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Based on observations and staff interview, it was determined that the facility failed to provide all patients with a notice of Patient Rights that is in accordance with State regulations for hospital patients.

Findings include:

Reference: N.J.A.C. Title 8 Chapter 43 G Hospital Licensing Standards states, "28... The hospital is required to provide each patient or guardian with the names, addresses, and telephone numbers of the government agencies to which the patient can complain and ask questions...31. To expect and receive appropriate assessment, management and treatment of pain as an integral component of that person's care in accordance with N.J.A.C. 8:43E-6."

1. The following tours were conducted during the survey:

a. The 2 West Unit was toured on 9/6/11.

b. The Kimball Institute for Rehabilitation and Occupational Health Services on 9/7/11.

c. The Behavioral Health Center on 9/8/11.

2. A review of the posted Patient Rights statement in each of the above areas lacked evidence of #31 as per reference above.

3. A review of the posted Patient Rights statement in each of the above areas, lacked evidence of the updated address to the N. J. Department of Health and Senior Services.

4. The above findings were confirmed with Staff #3, Staff #16 and Staff #17.

Based on a review of 3 of 4 medical records of patients receiving rehabilitation out patient services and a review of the facility's policy and procedure, it was determined that the facility failed to implement their policy and procedure for consents.

Findings include:

REFERENCE: The facility policy titled 'Consent Informed' Policy 3 AP-C03 revised 3/09 states on page 5 of 17 ," ...General Consent for Treatment: General consent differs from informed consent in that there are no risks, benefits, alternative to treatment, and/or possible problems to recuperation to be disclosed. The general consent allows for the provision of non-invasive examinations, diagnostic radiology, therapeutic intervention such as rehabilitation, blood specimens, IV insertion ect.., which occur in the general course of care/treatment..."

1. A review of 3 of 4 Medical Records (#23, #24 and #26) of patients receiving rehabilitation services at the facility's out patient rehabilitation site, revealed no evidence in the medical records of a general consent for treatment as per the policy stated above.

2. The above findings were confirmed with Staff #17 on 9/7/11.

Based on document review and staff interview, it was determined that the facility failed to measure, analyze and track quality issues related to the dietary, radiology, and respiratory hospital services.

Findings include:

1. On 9/8/11 the hospital wide Quality Assurance (QA) was reviewed. There was no evidence that the dietary, radiology, and respiratory departments reported to the quality assurance committee.

2. Upon interview on 9/8/11 at 2:50 PM, Staff #1 stated that the individual departments did their own monitoring, but because the monitoring was good, it was not reported at the QA meetings.

Based on medical record review, review of the facility's Medical-Dental Staff Bylaws and staff interview, it was determined that the facility failed to ensure that the Medical-Dental Staff Bylaws were enforced.

Findings include;

REFERENCE: Kimball Medical Center Medical-Dental Staff Bylaws, Revised 6/10, page 61 of 72 under Section 1 states, "E. A member of the Medical-Dental Staff shall be responsible for the medical care and treatment of each patient in the hospital, with a prompt completeness and accuracy of the medical record. Whenever these responsibilities are transferred to another staff member, a note covering the transfer of the responsibility shall be entered on the order sheet of the medical record..."

1. A review of Medical Record #12 revealed that Staff #31 was the attending physician for this patient whom was assigned to the 2 West unit.

a. A review of the progress notes on 9/6/11, in Medical Record #12, indicated that the last entry from Staff #31 was 9/2/11.

b. On 9/6/11, Staff #3 confirmed via the Medical Staff Office that Staff #31 was scheduled off from 9/2/11 through 9/5/11.

c. There was no evidence on the physician order sheets for the dates of 9/2/11 through 9/5/11, that the responsibility of Staff #31 was transferred to another credentialed medical staff member.

d. On 9/6/11 a review of the progress notes titled, 'Cardiology Hospital Progress Note,' in Medical Record #12, indicated that on 9/2/11, 9/3/11, 9/4/11 and 9/5/11, Staff #32 evaluated and examined Patient #12 for cardiology services. This finding was confirmed by Staff #3 on 9/6/11 at approximately 11:00 AM.

e. On 9/7/11, a review progress notes titled 'Cardiology Hospital Progress Note' in Medical Record #12 revealed that on, 9/2/11, 9/3/11, 9/4/11 and 9/5/11, a hand written note was observed above the statement, 'Cardiology Hospital Progress Note,' that stated, "Internal Medicine (Covering for Dr. ___ )."

f. There was no evidence of this hand written note being observed on 9/6/11 above the title of 'Cardiology Hospital Progress Note' in Medical Record #12 for the dates of 9/2/11, 9/3/11, 9/4/11 and 9/5/11.

g. Interview with Staff #3 on 9/6/11, confirmed the above findings and also confirmed that Staff #31 and Staff #32 are related to one another.

