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Based on record review and interview, the facility failed to ensure the nursing services is organized in a manner that ensures complete documentation and care planning to provide optimal care to Pts. for 10 of 10 MRs (1-10) reviewed in a sample of 10.

Findings include:

In 10 of 10 MRs, the facility failed to maintain nursing care plans that include Pt problems, goals with interventions and evaluation/resolution of problems. See tag A396.

In 9 of 10 MRs, the facility failed to ensure the Nursing AD is complete to determine a Pt's condition upon admission. See tag A450.

The cumulative effect of these deficiencies potentially affect 43 Inpatients on 10/6/14, 44 Inpatients on 10/7/14 and 42 Inpatients on 10/8/14, treated at the facility during survey.

Based on medical record review and interview, the facility failed to provide IM prior to discharge for 3 of 8 MRs of Medicare eligible patients (#2, 5 and 9) out of a total of 10 MRs reviewed.

Findings include:

Facility policy #CM-UR-03 "Issuance of the Important Message from Medicare (IM)" dated 9/10/2012 was reviewed on 10/6/2014 at 3:45 p.m. Per policy, "The follow-up copy of the IM will be issued...within 48 hours of the planned discharge date...The Case Manager or designated clinical staff person will sign, date and time the IM at the bottom of page 2. The beneficiary or their representative will initial the IM beside this signature."

Pt. #2's MR reviewed on 10/6/2014 at 11:25 a.m. revealed Pt. #2 was discharged on 7/22/2014. There is no documentation the IM was provided to Pt. #2 prior to discharge.

Pt. #5's MR reviewed on 10/6/2014 at 12:40 p.m. revealed Pt. #5 was discharged on 9/3/2014. There is no documentation the IM was provided to Pt. #5 prior to discharge.


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Pt #'s 9 MR reveiwed on 10/6/14 at 12:30 p.m. revealed Pt #9 was discharged on 9/29/14. There is no documentation the IM was provided to Pt #9 prior to discharge.

The above is confirmed in interview with DQM C on 10/6/14 at 2:30 p.m., stating the IM's should be signed by the CM at discharge.

Based on record review and interview, the facility failed to resolve the patient grievances, and notify the complainant within 7 days per policy, for 2 of 3 Pt complaints reviewed (1 and 11) out of 10 records reviewed.

Findings include:

Facility policy #C06-A "Complaint and Grievance Process" dated 10/01/2013, reviewed 10/6/2014 at 4:45 p.m., states under procedure 7. "The Director of Quality Management...will investigate the circumstances surrounding the concern or complaint...The investigative procedure should be completed, corrective action taken and a written response sent within 7 days of receipt of complaint. If the grievance will not be resolved or the investigation completed within 7 days, the hospital shall inform the patient or the patient's family member/representative, that the hospital is still working to resolve the grievance and will follow-up with a written response in a stated number of days."

Pt. #1's grievance, reviewed on 10/6/2014 at 4:30 p.m., dated 8/6/2014 and received by DQM C on 8/18/2014 includes an investigation of the complaint that reflects email correspondance between staff, but no actions taken or communications with the patient and/or complainant. There is no documentation of resolution of the complaint or response to complainant.

Pt. #11's grievance, reviewed on 10/6/2014 at 4:30 p.m., dated 3/26/2014 and received by DQM C on 3/31/2014 includes an investigation that reflects email correspondance with staff and limited actions taken to resolve complaints. There is no documentation of resolution of the complaint or response to complainant.

DQM C stated during an interview on 10/6/2014 at 4:30 p.m. that the complaint investigation and follow up should be complete 7 days from the date of the complaint, and DQM C states there is no follow up or response letter sent to Pt. #1 and Pt. #11.

Based on record review and interview, the facility failed to maintain nursing care plans that include Pt problems, goals with interventions and evaluation/resolution of problems, in 10 of 10 patients (#1-10).

