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Based on document review, it was determined that the governing body failed to ensure that the members of the medical staff were appointed and reappointed.

Findings include:

Reference #1: The Medical Staff Bylaws Rules and Regulations Article IV stated, "Procedures for appointmant and Reappointment-Section 2, Application of Initial Appointment, 4.8 Notice of Final Decision. 4.8.1. Notice of the Board's final decision shall be given, through the Medical Executive and the Credentials Committee and the Medical Director. The applicant shall be notified by means of a special note."

Reference #2: The facility's Medical Staff Bylaws Rules and Regulation stated, "Reappointments. Reappointments to any category of the Medical staff shall be for a period of not more than two (2) years ..."

1. On 11/22/10, Personnel File #15 lacked evidence of the special note for initial appointment to the medical staff in 2008 by the Board. This was not in accordance with the above policy.

2. On 11/22/10, Personnel Files #14, #16 and #17 lacked evidence of reappointment to the medical staff beginning 2009 by the Board.

3. Interview with Staff #1 indicated that a notice of appointment is only sent upon the initial appointment. Interview with Staff #13 confirmed that the governing body meeting minutes/med executive committee minutes lacked a listing of physicians appointed to the medical staff for 2009.

Based on medical record review and review of facility policy and procedure, it was determined that the governing body failed to ensure the medical staff implemented the facility's policy and procedure for Do Not Resuscitate in three of three medical records reviewed (medical records #9, #15, and #21).

Findings include:

Reference: Facility policy and procedure titled 'Do Not Resuscitate (DNR)' states "... PROCEDURE: ... 1. The physician during the initial exam of the patient will follow up on the Admission Advance Directive inquiry and will discuss the facility's DNR policy if the patient and/or responsible party has identified their intent by means of an Advance Directive, or if the patient's current medical situation is or has the potential to cause demise of the patient. 2. This discussion will be documented in the physician's progress notes."

1. On 11/23/10, review of three medical records for DNR orders indicated the following:

a. In Medical Record #9 a telephone physician order for DNR dated and timed 11/10/10 8:30 PM.

b. In Medical Record #15 a physician order for DNR dated and timed 10/29/10 4 PM.

c. In Medical Record #21 a physician order for DNR dated and timed 11/18/10 11:30 AM.

2. Medical records #9, #15, and #21 lacked evidence of a physician's discussion of the DNR with the patient and/or responsible party, in the physician's progress notes, as per policy.

Based on interview and document review, it was determined that the facility failed to ensure that contracted services were evaluated.

Findings include:

1. On 11/22/10 interview with Staff #1 confirmed that the contracted services of laboratory and radiology were not incorporated in the quality assessment and performance improvement evaluation.

Based on document review, it was determined that the facility failed to ensure that clinical reappointment privileges were granted according to the medical staff bylaws rules and regulations.

Findings include:

Reference: The facility's Medical Staff Bylaws Rules and Regulation stated,
"5.1 Information Form for Reappointment, At least sixty (60) days prior to the expiration date of the present staff appointment, each Medical Staff member will be provided with an interval information form for use in considering reappointment. Each staff member who desires reappointment shall, at least thirty (30) days prior to such expiration date, send his/her Reappointment Application along with a list of requested clinical privileges...
5.6 Time Periods for Processing. Transmittal of the interval information form to a staff member and his/her return of it shall be carried out within ninety (90) days. Thereafter and except for good cause, each person, department and committee required by these Bylaws to act thereon shall complete such action in timely fashion such that all reports and recommendations concerning the reappointment of a staff member shall have been transmitted to the Medical Executive Committee for its consideration and action and to the Board for its action, all prior to the expiration date of the staff membership of the member being considered for reappointment."

1. On 11/23/10 review of 3 physician's files for clinical reappointment revealed the following:

a. Staff #16 completed a reappointment application on 9/25/08. The approved clinical privileges were signed the Medical Chairman on 8/3/09.

b. Staff #17 completed a reappointment application on 9/25/08. The approved clinical privileges were signed by the Medical Chairman on 8/31/09.

c. Staff #14 had reappointment letter from 1/2007 thrugh 12/08. A reappointment application was completed and approved, however, both dates of reapplication and approval of priviledges were illegible.