2. A review of Medical Record #13 revealed that Staff #31 was the attending physician for this patient who was assigned to the 2 West unit.

a. A review of the progress notes on 9/6/11, in Medical Record #13, indicated that the last entry from Staff #31 was 9/2/11.

b. There was no evidence on the physician order sheets for the dates of 9/2/11 through 9/5/11, that the responsibility of Staff #31 was transferred to another credentialed medical staff member.

c. On 9/6/11 a review of the progress notes titled, 'Cardiology Hospital Progress Note,' in Medical Record #13, indicated that on 9/2/11, 9/3/11, 9/4/11 and 9/5/11, Staff #32 evaluated and examined Patient #13 for cardiology services. This finding was confirmed by Staff #3 on 9/6/11 at approximately 11:00 AM.

d. On 9/7/11, a review progress notes titled 'Cardiology Hospital Progress Note,' in Medical Record #13, revealed that on 9/2/11, 9/3/11, 9/4/11 and 9/5/11, a hand written note was observed above the statement, 'Cardiology Hospital Progress Note,' that stated, "Internal Medicine (Covering for Dr. ___ )."

e. There was no evidence of this hand written note for physician coverage observed on 9/6/11 above the title of 'Cardiology Hospital Progress Note' in Medical Record #13 for the dates of 9/2/11, 9/3/11, 9/4/11 and 9/5/11.

3. A review of Medical Record #14 revealed that Staff #31 was the attending physician for this patient who was assigned to the 2 West unit.

a. A review of the progress notes on 9/6/11, in Medical Record #14, indicated that the last entry from Staff #31 was 9/2/11.

b. There was no evidence on the physician order sheets for the dates of 9/2/11 through 9/5/11, that the responsibility of Staff #31 was transferred to another credentialed medical staff member.

c. On 9/6/11 a review of the progress notes titled, 'Cardiology Hospital Progress Note,' in Medical Record #14, indicated that on 9/2/11, 9/3/11, 9/4/11 and 9/5/11, Staff #32 evaluated and examined Patient #13 for cardiology services. This finding was confirmed with Staff #3 on 9/6/11 at approximately 11:00 AM.

d. On 9/7/11, a review progress notes titled 'Cardiology Hospital Progress Note,' in Medical Record #14, revealed that on, 9/2/11, 9/3/11, 9/4/11 and 9/5/11, a hand written note was observed above the statement, 'Cardiology Hospital Progress Note,' that stated, "Internal Medicine (Covering for Dr.___,)."

e. There was no evidence of this hand written note being observed on 9/6/11 above the title of 'Cardiology Hospital Progress Note' in Medical Record #14, for the dates of 9/2/11, 9/3/11, 9/4/11 and 9/5/11.

4. There is no evidence that the facility enforced the Medical-Dental Staff Bylaws regarding a covering attending physician when the patient's attending is not available.

Based on medical record review and review of the facility's Medical-Dental Staff Bylaws, it was determined that the facility failed to ensure that all patient care is provided by practitioners who meet the medical staff criteria.

Findings include:

REFERENCE: Kimball Medical Center Medical-Dental Staff Bylaws, Revised 6/10, page 22 of 72 under Section 1 General states, "E. Every practitioner practice at the Medical Center by virtue of Medical Staff membership or otherwise shall, in connection with such practice, be entitled to exercise only delineated clinical privileges specifically granted to him/her by the Medical Staff and by the Board of Trustees..."

1. A review of Medical Record #13 on 9/6/11, indicated that there was no evidence of a cardiology consult to initiate care to Patient #13.

a. A review of of the 'Daily Orders Summary' dated 9/2/11 at 07:24 AM, revealed that Staff #33 entered a physician's order that stated, "IV Line...Start Normal Saline 0.9% 1000 ML, Reg Rate: 65 ML/HR, cont around clock until DC' D."

b. A review of the credential file for Staff #33 indicated that Staff #33 had Nurse Practitioner privileges granted by the facility to practice cardiology medicine under the supervision of an associated Medical Physician.

c. There was no evidence that the facility enforced the Medical-Dental Staff Bylaws to prevent a practitioner from providing care to patients in accordance with delineated clinical privileges.

A. Based on observation and staff interview, it was determined that the facility failed to ensure that the nursing department ensured immediate availability of a registered nurse (RN) for the bedside care of a patient.

