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Based on record review and interviews, the hospital failed to implement its policy and procedure for prompt resolution of patient grievances as evidenced by failure to document the investigation performed to handle the grievance for 4 of 4 grievances reviewed (R1, R2, R3, R4) and failure to process a patient complaint as a grievance when it could not be resolved immediately (R2). Findings:

Patient R1
Review of the "Complaint/Grievance" form for Patient R1 revealed the complaint/grievance was received on 01/28/11 from Patient R1's daughter. Further review revealed the following documentation:
State Complaint/Grievance - "see attached" was documented;
Department Supervisor's Findings/Date: "see attached" was documented;
Action Taken (include date)" - "See attached" was documented;
Date Resolved: 02/01/11;
Date Response Letter Mailed: 01/31/11;
Findings of the Committee: no documentation written in blanks;
Actions/Recommendations: "appropriate actions taken; no further recommendations"; Department Manager/Date: signature of Administrator S1 dated 02/01/11.

Review of the attached e-mail sent by Administrator S1 to Social Worker S9 and copied to DON (director of nursing) S2 on 01/30/11 at 6:34am revealed S1 had received a call from a family member of Patient R1 related to conversations the family member had with a hospital employee that did not make her feel comfortable with the care at the hospital, and she also complained about her father not being turned every two hours. Further review revealed S1 asked Social Worker S9 to document a grievance for him on Patient R1. Further review of the e-mail revealed actions taken included a meeting on 01/12/11 with the employee mentioned above. There was no documented evidence who had written the complaint information, the action taken, and there was no investigation related to not turning the patient every two hours.

Review of the response letter dated 01/31/11 to Patient R1's daughter signed by Administrator S1 revealed that formal interviews had been conducted with staff members, administrative members, and the medical director. There was no documented evidence of formal interviews with the administrative members and the medical director. The "Complaint/Grievance" form revealed the grievance was resolved on 02/01/11, the day after the letter of response was sent to the complainant.

In a face-to-face interview on 08/19/11 at 9:05am, Administrator S1 indicated he thought the information that was present on the e-mail had been cut and pasted onto this e-mail by Social Worker S9. S1 further indicated he couldn't be sure, but he thought the action taken that was typed onto the e-mail was done by DON S2. S1 confirmed there was no way to determine who had done what, because there was no documentation of dates, times, and signatures of the individuals completing the investigation. S1 further confirmed there was no investigation into the complaint that Patient R1 had not been turned every two hours.

Patient R2
Review of Patient R2's "Complaint/Grievance" form revealed a complaint was received on 06/28/11 at 6:30pm from the spouse of Patient R2. Further review revealed the complaint was related to the nursing assistant's agitation and rude statement after being called three times for assistance after bowel movements. There was no documented evidence who wrote or received the complaint.

Review of the department supervisor's findings dated 06/30/11 revealed Patient R2's spouse spoke with the author of this note, and the author spoke with the LPN (licensed practical nurse) and the nursing assistant. There was no documented evidence of the signature of the individual who wrote this note and documentation of the dates and times the interviews were held with the LPN and the nursing assistant. Further review revealed the complaint was resolved on 06/30/11, two days after the reported event.

In a face-to-face interview on 08/19/11 at 9:05am, Administrator S1 indicated the complaint should have been handled as a grievance, and thus a written response letter should have been sent to Patient R2's spouse.

Patient R3
Review of Patient R3's "Complaint/Grievance" form revealed Patient R1 reported on 06/22/11 that a night nursing assistant was exceptionally rude and verbalized her irritation at his frequent needs. Further review revealed no documented evidence who had documented this grievance. Further review revealed the department supervisor's findings included that she spoke with Patient R3 and his wife. There was no documented evidence who had written the supervisor's findings. Further review revealed the action taken was a meeting with the nursing assistant on 06/27/11 at 2:30pm, and there was no documented evidence of the signature of whom had met with the nursing assistant.

Review of the response letter sent to Patient R3 revealed it was written by Administrator S1 on 06/23/11, prior to the completion of the investigation as evidenced by the meeting with the nursing assistant being held on 06/27/11 at 2:30pm. Review of the "Complaint/Grievance" form revealed the grievance was resolved on 06/27/11.

