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On the days of the Recertification Survey based on interview, record review, and hospital policy review, the facility failed to ensure restraint orders were not written "as needed" (PRN) and that once the patient was removed from restraint that another restraint order was written to resume restraint for 1 of 5 closed patient records reviewed for restraints. (Patient #7)

The findings include:

A clinical record review conducted on 5/25/10 at 1335 revealed Patient #7 was admitted to the hospital on 12/23/09 and expired on 1/1/10 with the diagnosis of Respiratory Failure. A Restraint Order was initiated on 12/23/09 and renewed through 12/31/09. On 12/24/09, 12/25/09, 12/26/09, 12/27/09, and 12/28/09, the restraint order was written as, "B (Bilateral) Wrist, if necessary, only". On 12/26/09 and 12/27/09, the 24 HOUR RESTRAINT RECORD showed staff documented the restraint was "OFF" during the 10, 12, 14, 16, and 18 hours. Documentation showed the patient's restraint was reinstated at 2000 but there was no additional physician order written for restraint. During an interview with the Unit Manager on 5/26/10 at 1330, the Unit Manager reported, "It is not our practice to write restraint orders PRN. We have spoken with this practitioner regarding this issue previously".

Facility Policy #215-N, titled, "RESTRAINT INTERVENTIONS", revised 11/03, 7/07, states, "...C. Frequency of Assessment and Intervention...2. Restraint Use...b. The restraint order cannot be either a standing or a PRN order...".

On the days of the Recertification Survey based on interview, record review, and hospital policy review, the hospital failed to ensure discontinuation of restraint at the earliest possible time, and the accurate and complete assessment of the patient while restrained for 4 of 5 records reviewed with a potential to affect all patients in restraints. (Patient #7, 8, 10, and 15)

The findings include:

A clinical record review conducted on 5/25/10 at 1335 revealed Patient #7 was admitted to the hospital on 12/23/09 and expired on 1/1/10 with the diagnosis of Respiratory Failure. A Restraint Order was initiated on 12/23/09 and renewed through 12/31/09, but there was no documentation of restraint on the patient's Plan of Care. The hospital forms, titled, "24 HOUR RESTRAINT RECORD", dated 12/23/09 - 12/31/09, were inconsistently documented upon by the nursing staff.

A clinical record review conducted on 5/25/10 at 1430 revealed Patient #8 was admitted to the hospital on 12/9/09 and transferred on 12/17/09 with the diagnosis of Diskitis Requiring Long Term Intravenous Antibiotics. A restraint order was written on 12/16/09, but there was no documentation of the restraint on the patient's plan of care. There was no 24 hour restraint assessment by nursing within the clinical record.

A clinical record review conducted on 5/25/10 at 1500 revealed Patient #10 was admitted to the hospital on 11/5/09 and transferred on 11/11/09 with the diagnosis of Septic Shock. A restraint order was initiated on 11/5/09 and renewed through 11/11/09, but the 24 hour restraint records dated 11/5/09 - 11/10/09 were inconsistently documented upon by the nursing staff.

A clinical record review conducted on 5/26/10 at 1120 revealed Patient #15 was admitted to the hospital on 1/22/10 and expired on 2/2/10 with the diagnosis of Cardiopulmonary Arrest. A restraint order was initiated on 1/24/10 and renewed through 2/2/10 but there was no documentation of the restraint on the patient's plan of care. The 24 hour restraint records dated 1/27/10, 1/28/10, and 1/30/10 were inconsistently documented upon by the nursing staff. There were no 24 hour restraint records within the clinical record for 1/26/10 and 1/29/10.