2. The above process was not followed in the appropriate time frame required. This was confirmed with Staff #13.

3. These physicians were practicing without being reappointed and without being granted clinical privileges.

A. Based on 3 of 3 medical records reviewed (#1, #6, and #8) and interview, it was determined that the facility failed to ensure that Registered Nurses (RNs) supervised and evaluated the nursing care of patients receiving enteral feedings.

Findings include:

1. On 11/22/2010 review of Medical Record #1 indicated a physician order dated 10/27/2010 for "Residual every 4 hours HOB (height of bed) >(greater than)30 circle (degree)." Review of the patient's daily flow sheet from 11/9/2010 to 11/21/2010 revealed that the patient was receiving continuous enteral feeding. There was no evidence that residual of the feeding was checked every 4 hours, as required.

2. On 11/22/2010 review of Medical Record #6 indicated a physician order dated 9/7/2010 for "Residual every 4 hours HOB (height of bed) >(greater than)30 circle (degree)." Review of the patient's daily flow sheet from 9/8/2010 to 9/24/2010 revealed that the patient was receiving continuous enteral feeding. There was no evidence that residual of the feeding was checked every 4 hours, as required.

3. On 11/22/2010 review of Medical Record #8 indicated a physician order dated 7/9/2010 for "Residual every 4 hours HOB (height of bed) >(greater than)30 circle (degree)." Review of the patient's daily flow sheet from 7/10/2010 to 7/30/2010 revealed that the patient was receiving continuous enteral feeding. There was no evidence that residual of the feeding was checked every 4 hours, as required.

B. Based on 3 of 3 medical records reviewed (#6 #18, and #8) and interview, it was determined that the facility failed to ensure that Registered Nurses (RNs) supervised and evaluated the nursing care of patients receiving wound care.

Findings include:

Reference: The facility's Skin Integrity/Wound Care Program policy stated, "Policy Statement: 5. Skin assessments are to be completed weekly on all patients to assess for skin integrity and development of new pressure ulcers."

1. On 11/23/2010 review of Medical Record #6 indicated an initial wound assessment dated
9/8/2010 for an "abdominal wound/sx (surgery) site," and a "L (left) buttocks, Stage 3 Pressure Ulcer." The Weekly Wound Assessment form for the abdominal wound had two sets of entries without a date or a signature. The Weekly Wound Assessment form for the "L buttocks" had only one set of entries without a date or a signature. The patient was transferred on 9/24/10. There was no evidence that the above referenced policy was followed in view of incomplete documentation.

2. On 11/23/2010 review of Medical Record #8 indicated an Initial Wound Assessment dated 7/9/2010 for the following skin/pressure ulcers: "L (left) hip, Pressure Ulcer, Stage 2 (blister/partial thickness); R (right) outerside of foot 3 necrotic areas, Pressure Ulcer, Unstageable; R (right) Heel, Pressure Ulcer, Stage 2; L outer aspect of foot, Pressure Ulcer, Unstageable; R hip, Pressure Ulcer, Stage 2." There was no evidence in the medical record that the above ulcers were measured weekly. The patient expired on 7/31/10.

3. On 11/23/2010 review of Medical Record #18 indicated an initial wound assessment dated 7/23/2010 for an "Abd (abdominal) wound surgical," and "Stage III (illegible) noted on sacrum." The abdominal surgical wound was documented as being reassessed on the Weekly Wound Assessment on "7/26 and 8/24" and on a second sheet on "8/6 and 8/20." The assessments were not done weekly as required in the above referenced policy. The sacral ulcer was documented as being reassessed on the Weekly Wound Assessment on "7/26, 8/4 and 8/16," and on a second sheet on "8/6." The assessments were not done weekly, as required in the above referenced policy.

Based on 3 of 3 medical records reviewed for authentification of verbal orders, it was determined that the facility failed to ensure that verbal orders were authenticated within 48 hours of being given.