Findings include:

1. A tour was conducted on 9/6/11 at approximately 11:00 AM of the unit 2 west and the following was observed;

a. From 11:05 AM to 11:16 AM (11 minutes), in the presence of Staff #3, it was observed that Patient #15's nurse call light was illuminated and audible without evidence of nursing personnel's acknowledgement of such. During this time, it was observed that there were approximately 10 nursing staff personnel located at the Nurses Station of unit 2 West and no one responded to the nurse call light.

b. At 11:16 AM, Staff #13 responded to the call light only after being questioned by the surveyor as to whom this patient was assigned. Staff #13 responded that he/she was not assigned to this patient and Staff #20 was.

c. Staff #13 entered Room 240 B to determine the needs of Patient #15 and reported that the patient was requesting a pain medication (that was not scheduled to be given).

d. From 12:00 PM to 12:08 PM, in the presence of Staff #3, the nurse call light for Patient #15 was once again illuminated and audible without evidence of nursing personnel's acknowledgement of such.

e. At 12:15 PM, Patient #15 was observed walking towards the Nurses Station on 2 West, pushing an IV (Intravenous) pole with dangling electrical cord attached.

f. Patient #15 approached Staff #20 and requested pain medication and stated that he/she was experiencing pain and had multiple requests for pain medication.

g. Staff #20 redirected Patient #15 to return to room 240 B and did not provide assistance.

h. A return visit to unit 2 West was conducted at approximately 2:00 PM on 9/6/11 and it was observed that the nurse call light was illuminated and audible for approximately 8 minutes without evidence of nursing personnel's acknowledgement of such.

2. There is no evidence that the facility ensured immediate availability of a registered nurse (RN) for the bedside care of a patient.

3. The above findings were confirmed by Staff #3 on 9/6/11.

B. Based on medical record review and review of facility policies and procedures, it was determined that the facility failed to ensure that pain levels and the effectiveness of pain medication were assessed in accordance with facility policy.

Findings include:

Reference: Facility policy titled, "Pain Assessment and Management" Policy # CP-P-01 states, "... 2. The nurse performs all subsequent pain assessments and reassessments. This assessment/reassessment includes pain intensity using an appropriate pain scale, location, onset and other factors indicated. Use the patient's self-report as the primary source of assessment of pain intensity...Interventions/Plan of Care:...Medications for persistent pain should be administered on an around the clock basis, with additional "as needed" doses..."

1. During a tour of unit 2 West on 9/6/11 the following was observed:

a. From 11:05 AM to 11:16 AM (11 minutes), in the presence of Staff #3, it was observed that Patient #15's nurse call light was illuminated and audible without evidence of nursing personnel's acknowledgement of such. During this time, it was observed that there were approximately 10 nursing staff personnel located at the Nurses Station of unit 2 West and no one responded to the nurse call light.

b. At 11:16 AM Staff #13 responded to the call light only after being questioned by the surveyor as to whom this patient was assigned. Staff #13 responded that he/she was not assigned to this patient and Staff #20 was.

c. Staff #13 entered the room 240 B to determine the needs of Patient #15 and reported that the patient was requesting a pain medication that was not scheduled to be given.

d. At 12:15 PM, Patient #15 was observed walking towards the Nurses Station on 2 West, pushing an IV (Intervenous) pole with a electrical cord attached.

e. Patient #15 approached Staff #20 and requested pain medication and stated that he/she was experiencing pain and had multiple requests for pain medication.

f. Staff #20 redirected Patient #15 to return to room 240 B, did not provide assistance, and did not assess the self-reported pain as per the policy stated above.

2. A review of Medical Record #15 revealed the following:

a. The 'Daily Orders Summary' dated 9/5/11 at 07:11, indicated the following physician's verbal orders:

i. "Hydromorphone (Dilaudid) 2 mg/ml INJ 1 mg/.05 ml IV push over 3-5 mins, Q4H as needed for pain."

ii. " Hydromorphone (Dilaudid) 2 mg/ml INJ 1 mg/.05 ml IV push over 3-5 mins, Q3H as needed for pain."

iii. Acetaminophen (Tylenol) tab 325 mg, Give #2, PO, Q6H, as needed for pain."

3. A review of the "Patient Record" dated 9/6/11 at 09:12 AM, in Medical Record #15, revealed that Patient #15 received 1 mg/0.5 ml, IV push for pain 9/10.

a. A review of the "Patient Record" dated 9/6/11 at 12:30 PM, in Medical Record #15, revealed that Patient #15 received 1 mg/0.5 ml, IV push for pain 7/10.