Findings include:

Per review on 10/6/14 at 4:00 p.m. of facility P&P titled Nursing Care Plan, dated 10/13, it states under #7 "To simplify the care planning process for Nursing, the care plan along with relevant internal and external bundles and standard assessment formats have been incorporated into the 24 Hour Patient Record and Plan of Care ...8. Additional problems can be noted on the Care Plan Kardex ...9. The elements of care planning include: a. Assessment; b. Problem identification; c. Intervention; d. Evaluation; e. Communication...Procedure: 1. Nursing care planning begins with the assessment of the patient at the time of admission, with attention to the key issues assigned to Nursing ...4. Evaluation will be noted on the flow sheet."

Per interview with RN G on 10/6/14 at 3:15 p.m., the MRs have a 24 PRPOC document, that is not used as a POC, rather used to document daily Pt care. Per RN G, the POC is on a Kardex (a listing of current issues with the patient, including scheduled procedures and tests) at the Nursing Station, and reviewed at the beginning of each shift for problems and interventions.

Per interview with DQM C on 10/6/14 at 3:15 p.m., the NPL is part of the careplan and Kardex is reviewed daily with changes made as needed, but is not part of the MR after Pt discharge and agreed the PRPOC is not a POC.

Per follow up telephone interview on 10/8/14 at 10:04 a.m. with DQM C and DON J, the NPL is developed based on the AD and the first PRPOC. DQM C and DON J acknowledged there should be unique interventions, changes to interventions and measurable goals with evaluations and resolutions r/t the problems, and all areas should be complete on the AD.

The following MRs reviewed on 10/6/14 between 9:30 a.m. and 1:50 p.m. and confirmed with DQM C on 10/6/14 at 2:30 p.m. interview stating the records were incomplete:

Pt. #1's MR review on 10/6/2014 at 9:30 a.m. revealed the AD was completed by an RN on 5/23/2014 at 3:50 p.m. upon Pt. #1's admission. The NPL for Pt. #1 identified the following: risk for infection, nutrition: less than, pain management. The infection section of the daily RPOC is crossed out. There is no evidence in the MR of infection screening, goals or interventions related to Pt. #1's risk for infection. The nutrition portion of the RPOC is incomplete. There are no goals specific to the patient; the plan for interventions and the evaluation of the interventions is not documented. Pt. #1 was discharged on 8/18/2014, there is no documentation of Pt. #1's goals being met or of problems being improved or resolved.

Pt. #2's MR reviewed on 10/6/2014 at 11:25 a.m. revealed the AD was completed by an RN on 7/2/2014 at 4:10 p.m. upon Pt. 2's admission. The NPL for Pt. #2 developed based on information from the above AD on 7/2/2014 identified the following: impaired mobility r/t discomfort, activity intolerance r/t immobility and imbalanced nutrition. There is no data in the AD to support a diagnosis of imbalanced nutrition. There are no goals specific to the patient; the plan for interventions and the evaluation of the interventions is not documented. Pt. #2 was discharged on 7/22/2014, there is no documentation of Pt. #2's goals being met or of problems being improved or resolved.

Pt. #3's MR reviewed on 10/6/2014 at 11:55 a.m. revealed that Pt. #3 was admitted to facility on 6/18/2014 and discharged on 7/3/2014. The NPL for Pt. #3 included the following problems identified on 6/26/2014: ineffective airway clearance, impaired mobility and impaired skin integrity. These problems are documented as resolved on 6/26/2014, there are no goals specific to the patient; a plan for interventions and evaluation of the interventions is not documented. There is no documentation of Pt. #3's goals being met.

Pt. #4's MR reviewed on 10/6/2014 at 12:10 p.m. identified the following problems in the NPL: altered comfort, impaired airway, altered nutrition, risk for infection, altered GI function. The infection section of the daily RPOC is crossed out. There is no evidence in the MR of infection screening, goals or interventions related to Pt. #4's risk for infection. There are no goals specific to the patient; a plan for interventions and evaluation of the interventions is not documented. Pt. #4 was discharged on 7/7/2014, there is no documentation of Pt. #4's goals being met or of problems being improved or resolved.