Findings include:

1. On 11/22/10 review of Medical Record #1 indicated a telephone order dated 11/10/10 and 11/11/10 that were not authenticated by the prescriber within 48 hours of being given.

2. On 11/22/10 review of Medical Record #5 indicated telephone orders dated 7/1/10 (#3), 7/2/10 (#2), 7/4/10 (#3), 7/5/10 (#1), and 7/7/10 (#4) that were signed by the prescriber. However, it lacked the date and time they were signed. Therefore, it could not be determined if the verbal orders were signed within 48 hours of being given.

3. On 11/22/10 review of Medical Record #6 indicated a telephone orders dated 9/710, 9/9/10, 9/16/10, 9/17/10, 9/18/10, and 9/23/10 that were signed by the prescriber. However, it lacked the date and time they were signed. Therefore, it could not be determined if the verbal orders were signed within 48 hours of being given.









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B. Based on medical record review, and review of facility policy and procedure, it was determined that the facility failed to authenticate all telephone orders within 48 hours.

Findings include:

Reference: Facility policy and procedure RB-MR, titled 'TIMELINESS OF MEDICAL RECORD DOCUMENTATION' states "POLICY: ... The entire medical record must be completed within 30 days of discharge. PROCEDURE: The following significant clinical information shall be documented within the following required timeframe: Clinical Information: ... Telephone Orders Required Time Frame: ... within 48 hours of receipt ... Detailed Requirements ... 4. Telephone Orders: All treatment orders must be entered into the patient's medical record with time, date, and signature by the responsible physician. All telephone orders must be authenticated within 48 hours of receipt."

1. On 11/24/10 three medical records were reviewed for Code Blue procedures (Medical Records #5, #22, and #24). Upon review, it was noted that all telephone orders were not signed, dated and timed by the authorizing physician as follows:

a. Medical Record #5 contained 23 telephone orders on the 'Physician Orders' forms. All 23 telephone orders were signed by the physician without a date and time of his/her signature entry.

b. Medical Record #24 contained 9 telephone orders on the 'Physician Orders' forms.

i. Five of the orders were signed by the physician without indication of the date and time of his/her signature entry.

ii. Two of the orders were signed by the physician without indication of the time of his/her signature entry.

iii. Two were not signed, dated or timed.

2. Without indication as to the date and time of the physician's signature entry, it could not be determined if the telephone orders were signed within 48 hours as per facility policy and procedure.

Based on observation, document review and staff interview conducted on 11/22/10 it was determined that the facility failed to ensure that controlled dangerous substances were obtained in accordance with facility policy.

Findings include:

1. During controlled drug reconciliation, a plastic bag, containing 6 unit dosed Percocet, was found stapled to a yellow controlled drug record sheet numbered 172713 and dated 10/17/10. The record sheet was not the form utilized by the facility. Neither the form nor the bag had a pharmacy label. Upon interview, Staff #3 stated that it appeared that the Percocet had been dispensed by the host hospital pharmacy. He/she stated that the facility did not have a policy and procedure addressing obtaining stock controlled substances from the host hospital because that was not the appropriate way of obtaining stock controlled medications and that facility policy allowed for stock controlled medications to be obtained only from the provider pharmacy. He/she was unable to provide the surveyor with a DEA 222 form indicating that the Percocet had been obtained from the host hospital.

Based on observation, document review and staff interview conducted on 11/22/10 it was determined that the facility failed to ensure that medications are dispensed in accordance with physician's medication orders and that the pharmacy has a system in place to reconcile medications that remain in the patient's medication drawer when the pharmacy restocks patient medications and to dispense medications in accordance with facility policies.

Findings include:

1. At 10:55 AM the contents of Patient #13's medication cassette drawer was compared to the patient's medication administration record (MAR). Levaquin 750mg, which had been discontinued after the 11/9/10 dose on the MAR was found in the medication cassette drawer. Review of physicians' orders confirmed that the last dose of Levaquin should have been on 11/9/10 (order was discontinued). Staff #7 stated that the provider pharmacy still had an active order for Levaquin 750mg for the patient. The provider pharmacy had failed to reconcile the patient's medication profile with the facility to determine why the medication had been returned in the patient's medication cassette drawer for approximately 11 days. Upon interview Staff #7 confirmed that the pharmacy did not have a mechanism in place to address medications are were not administered.