In a face-to-face interview on 08/19/11 at 9:05am, Administrator S1 confirmed the letter of response was sent to Patient R3 prior to the conclusion of the investigation.

Patient R4
Review of Patient R4's grievance revealed an e-mail sent by Patient R4's daughter to Case Manager S4 on 06/02/11 at 10:15pm. Further revealed the complainant wished "to wage a formal complaint at the lack of communication, coordination and the fact that he was released in such serious condition with the staph infection still in place". Further review revealed no documented evidence that a "Complaint/Grievance" form had been documented by Case Manager S4.

Review of an e-mail sent by Case Manager S4 to Administrator S1 and DON S2 on 06/03/11 at 10:32am revealed the steps she had taken in following up with Patient R4's daughter. Further review revealed S4 had reported the grievance to the assistant administrator. There was no documented evidence of an investigation by the assistant administrator.

Review of the response letter sent to Patient R4's daughter by Administrator S1 on 06/08/11 revealed formal interviews had been conducted with staff members, administrative members, and the medical director. There was no documented evidence of such formal interviews.

In a face-to-face interview on 08/19/11 at 9:05am, Administrator S1 confirmed there was no investigation conducted, no preparation of the "Complaint/Grievance" form, and the response letter was not accurate.

Review of the hospital policy titled "Patient / Family Grievance", policy number 11-4.0.0 revised 10/08 and submitted by Administrator S1 as their current policy for grievances, revealed, in part, "... The procedure will also allow for investigation, identification of the problems/issues, and development of a corrective action plan to prevent reoccurrence, as well as tracking and trending to provide the hospital with patient feedback and measure patient satisfaction. ... Verbal complaints will be recorded on a confidential Complaint/Grievance Form by any staff member that takes the complaint. The Complaint/Grievance Form will include the nature of the complaint, the parties involved and the action plan for resolution. The staff member recording the complaint will initiate immediate measures to resolve the issue. Once the complaint is resolved, the completed form will be forwarded to the Resource Management Department, or designated representative, for any follow-up. If a complaint is not resolved immediately, then it will be addressed as a grievance. ... All verbal complaints that cannot be resolved at the time of the complaint by the staff present will be addressed as a grievance. ... A response to a grievance will be initiated (any action to begin the resolution process) within 24 hours during normal business hours, or the following business day if on the weekend. ... A grievance will be recorded on the Complaint/Grievance Form. The Complaint/Grievance Form will include a thorough description of the grievance and the parties involved. ... The hospital's Administrator/Assistant Administrator/Operations Officer will be responsible for the review, investigation and resolve of all patient grievances. In the resolution of the grievance, the hospital will provide a *written response of its decision within 7 days. The written response will identify the Administrator/Assistant Administrator/ COO (chief operating officer) as the contact person, the steps that will be taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of the completion of the process...".

Based on record reviews and staff interviews, the hospital failed to ensure the patient had the right to make informed decisions regarding his or her care as evidenced by failure to implement the policy for "Do Not Resuscitate (DNR)" for a patient's (#9's) DNR request for approximately 2 days after the DNR form was signed by the patient and witnessed by two (2) RNs (S30, S31) and by failure of the physician to provide documentation of a discussion with the patient or his/her representative explaining the basis for and the consequences of a DNR order. Findings were noted for 4 of 6 patients reviewed with a DNR order from a total of 20 sampled patients (#9, #6, #12, #13). Findings:

Patient #9: Review of the medical record revealed Patient #9 was admitted to the hospital on 07/11/11 with an admitting diagnosis of Panniculitis with Panniculectomy. Further review revealed the patient signed the hospital's "Patient Do Not Resuscitate (DNR) Status Acknowledgement Form" on 07/13/11 with 2 RN witnesses (S30RN, S31RN) at 11:40am (1140). Review of the "Physicians Progress Notes" dictated date of 07/15/11 at 04:50PM (4:50pm) and transcribed date of 07/16/11 at 10:45PM (10:45pm) read, "Patient #9 (named) is asking to have a DNR order placed on her chart". Review of the "Physician's Orders" dated/timed 07/15/11 at 1700 (5:00pm) read, "DNR". Further review of the record revealed no documented evidence that Patient #9's DNR request on 07/13/11 was followed by a physicians order untill 7/15/11 which was 2 days after being requested.