Hospital Policy #215-N, titled, "RESTRAINT INTERVENTION", revised 11/03, 7/07, states, "...Guidelines...B. Accountability 1. It is the responsibility of the day shift Charge Nurse (RN) to: *obtain a physician's order for appropriate restraint This must be done every calendar day. *assure that the patient is monitored, *insure that safe and appropriate care is given, *monitor that all staff comply with these standards 2. It is the responsibility of the nurse caring for the patient to: *carry out patient care, *document according to this policy 3. An LPN (Licensed Practical Nurse) or Nurse Tech may apply a restraint under the supervision of the RN (Registered Nurse)...Standards of Practice A. Restraint Orders 1. Initiation in advance of a physician order. If the attending physician is not available, a registered nurse may initiate restraint in advance of a physician's order. *This action is to be documented in the Nurses Notes and Restraint Flow Sheet. *If restraint was necessary dur to a significant change in the patients condition, the physician shall be contacted immediately for a physician order. *Otherwise, the attending physician must be notified and a restraint order requested within 12 hours of its initiation. 2. Initial order. The attending physician shall perform a face-to-face assessment of the patient within 24 hours of the initiation of the restraint at which time he or she shall either discontinue or write an order for continuation of the restraint. 3. Reorder. The physician or his/her authorized designee shall perform face-to-face assessment of the patient at least once every calendar day, at which time restraint may be either reordered or discontinued as indicated. 4. An RN or LPN may receive, record and initiate a verbal order for a medical/surgical or emergency restraint. *If a verbal order is obtained, it shall be recording in the patient's Medical Record and will be signed by the physician within twenty-four (24) hours...".

During an interview with the Unit Manager on 5/26/10 at 1330, he/she was unable to locate the physician assessment of patient prior to restraint order, during restraint, and prior to renewal of restraint order within the medical record. It was also stated that there should be such an assessment within the record.

On the days of the Recertification survey based on interview, record review, and hospital policy review, the hospital failed to ensure that the nursing staff document the reassessment of pain, the condition of the patient during restraint, and restraint on the patient plan of care for 5 of 5 closed records reviewed for restraints. (Patient #7, 8, 10, 13, and 15)

The findings include:

A clinical record review conducted on 5/25/10 at 1335 revealed Patient #7 was admitted to the hospital on 12/23/09 and expired on 1/1/10 with the diagnosis of Respiratory Failure. A Restraint Order was initiated on 12/23/09 and renewed through 1/1/10, but there was no documentation of restraint on the patient's Plan of Care. The hospital form, titled, "PAIN ASSESSMENT FLOWSHEET" showed no documentation of a reassessment of the patient's pain on 12/29/09 and 1/1/10. The hospital form, titled, "24 HOUR RESTRAINT RECORD", dated 12/23/09 - 12/31/09 had inconsistent documentation by the nursing staff.

A clinical record review conducted on 5/25/10 at 1430 revealed Patient #8 was admitted to the hospital on 12/9/09 and transferred on 12/17/09 with the diagnosis of Diskitis Requiring Long Term Intravenous Antibiotics. A restraint order was written on 12/16/09, but there was no documentation of the restraint on the patient's plan of care, and there was no 24 hour restraint assessment by nursing within the clinical record.

A clinical record review conducted on 5/25/10 at 1500 revealed Patient #10 admitted to the hospital on 11/5/09 and transferred on 11/11/09 with the diagnosis of Septic Shock. There was no evidence of a patient care plan within the patient record. A restraint order was initiated on 11/5/09 and renewed through 11/11/09. The 24 hour restraint records dated 11/5/09 - 11/10/09 had inconsistent documentation by the nursing staff.

A clinical record review conducted on 5/26/10 at 1055 revealed Patient #13 admitted to the hospital on 1/14/10 and expired on 2/6/10 with the diagnosis of Acute Respiratory Failure with Mechanical Ventilation. The hospital form, titled, "PAIN ASSESSMENT FLOWSHEET" showed no documentation of a reassessment of the patient's pain on 1/17/10, 1/22/10, 1/26/10, and 1/28/10.

A clinical record review conducted on 5/26/10 at 1120 revealed Patient #15 admitted to the hospital on 1/22/10 and expired on 2/2/10 with the diagnosis of Cardiopulmonary Arrest. A restraint order was initiated on 1/24/10 and renewed through 2/2/10, but there was no documentation of the restraint on the patient's plan of care. The 24 hour restraint records dated 1/27/10, 1/28/10, and 1/30/10, had inconsistent documentation by the nursing staff. There were no 24 hour restraint records within the clinical record for 1/26/10 and 1/29/10.
The findings were verified by the Unit Manager on 5/26/10 at 1330.