2. At 11:00 AM the contents of Patient #15's medication cassette drawer was compared to the patient's medication administration record (MAR). Zyprexa 5mg was found in the "as needed" section of the cassette drawer. The medication had been discontinued on the MAR on 11/19/10. Review of the physicians' orders revealed that the physician had ordered "Hold Zyprexa." Upon interview, Staff #3 stated that the facility policy was to discontinue any "hold medication" orders. Upon interview, Staff #7 stated that the pharmacy had not discontinued the medication because the provider pharmacy did not routinely discontinue "hold medication" orders. The pharmacy failed to dispense medications in accordance with the facility's approved policies and procedures.

Based on staff interviews, observations, and document review, it was determined that the dietitian failed to ensure that all the Dietitian's "Duties & Responsibilities" are implemented as written in the Position Description for "Dietitian," signed and dated by the dietitian on September 7, 2010.

Findings include:

Reference 1: The "Dietitian," position description dated 9/7/10 states that the dietitian "1. Plans, develops, organizes, implements, evaluates and directs the Nutrition Services Department, its programs and activities. 2. Coordinates nutrition services and activities with other related departments. 3. Develops and maintains written dietary policies and procedures."

Reference 2: The "Provision of Food & Nutrition Services" policy and procedure states, the "Rehabilitation Hospital Nutrition Service at Raritan Bay Medical Center provides patient services that include: Admitting patient into RBMC dietary computer system (CBORD),... Collecting/correcting menus, Entering menu selections to prepare patient tray tickets."

Reference 3: The "Maintaining Menu Files on Units & Book Menu" policy and procedure states, "1. Dietitian will provide patient or family with a one week supply of menus. 2. Assemble book menus by clipping together one copy of each of the appropriate daily menus; deliver to individual patient and/or family member as requested. 3. Collect menus prepared by family members of staff left at patients bedside. Dietitian will fax the book menus to Food & Nutrition Services at Raritan Bay Medical Center."


1. On 11/22/10 at 10:30 AM, Staff #5, Staff #7 and Staff #11 stated that the facility on November 2nd implemented a new room service menu ordering system utilizing "Health Touch " technology. The dietitian visits the patients daily and obtains the patient menu/meal choices. The meal choices are entered into a hand held "Health Touch" device. The dietitian takes this devise back to the food service department and then imports the meal choices into the meal planning and distribution system.

a. On 11/22/10 at 10:30 AM, Staff #5 was asked to provide the policies and procedures for the new room service menu ordering system utilizing "Health Touch" technology. Staff #5, stated and confirmed that the policies and procedures to reflect the new meal ordering system are not available since they were not developed.

b. On 11/22/10 at 10:30 AM, the policies and procedures "Provision of Food & Nutrition Services" (see Reference 2) and the "Maintaining Menu Files on Units & Book Menu" (see Reference 3) were reviewed with Staff #5. Staff #5 stated and confirmed that the meal ordering procedures had changed effective November 2, 2010. Staff #5 confirmed the observation that the policies and procedures were not revised and updated to reflect the new meal ordering system.

2. All the above was confirmed by Staff #5 and Staff #9 on 11/23/10 at 10:00 AM.

Based on staff interviews and medical record review, it was determined that the physicians failed to write specific dietary orders for each patient.

Findings include:

1. On 11/23/10 at 10:30 AM, two of two medical records, Medical Record #14 and Medical Record #20, contained non specific enteral/tube feeding orders.

a. Medical Record #14, in the presence of Staff #9 was observed to contain the following non-specific enteral/tube feeding orders:

i. "Restart GT (gastric tube) feedings at 20 ml/hr & then advance as tolerated in 24 hrs," signed and dated by the physician on 11/09/10.

ii. "Resume GT feeding 45 ml/hr," signed and dated by the physician on 11/11/10.

iii. "Restart feeding at 30 ml/hr," signed and dated by the physician on 11/19/10.

iv. "Increase feeding rate up to 50 ml/hr," signed and dated by the physician on 11/20/10.