In a face-to-face interview on 08/18/11 at 1:55pm, S30RN confirmed the "DNR Acknowledgement Form" was signed by the patient (#9) and witnessed by 2 RNs, (S30, S31RN) on 07/13/11. She confirmed there was no physician's order written for Patient #9's DNR for 2 days, from 07/13/11 through 07/15/11. S30RN verified there was no documented evidence Patient #9 was a DNR from 07/13/11 through 07/15/11 as per policy. She confirmed there was no documentation the physician was notified of Patient #9's DNR request from 07/13/11 to 07/15/11. S30RN indicated the physician should have been notified within the hour of the patients informed decision regarding a DNR that same day, 07/13/11. S30RN indicated Patient #9's right to make an informed decision for a DNR status was not followed as per policy.

In a face-to-face interview on 08/18/11 at 2:45pm, S2DON confirmed the "DNR Acknowledgement Form" was signed by the patient (#9) and witnessed by 2 RNs, (S30, S31) on 07/13/11. S32DON indicated Patient #9's right to make an informed decision for a DNR status was not followed as per policy.

Patient #6: Review of Patient #6's medical record revealed he was admitted on 08/15/11 at 7:10pm with diagnoses of pneumonia, sepsis, and acute renal failure. Review of the "Admit Orders" revealed his code status was "Do Not Resuscitate". Review of the "Do Not Resuscitate (DNR) Acknowledgement Form" dated 08/16/11 at 8:00am revealed it was signed by Patient #6's spouse and witnessed by two staff members. Further review revealed no documented evidence Physician S21 had signed the form, and there was no documented evidence in the physician progress notes that S21 had a discussion with Patient #6 or his spouse regarding the basis for and the consequences of a DNR order. Review of Physician S21's H&P (history and physical) dictated on 08/16/11 revealed Patient #6 was awake, alert, and oriented times three. There was no documented evidence that Patient #6's spouse had medical power of attorney for him and should be the individual giving consent for a DNR order.

Patient #12: Review of Patient #12's medical record revealed she was admitted on 08/05/11 with diagnoses of acute respiratory failure, bilateral pulmonary emboli, malnutrition, myasthenia gravis, muscular dystrophy, hypertension, hyperlipidemia, and degenerative joint disease. Review of the "Admit Orders" revealed the code status was "Do Not Resuscitate". Review of the H&P dictated on 08/05/11 revealed "the patient wishes to continue fairly aggressive therapeutic measures...". Review of the "Do Not Resuscitate (DNR) Acknowledgement Form" dated 08/05/11 at 4:20pm revealed it was signed by Patient #12's son and witnessed by two staff members. There was no documented evidence that Patient #12's physician had signed the form, and there was no documented evidence in the physician progress notes that the physician had a discussion with the son regarding the basis for and the consequences of a DNR order.

Patient #13: Review of Patient #13's medical record revealed she was admitted on 06/23/11 with diagnoses of necrotic right leg ulcer, peripheral artery disease, and diabetes mellitus. Review of the "Admit Orders" revealed she was a full code. Review of Patient #13's "Nursing Admission History and Assessment" performed on 06/23/11 at 6:30pm revealed she had a living will but no copy was available for the chart, and she had a durable power of attorney for healthcare but no copy was available on the chart. Review of Patient #13's "Resource Management Initial Assessment" completed by Case Manager S4 on 06/24/11 at 9:35am revealed the patient did not have an advanced directive and did not wish to execute an advanced directive, thus she was a full code. Review of the physician progress notes revealed an entry by Physician S19 on -7/07/11 (no time documented) that "pt (patient) has living will ... she is DNR". Further review revealed no documented evidence of a discussion by S19 with Patient #13 or her representative of the basis for and consequences of a DNR. Review of the "Physician's Routine Orders" revealed a verbal order was received on 07/07/11 at 8:50am from Physician S19's partner for "DNR per pt request". Review of the "Do Not Resuscitate (DNR) Acknowledgement Form" dated 07/14/11 at 10:00am revealed it was signed by Patient #13 and witnessed by two staff members. There was no documented evidence that Physician S19 or his partner had signed the form. This surveyor was not able to determine by record review or interview why the order was given on 07/07/11 and the form was not prepared until 07/14/11.

