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Based on patient interview the hospital failed to meet the needs of 6 of 7 patients interviewed, patients #12, 13, 15, 16, 17 and 18.

Findings include:

On 10-19-2010 at 11:08 am in room 307 pt. #12 was interviewed. IV pump was beeping when surveyor entered the room, pt. #12 explained it has " been beeping for half an hour " . Pt. #12 explained, " I ' m leaving Thursday, happy to be leaving. " Pt. #12 complained about the length of time it takes for staff to answer the call light, " takes them a long time. " " They say I yell at them. " " They complain about being short staffed. "

On 10-19-2010 at 11:31 am in room 312 pt. #13 was interviewed. Pt. #13 explained. " been here for over a month " . Pt. #13 stated, " sometimes the staff come in time, I have sat here an hour waiting. " " All I ever hear is we are short staffed. So now I try not to call. " This is unusual for him to be in here this much " , pt. #13 referring to the certified nursing assistant, (CNA) L. " They are supposed to come in here and turn me every two hours and they don ' t. " " They don ' t give me my medication on time, I start having anxiety attacks because I don ' t get my anxiety medicine on time. " Surveyor was leaving the room when pt. #13 called for help stating, "I can't find my call light, he (CNA L) didn ' t make sure I had it. "

On 10-19-2010 at 12:01 pm in room 306 pt. #15 was interviewed. Pt. #15 stated that when in need of help pt. #15 pushes the call light, " sometimes they come, sometimes they don ' t. " The longest time to wait has been 15 minutes.

On 10-21-2010 at 9:05 am in room 209 pt. #16 was interviewed. Pt. #16 cannot speak full sentences, whispers words. Pt. #16 stated in few words that sometimes staff answer the call light timely, has had to wait more than 30 minutes a few times.

On 10-21-2010 at 9:17 am in room 201 pt. #17 was interviewed. Pt. #17 explained that staff answer the call light within 20 minutes. Surveyor asked if staff check on pt. #17 every hour, " not every hour, (pt. #17 laughing) " . Pt. #17 has wounds and is sometimes in pain, pt. #17 explained there are times when pain medication is delivered late because, " they are too busy with other patients. " Pt. #17 stated. " I hear them talking to each other in the room saying they are short staffed. "

On 10-21-2010 at 9:36 am in room 212 pt. #18 was interviewed. Pt. #18 explained that at times it takes staff 30 -45 minutes to answer the call light. Pt. #18 described waiting 45 minutes for help when a urinary catheter came out.

Above findings shared with Director of Quality Management, B and Chief Clinical Officer, C. No additional information was offered on 10-25-2010.

Based on interview, observation, policy & procedure review and medical record review the hospital failed to administer drugs as ordered. This occured in 4 out of 10 records reviewed (patients #2,4,6 & 8), and 1 out of 2 observation/interviews (pt. #11).

Findings incude:

On 10-18-2010 at 1:20 pm a review of hospital policy & procedure titled, Administration of Medication revealed, "The 7 R's of administering medications will be followed with each medication administration: -Right patient, Right medication, Right dose, Right time, Right route, Right reason, Right documentation" "Medications will be administered within 30 minutes before or after the scheduled time."

On 10-25-2010 at 9:45 am interview with pt. #11 in room 317 revealed this patient was being discharged that afternoon to a skilled nursing facility for rehabilitation and then to patients home. At 10:00 am RN I prepared oral medication for pt. #11. RN I gave pt. #11 the medicine cup of pills (approximately 6 pills) and pt. #11 took them with water. Surveyor asked pt. #11 if pt. knew what the medication was, and pt. #11 stated " no, I just take what they give me. " Surveyor asked RN I what medication pt. #11 just took and RN I stated, " vitamin and potassium, I ' m not sure what the other pills were. " RN #11 explained to surveyor that the pills administered were the 9:00 am medications. RN #11 explained, " We give medication within one hour of scheduled time, not possible to give within 30 minutes. Sometimes we are short staffed and have five patients or more to give medications to. "

On 10-25-2010 at 10:53 am interview with LPN H revealed that medications should be given within 30 minutes of the scheduled time but, " it is hard to follow, I have run over. " Surveyor asked LPN H if the hospital is ever short staffed, LPN H stated, " at times yes, very frustrating. " LPN H explained further that med teaching is done if the patient is capable, and " I find out what medications they are taking, I check for allergies before giving medications. "

On 10-21-2010 at 11:23 am and on 10-25-2010 at 10:20 am a review of the medical record for pt. #2 was completed with RN K, Director of Quality Management B and Chief Clinical Officer, C. The Transfer Summary shows pt. #2 was admitted to the hospital on 6-29-2010 and discharged on 8-18-2010. The chief complaint is listed as Chronic respiratory failure requiring ventilatory support. Review of medication administration records show that on 8-12-2010 heparin was ordered then stopped on 8-13-2010, and ordered again on 8-15-2010 and stopped on 8-16-2010 for pt. #2. Allergies listed on pt. #2 ' s medical record are heparin, vaccine and acetaminophen. Medication administration record for 8-15-2010 shows pt. #2 received an injection of heparin at 8:00 pm. Chief Clinical Officer, C agreed this was a medication error

