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Based on medical record review, interview and policy/procedure review the facility failed to protect the rights of patients cared for at the facility, resulting in the potential loss of rights to all patients being served by the facility.
Findings include:

-The facility failed to respond to grievances according to policy. See tag 0118
-The facility failed to provide care in a safe setting. See tag 0144
-The facility failed to ensure restraints were used according to policy. See tag 0173

Based on document review, interview, and policy review the facility failed to update the patient's plan of care in 12 of 15 patients (patient #5, #6, #7, #8, #12, #14, #15, #17, #31, #32, #34, and #36) resulting in the potential for poor patient outcomes. See tag A 396.

Based on document review, interview and policy/procedure review the facility failed to ensure that complaints/grievances were designated and resolved according to policy for 5 out of 12 (#1, #37, #38, #39 and #40) patient complaints/grievances reviewed. Resulting in the potential loss of rights for all patients receiving care at the facility. Findings include:
On 12/4/14 at approximately 0900 during review of patient #1's complaint, it was revealed that the complaint could not be resolved by the staff present, further investigation and intervention was required. The complaint should have been designated as a grievance including follow up with the complainant as required in writing.
On 12/4/14 at approximately 0930 during review of patient #37's complaint it was revealed that further investigation and intervention was required and could not be resolved at the time the complaint was made by the staff present. The complaint should have been designated as a grievance including follow up with the complainant as required in writing.
On 12/4/14 at approximately 1000 during review of patient #38's complaint it was revealed that further investigation and intervention was required and could not be resolved at the time the complaint was made by the staff present. The complaint should have been designated as a grievance including follow up with the complainant as required in writing.
On 12/4/14 at approximately 1030 during review of patient #39's complaint it was revealed that the complaint was received via e-mail. The complaint required investigation and intervention and was in writing. The complaint should have been designated as a grievance and follow up with the complainant was required in writing.
On 12/4/14 at approximately 1100 during review of patient #40's complaint it was revealed that further investigation and intervention was required and could not be resolved at the time the complaint was made by the staff present. The complaint should have been designated as a grievance including follow up with the complainant as required in writing.
On 12/4/14 at approximately 1130 during an interview with staff B, when queried as to why the aforementioned complaints were not designated as grievances, she replied, "I thought if they could be resolved by the end of the day that they are considered complaints." When asked about the complaint received via e-mail, a written complaint, staff B replied, "A staff member emailed that to me about a complaint they received from a patient for me to follow up on, I didn't think it was defined as 'in writing' by the complainant."
On 12/4/14 at approximately 1200, during review of the facility's policy titled, "Patient Complaint and Grievance Policy," revision date of September 2013, stated under definitions, "Patient Grievance: A Patient Grievance is a written complaint or a verbal complaint (when the verbal complaint about Patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative..." Further review of the policy revealed under the section policy, #7, "A written complaint is always considered a grievance...Email or faxes are considered written." Under the section procedure, #14, "Complaints which have not been resolved at the point of contact should be investigated and resolved by a team comprised of at least the Department Manager, DQM (Director of Quality Management), CCO (Chief Compliance Officer) and the CEO (Chief Executive Officer)," and under #15, "Facility A Hospital should ensure the patient/patient representative is provided written notice of its decision regarding a grievance within (seven) 7 days of the facility's receipt of the grievance."

Based on observation, document review, interview, and policy review the facility failed to ensure patients received care in a safe setting resulting in falls in 2 of 2 patients (#1 and #19) and failed to identify 7 of 7 patients as being a high fall risk (patients #5, #7, #17, #20, #21, #25, and #26) resulting in potential for patient harm. Findings include:

On 12/2/2014 at 1015 during a tour of facility #1, it was discovered that the facility did not have any fall risk signs placed on patient room doors. Staff A was asked how patients were identified as being at risk for falls. Staff A said that patients who were at risk for falls were to have a sign placed outside of the patient's room.