4. There was no evidence that Patient #15 was given Acetaminophen (Tylenol) tab 325 mg, Give #2, PO, Q6H, as needed for pain on 9/6/11 at 11:16 AM or 12:15 PM when the patient self-reported pain.

5. There is no evidence that Patient #15 was assessed for self-reported pain on 9/6/11 at 11:15 AM and 12:15 PM as per policy referenced above.

6. There is no evidence that Patient #15 was reassessed for the effectiveness of the pain medication given at 12:30 PM on 9/6/11.

7. The above findings were confirmed with Staff #3 on 9/6/11.

Based on medical record review and staff interview, it was determined that the facility failed to ensure that medications were administered in accordance with physician's orders and acceptable standards of practice.

Findings include:

Reference: The Nurse Practice Act for the State of New Jersey states:
"The practice of nursing as a registered professional nurse (RN) is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist..."

1. The following medication orders were written on the Post Anesthesia Care Unit Order Sheet in Medical Record #20, dated 8/29/11:

a. Morphine 2 mg [milligrams] IVP [intravenous push], q [every] 5 minutes prn [as needed] pain x 8 doses

b. Demerol 12.5 mg IVP q 5 minutes prn pain x 1 doses

c. Vistaril 25 mg IM [intramuscularly] x one dose prn pain.

2. Three different medications were ordered for pain in Medical Record #20, without parameters to determine which one the nurse should give. Without parameters, the nurse would be making the decision. This is not in compliance with the Nurse Practice Act for the State of New Jersey referenced above.

3. The following medication orders were written on the Post Anesthesia Care Unit Order Sheet in Medical Record #20, dated 8/29/11:

a. Compazine 5 mg IVP x one dose prn nausea/vomiting

b. Zofran 4 mg IVP prn x one dose prn nausea/vomiting; may repeat once prn

c. Reglan 10 mg IVP x one dose prn nausea/vomiting

d. Decadron 4 mg IVP prn nausea/vomiting.

4. Four different medications were ordered for nausea/vomiting in Medical Record #20, without parameters to determine which one the nurse should give. Without parameters, the nurse would be making the decision. This is not in compliance with the Nurse Practice Act for the State of New Jersey referenced above.

5. The following medication orders were written on the Post Anesthesia Care Unit Order Sheet in Medical Record #19, dated 8/26/11:

a. Demerol 12.5 mg IVP q 5 minutes prn pain x 5 doses

b. Toradol 30 mg IVP x one dose prn pain (15/30).

6. Two different medications were ordered for pain in Medical Record #19, without parameters to determine which one the nurse should give. Without parameters, the nurse would be making the decision. This is not in compliance with the Nurse Practice Act for the State of New Jersey referenced above.

7. The following medication orders for were written on the Post Anesthesia Care Unit Order Sheet in Medical Record #19, dated 8/26/11:

a. Zofran 4 mg IVP prn x one dose prn nausea/vomiting; may repeat once prn

b. Reglan 10 mg IVP x one dose prn nausea/vomiting.

8. Two different medications were ordered for nausea/vomiting in Medical Record #19, without parameters to determine which one the nurse should give. Without parameters, the nurse would be making the decision. This is not in compliance with the Nurse Practice Act for the State of New Jersey referenced above.

9. The following medication orders were written on the Post Anesthesia Care Unit Order Sheet in Medical Record #18, dated 8/29/11:

a. Morphine 2 mg [milligrams] IVP [intravenous push], q 5 minutes prn [as needed] pain x 5 doses

b. Demerol 12.5 mg IVP q 5 minutes prn pain x 1 dose

c. Dilaudid 1 mg IVP, q 5 minutes prn pain x 5 doses

d. Vistaril 12.5 mg IM [intramuscularly] x one dose prn pain.

10. Four different medications were ordered for pain in Medical Record #18, without parameters to determine which one the nurse should give. Without parameters, the nurse would be making the decision. This is not in compliance with the Nurse Practice Act for the State of New Jersey referenced above.

11. The following medication orders were written on the Post Anesthesia Care Unit Order Sheet in Medical Record #18, dated 8/29/11:

a. Zofran 4 mg IVP prn x one dose prn nausea/vomiting; may repeat once prn.

b. Benadryl 25 mg IVP x one dose prn nausea/vomiting.

12. Two different medications were ordered for nausea/vomiting in Medical Record #18, without parameters to determine which one the nurse should give. Without parameters, the nurse would be making the decision. This is not in compliance with the Nurse Practice Act for the State of New Jersey referenced above.