On the days of the Recertification survey based on interview, record review, and hospital policy review, the hospital failed to ensure that the nursing staff document the restraint on the patient plan of care for 4 of 5 closed records reviewed for restraints. (Patient #7, 8, 10, and 15)

The findings are:

A clinical record review conducted on 5/25/10 at 1335 revealed Patient #7 was admitted to the hospital on 12/23/09 and expired on 1/1/10 with the diagnosis of Respiratory Failure. A Restraint Order was initiated on 12/23/09 and renewed through 1/1/10, but there was no documentation of restraint on the patient's Plan of Care.

A clinical record review conducted on 5/25/10 at 1430 revealed Patient #8 was admitted to the hospital on 12/9/09 and transferred on 12/17/09 with the diagnosis of Diskitis Requiring Long Term Intravenous Antibiotics. A restraint order was written on 12/16/09, but there was no documentation of the restraint on the patient's plan of care

A clinical record review conducted on 5/25/10 at 1500 revealed Patient #10 admitted to the hospital on 11/5/09 and transferred on 11/11/09 with the diagnosis of Septic Shock. There was no evidence of a patient care plan within the patient record. A restraint order was initiated on 11/5/09 and renewed through 11/11/09.

A clinical record review conducted on 5/26/10 at 1120 revealed Patient #15 admitted to the hospital on 1/22/10 and expired on 2/2/10 with the diagnosis of Cardiopulmonary Arrest. A restraint order was initiated on 1/24/10 and renewed through 2/2/10, but there was no documentation of the restraint on the patient's plan of care.

On the days of the Recertification Survey based on interview, clinical record review, and policy and procedure review the facility failed to ensure all patient clinical records were completed by containing the date and time in which physician's signed orders, consultation reports, operative notes, history and physical reports, transfer reports, and discharge summary reports for 9 of 15 closed records. (Patient #1, 3, 7, 8, 10, 11, 12, 13, and 15)

The findings include:

A clinical record review conducted on 5/25/10 at 1050 revealed Patient #1 was admitted to the facility on 12/18/09 and expired on 2/24/10 with the diagnosis of Respiratory Failure Requiring Mechanical Ventilation. The (H & P) History and Physical and the transfer summary dated and an addendum transfer summary were not dated by the physician upon etherification. Verbal Orders (VO)/Telephone Orders (TO) dated 12/18/09, 12/19/09, 1/7/10, 1/11/10, 1/13/10, 1/17/10, 1/19/10, and 2/19/10 were not dated when authenticated by the physician to ensure 24 hour timeframe for physician signature.

A clinical record review conducted on 5/25/10 at 1215 revealed Patient #3 was admitted to the facility on 11/13/09 and expired on 12/5/09 with the diagnosis of Cardiopulmonary Arrest. The History and Physical and the Discharge/Death Summary were not dated by the physician when authenticated. VO/TO dated 11/13/09, 11/15/09, 11/23/09, and 12/2/09 were not dated when authenticated by the physician to ensure 24 hour timeframe for physician signature.

A clinical record review conducted on 5/25/10 at 1335 revealed Patient #7 was admitted to the facility on 12/23/09 and expired on 1/1/10 with the diagnosis of Respiratory Failure. The History and Physical and the Discharge/Death Summary were not dated by the physician upon authenticated. VO/TO dated 12/23/09, 12/24/09, 12/28/09, and 1/1/10 were not dated when authenticated by the physician to ensure 24 hour timeframe for physician signature.

A clinical record review conducted on 5/25/10 at 1430 revealed Patient #8 was admitted to the facility on 12/9/09 and transferred on 12/17/09 with the diagnosis of Diskitis Requiring Long Term Intravenous Antibiotics. The History and Physical and the Transfer Summary were not dated by the physician when authenticated. VO/TO dated 12/9/09, 12/13/09, 12/14/09, 12/15/09, 12/16/09, and 12/17/09 were not dated when authenticated by the physician to ensure 24 hour timeframe for physician signature.