On 10/21/2010 at 2:30 pm a review of pt. #4 ' s medical record was completed with RN, K and Director of Quality Management, B. Pt. #4 was admitted to the hospital on 6-30-2010 and discharged on 9-8-2010. The admitting diagnosis for pt. #4 was ventilator dependent respiratory failure. Additional pertinent diagnosis are quadriparesis and buttock decubitus. Review of the medication administration records show a medication error identified in a nursing note on 7-30-2010 at 12:51 pm that states, " realized patient had been given IV Ativan 1 mg versus 1 mg oral Ativan over 2 days for increased agitation and anxiety. "

On 10/25/2010 at 8:45 am review pt. #6 ' s medical record was completed with Director of Quality Management, B and Chief Clinical Officer, C. Pt. #6 was admitted to the hospital on 8-24-2010 and discharged on 9-24-2010. Primary diagnosis for pt. #6 was status post extensive abdominal surgery for colon cancer and prolonged ileus. Medication administration records showed on 8-28-2010 at 10:00 am medication Acetazolamide was given, this medication is scheduled for 9:00 am. Pt. #6 had an order for Insulin, to be administered at 9:00 am and 9:00 pm everyday. On 9-12-2010 at 8:00 am pt. #6 received 12 units insulin, on 9-8-2010 at 10:29 pt. #6 received 12 units insulin, on 9-5-2010 pt. #6 received 12 units of insulin at 10:04 am, on 9-4-2010 12 units of insulin were given at 10:23 pm, on 9-2-2010 12 units of insulin were administered at 11:00 pm, on 8-31-2010 12 units of insulin were given at 8:03 am. Pt. #6 had a physician order for Furoseomide to be administered at 9:00 am daily. On 8-28-2010 the Furoseomide was given at 10:00 am. Pt. #6 had a physician order for Mirtazapine to be administered at 9:00 pm daily. On 9-12-2010 the Mirtazapine was administered at 10:15 pm, on 9-8-2010 it was administered at 10:28 pm, on 9-4-2010 it was administered at 10:22 pm and on 9-2-2010 it was administered at 11:15 pm.

On 10-20-2010 at 3:30 pm a review of the medical record for pt. #8 was conducted with Director of Quality Management, B and RN, K. Pt. #8 had a physician order for, Meperidine IV injection to be given 30 minutes before amphotercin B lipid complex infusion. On 10-17-2010 the Meperidine IV injection was administered at 9:45 am, and the amphotercin B lipid complex was administered at 10:00 am. There was only 15 minutes between the two medications, not 30 minutes as ordered. All other treatments and medications were administered as ordered.

Director of Quality Management, B and Chief Clinical Officer, C had no additional information on 10-25-2010.

Based on record review, policy & procedure review and complainant file review the hospital failed to inform the patent and patient's power of attorney of discharge in 1 of 6 discharge records (pt. #3)out of a total sample of 10.

Findings include:

On 10-20-2010 at 1:15 pm review of medical record for pt. #3 was completed with RN K and Director of Quality Management B. Pt. #3 was admitted to the hospital on 4-22-2010 and discharged on 8-4-2010. Pt. #3 was admitted for wound care and antibiotic therapy. Admission forms are signed by pt. #3 ' s sister, F with " P.O.A " printed behind the signature. Advanced Directives Legal Representative page lists #3 ' s sister, F as the designee. Power of Attorney for Health Care form lists sister, F as the power of attorney, document is signed 10-1-2009, attached is a Statement of Incapacity signed by two physicians activating the Power of Attorney for Health Care on 2-10-2010. Consent to Transfer form dated 8-4-2010, transferring pt. #3 to Lutheran Home for Hospice services is not signed by the patient or the POA, F. It states near the space for signature, " Pt. unable to sign due to weakness. Patient gave verbal consent. "

Complaint filed with the hospital from pt. #3 ' s sister, F dated 8-5-2010. The complaint form states in the Summary section, " Sister states patient was D/C (discharged) 8-4-2010 and she was not notified. Sister states she is patient ' s POA. " Review and documentation section states in part, " POA papers noted, above c/o (complaint of) substantiated. Nurse manager spoke with sister, she is threatening litigation. " Follow up letter dated 8-10-2010 states in part, " we have taken the following measures to investigate your concern: interviewed involved staff, reviewed medical records and reviewed our discharge planning process. Our investigation resulted in the following actions: re-education with the involved staff was provided, review and education regarding theses issues were done at applicable staff meetings and a new process to ensure appropriates notifications are being made has been put into place. "

On 10-18-2010 at 1:20 pm review of hospital policy & procedure titled, Discharge Planning states in part, "At least two days prior to discharge, the Case Manager or Social Worker will confirm the discharge plans with the patient, family, physician, specialist and ancillary staff to complete final preparation."

Director of Quality Management B and Chief Clinical Officer, C did not have additional information on 10-25-2010.