In a face-to-face interview on 08/19/11 at 12:30pm, DON S2 confirmed the DNR policy was not followed for Patients #6, #12, and #13. S2 further confirmed the physicians did not sign any of the DNR acknowledgement forms.

Review of the hospital policy titled "Do Not Resuscitate", policy number 9-2.2.0 revised 10/10 and submitted by DON S2 as their current policy for DNR, revealed, in part, "...The purpose of this policy is to establish procedures when decisions concerning "Do Not Resuscitate" ("DNR") orders must be made. ... If the patient's attending physician determines that a DNR order is medically appropriate, the physician must then discuss the matter with the patient, explaining the basis for and the consequences of a DNR order. If the patient is incompetent, this discussion must be held with the patient's family or legal guardian. All such discussions must be noted in the patient's medical record. The DNR Acknowledgement Form may be used to document this discussion. The notation of such discussions shall include at least the following information: persons present, information conveyed by physician, date / time of conference with family and/or patient, and decision of family, patient and/or legal guardian...".

DNR Acknowledgement Form By Patient:
The patient must be informed of the specific processes of a DNR status and must express a clear understanding of the DNR status/order.
The patient must be alert, oriented X 3, and able to demonstrate an understanding verbally or in writing.
The form is completed (fill in blanks where appropriate), signed by the patient, and witnessed by two nurses (one of which is an RN). An RN and a social worker may act as as witnesses to a DNR
Acknowledgement Form. The patient's family and/or friends may NOT sign as witnesses.

There must be an order written under "Physician's Orders" in the chart. This may be done in one of two ways:
1) Physician/NP writes an order for DNR
2) An RN takes a verbal order from a physician/NP for a DNR and writes the order in the chart. Only RNs are allowed to take verbal orders for DNR.

When a valid DNR order is entered in the patient's chart, the unit nursing staff and ancillary personnel shall follow the order, a cardiopulmonary code will not be called if and when the patient suffers cardiac or respiratory arrest, and CPR will not be administered, a "DNR" sticker will be placed on the front of the chart for easy identification, and DNR code status will be represented on all nursing report sheets and communicated by staff during shift report.







25065

Based on record review and interview, the hospital failed to follow the advanced directive by failing to determine and document that the patient had a terminal condition and/or in a state of permanent unconsciousness before writing an order to make the patient a DNR (Do Not Resuscitate) for 1 of 5 patients (#14) with a DNR order out of a total of 20 sampled medical records. Findings:

Review of the medical record for Patient #14 revealed a 61 year old male admitted to the hospital on 07/29/11 with respiratory failure and was on ventilatory support.

Review of the "Advanced Directive Declaration" dated 06/27/11 for Patient #14 revealed.... I direct my attending physician to withhold or withdraw i.e. life sustaining treatment that serves only to prolong the process of dying, if I should be in a terminal condition or in a state of permanent unconsciousness. In addition, if I am in the description described above, I feel especially strong about the following forms of treatment: (Checked as "I Do" in the boxes next to the following statements) Want cardiac resuscitation. Want mechanical resuscitation. Want tube feeding. Want other artificial or invasive form of nutrition (food). Want blood or blood products. Want any form of surgery. Want any form of surgery. Want any invasive diagnostic test. Want kidney dialysis, Want antibiotics. All of this was to be done only until organ procurement was completed.

Review of the Power of Attorney for Patient #14 dated 07/10/11 revealed..... "The said Principal authorizes said Mandatory to make or control the decisions relating to the Principal's medical care, including the decision to have life-sustaining procedures withheld or withdrawn in an instance where the Appearer is diagnosed as having a terminal and irreversible condition to the full extent allowable under LSA-R.S. 40:1299.58.2, et seq.".

