On-Call Personnel in Emergent, Non-Emergent Situations and Consultations" was reviewed. The policy/procedure documents "if the charge RN is unable to contact the physician on call within a reasonable amount of time not to exceed 30 minutes, in non-emergent situation, then a medical staff leader (i.e. the Chief of Staff or the Medical Director) should be notified". The policy/procedure further documents "any failed attempts to contact the on-call MD will be reported to the Chief of Staff, Medical Director, and the Medical Executive Committee via an incident report".

S10 (MD) was interviewed on 12/08/10 at 1:20 p.m. S10 reported that he was the hospital's Medical Director. S10 reported that he did not recall being made aware of the cardiologist (S12) failure to respond timely to nursing personnel's call on 10/30/10 at 10:45 a.m. (3 hour and 5 minute delay in responding) or 10/31/10 at 3:15 p.m. (1 hour and 20 minute delay in responding) regarding Patient #2. S10 reported that he did not receive an incident report relating to S12's failure to respond timely to staff members attempts to contact him on 10/30/10 regarding Patient #2.

Based on record review and interview, the registered nurse failed to supervise and evaluate the care provided to 1 of 5 sampled patients by:

1. Failing to ensure that patient procedures are performed only when ordered by a physician and/or practitioner and performed by personnel who have been deemed qualified and competent by the hospital and not by caregivers or non-hospital personnel. Findings:

The medical record of Patient #2 was reviewed. This review revealed that Patient #2 is a 49 year old male who was hospitalized at LTAC of Louisiana from 10/27/10 through 10/31/10. Review of the admission orders revealed that Patient #2's admission diagnoses included Severe Dehydration, Atrial Fibrillation, Pain, and C6 Quadriplegia. Nursing documentation revealed an entry dated 10/29/10 at 6:45 p.m. (entered by S11-LPN) which read "Assessment to be completed p (after) Home Health complete c (with) bowel program". Documentation revealed an entry dated 10/29/10 at 7:00 p.m. (entered by S11-LPN) which read in part "Home Health nurse stated bowel program unsuccessful. Pt. abdomen distended with SOB noted". Nursing documentation revealed an entry dated 10/30/10 at 8:20 a.m. indicating that Patient #2 was complaining of abdominal distention and the need to pass flatus. Documentation indicated that digital stimulation was provided and that a dulcolax suppository was administered. Documentation indicated that there was no bowel movement and that a rectal speculum was placed for 10 minutes for flatus as requested by Patient #2. Review of the medical record revealed no orders for the use of a rectal speculum on Patient #2. Nursing documentation revealed an entry dated 10/31/10 at 10:00 a.m. indicating that a home health agency staff member was in room for Bowel Regimen. Documentation dated 10/31/10 at 11:30 a.m. revealed in part, "Bowel Regimen complete. States has had large BM. HH (Home Health) Aide also performs in & out cath".

S4 (RN) was interviewed on 12/06/10 at 1:15 p.m. S4 reported that she works as a registered nurse on the day shift (6:00 a.m. thru 6:00 p.m.). S4 reviewed the medical record of Patient #2 and reported that she did remember the patient. S4 reported that her initial involvement with Patient #2 was on 10/30/10 at approximately 6:45 a.m. S4 reported that Patient #2's abdomen was firm and distended on the 2 days that she provided care to him (10/30/10 & 10/31/10). S4 indicated that Patient #2 had not had a bowel movement in a couple of days and was reporting that he needed to have a bowel movement and pass gas. S4 reported that Patient #2 informed her that he was on a bowel program at home which consisted of an IV pole, a 3 liter bag of clear fluid/solution, and a rectal speculum. S4 reported that she was not familiar with the bowel program that Patient #2 was reporting to have been on at home. S4 reported that she could not identify the fluid/solution in the 3 liter bag and was not familiar with the rectal speculum. S4 reported that she inserted the rectal speculum in Patient #2's rectum at Patient #2's request in the a.m. on 10/30/10 because he (Patient #2) told her that is what is done for him at home to help stimulate a bowel movement and to assist in the passing of gas. S4 reported that she followed Patient #2's instructions while using the rectal speculum. S4 reported that she again provided care for Patient #2 on the day shift of 10/31/10 and indicated that someone from the home health agency approached her on 10/31/10 and this person informed her that he works with Patient #2 at his home and that he was going to be performing the bowel regimen on Patient #2. S4 reported that this person entered Patient #2's room at 10:00 a.m. to begin the bowel regimen and remained in the room until 11:30 a.m. S4 reported that the person approached her after completing the bowel regimen and informed her that Patient #2 had a large bowel movement. S4 reported that there were no physician orders for the bowel regimen to be performed.