A clinical record review conducted on 5/25/10 at 1500 revealed Patient #10 was admitted to the facility on 11/5/09 and transferred on 11/11/09 with the diagnosis of Septic Shock. The History and Physical, Consultations, and Transfer Summary were not dated by the physician when authenticated. VO/TO dated 11/5/09, 11/10/09, and 11/11/09 were not dated when authenticated by the physician to ensure 24 hour timeframe for physician signature. There was no evidence of a care plan within the patient record.

A clinical record review conducted on 5/26/10 at 1015 revealed Patient #11 was admitted to the facility on 12/3/09 and expired on 12/30/09 with the diagnosis of Acute Respiratory Failure. The History and Physical and Discharge/Death Summary were not dated by the physician when authenticated. VO/TO dated 12/3/09, 12/6/09, 12/8/09, 12/10/09, 12/12/09, and 12/16/09 were not dated when authenticated by the physician to ensure 24 hour timeframe for physician signature.

A clinical record review conducted on 5/26/10 at 1040 revealed Patient #12 was admitted to the facility on 4/29/09 and transferred on 5/15/09 with the diagnosis of Acute On Chronic Respiratory Failure. The History and Physical, a Consultation, and Transfer Summary were not dated by the physician when authenticated.

A clinical record review conducted on 5/26/10 at 1055 revealed Patient #13 was admitted to the facility on 1/14/10 and expired on 2/6/10 with the diagnosis of Acute Respiratory Failure with Mechanical Ventilation. The History and Physical, a Consultation, and the Discharge/Death Summary were not dated by the physician when authenticated. A VO obtained on 2/6/10 was signed and dated on 2/11/10 which was greater than the 24 hour timeframe for physician signature. VO dated 1/15/10, 1/21/10, 1/26/10, 1/29/10, 2/1/10, and 2/4/10 were not dated when authenticated by the physician to ensure 24 hour timeframe for physician signature.

A clinical record review conducted on 5/26/10 at 1120 revealed Patient #15 was admitted to the facility on 1/22/10 and expired on 2/2/10 with the diagnosis of Cardiopulmonary Arrest. The History and Physical and Discharge/Death Summary were not dated by the physician when authenticated. The CODE BLUE FLOWSHEET (that occurred on 2/2/10) was not signed or dated by the physician. VO dated 1/25/10, 1/27/10, and 1/28/10 were not dated when authenticated by the physician to ensure 24 hour timeframe for physician signature.
The findings were verified by the Unit Manager on 5/26/10 at 1330.

On the days of the Recertification Survey based on interview, record review, and hospital policy review, the hospital failed to ensure that all verbal orders were authenticated within the 24 hour timeframe dictated by facility policy for 8 of 15 closed records. (Patient #1, 3, 7, 8, 10, 11, 13, and 15)

The findings include:

A clinical record review conducted on 5/25/10 at 1050 revealed Patient #1 was admitted to the facility on 12/18/09 and expired on 2/24/10 with the diagnosis of Respiratory Failure Requiring Mechanical Ventilation. Verbal Orders (VO)/Telephone Orders (TO) dated 12/18/09, 12/19/09, 1/7/10, 1/11/10, 1/13/10, 1/17/10, 1/19/10, and 2/19/10 were not dated when authenticated by the physician to ensure 24 hour timeframe for physician signature.

A clinical record review conducted on 5/25/10 at 1215 revealed Patient #3 was admitted to the facility on 11/13/09 and expired on 12/5/09 with the diagnosis of Cardiopulmonary Arrest. VO/TO dated 11/13/09, 11/15/09, 11/23/09, and 12/2/09 were not dated when authenticated by the physician to ensure 24 hour timeframe for physician signature.

