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Based on record review and interviews, the LTACH failed to ensure that Patient #1's Care Plan and/or Kardex reflected the type and number of persons required to assist Patient #1 in turning and repositioning.

Findings include:

The Admission Face Sheet indicated that the Long Term Acute Care Hospital (LTACH) admitted Patient #1 to the Acute Care Unit on 5/13/11.

The History and Physical (H&P), dated 5/16/11, indicated that Patient #1's diagnoses included morbid obesity with hypoventilation syndrome and chronic respiratory failure with a tracheostomy and mechanical ventilation at night. The H&P indicated that Patient #1 was alert and oriented.

The Physical Therapy (PT) Evaluation, dated 5/17/12, indicated that Patient #1 rolled from side to side with assist of three persons along with using the side rails to pull him/herself over. The PT Evaluation indicated that the plan was to provide PT five times weekly to maximize functional mobility.

The electronic Patient Care Plan regarding decreased functional mobility, dated 5/17/11, indicated that the desired outcome was to increase bed mobility to rolling with max assist of one person along with using the side rails to pull him/herself over. The Patient Care Plan did not indicate what Patient #1's current level of functioning was or the type and number of persons required to assist Patient #1 in turning and repositioning.

The electronic Kardex, generated from medical record information, did not indicate what Patient #1's current level of functioning was or the type and number of persons required to assist Patient #1 in turning and repositioning.

The PT Note, dated 5/20/11, indicated that Patient #1 rolled with moderate assist of two persons with the side rails up.

The PT Note, dated 6/2/11, indicated that Patient #1 rolled side to side with max assist of one person with the side rails up.

The electronic Patient Care Plan regarding decreased functional mobility, dated 6/10/11, indicated that the desired outcome was to increase bed mobility rolling with max assist of one person along with using the side rails to pull him/herself over. The Patient Care Plan did not indicate what Patient #1's current level of functioning was or the type and number of persons required to assist Patient #1 in turning and repositioning.

The electronic Kardex did not indicate what Patient #1's current level of functioning was or the type(s)/amount of assistance needed for turning.

The PT Note, dated 6/15/11, indicated that Patient #1 rolled side to side with max assist of one person with verbal cues.

The PT Note, dated 6/19/11, indicated that Patient #1 rolled side to side with use of the side rail.

The PT Note, dated 6/24/11, indicated that Patient #1 rolled side to side with minimum assist of 2 persons.

The Surveyor interviewed the Rehabilitation Director (Rehab Director) on 3/20/112 at 9:40 A.M. The Rehab Director said that Patient #1's participation in the therapy sessions was inconsistent and there were days when Patient #1 required more assistance than others. The Rehab Director said that by 6/25/11, Patient #1 was able to turn and reposition on the gym mat with assist of one person.

The Surveyor interviewed Unit Manager (UM) #1 on 3/20/12 at 8:00 A.M. and throughout the survey. UM #1 said information regarding turning and repositioning assistance was passed on shift to shift through verbal report. UM #1 said that specific information regarding turning and positioning assistance appeared in the Patient Care Plan or Kardex only when the information was entered into the clinical record as a nursing/physician order .

The Physician Orders, dated 6/20/11 and 6/24/11, did not include orders regarding turning and repositioning assistance.