S11 (LPN) was interviewed on 12/09/10 at 9:15 a.m. S11 reported that she works primarily on the night shift (6:00 p.m. thru 6:00 a.m.) as a licensed practical nurse. S11 reviewed the medical record of Patient #2 and reported that she did remember the patient. S11 indicated that her first involvement in the care of Patient #2 was on 10/29/10 at approximately 6:45 p.m. when she was told that the home health nurse was in room doing a bowel program on the patient. S11 reported that the home health nurse came out of the patient's room and reported that the bowel program was unsuccessful and for her to pass it on in report. S11 reported that there were no orders for the bowel program to be performed on Patient #2.

The Director of Nursing was interviewed on 12/09/10 at 10:00 a.m. The Director of Nursing reviewed the medical record of Patient #2 and confirmed that the documentation indicated that a bowel program was performed on Patient #2 during the patient's hospitalization by personnel who were not deemed competent or qualified to perform the bowel program in the hospital.


2. Failing to ensure the effective implementation of the medication administration process by failing to ensure that all medications were administered as ordered by the physician and/or practitioner, failing to identify all medication errors that occur while providing patient care, and failing to notify the physician and/or practitioner of medication errors. Findings:

The medical record of Patient #2 was reviewed. This review revealed that Patient #2 is a 49 year old male who was hospitalized at LTAC of Louisiana from 10/27/10 through 10/31/10. Review of the admission orders revealed that Patient #2's admission diagnoses included Severe Dehydration, Atrial Fibrillation, Pain, and C6 Quadriplegia. Nursing documentation revealed an entry dated 10/30/10 at 6:45 a.m. indicating that Patient #2's heart rate was 119 and blood pressure was 91/63 and that 25mg of Lopressor was administered to Patient #2 (1/2 of the dose scheduled to be administered to Patient #2 at 9:00 a.m.). Documentation dated 10/30/10 at 12:45 p.m. revealed that an additional 25mg of Lopressor was administered for a heart rate of 133. Review of the physician orders revealed no orders for the 25mg of Lopressor that was documented as being administered to Patient #2 on 10/30/10 at 6:45 a.m. and 12:45 p.m.

S4 (RN) was interviewed on 12/06/10 at 1:15 p.m. S4 reported that she works as a registered nurse on the day shift (6:00 a.m. thru 6:00 p.m.). S4 reviewed the medical record of Patient #2 and reported that she did remember the patient. S4 reported that 25mg of Lopressor was administered to the patient on 10/30/10 at 6:45 a.m. and at 12:45 p.m. S4 confirmed that there were no orders for the two 25mg doses of Lopressor that was administered to Patient #2. S4 reported that 50mg of Lopressor was ordered and the 50mg were administered in two 25mg doses at different times at the request of the charge nurse. S4 reported that the administration of the 25mg of Lopressor should have been identified and reported as a medication error because there was no order for the 25mg dose. S4 reported that the physician should have been notified and she was unable to provide documentation to indicate that the physician was notified of the administration of the 25 mg of Lopressor at 6:45 a.m. and 12:45 p.m.

The Director of Nursing was interviewed on 12/09/10 at 10:00 a.m. The Director of Nursing reviewed the medical record of Patient #2 and confirmed that the documentation indicated that the Lopressor was not administered as ordered to Patient #2 on 10/30/10 and that there were 2 medication errors that occurred on 10/30/10 regarding the Lopressor. The Director of Nursing confirmed that there was no documentation to indicate the medication errors (Lopressor) were identified by nursing staff and no documentation to indicate that the physician was notified of the medication errors.