A clinical record review conducted on 5/25/10 at 1335 revealed Patient #7 was admitted to the facility on 12/23/09 and expired on 1/1/10 with the diagnosis of Respiratory Failure. VO/TO dated 12/23/09, 12/24/09, 12/28/09, and 1/1/10 were not dated when authenticated by the physician to ensure 24 hour timeframe for physician signature.

A clinical record review conducted on 5/25/10 at 1430 revealed Patient #8 was admitted to the facility on 12/9/09 and transferred on 12/17/09 with the diagnosis of Diskitis Requiring Long Term Intravenous Antibiotics. VO/TO dated 12/9/09, 12/13/09, 12/14/09, 12/15/09, 12/16/09, and 12/17/09 were not dated when authenticated by the physician to ensure 24 hour timeframe for physician signature.

A clinical record review conducted on 5/25/10 at 1500 revealed Patient #10 was admitted to the facility on 11/5/09 and transferred on 11/11/09 with the diagnosis of Septic Shock. VO/TO dated 11/5/09, 11/10/09, and 11/11/09 were not dated when authenticated by the physician to ensure 24 hour timeframe for physician signature.

A clinical record review conducted on 5/26/10 at 1015 revealed Patient #11 was admitted to the facility on 12/3/09 and expired on 12/30/09 with the diagnosis of Acute Respiratory Failure. VO/TO dated 12/3/09, 12/6/09, 12/8/09, 12/10/09, 12/12/09, and 12/16/09 were not dated when authenticated by the physician to ensure 24 hour timeframe for physician signature.

A clinical record review conducted on 5/26/10 at 1055 revealed Patient #13 was admitted to the facility on 1/14/10 and expired on 2/6/10 with the diagnosis of Acute Respiratory Failure with Mechanical Ventilation. A VO dated 2/6/10 was signed and dated on 2/11/10 greater than the 24 hour timeframe for physician signature. VO dated 1/15/10, 1/21/10, 1/26/10, 1/29/10, 2/1/10, and 2/4/10 were not dated when authenticated by the physician to ensure 24 hour timeframe for physician signature.

A clinical record review conducted on 5/26/10 at 1120 revealed Patient #15 was admitted to the facility on 1/22/10, expired on 2/2/10 with the diagnosis of Cardiopulmonary Arrest. VO dated 1/25/10, 1/27/10, and 1/28/10 were not dated when authenticated by the physician to ensure 24 hour timeframe for physician signature.
The findings were verified by the Unit Manager on 5/26/10 at 1330

Hospital Policy #1201-12, titled, "Patient Care Orders", dated 12/98, revised 1/01, states, "...2. Telephone Orders:...2.3 Must be countersigned and dated within 24 hours by the physician...".

On the days of the Recertification Survey based on medical record review, and staff interview, the hospital failed to ensure the proper execution of informed consent for diagnostic treatment for 2 of 15 closed records. (Patient #11 and 13)

The findings include:

A clinical record review conducted on 5/26/10 at 1015 revealed Patient #11 was admitted to the facility on 12/3/09 and expired on 12/30/09 with the diagnosis of Acute Respiratory Failure. The hospital form, CONSENT FOR OPERATION, DIAGNOSTIC AND/OR TREATMENT PROCEDURES, dated 12/10/09, for a Peripherally Inserted Central Catheter, and 12/14/10 to Unclog or Replace a (PEG) Percutaneous Endoscopic Gastrostomy tube were not signed and dated by the physician.
A clinical record review conducted on 5/26/10 at 1055 revealed Patient #13 was admitted to the facility on 1/14/10 and expired on 2/6/10 with the diagnosis of Acute Respiratory Failure with Mechanical Ventilation. The hospital form, CONSENT FOR OPERATION, DIAGNOSTIC AND/OR TREATMENT PROCEDURES, dated 2/1/10, for Placement of Peripherally Inserted Central Catheter was not signed and dated by the physician. An interview with the Unit Manager on 5/26/10 at 1330 revealed the patient consent forms should have been signed by the performing physician on the date of the procedure.