Pt. #5's MR reviewed on 10/6/2014 at 12:40 p.m. did not contain a list of nursing problems with goals specific to the patient; a plan for interventions and evaluation of the interventions. Pt. #5 was discharged on 9/3/2014, there is no documentation of Pt. #5's goals being met or of problems being improved or resolved.


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Pt #6's MR review on 10/6/14 at 9:30 a.m. revealed the AD completed by an RN on 7/23/14, upon Pt #6's admission, is incomplete missing the following information: Chief complain/reason for hospitalization, Allergies, Current Medications, Orientation to Hospital, Patient Belongings, Fall Risk, High Risk Swallowing Disorder Screen, Educational Assessment, TB Screening, Functional Items for Initial Rehab Screen, Self Concept Preception(sic), Medical Services received in last 2 months, Physical Assessment for skin condition, and time completed. The PRPOC dated 7/23/14 has the Infection Control section "X" out, under Mobility has Pt at level 3 needing transfer assistance of 2.

The NPL for Pt #6 developed based on information from the above AD on 8/3/14 listed the following: Impaired skin integrity, Risk for infection, Fluid imbalance and Decreased mobility. There is no data in the MR to support the Risk for infection, no measurable goals for mobility and there are no there are no goals or interventions r/t the skin integrity, infection, or fluid imbalance. Pt #6 was admitted with a ventilator to help breathe, there are no goals documented related to the ventilator or weaning. The Kardex revealed there are areas written in pencil that has been changed, but there is no record of what was previously in place to determine if any problems are resolved, interventions that are changes or if any previous goals are met.

Pt #7's MR review on 10/6/14 at 11:30 a.m. revealed the AD completed by an RN on 9/8/14, upon Pt #7's admission, is incomplete missing the following information: Allergies, Current Medications, Physical Assessment for skin condition, and time completed. The PRPOC dated 9/9/14 and was not used for the 9/8/14 NPL.

The NPL for Pt #7 developed based on information from the above AD on 9/8/14 listed the following: Activity intolerance, Risk of infection and Ineffective airway clearance. There is no data for activity intolerance, risk of infection or airway clearance, there are no goals r/t the problems and no interventions to help the Pt meet goals. Pt #7 was discharged on 10/1/14, there is no documentation of Pt #7's problems being resolved. There is no Kardex to view for interventions, goals and evaulation/resolution of problems.

Pt #8's MR review on 10/6/14 at 12:00 p.m. revealed the AD completed by an RN on 9/5/14, upon Pt #8's admission, is incomplete and missing the following information: Chief complaint/reason for hospitalization, Nutrition Screen, High Risk Swallowing Disorder Screen, Functional Items for Initial Rehab Screen, Self Concept Preception(sic), Physical Assessment for skin condition and time completed. The PRPOC dated 9/5/14 has the Infection Control section "X" out.

The NPL for Pt #8 developed based on information from the above AD on 9/5/14 listed the following: Risk of infection, Impaired mobility and Ineffective airway clearance. There is no data in the MR to support the NPL for risk of infection, with goals and interventions, and no measurable goals for mobility and airway clearance. Pt #8 was discharged on 9/21/14, there is no documentation of Pt #8's problems being resolved.

Pt #9's MR review on 10/6/14 at 12:30 p.m. revealed the AD completed by an RN on 8/29/14, upon Pt #9's admission, is incomplete and missing the following information: Chief complaint/reason for hospitalization, Allergies, Health History, Orientation to Hospital, Patient Belongings, Fall Risk, Nutrition Screen, High Risk Swallowing Disorder Screen, Functional Items for Initial Rehab Screen, Self Concept Preception(sic), Medical Services received in last 2 months, Physical Assessment for skin condition, and time completed. The PRPOC dated 8/28/14 has the Infection Control section "X" out.