On 12/2/2014 at approximately 1020 during the initial tour of facility #1, an interview was conducted with patient #19 and the patient's medical power of attorney (POA) (a person who is responsible for making decisions for the patient when the patient is unable to make decisions in regards to their care). The patient's POA was asked if the patient had experienced any problems during his current admission. The patient's POA indicated that the patient had experienced a fall on 11/25/2014. When asked if any injuries had occurred during the fall the POA said, "Yes. My father hit his head during the fall. He had to be taken to the hospital for a CT (commuted tomography) scan and x-rays." The patient was observed to have a bruise from the base of his skull down the back of his neck approximately 5 inches in length and 3 inches in width. The POA had stated that the bruise was a result of the patient's fall. The patient was not observed to have a fall risk band on nor were there any signs either inside the room or outside the patient's room to identify the patient as a high fall risk.

On 12/2/2014 at approximately 1040 during tour of facility #1, it was observed that patient #21's bed was a "low-boy" bed (a bed approximately two feet from the ground used to help prevent injury from falls due to the close proximity to the ground should the patient fall out of bed) and mats were surrounding the patient's bed. Staff A was asked if the patient was considered a fall risk. Staff A responded that, "Yes. The patient is a fall risk." Staff A was then asked if signage was located outside of the room to indicate the patient was a fall risk. Staff A responded, "No."

On 12/2/2014 at approximately 1100 at facility #1, a review of patient #19 medical record occurred. During review of the patient's medical record it was discovered the patient was deemed a fall risk on his admission of 11/17/2014. On 11/25/2014 at approximately 1930 the patient experienced a syncopal episode (loss of consciousness) and was found on the ground in the bathroom located inside the patient's room. The patient was transported to a local hospital on 11/26/2014 for a CT scan and X-rays in order to rule out fractures and internal bleeding. The patient was placed in the high observation unit for close monitoring. Further review of the patient's chart showed that the fall risk assessment on 11/26/2014 did not indicate the patient had recently had experienced a fall according to nursing documentation.

On 12/2/2014 at approximately 1125 (facility #1) staff C was asked if the patient (#19) was considered a high fall risk. Staff C responded "Yes." Staff C was then asked if the nursing documentation indicated that the patient was a high fall risk on the nursing assessment on 11/26/2014. Staff C stated "No. The documentation does not show that the patient had a recent fall." Staff C was then asked to review the initial assessment that occurred upon admission on 11/17/2014 for patient #19. Staff C was shown where patient #19 had been deemed a high fall risk upon admission and interventions were listed to address the problem. Intervention listed "post a sign at the door to identify to all health care providers patient fall risk and communicate fall risk to other health care team members." When asked if a sign had been posted outside the patient's room, staff C responded "No."

On 12/2/2014 at approximately 1130 at facility #1, a review of patient #21's medical record it was discovered the patient was considered a high fall risk. Staff C was questioned if the patient was identified as a high fall risk outside of the patient's room. Staff C stated "No." Staff C was shown where patient #21 had been deemed a high fall risk upon admission on 11/21/2014 and interventions were listed to address the problem. Intervention listed "post a sign at the door to identify to all health care providers patient fall risk and communicate fall risk to other health care team members." When asked if a sign had been posted outside the patient's room, staff C responded "No."

On 12/2/2014 at approximately 1430,during the initial tour of facility #2, an interview occurred with patient #17. The patient (#17) was asked how he felt he was progressing since his admission on 11/15/2014. The patient stated "I keep getting weaker." The patient the stated "they (the facility) took my walker away because they (physical therapy) said it wasn't safe." The patient was not listed as being on fall risk precautions either by use of a fall risk band on his person or a fall risk sign being placed outside of his room.

On 12/2/2014 at approximately 1500 during medical record review it was revealed the patient (#17) was not identified as a fall risk although the Morse Fall Scale (a tool used to determine if the patient is at risk for falls) indicated the patient was a fall risk. On 12/2/2014 at approximately 1530 staff E was asked why the patient's walker had been removed for the patient's use. Staff E stated that the patient was unsteady on his feet and that there were concerns about the patient using the walker in his weakened state. Staff E was then asked if the patient was considered a high fall risk. Staff E responded, "Yes."