On the days of the Recertification Survey based on interview and record review, the hospital failed to ensure that each clinical record contained a discharge summary which was completed within 30 days of discharge for 6 of 15 records reviewed. (Patient #1, 3, 7, 11, 13, and 15)

The findings include:

A clinical record review conducted on 5/25/10 at 1050 revealed Patient #1 was admitted to the facility on 12/18/09 and expired on 2/24/10 with the diagnosis of Respiratory Failure Requiring Mechanical Ventilation. The Addendum (Discharge Summary) was not dated by physician to ensure the 30 day timeframe for physician signature.

A clinical record review conducted on 5/25/10 at 1215 revealed Patient #3 admitted to the facility on 11/13/09 and expired on 12/5/09 with the diagnosis of Cardiopulmonary Arrest. The Discharge/Death Summary was not dated by the physician to ensure the 30 day timeframe for physician signature.

A clinical record review conducted on 5/25/10 at 1335 revealed Patient #7 admitted to the facility on 12/23/09 and expired on 1/1/10 with the diagnosis of Respiratory Failure. The Discharge/Death Summary was not dated by the physician to ensure the 30 day timeframe for physician signature.

A clinical record review conducted on 5/26/10 at 1015 revealed Patient #11 admitted to the facility on 12/3/09 and expired on 12/30/09 with the diagnosis of Acute Respiratory Failure. The Discharge/Death Summary was not dated by the physician to ensure the 30 day timeframe for physician signature.

A clinical record review conducted on 5/26/10 at 1055 revealed Patient #13 admitted to the facility on 1/14/10 and expired on 2/6/10 with the diagnosis of Acute Respiratory Failure with Mechanical Ventilation. The Discharge/Death Summary was not dated by the physician to ensure the 30 day timeframe for physician signature.

A clinical record review conducted on 5/26/10 at 1120 revealed Patient #15 admitted to the facility on 1/22/10 and expired on 2/2/10 with the diagnosis of Cardiopulmonary Arrest. The Discharge/Death Summary was not dated by the physician to ensure the 30 day timeframe for physician signature. The findings were verified by the Unit Manager on 5/26/10 at 1330.

On the days of the Recertification Survey based on interview and review of facility records, the hospital failed to have an Organ Procurement Agreement with an organization, nor did the hospital have an agreement with a tissue or eye bank.

The findings are:

On 05/25/10 at 1500, a review of facility records failed to show the hospital had an agreement with an organ procurement organization . On 05/25/10 at 1515, the Chief Clinical Officer verified the hospital does not have an agreement with an Organ Procurement Organization. He/She explained that most of their patients are not suitable for organ retrieval.

On the days of the Recertification Survey based on interview and review of facility records, the hospital failed to have an agreement with a tissue or eye bank.

The findings are:

On 05/25/10 at 1500, a review of facility records failed to show the hospital had an agreement with an organ procurement organization, or a designated tissue and eye bank to provide services for donations. On 05/25/10 at 1515, the Chief Clinical Officer verified that the hospital does not have an agreement with an Organ Procurement Organization, nor a designated eye or tissue bank. He/She explained that most of their patients are not suitable for organ retrieval.

On the days of the Recertification survey based on record review and interview, the facility failed to ensure that Physician Orders were obtained for all Rehabilitation Services provided to the patients for 15 of 35 patient records reviewed, and there were no Physician orders for the Rehabilitation Services provided. (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15)

The findings are:

Record review for Patient # 5 on 5/26/10 revealed an Admission Date of 5/19/10 and a diagnosis of Sacral Decubitus. The Physician ordered an evaluation by Physical Therapy on 5/19/10. Physical Therapy performed an evaluation on 5/20/10. Then, Physical Therapy developed a care plan to see the patient 5 times a week for 8 weeks without documentation Physician orders or Physician involvement. The Physician ordered an evaluation by Occupational Therapy on 5/12/10. Occupational Therapy performed an evaluation on 5/12/10. Occupational Therapy developed a care plan to see the patient 5-6 times a week for 2-8 weeks without further Physician orders or Physician involvement. The Physician ordered an evaluation by Speech Therapy on 5/12/10. Speech Therapy performed an evaluation and then, proceeded to order Dysphagia therapy and a Modified Barium Swallow Study immediately without documentation of consulting with the physician.