Review of a for titled "DO NOT RESUSCITATE (DNR) STATUS ACKNOWLEDGEMENT (Family) dated/timed 07/29/11 at 1738 (3:38pm) revealed... This is to certify that I/We have discussed the health status of Patient #14 with his/her physician. I/We request that in the event Patient #14's heart and breathing should stop, no person shall attempt to resuscitate Patient #14. I/We are aware that I/We can revoke the DNR status at any time by simply expressing my/our request verbally or in writing to Patient #14's physician.
I/We being of sound mind, do acknowledge this DNR status, understanding its full import, after thorough explanation by the doctor with an opportunity to ask all questions. It as signed by the designated Power of Attorney and Patient #14's mother and witnessed by two nurses of Louisiana Extended Care of Lafayette.

Review of the Physician's Progress Notes dated 07/29/11 through 08/17/11 revealed no documented evidence Patient #14 had been diagnosed with a terminal diagnosis or was permanently unconscious.

In a face to face interview on 08/19/11 at 12:30pm RN S2 DON (Director of Nursing) reviewed the chart and indicated the form "Do Not Resuscitate (DNR) Status Acknowledgement was not a hospital form, but rather one used by a particular physician group. After further review of the chart, S2 verified there was no documented evidence the physician had assessed Patient #14 to be terminal or with an irreversible condition. S2 indicated Patient #14 was weaned from the ventilator, is now ambulating and is expected to be discharged home.

Based on record review and interview the hospital failed to follow the Medical Staff By-Laws as evidenced by failing to suspend physicians with delinquent medical records greater than 60 days (S15, S16, S17, S18, S19, S20, S21) and require automatic resignation after 90 days (S22, S23, S24, S25) for 11 of 303 physicians on staff at the hospital. Findings:

Review of the "Chart Deficiency Listing By Physician", presented by RHIA (registered health information administrator) S8 as the current list of physicians who were delinquent with completion of medical records, revealed Physicians S15, S16, S17, S18, S19, S20, and S21 had medical records delinquent greater than 60 days and should be suspended according to the medical staff bylaws. Further review revealed Physicians S22, S23, S24, and S25 had medical records delinquent greater than 90 days and should have automatic resignation according to the medical staff bylaws.

In a face-to-face interview on 08/18/11 at 12:10pm, RHIA S8 indicated Physicians S22, S23, and S25 were currently suspended due to delinquent medical records. S8 further indicated no physician had been automatically resigned. After review of the dates of delinquency, S8 confirmed that Physician 25 had a medical record with a discharge date of 11/24/10 which was greater than 90 days, and he should be automatically resigned.

In a face-to-face interview on 08/19/11 at 8:15am, RHIA S8, after review of the delinquency data submitted to the surveyor on 08/18/11, confirmed that Physicians S15, S16, S17, S18, S19, S20, and S21 should be currently suspended and Physicians S22, S23, S24, and S25 should be automatically resigned. S8 indicated Physicians S15 and S16 were on vacation at the time they were due to be suspended, and the bylaws allowed for extension. After review of the medical records policy which stated that physicians "will not be placed on suspension while absent due to illness, vacation or leave of absence provided that the practitioner notified the Medical Staff Office prior to the practitioner's absence", S8 confirmed that Physicians S15 and S16 did not notify the Medical Staff Office of their vacation time as required by policy.

In a face-to-face interview on 08/19/11 at 9:50am, Administrator S1, after being presented the data from medical records on the delinquency of medical records, confirmed that Physicians S15, S16, S17, S18, S19, S20, and S21 should be currently suspended and Physicians S22, S23, S24, and S25 should be automatically resigned. S1 indicated that the system for suspension of physicians for delinquent medical records was not working. S1 further indicated the process needed to be taken out of the hands of administration and given to RHIA S8 to handle.

Review of the Medical Staff By-Laws dated April 2011 revealed....."B. Suspension: If the record is still Delinquent upon the lapse of the second notice, the Administrator shall suspend the practitioner's privileges. The practitioner will be notified of automatic suspension by phone, as well as by mail to his/her primary office. E. Automatic Resignation: 1. If a Delinquent medical record remind incomplete by ninety (90) days post discharge, the practitioner will be sent notice that the practitioner will be deemed to have automatically resigned from the Medical Staff and relinquished all privileges at the hospital....".