On 12/3/2014 at approximately 0900 during the medical record review of patient #1 who was admitted as a patient at facility #2 on 9/3/2014, it was revealed the patient experienced a fall on 9/17/2014. Patient #1 was admitted on 9/3/2014 at approximately 1200. According to the patient's initial admission assessment, the patient was deemed a high fall risk on 9/3/2014 at 2000. According to the nursing assessment on 9/3/2014 at 2000 the Morse Fall Risk assessment upon admission was 75 points identifying the patient as a high fall risk. The fall risk was based upon the patient having a secondary diagnosis - 15 points, the patient having intravenous access - 20 points, impaired gait/transferring - 20 points, mental status of forgetting limitations - 15 points. On 9/4/2014 the patient was identified as a high fall risk both at 0715 and 1930 nursing assessments. On 9/5/2014 the patient was identified as a high fall risk both at 0700, 2000, and 0400 nursing assessments. On 9/6/2014 the patient was identified as a high fall risk at 0700, 2000, and 0400 nursing assessments. On 9/7/2014 the patient was not identified as a high fall risk on the 0800, 2000, or 0400 nursing assessments although the patient's level of consciousness, acuity of care, or diagnosis had not changed from previous days' assessments. On 9/8/2014 the patient was identified as a high fall risk both at 0900 and 1930 nursing assessments. On 9/9/2014 the patient was identified as a high fall risk both at 0730 and 1950 nursing assessments. On 9/10/2014 the patient was identified as a high fall risk both at 0730 and 2000 nursing assessments. On 9/11/2014 the patient was not identified as a fall risk both at 0700 and 2000 nursing assessments although the patient's level of consciousness, acuity of care, or diagnosis had not changed from previous days assessments. On 9/12/2014 the patient was not identified as a fall risk either at 0700 and 2000 nursing assessments. On 9/13/2014 the patient was not identified as a fall risk either at 0740 and 2000 nursing assessments. On 9/14/2014 the patient was not identified as a fall risk at 0700 nursing assessment but was identified as a high fall risk at the 2000 nursing assessment. On 9/15/2014 the patient was not identified as a fall risk both at 0700 and 2000 nursing assessments although the patient's level of consciousness, acuity of care, or diagnosis had not changed from previous days assessments. On 9/16/2014 the patient was not identified as a fall risk both at 0700 and 2000 nursing assessments.

On 9/17/2014 at 0200 nursing documentation stated "Pt. (patient) (#1) has attempted to get out of bed throughout shift multiple times, attempted to down grade mitten restraint on left hand, pt. continues to pull out tubes, and trachea mask. Will cont. (continue) to monitor." On 9/17/2014 at 0800 nursing documentation stated "(patient) restless, with involuntary movements, non-verbal, unable to follow commands." The nursing assessment on 9/17/2014 at 0800 does not identify the patient as being a high fall risk. On 9/17/2014 at 1100 nursing documentation stated "left mitt (mitten) restraint d/c'd (discontinued)." On 9/17/2014 (time missing) nursing documentation stated "assessment complete at 1935 the PCT (patient care technician) went into room and found pt. face down on floor. Went in checked him out and patient care technician (PCT) and 3 nurses picked him up and put him back to bed, VSS (vital signs stable), one small skin tear on right inner lower left leg noted. Pt. is being closely monitored by nurse and PCT. Will continue to monitor." The chart did not have any additional nursing notes or documentation for the 1900 - 0700 nursing shift after the patient fall to support additional monitoring.

On 9/18/2014 the patient (#1) was identified as a high fall risk both at 0730 and 2000 nursing assessments. On 9/19/2014 the patient was identified as a high fall risk both at 0800 and 1950 nursing assessments. On 9/19/2014 at 2110 nursing documentation stated "RT (respiratory therapy) found pt. (patient) sliding out of bed on pt's (patient's) left hand side. Arms and head remain in bed and feet on floor." The patient was noted to have a "low boy" bed at the time of the occurrence. The patient remained as a high fall risk from 9/19/2014 to time of transfer on 9/22/2014 to facility #3.

On 12/2/2014 at approximately 1330 during a tour of facility #2, patient's rooms with fall risk signs located outside of the patient rooms were identified. During the tour 5 of 5 patients (#5, #7, #20, #25 and #26)identified as fall risks by signage outside of the door failed to have fall risk bracelets.

On 12/3/2014 at approximately 1500 a review of the policy titled, "Fall Prevention and Management Program" dated 9/2013 occurred. According to the policy #5, page 2, the policy stated "Patients assessed as 'at risk' will have a yellow armband placed and a visual alert placed on the door of the patients room."