3. Failing to ensure that the physician and/or practitioner was aware of a fluid volume difference of 7974 cc's in five days for a new onset cardiac patient whose weight was 137.5 pounds as indicated on the graphic intake/output records. Findings:

The "Graphic Sheet" was reviewed. This review revealed the following documentation relating to Patient #2's intake/output:
? 10/27/10- Intake of 1180; Output of 300. (880cc volume difference)
? 10/28/10- Intake of 3240; Output of 650. (2590cc volume difference)
? 10/29/10- Intake of 3404; Output of 1400. (2004cc volume difference)
? 10/30/10- Intake of 1230 (day shift), No documented intake for the night shift on the "Graphic Sheet". Nursing documentation indicated that normal saline was infusing at 100cc / hour for the 12 hour night shift which would be a total of 1200 cc on night shift; Output of 425. (2005cc volume difference)
? 10/31/10- Intake of 1155; Output of 660. (495cc volume difference)
Based on the review of the intake/output for Patient #2 revealed that the total volume difference for the five (5) day hospitalization for Patient #2 (whose weight was documented as 137.5 pounds on day of admission to LTAC of Louisiana) was 7974cc's of fluid. There was no documentation in the medical record to reveal that the treatment team identified the 7974cc fluid retention for Patient #2. Documentation revealed an order dated 10/30/10 at 8:30 a.m. for an In & Out cath to be done twice daily at 9:30 a.m. and 9:30 p.m. Review of the medication administration record revealed that Patient #2 was refusing to allow hospital personnel to perform the In & Out cath on 10/30/10 at 9:30 p.m. and on 10/31/10 at 9:30 a.m. No documentation was found to indicate that the physician/practitioner was made aware of Patient #2's refusing to allow the In & Out catheterization be performed as ordered.

The medical record relating to Patient #2's hospitalization at Hospital A was reviewed. This review revealed that Patient #2 was admitted to Hospital A on 10/31/10. Review of the ED record revealed the final impression, after being evaluated in the ED, was bilateral pleural effusions, abdominal pain- r/o cholecystitis, metabolic acidosis, hypoxia, C6-quadriplegia, and Atrial fibrillation. Patient #2's weight was documented to be 150 pounds while in the ED. Documentation revealed the following medications were administered to Patient #2 while in the ED: piperacillin-tazobactam 4.5gm; furosemide, 60mg; hydromorphone, 0.5mg; diltiazem 4mg/hr. Documentation indicated that Patient #2 was admitted to the intensive care unit. Review of the initial intake/output records while in the ED revealed that on 11/01/10 at 1:54 a.m., Patient #2's intake was 217 ml and output was 3250 ml; on 11/01/10 at 6:05 a.m., Patient #2's intake was 470 ml and output was 4575 ml.

S4 (RN) was interviewed on 12/06/10 at 1:15 p.m. S4 reported that she works as a registered nurse on the day shift (6:00 a.m. thru 6:00 p.m.). S4 reviewed the medical record of Patient #2 and reported that she did remember the patient. S4 reported that her initial involvement with Patient #2 was on 10/30/10 at approximately 6:45 a.m.

The Director of Nursing was interviewed on 12/09/10 at 10:00 a.m. The Director of Nursing reviewed the medical record of Patient #2 and confirmed that there was no documentation in the medical record to indicate that the physician and/or practitioner was made aware of the fluid volume difference of 7974 cc's in five days for a new onset cardiac patient whose weight was 137.5 pounds.

Based on record review and interview, the hospital failed to ensure that the nursing care plan was kept current for 1 of 5 sampled patients (Patient #2) by failing to include documentation relating to Patient #2's gastrointestinal problems including information relating to constipation and the bowel program that was performed on Patient #2 during his hospitalization at LTAC of Louisiana. Findings:

The medical record of Patient #2 was reviewed. This review revealed that Patient #2 is a 49 year old male who was hospitalized at LTAC of Louisiana from 10/27/10 through 10/31/10. Review of the admission orders revealed that Patient #2's admission diagnoses included Severe Dehydration, Atrial Fibrillation, Pain, and C6 Quadriplegia.

Nursing documentation revealed an entry dated 10/29/10 at 6:45 p.m. (entered by S11-LPN) which read "Assessment to be completed p (after) Home Health complete c (with) bowel program". Documentation revealed an entry dated 10/29/10 at 7:00 p.m. (entered by S11-LPN) which read in part "Home Health nurse stated bowel program unsuccessful. Pt. abdomen distended with SOB noted".