The NPL for Pt #9 developed based on information from the above AD and PRPOC on 8/29/14 listed the following: Risk for Aspiration r/t absence of protective measures, Risk for infection r/t external factors, Impaired physical mobility r/t pain or discomfort and Impaired skin integrity r/t external factors. There no measurable goals with interventions r/t the problems and no interventions to help the Pt meet goals. Pt #9 was discharged on 9/29/14, there is no documentation of Pt #9's problems being resolved. There is no Kardex to view for interventions, goals and evaulation/resolution of problems.

Pt #10's MR review on 10/6/14 at 1:50 p.m. revealed the AD completed by an RN on 7/25/14, upon Pt #10's admission, is incomplete and missing the following information: Health History, and Physical Assessment for skin condition. The PRPOC dated 7/25/14 has the Infection Control section "X" out.

The NPL for Pt #10 developed based on information from the above AD on 7/25/14 listed the following: Impaired gas Exchange, Impaired skin integrity, Bowel Incontinence. There no measurable goals with interventions r/t the problems and no interventions to help the Pt meet goals. Pt #10 was discharged on 8/28/14, there is no documentation of Pt #10's problems being resolved. There is no Kardex to view for interventions, goals and evaulation/resolution of problems.

Based on record review and interview, the facility failed to ensure the Nursing AD was completed in order to determine a Pt's condition upon admission, in 9 of 10 MRs reviewed (1, 2, 3, 4, 6, 7, 8, 9 and 10) in a sample of 10.

Findings include:

Per telephone interview with DQM C and DON J on 10/8/14 at 10:04 a.m., all areas of the AD is expected to be complete, and used for development of the careplan.

The following MRs reviewed on 10/6/14 between 9:30 a.m. and 1:50 p.m. were confirmed with DQM C on 10/6/14 at 2:30 p.m.

Pt. #1's MR review on 10/6/2014 at 9:30 a.m. revealed the AD completed by an RN on 5/23/2014 at 3:50 p.m. upon Pt. #1's admission was missing the following information: Chief complaint/reason for hospitalization and High risk swallowing disorder screen.

Pt. #2's MR reviewed on 10/6/2014 at 11:25 a.m. revealed the AD completed by an RN on 7/2/2014 at 4:10 p.m. upon Pt. 2's admission was missing the following information: Allergies, Patient belongings, Functional mobility.

Pt. #3's MR reviewed on 10/6/2014 at 11:55 a.m. revealed that Pt. #3 was admitted to facility on 6/18/2014 and discharged on 7/3/2014. There was not an AD available in Pt. #3's MR.

Pt. #4's MR reviewed on 10/6/2014 at 12:10 p.m. revealed the AD completed by an RN on 6/24/2014 at 1:20 p.m. upon Pt. #4's admission was missing the following information: Chief complaint/reason for hospitalization, Current Medications, Self Concept, and Services.



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Pt #6's MR review on 10/6/14 at 9:30 a.m. revealed the AD completed by an RN on 7/23/14 upon Pt #6's admission is incomplete and missing the following information: Chief complaint/reason for hospitalization, Allergies, Current Medications, Orientation to Hospital, Patient Belongings, Fall Risk, High Risk Swallowing Disorder Screen, Educational Assessment, TB Screening, Functional Items for Initial Rehab Screen, Self Concept Preception(sic), Medical Services received in last 2 months, Physical Assessment for skin condition, and time completed.

Pt #7's MR review on 10/6/14 at 11:30 a.m. revealed the AD completed by an RN on 9/8/14 upon Pt #7's admission is incomplete and missing the following information: Allergies, Current Medications, Physical Assessment for skin condition, and time completed.

Pt #8's MR review on 10/6/14 at 12:00 p.m. revealed the AD completed by an RN on 9/5/14 upon Pt #8's admission is incomplete and missing the following information: Chief complaint/reason for hospitalization, Nutrition Screen, High Risk Swallowing Disorder Screen, Functional Items for Initial Rehab Screen, Self Concept Preception(sic), Physical Assessment for skin condition and time completed.