13. An order was written on the Post Anesthesia Care Unit Order Sheet in Medical Record #20, dated 8/29/11, for "Demerol 12.5 mg IVP, q 5 minutes prn pain x 1 doses." The administration of "Demerol 12.5 mg IV shivering" at 17:15 is recorded on the Post Anesthesia Care Record. Demerol had been ordered for pain. There was no order for shivering.

14. The following verbal medication orders were in the Physician's order sheet in Medical Record #15, dated 9/6/11:

a. Hydromorphone (Dilaudid) 2 mg/ml INJ 1 mg/.05 ml IV push over 3-5 mins, Q4H as needed for pain,

b. Hydromorphone (Dilaudid) 2 mg/ml INJ 1 mg/.05 ml IV push over 3-5 mins, Q3H as needed for pain

c. Acetaminophen (Tylenol) tab 325 mg, Give #2, PO, Q6H, as needed for pain.

15. Three different medications were ordered for pain in Medical Record #15, without parameters to determine which one the nurse should give. Without parameters, the nurse would be making the decision. This is not in compliance with the Nurse Practice Act for the State of New Jersey referenced above.

16. The above findings were confirmed by Staff #5.

Based on observation, review of Operating Room (OR) flash sterilization logs, staff interview and sterilizer records, it was determined that the facility failed to ensure that methods for processing reusable medical devices conform with the Association for the Advancement of Medical Instrumentation (AAMI) ST79:2006 (ST 79 replaces and supersedes ST46 by consolidating ST46 with 4 other AMMI standard [ST33, ST37,ST42 and ST 35] approved 7/10/2009), Comprehensive guide to Steam Sterilization and sterility assurance in health care facilities.
Reference #1: AAMI ST 79 section 11.2.4 states; " Procedure for flash sterilization should be based on a documented quality process that measures objective performance data."
Reference # 2: CDC ' s Guideline for Prevention of Surgical Site Infection 1999, section C. Recommendations, Intraoperative d.21 states, " Do not flash sterilize for reasons of convenience, as an alternative to purchasing additional set, or to save time. "
Reference # 3: Facility Policy and Procedure # S-330 Sterilization for Immediate Use states; Policy # 1 "Sterilization for immediate use will be restricted to those items needed in an emergency .... " , # 3 " Sterilization for immediate use will not be used for routine sterilization of devices used on patients.. " and # 4 "Sterilization for immediate use should not be used as a substitute for sufficient instrumentation."
Reference # 4: Facility Policy and Procedure # S-330 Sterilization for Immediate Use states under # 61 "Load Records should contain; Specific items sterilized .....Specific reason for sterilization."
1. On 9/20/11, review of flash sterilization records indicated approximately 70% of the flash sterilization cycles run from January 1, 2011 to October 2011 had only "One of a Kind" written on the OR's flash sterilization log.
a. The OR Supervisor stated upon interview, that those instruments were from Orthopedic cases.
2. As per Reference #4, there was no specific instrumentation or reason for flashing other than the notation "One of a Kind."

Based on medical record review, it was determined that the facility failed to deliver respiratory services as directed by the physicians orders in two of three respiratory medical records reviewed (Medical Records #35 and #36).

Findings include:

1. On 9/8/11, review of Medical Record #35 indicated a physician order dated and timed 9/7/11 at 6:25 PM, for Flovent inhaler 220 micrograms, give 4 puffs inhaled via ventilator, Q [every] 12 H [hours] by resp [respiratory].

a. Review of the MAR [medication administration record] in the computer, in the presence of Staff #26, lacked evidence of administration of the 9/7/11, 8 PM dose.

b. Upon interview on 9/8/11 at 11:20 AM, Staff #28 stated that the the ordered medication at 6:25 PM would print directly to the respiratory department. Staff #28 confirmed that the Flovent should have been given at 8 PM.

2. On 9/8/11, review of Medical Record #36 indicated a physician order dated 9/1/11 for Chest PT/Postural Drainage, Concentration - all lobes... 4 X daily by resp.

a. Review of the MAR in the computer, in the presence of Staff #33, and then Staff #29, lacked evidence of Chest PT/Postural Drainage 4 times daily on the following days:

i. On 9/4/11 Chest PT/Postural drainage was administered at 7:45 AM. This is only one time this day instead of the ordered four.

ii. On 9/5/11 there is no evidence in the medical record that Chest PT/Postural drainage was administered to the patient as ordered four times daily.

iii. On 9/6/11 Chest PT/Postural drainage was administered at 8:45 AM, 11:45 AM, and 3:15 PM. This is only three times this day instead of the ordered four.

iv. On 9/7/11 Chest PT/Postural drainage was administered at 11 AM. This is only one time this day instead of the ordered four.

b. Staff #29 and Staff #33 confirmed the above findings.