2. Medical Record #20, in the presence of Staff #9 was observed to contain the following non-specific enteral/tube feeding order:

i. "Change tube feeds from 8 P-7 AM at 60 ml/hr," signed and dated by the physician on 11/11/10.

3. On 11/23/10 at 2:30 PM, Staff #5 and Staff #9 confirmed that the physician failed to write specific diet orders for the enteral/tube feedings. The enteral/tube feeding orders failed to contain the name of the enteral formula, rate, goal rate, route and method of delivery.

4. All the above was confirmed by Staff #5 and Staff #9 on 11/23/10 at 2:30 PM.

Based on observation, it was determined that the facility failed to maintain the hospital environment.

Findings include:

1. On 10/22/10, at 10:15 AM, with Staff #4, in the soiled utility room, the sink could not be used due to the bowl being filled with paper trash and a sharps container.

Based on observation, review of facility policies and procedures, and staff interview it was determined that the facility failed to implement it's policies and procedures for Clostridium Difficile (C-diff) and Contact Precautions, and infection prevention and control precautions, such as current CDC guidelines and recommendations.

Findings include:

Reference #1: Facility policy and procedure RB-IP , titled 'Clostridium Difficile (C-diff)' state , "POLICY: It is the most commonly identified cause of hospital acquired diarrhea. The major reservoirs are infected patients and the hospital environment. Because of C-difficile's ability to form spores, it can persist in the environment for weeks or months and can be resistant to cleaning. ... PROCEDURE: ... 5. Staff will wear cover gowns when cleaning incontinent patients. ... 8. ... the Contact Precautions signs will be posted outside of the patient rooms and marked with a green dot to alert staff about C. diff precautions."

Reference #2: Facility policy and procedure RB-IC, titled 'CONTACT PRECAUTIONS' states "POLICY: Used for patients who are infected with organisms that are transmitted by direct skin to skin contact or by indirect contact environmental surfaces, or patient care items. ... PROCEDURE: ... 2. Gowns are indicated if soiling is likely. 3. Gloves are indicated if soiling is likely and when touching infective material. 4. Masks are indicated if patient is coughing, sneezing, or being suctioned.

Reference #3: 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, http://www.cdc.gov/hicpac/pdf/isolation/Isolation 2007.pdf states "... III.B.1. Contact Precautions ... Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. ..."

1. On 11/22/10 10:15 AM in the presence of Staff #3, the LTACH unit was toured. A contact isolation sign with a green dot was observed outside of Room 235.

a. Per Staff #3, the green dot indicates that the patient in the room is on Contact Precautions for C-diff.

b. A Respiratory Therapist (RT) was observed in room #235 suctioning Patient #2. The RT was at the bedside with only gloves on. The RT did not have a gown on as indicated in reference #3 "for interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment", and/or as per reference #2 "by indirect contact environmental surfaces".

c. The RT also did not have a mask on as per reference #2, while he/she was suctioning Patient #2 in Room 235.

2. An RN was observed at the bedside of a Patient in Room 229 that had Contact Isolation sign posted outside the room [no green dot]. The RN was observed arranging the patient's sheets and handling patient items. The RN did not have gloves or a gown on.

a. Per Staff #3 on 11/22/10 at 10:30 AM, a gown is only indicated for Contact Precautions if soiling is likely. This does not correlate with the current CDC guidelines in reference #3 that indicates a gown and gloves are necessary for "...all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment."

3. A Contact Isolation sign was observed posted outside of Room #233. The patient was vomiting and a nurse was observed assisting the patient with an emesis basin at the bedside. The nurse was wearing gloves, but no gown.

4. A Contact Isolation sign with a green sticker, indicating the patient had C-diff, was observed outside Room #232. The patient's husband was observed at the bedside without a gown or gloves. He was observed sitting at the bedside and assisting his wife to drink with a straw out of a cup.

5. A Contact Isolation sign was observed posted outside of Room #229. A RT was observed suctioning a patient. The RT had gloves on, but no mask as per reference #2.