Record review for Patient #6 on 5/26/10 revealed an Admission Date of 5/18/10 and a diagnosis of Ischial Osteomyelitis. The Physician ordered an evaluation by Physical Therapy on 5/18/10. Physical Therapy performed an evaluation on 5/19/10. Physical Therapy discharged the patient but there was no notification of discharge to the Physician found in the chart. The Physician ordered an evaluation by Occupational Therapy on 5/18/10. Occupational Therapy performed an evaluation on 5/19/10. Occupational Therapy developed a care plan to see the patient 3 times a week for 2-4 weeks but there was no documentation Physician orders or Physician involvement in the plan of care.

Record review for Patient #7 on 5/26/10 revealed an Admission Date of 5/7/10 and a diagnosis of Paraspinal Abscess. The Physician ordered an evaluation by Physical Therapy on 5/7/10. Physical Therapy performed an evaluation on 5/7/10. Physical Therapy developed a care plan to see the patient 6 times a week for 6 weeks without documentation of Physician orders or Physician involvement. The Physician ordered an evaluation by Occupational Therapy on 5/7/10 and Occupational Therapy performed an evaluation on 5/8/10. Occupational Therapy developed a care plan to see the patient 3 times a week for 1 weeks without documentation of Physician orders or Physician involvement.

Record review for Patient #8 on 5/26/10 revealed an Admission Date of 5/4/10 and a diagnosis of Osteomyelitis. The Physician ordered an evaluation by Physical Therapy on 5/4/10. Physical Therapy performed an evaluation on 5/4/10. Physical Therapy developed a care plan to see the patient 6 times a week for 12 weeks without documentation of Physician orders or Physician involvement.

Record review for Patient # 9 on 5/26/10 revealed an Admission Date of 4/14/10 and a diagnosis of Chronic Lower Back Pain at Lumbar 4-5. The Physician ordered an evaluation by Physical Therapy on 4/14/10. Physical Therapy performed an evaluation on 4/14/10. Physical Therapy developed a care plan to see the patient 5 times a week for 12 weeks, without documentation of Physician orders or Physician involvement. The Physician ordered an evaluation by Occupational Therapy on 4/14/10. Occupational Therapy performed an evaluation on 4/14/10. Occupational Therapy developed a care plan to see the patient 5 times a week for 2-8 weeks without documentation of Physician orders or Physician involvement.

Record review for Patient # 10 on 5/26/10 revealed an Admission Date of 5/17/10 and a diagnosis of Medical Management. The Physician ordered an evaluation by Physical Therapy on 5/17/10. Physical Therapy performed an evaluation on 5/18/10. Physical Therapy developed a care plan to see the patient 5 times a week for 8 weeks without documentation of Physician orders or Physician involvement. The Physician ordered an evaluation by Occupational Therapy on 5/17/10. Occupational Therapy performed an evaluation on 5/18/10. Occupational Therapy developed a care plan to see the patient 5-6 times a week for 2-8 weeks without documentation of Physician orders or Physician involvement.

Record review for Patient #11 on 5/26/10 revealed an Admission Date of 4/27/10 and a diagnosis of Peritonitis. The Physician ordered an evaluation by Physical Therapy on 5/12/10. Physical Therapy performed the evaluation on 4/27/10. Physical Therapy developed a care plan to see the patient 3 times a week for 3 weeks without documentation of Physician orders or Physician involvement. The Physician ordered an evaluation by Occupational Therapy on 5/12/10. Occupational Therapy performed an evaluation on 5/12/10. Occupational Therapy developed a care plan to see the patient 3 times a week for 3 weeks without documentation of Physician orders or Physician involvement.