25065

Based on record review and interviews, the medical staff failed to ensure a medical history and physical examination (H&P) was completed and documented in the medical record no more than 24 hours after admission for 2 of 20 sampled patient records (#6, #7). Findings:

Patient #6
Review of Patient #6's medical record revealed he was admitted on 08/15/11 with a diagnosis of acinetobacter sepsis with necrotizing pneumonia. Review of the H&P revealed Physician S21 dictated the H&P on 08/16/11 at 6:46pm, and it was transcribed on 08/17/11 at 7:47am. There was no documented evidence the H&P was dictated, transcribed, and placed on Patient #6's medical record within 24 hours of admission.

Patient #7
Review of Patient #7's medical record revealed he was admitted on 07/28/11 for wound care and hyperbaric oxygen therapy evaluation and long term intravenous antibiotics. Review of the H&P revealed it was dictated and transcribed on 07/31/11, 3 days after admission.

In a face-to-face interview on 08/18/11 at 12:10pm, RHIA (registered health information administrator) S8 indicated checking for dictation and transcription of a H&P within 24 hours of admit was a quality indicator for the medical record department. S8 further indicated the June 2011 compliance rate was 85% (percent). S8 could offer no explanation for the H&Ps not being present on the patients' medical records within 24 hours of admission.

20177


Based on record review and interview, the registered nurse failed to ensure the supervision and evaluation of care provided to patients as evidenced by:

1. Failing to ensure comprehensive assessments were performed and completed on hospitalized patients including a) comprehensive assessments of wounds (Patient's #2, #6, #7, #10); b) the consistent monitoring of telemetry patients (Patient's #3, #5, #6, #14); c) the monitoring of patient weights as ordered (Patient's #3, #4, #5, #7, #14); and d) the consistent monitoring of vital signs (Patient's #6, #17); and 2) 2. Failing to notify the licensed practitioner of a change in a patient's condition (#7, #20). Findings were noted in the medical records of 10 of 20 sampled patients. Findings:

A) Comprehensive assessments of wounds (#2, #6, #7, #8, #10).

Patient #2: Review of Patient #2's medical record revealed the patient was admitted on 8/05/11 at 7:10 p.m. with a diagnosis of Infected Right Foot Abcess. Review of Patient #2's medical record revealed no documentation to indicate that a comprehensive assessment, to include measurements of the infected abcess on the patient's right foot, was performed upon admission to the hospital. Documentation revealed the initial measurements of the patient's right foot wound were not obtained until 8/11/11 which revealed the wound measured 2.5cm X 0.5cm. In an interview on 8/17/11 at 1:25 p.m., the Director of Nursing confirmed there was no documentation in the medical record to indicate that measurements were obtained on the patient's wound at the time of admission.

Patient #6: Review of Patient #6's medical record revealed he was admitted on 08/15/11 at 7:10pm with diagnoses of pneumonia, sepsis, and acute renal failure. Review of Patient #6's "Nursing Admission History and Assessment" performed on 08/15/11 at 2030 (8:30pm) revealed the integumentary assessment included a Stage I to the coccyx and bilateral forearm bruising. Further review revealed if a wound or surgical incision was present, the nurse was to "initiate "Wound Assessment" form. There was no documented evidence that the admitting RN had completed the "Wound Assessment" form or assessed the wound to the coccyx to include the wound type, size, presence or absence of undermining and tunneling, the appearance of the wound bed, the wound edges, the drainage odor, type, and amount, and the appearance of surrounding tissue. Review of the "Wound Assessment Form" and the "Wound Care Narrative Note" revealed Wound Care RN S6 assessed Patient #6's wound to the coccyx on 08/16/11 at 4:30pm as "coccyx with excoriation". There was no documented evidence of the type of wound and the stage of the wound.