On 12/4/2014 at approximately 1000 a review of the documents titled, "Fall Committee Meeting minutes" dated 11/24/2014 occurred. According to the document the topic, "use of yellow fall risk bands" it stated a discussion was held to initiate education and begin use of yellow arm bands to identify patients as risk for falls. On 12/4/2014 at approximately 1030 an interview with staff D occurred. Staff D was asked if fall risk bracelets were currently being used on the floor. Staff D stated, "no, not at this time." Staff D was asked how often the fall committee met. Staff D stated that the committee had tried to meet on a quarterly basis but had not actively met since July 2014.

On 12/4/2014 at approximately 1045 an interview with staff B occurred. A review of recorded falls of facility #1 from January 2014 to October 2014 showed facility #1 identified fall rates for January 2014 as 3.9% (4), February 2014 as 4.6% (5), March 2014 as 9.6 % (11 falls), April 2014 as 11.1% (9 falls), May 2014 as 7.6% (6 falls), June 2014 as 6.0% (4 falls), July 2014 as 11.3% (6 falls), August 2014 as 3.7% (8 falls), September 2014 as 8.9% (5 falls), and October 2014 as 18.8% (8 falls). A review of recorded falls of facility #2 from March 2014 to October 2014 showed facility #2 identified fall rates for March 2014 as 1.9 % (0 falls), April 2014 as 9.7% (1 falls), May 2014 as 11.2% (7 falls), June 2014 as 3.3% (5 falls), July 2014 as 10.2% (3 falls), August 2014 as 6.3% (8 falls), September 2014 as 7.8% (9 falls), and October 2014 as 6.6% (12 falls). Staff B was asked if facility #1 and facility #2 had put into place any fall prevention initiatives to address the falls occurring at the facility. Staff B stated, "We recognize the need to address falls and actively put into place interventions. The fall committee is working on implementing actions to address the prevention of falls." According to staff B the target goal of a fall rate of 6% or lower was the goal of both facility #1 and facility #2.

Based on medical record review, interview and policy/procedure review the facility failed to ensure that restraint orders were renewed per facility policy for 4 out of 5 (#16,#33, #35 and #36) restrained patients, resulting in the potential for patients to be restrained without a physician order.
Findings include:

On 12/3/14 at approximately 1530, during medical record review of patient #33, revealed that the patient was in restraints from 11/5/14 through 11/20/14 at time of discharge. On the document titled, "Restraint Order and Flow Record, Medical," (restraint order sheet), dated 11/5/14, the document lacked a time the physician was notified of the patient being placed in restraints and was timed at 2200 by the registered nurse (RN) for the initiation of restraints. The physician did not sign the restraint order until 11/8/14 at 1430. The same document dated 11/6/14 lacked a time the physician was notified of the patient being placed in restraints and was timed at 0725 by the RN. The physician did not sign the restraint order until 11/8/14 at 1430. The restraints were discontinued on 11/6/14 at 1230 and a new order for restraints was initiated at 1935 on 11/6/14. The physician was not notified until 2330 of the patient being placed in restraints and did not sign the order until 11/8/14 at 1430. On 11/7/14 restraints were initiated at 0750 and the physician did not sign the order until 11/8/14 at 1430. On 11/13/14 restraints were initiated at 0700 and lacked a time the physician was notified of the restraint use. The same date of 11/13/14 was used to initiate restraints at 1918 and showed the physician signing the order on 11/13/14 at 1115, approximately 8 hours prior to the restraints being initiated. The restraint orders for 11/16/14 showed an initiation of restraints at 0700 by the RN and the physician did not sign the orders until 11/17/14 at 1216. On 11/19/14 the restraint order sheet showed restraints being initiated at 0700 by the RN and the physician did not sign the orders until 11/20/14 at 1630.

On 12/4/14 at approximately 0930, during review of patient #35's restraint orders from 11/12/14 to present revealed that restraints were initiated on 11/12/14 at 0700 by the RN and the physician did not sign the orders until 11/13/14 at 0845. The restraint orders dated 11/15/14 showed that restraints were initiated at 0700 by the RN and the physician did not sign the order until 11/16/14 at 0900. The restraint orders dated 11/16/14 showed that restraints were initiated at 0700 by the RN and the physician did not sign the order until 11/17/14 at 0810. The restraint orders dated 11/18/14 showed that restraints were initiated at 0700 by the RN and the physician did not sign the order until 11/21/14 at 0800. The restraint orders dated 11/21/14 showed that restraints were initiated at 0700 by the RN and the physician did not sign the order until 11/22/14 at 0820. The restraint orders dated 11/28/14 showed that restraints were initiated at 0700 by the RN and the physician signed the order dated 11/28/14 without timing the order.