Nursing documentation revealed an entry dated 10/30/10 at 8:20 a.m. indicating that Patient #2 was complaining of abdominal distention and the need to pass flatus. Documentation indicated that digital stimulation was provided and that a dulcolax suppository was administered. Documentation indicated that there was no bowel movement and that a rectal speculum was placed for 10 minutes for flatus as requested by Patient #2. Review of the medical record revealed no orders for the use of a rectal speculum on Patient #2.

Nursing documentation revealed an entry dated 10/31/10 at 10:00 a.m. indicating that a home health agency staff member was in room for Bowel Regimen. Documentation dated 10/31/10 at 11:30 a.m. revealed in part, "Bowel Regimen complete. States has had large BM. HH (Home Health) Aide also performs in & out cath".

Review of the medical record revealed no orders to indicate that a Bowel Program was to be performed on Patient #2. Review of the care plan revealed no documentation to indicate that bowel problems were included on the care plan of Patient #2 that included goals, interventions, results of interventions relating to the bowel program that was mentioned in nursing documentation to have been performed on Patient #2 by the home health agency personnel.

S4 (RN) was interviewed on 12/06/10 at 1:15 p.m. S4 reported that she works as a registered nurse on the day shift (6:00 a.m. thru 6:00 p.m.). S4 reviewed the medical record of Patient #2 and reported that she did remember the patient. S4 reported that her initial involvement with Patient #2 was on 10/30/10 at approximately 6:45 a.m. S4 reported that Patient #2's abdomen was firm and distended on the 2 days that she provided care to him (10/30/10 & 10/31/10). S4 indicated that Patient #2 had not had a bowel movement in a couple of days and was reporting that he needed to have a bowel movement and pass gas. S4 reported that Patient #2 informed her that he was on a bowel program at home which consisted of an IV pole, a 3 liter bag of clear fluid/solution, and a rectal speculum. S4 reported that she was not familiar with the bowel program that Patient #2 was reporting to have been on at home. S4 reported that she could not identify the fluid/solution in the 3 liter bag and was not familiar with the rectal speculum. S4 reported that she inserted the rectal speculum in Patient #2's rectum at Patient #2's request in the a.m. on 10/30/10 because he (Patient #2) told her that is what is done for him at home to help stimulate a bowel movement and to assist in the passing of gas. S4 reported that she followed Patient #2's instructions while using the rectal speculum. S4 reported that she again provided care for Patient #2 on the day shift of 10/31/10 and indicated that someone from the home health agency approached her on 10/31/10 and this person informed her that he works with Patient #2 at his home and that he was going to be performing the bowel regimen on Patient #2. S4 reported that this person entered Patient #2's room at 10:00 a.m. to begin the bowel regimen and remained in the room until 11:30 a.m. S4 reported that the person approached her after completing the bowel regimen and informed her that Patient #2 had a large bowel movement. S4 reviewed the nursing care plan and reported that Patient #2's care plan did not include the bowel regimen that was performed and there were no physician orders for the bowel regimen to be performed.

S11 (LPN) was interviewed on 12/09/10 at 9:15 a.m. S11 reported that she works primarily on the night shift (6:00 p.m. thru 6:00 a.m.) as a licensed practical nurse. S11 reviewed the medical record of Patient #2 and reported that she did remember the patient. S11 indicated that her first involvement in the care of Patient #2 was on 10/29/10 at approximately 6:45 p.m. when she was told that the home health nurse was in room doing a bowel program on the patient. S11 reported that the home health nurse came out of the patient's room and reported that the bowel program was unsuccessful and for her to pass it on in report. S11 reported that there were no orders for the bowel program to be performed on Patient #2 and indicated that the bowel program was not included in Patient #2's care plan.

The Director of Nursing was interviewed on 12/09/10 at 10:00 a.m. The Director of Nursing reviewed the medical record of Patient #2 and confirmed that the documentation indicated that a bowel program was performed on Patient #2 during the patient's hospitalization by personnel who were not deemed competent or qualified to perform the bowel program in the hospital. The Director of Nursing confirmed that there was no information relating to the bowel program in Patient #2's care plan.