Record review for Patient #12 on 5/26/10 revealed an Admission Date of 5/20/10 and a diagnosis of Medical Management. The Physician ordered an evaluation by Physical Therapy on 5/20/10. Physical Therapy performed an evaluation on 5/20/10. Physical Therapy developed a care plan to see the patient 5 times a week for 6 weeks without documentation of Physician orders or Physician involvement. The Physician ordered an evaluation by Occupational Therapy on 5/20/10. Occupational Therapy performed an evaluation on 5/21/10. Occupational Therapy developed a care plan to see the patient 5-6 times a week for 2-8 weeks without documentation of Physician orders or Physician involvement.

Record review for Patient #13 on 5/26/10 revealed an Admission Date of 5/11/10 and a diagnosis of Epidural Abscess. The Physician ordered an evaluation by Physical Therapy on 5/11/10. Physical Therapy performed an evaluation on 5/12/10. Physical Therapy developed a care plan to see the patient 5 times a week for 8 weeks without documentation of Physician orders or Physician involvement. The Physician ordered an evaluation by Occupational Therapy on 5/11/10. Occupational Therapy performed an evaluation on 5/12/10. Occupational Therapy developed a care plan to see the patient 5-6 times a week for 2-8 weeks without documentation of Physician orders or Physician involvement.
During an interview on 5/26/10 at 1530 with the Director of Rehabilitation, the Director confirmed that the current system for providing Rehabilitation Services bypasses the Physician, and no additional orders were acquired from the physician after the initial order for a rehabilitation evaluation.

Hospital policy, entitled, Patient Care Orders, dated 1/20/0,1 reads, " Non-routine patient care will be administered only as ordered by the number of medical staff responsible for the patient. Personnel who carry out physician orders have the responsibility to verify and/or question for clarification any order that is not thoroughly understood or is questionable." Hospital policy, entitled, .... Hospital of South Carolina Contractual Policy with Rehab Services, reads, "The rehabilitation staff works under the direction of the physicians/physician assistants/nurse practitioner to provide prescribed therapy services".









27544

On 05/26/10 at 1100, a review of Patient #4's record showed the patient was admitted on 05/18/10 with a diagnosis of Bilateral Ischial Osteomyelitis. The patient's chart revealed that on 05/18/10, the clinical record, titled, admission orders, read, "...17. Consult: Physical Therapy (PT), Occupational Therapy(OT)..." The order was signed by the Nurse Practitioner. Review of clinical record, titled, OT Therapy Initial Evaluation, dated 05/19/10, reads, ".... Frequency/Duration -3 times a week for 2-4 weeks. Treatment and Education Provided this Date: Evaluation By OT.... ". Services were provided by the Certified Occupational Therapy Assistant (COTA) on 05/24/10 and 05/25/10. Review of clinical record did not provide documentation that physician orders for these services were obtained from the physician.


28552

On 05/26/10 at 1430, a review of patient charts revealed that Patient #1 who was admitted 05/10/10 for Respiratory Failure had orders for consultation of rehabilitation service. The consultations were done and rehabilitation therapy implemented consult was written, but there was no documentation of physician orders for subsequent treatment following consultation.

On 05/26/10 at 1430, during review of patient charts, it was revealed that Patient #2 admitted 05/24/10 for Respiratory Insufficiency had orders for consultation of rehabilitation service. The consultations were done and rehabilitation therapy implemented, but there was no documentation of physician orders for subsequent treatment following consultation.

On 05/26/10 at 1430, during review of patient charts, it was revealed that Patient #3 admitted 05/05/10 for Respiratory Failure had orders for consultation of rehabilitation service. The consultations were done and rehabilitation therapy implemented, but there was no documentation of physician orders for subsequent treatment following consultation.

On 05/26/10 at 1430, during review of patient charts, it was revealed that Patient #14 admitted 05/19/10 for Respiratory Failure had orders for consultation of rehabilitation service. The consultations were done and rehabilitation therapy implemented, but there was no documentation of physician orders for subsequent treatment following consultation.

On 05/26/10 at 1430, during review of patient charts, it was revealed that Patient #15 admitted 05/11/10 for Respiratory Failure had orders for consultation of rehabilitation service. The consultations were done and rehabilitation therapy implemented, but there was no documentation of physician orders for subsequent treatment following consultation.