On 12/4/14 at approximately 1030 during review of patient #36's restraint orders from 11/14/14 to 11/22/14 it was revealed that restraints were initiated on 11/16/14, 11/17/14 and 11/18/14 at 0700 by the RN and the physician did not sign the orders for all three days until 11/20/14 at 1505.

On 12/4/14 at approximately 1115 during an interview with staff B, when asked when physicians are required to sign restraint orders after initiation by the RN, to which she replied, "As soon as possible, but within 24 hours." When queried as to when physicians are supposed to be notified of a patient being placed in restraints, she responded, "Within an hour." Staff B was then asked how often restraint orders needed to be renewed, she said, "Every 24 hours, they expire at the end of each day."

On 12/4/14 at approximately 1200 during review of the policy titled, "Restraint Use," with a revised date of May 2014, it was revealed under the section titled, "General Provisions," #4, "Telephone Orders: a) The RN initiates emergency use of restraints and obtains a telephone order from the physician within 30 minutes of application. b) A telephone order for restraint is only accepted for the initial application. The telephone order is obtained immediately after application of the restraint." Further review of the policy revealed under the section titled, "Restraints Used For Medical Reasons (Medical Restraint)," #1, "Orders: a) Restraints used to ensure the physical safety of the non-violent or non-self-destructive patient are renewed every calendar day. b) A face-to-face assessment of the patient by the attending physician is documented daily following initiation of restraint and before renewal of restraint orders. c) An order is considered expired at the end of the calendar day."


29955

On 12/4/2014 at approximately 1030 during medical record review it was revealed the medical restraints for patient #16 (a patient at facility #2) it was discovered the patient was placed in restraints on 9/17/2014. Review of the patient's restraint orders dated on 9/20/2014 at 0700 and on 9/21/2014 at 0700 revealed that both orders were not signed by the physician until 9/22/2014 at 0700.

On 12/4/2014 at approximately 1100 staff A was interviewed. Staff A was asked what was the expectation for restraint orders to be reviewed by the physician. Staff A responded, "restraint orders are to be reviewed every twenty-four hours and if restraints are to be continued, new orders (are) to be signed on the day of the order." Staff A was then asked if the orders dated on 9/20/2014 and 9/21/2014 had been signed by the physician on those days. Staff A responded, "No."

Based on document review, interview, and policy review the facility failed to update the patient's plan of care in 12 of 15 patients (patient #5, #6, #7, #8, #12, #14, #15, #17, #31, #32, #34, and #36) and failed to provide nursing wound care in 1 of 3 patients (patient #1) resulting in the potential for poor patient outcomes. Findings include:

On 12/2/2014 at approximately 1400 during medical record review of it was revealed patient #17 was admitted on 11/15/2014. On the document titled "Facility 2 Interdisciplinary Team Meeting/Care Conference," the initial interdisciplinary team (IDT) conference for the patient's plan of care was initiated on 11/16/2014 and did not contain the signature of the physician. The next IDT conference was dated 11/22/2014 and did not contain the signature of the physician. As of 12/2/2014 there were no further IDT conferences for the patient.

On 12/3/2014 at approximately 0900 during the medical record review of patient #1, it was revealed the patient had a documented skin tear on the lower right leg as a result of a fall that occurred on 9/17/2014. On 12/3/2014 at approximately 1630 the medical record for patient #1 was obtained from facility #3 (the facility the patient transferred to on 9/22/2014). According to the medical record and photo documentation in patient #1's chart from facility #3, the patient was received at facility #3 with excoriation and small open skin areas of the buttocks and genital area. Medical record review of patient #1's chart at the time of discharge from facility #2 failed to identify patient #1 as having excoriation and small open skin areas of the buttocks and genital area.

On 12/3/2014 at approximately 0930 staff B was interviewed. Staff B was asked if the IDT plan of care for the patient should be signed by the physician. Staff B stated "Yes. The physician should sign the plan of care. Staff B was then confirmed the physician had failed to sign the IDT plan of care on 11/16/2014 and 11/22/2014. Staff B also confirmed there were no further IDT plans of care for patient #17 available for review.