Pt #9's MR review on 10/6/14 at 12:30 p.m. revealed the AD completed by an RN on 8/29/14 upon Pt #9's admission is incomplete and missing the following information: Chief complaint/reason for hospitalization, Allergies, Health History, Orientation to Hospital, Patient Belongings, Fall Risk, Nutrition Screen, High Risk Swallowing Disorder Screen, Functional Items for Initial Rehab Screen, Self Concept Preception(sic), Medical Services received in last 2 months, Physical Assessment for skin condition, and time completed.

Pt #10's MR review on 10/6/14 at 1:50 p.m. revealed the AD completed by an RN on 7/25/14 upon Pt #10's admission. The AD is incomplete and missing the following information: Health History, and Physical Assessment for skin condition.

Based on record review and interview, the facility failed to ensure TOs are authenticated by the medical staff per facility P&P, in 3 of 10 MRs reviewed (#5, 8, 10).

Findings include:

Per review on 10/6/14 at 10:30 a.m., of facility Medical Staff By-Laws dated 3/2/14, it states under III.D.1. "...All orders dictated over the telephone shall be signed...the practitioner shall...authenticate, time and date all orders promptly, within the time frame specified by state law..."

Pt. #5's MR reviewed on 10/6/2014 at 12:40 p.m. revealed TO's written on 7/18/2014 is authenticated without a time, by medical staff on 7/23/2014, after the 24 hour requirement per policy. This is confirmed in interview with MRM B on 10/6/14 at 2:15 p.m.


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Pt #8's MR review on 10/6/14 at 12:00 p.m. revealed there are TOs written on 9/20/14 that are not authenticated by the medical staff. This is confirmed in interview with MRM B on 10/6/14 at 12:15 p.m.

Pt #10's MR review on 10/6/14 at 1:50 p.m. revealed there is a TO written on 8/19/14 that is not authenticated by the medical staff. This is confirmed in interview with MRM B on 10/6/14 at 2:15 p.m.

Based on record review and interview the facility failed to ensure that patients' medical record contained complete and accurate documentation relating to patient care for 1 of 10 (#1) patients reviewed in a sample of 10.

Findings:

Facility policy #C41-N "Change in Patient Condition" dated 7/1/2014 was reviewed on 10/6/2014 at 4:30 p.m. The policy defines documentation guidelines related to significant change in a patient's condition. According to the policy, following a significant change "A complete head to toe assessment will be performed..."

Pt. #1 transferred to the facility from another acute care facility on 5/23/2014, the MR did not include orders from the transferring facility upon admission.

Pt. #1's MR reviewed on 10/6/2014 at 9:30 a.m. revealed a change in condition resulting in a rapid response on 5/26/2014 at 10:27 a.m. There was no documentation of a complete assessment as a result of this change in condition per policy. This was confirmed in interview with RN G on 10/6/14 at 3:15 PM.

Pt #1 was transferred to an inpatient hospice unit on 8/18/2014, MRM B was unable to produce evidence of comprehensive transfer orders, including a medication list, upon discharge.

During an interview with CM E and CM D on 10/6/2014 at 3:50 p.m., CM E stated that discharge orders are faxed to transferring facilities prior to discharge but was unable to produce evidence that the fax occurred, and that a medication and medical equipment (bipap for oxygenation at night) list was included.

Based on record review and interview, the facility failed to ensure the P&P for Discharge Planning included the qualifications required for staff to perform Discharge Planning. This deficient practice had the potential to affect all patients who were discharged from the hospial. The patient census was 43 at the time of survey.

Findings include:

Per review on 10/9/14 at 3:00 p.m. of facility P&P titled Discharge Planning, dated 7/1/14, it states "Case Manager, Registered Nurse or other appropriately qualified personnel will develop or supervise the development of the evaluation and discharge plan." There is no description of qualifications required to ensure staff have appropriate training, education and experience to perform Discharge Planning.

This was confirmed in interview with DQM C on 10/9/13 at 3:00 p.m.. The DQM further stated that there was no description of the qualifications required.