29313

On 12/2/14 at approximately 1430 during review of medical record #5 it was revealed that the patient was admitted on 11/15/14. On the document titled, "Facility 2 Interdisciplinary Team Meeting/Care Conference," the initial interdisciplinary team (IDT) conference for the patient's plan of care (POC) was on 11/16/14, the next IDT conference was dated 11/22/14 and there were no further conferences as of the date of this review.

On 12/2/14 at approximately 1500 during review of medical record #6 it was revealed that the patient was admitted on 11/12/14. On the document titled, "Interdisciplinary Plan of Care," the initial care plan was not initiated on the patient until 11/23/14.

On 12/2/14 at approximately 1530 during review of medical record #7 it was revealed that the patient was admitted on 11/17/14. On the document titled, "Interdisciplinary Plan of Care," the initial care plan was initiated on 11/17/14, with an update on 11/23/14 and no further updates as of the date of this review.

On 12/2/14 at approximately 1600 during review of medical record #8 it was revealed that the patient was admitted on 11/10/14. On the document titled, "Interdisciplinary Plan of Care," the initial care plan was initiated on 11/10/14, with an update on 11/16/14 and no further updates as of the date of this review.

On 12/2/14 at approximately 1630 during review of medical record #12 it was revealed that the patient was admitted on 11/21/14. On the document titled, "Facility 2 Interdisciplinary Team Meeting/Care Conference," the initial interdisciplinary team (IDT) conference for the patient's plan of care (POC) was on 11/22/14 and there were no further conferences as of the date of this review. The patient's care plan was initiated on 11/21/14 and updated once on 11/30/14.

On 12/3/14 at approximately 0900 during review of medical record #14 it was revealed that the patient was admitted on 7/9/14. On the document titled, "Interdisciplinary Plan of Care," the initial care plan was initiated on 7/9/14 and updated on 7/20/14.

On 12/3/14 at approximately 0930 during review of medical record #15 it was revealed that the patient was admitted on 9/17/14 and discharged on 9/26/14. On the document titled, "Interdisciplinary Plan of Care," the initial care plan was initiated on 9/17/14 and there were no further updates prior to discharge.

On 12/3/14 at approximately 1100 during review of medical record #31 it was revealed that the patient was admitted on 8/26/14 and discharged on 9/15/14. On the document titled, "Facility 2 Interdisciplinary Team Meeting/Care Conference," the initial interdisciplinary team (IDT) conference for the patient's plan of care (POC) was on 8/30/14 and there were no further conferences prior to discharge.

On 12/3/14 at approximately 1130 during review of medical record #32 it was revealed that the patient was admitted on 11/7/14 and discharged on 11/26/14. No care plan was available for review for this patient.

On 12/3/14 at approximately 1330 during review of medical record #34 it was revealed that the patient was admitted on 11/3/14 and discharged on 11/22/14. On the document titled, "Interdisciplinary Plan of Care," the initial care plan was initiated on 11/3/14, updated on 11/16/14 and there were no further updates prior to discharge.

On 12/4/14 at approximately 0930 during review of medical record #36 it was revealed that the patient was admitted on 11/3/14. On the document titled, "Interdisciplinary Plan of Care," the initial care plan was not initiated until 11/16/14 and updated on 11/30/14.

On 12/2/14 at approximately 1610 during an interview with staff D, when queried as to when nursing care plans are supposed to be initiated after a patient is admitted, she replied, "Usually within the first day." When asked how often care plans are supposed to be updated, she said, "They are supposed to be updated every week." When questioned about how often the IDT meets to update a patient's plan of care, staff D responded, "We meet every Thursday to update every patients' plan of care."

On 12/3/14 at approximately 1500 during review of the policy titled, "Nursing Care Plan," with a revised date of 10/2011, stated, "Process of Care: The RN will: B. Document a plan of care for the management of immediate problems within 12 hours of admission." Further review revealed that the policy states, "Procedure: C. Review and update the care plan weekly."

On 12/3/14 at approximately 1530 during review of the policy titled, "Interdisciplinary Team Care Conference/Meeting," with a revision date of October 2013, stated, "Procedure: I. An IDT (Interdisciplinary Team) meets at least once, within seven (7) calendar days of a patient's admission and then at least weekly."