Patient #7: Review of Patient #7's medical record revealed he was admitted on 07/28/11 with diagnoses of multiple infected wounds, stage IV sacral decubitus, left foot Osteomyelitis, paraplegic secondary to motor vehicle accident, right hip disarticulation, neurogenic bladder with suprapubic catheter, colostomy, and gastroesophageal reflux disease. Review of Patient #7's "Nursing Admission History and Assessment" performed on 07/28/11 at 1620 (4:20pm) revealed the integumentary assessment had a check mark to the box for "yes" indicating that Patient #7 had a wound or surgical incision. There was no documented evidence that the admitting RN had completed the "Wound Assessment" form or assessed the wound to the coccyx to include the wound type, size, presence or absence of undermining and tunneling, the appearance of the wound bed, the wound edges, the drainage odor, type, and amount, and the appearance of surrounding tissue. Review of the "Wound Assessment Form" and the "Wound Care Narrative Note" revealed Wound Care RN S6 assessed Patient #7's three wounds on 07/29/11. Further review revealed no documented evidence of the presence or absence of undermining and tunneling of the Stage II pressure ulcer to the left lateral foot and the type of wound to the left second toe as well as the type and amount of drainage. In a face-to-face interview on 08/19/11 at 12:30pm, DON S2 could offer no explanation for the wound assessments not being performed during the admission assessment.

Patient #10: Review of the Wound Assessment Form for patient #10 revealed the following: Wound # 1 to the right heel was staged as "PU" (pressure ulcer) on 08/07/11. Wound #2 to the Right buttock was staged as "PU" on 08/02/11 and 08/07/11. Wound #3 to the Left buttock was staged as "PU" on 08/02/11 and 08/07/11. Further review of the Wound Assessment Form revealed the document was signed by S33LPN. In an interview on 08/18/11 at 12:55 p.m. with S32DON (offsite campus "b") she stated that S33LPN was a certified wound care nurse and could stage wounds. She further stated that "PU" is not appropriate documentation for wound staging.

The hospital's policy/procedure titled "Patient Assessment/Reassessment" documents under the section of "Initial Patient Assessment" that "all wound dressings will be removed and wounds will be visualized, assessed, and measured". The policy/procedure also documents "...Patient Reassessment...Wound Reassessment: all wounds will be re-assessed at each dressing change and measured at least weekly and prn..."

B) Telemetry (#3, #5, #6, #14).

Patient #3: Review of the medical record for Patient #3 revealed a 44 year old male admitted to the hospital on 08/01/11 with respiratory failure and severe cardiomyopathy. Review of the Physician's Orders dated/timed 08/01/11 at 1655 (4:55pm) revealed an order for Telemetry. Review of the Telemetry documentation for Patient #3 revealed no documented evidence of a telemetry strip for 08/08/11- 7A shift; 08/12/11- 7A shift; 08/13/11 - 7A shift; 08/14/11 - 7A shift; 08/15/11- 7P shift and 08/17/11- 7A shift.

Patient #5: Review of the medical record for Patient #5 revealed a 55 year old female admitted to the hospital on 05/05/11 for pneumonia, weakness, debility and multiple decubitus. Review of the Physician's Orders dated 05/05/11 revealed an order for Telemetry. Review of the Telemetry documentation for Patient #5 revealed no documented evidence of a telemetry strip for 05/06/11- 7P shift; 05/07/11- 7P shift; 05/10/11 - 7A shift; 05/11/11 - 7A and 7P shifts; 08/15/11- 7P shift; 05/12/11- 7P shift; 05/13/11 - 7A shift; 05/14/11 - 7P shift; 05/15/11 - 7A shift and no documented evidence the nurse reviewed the strip on the 7P shift; 05/16/11 - 7A shift and no documented evidence the nurse reviewed the strip on the 7P shift; 05/17/11 and 05/18/11 7A and 7P shifts; 05/19/11 - 7P shift; 05/20/11 - no documented evidence the nurse reviewed the strip 7A; 05/21/11, 05/22/11, 05/23/11, 05/24/11 and 05/25/11 - &a and 7P shifts; and 05/26/11 no documented evidence the nurse reviewed the strip 7A shift.

Patient #6: Review of Patient #6's medical record revealed he was admitted on 08/15/11 at 7:10pm with diagnoses of pneumonia, sepsis, and acute renal failure. Review of the "Admit Orders" revealed an order for "Telemetry/cardiac monitor; place strip on chart at admit, Q (every) shift and prn (as needed)". Review of the entire medical record on 08/17/11 revealed a telemetry strip report was documented for 08/16/11 at 1935 (7:35pm). Further review revealed no documented evidence of a telemetry strip upon admit and for the 7A shift of 08/16/11.

Patient #14: Review of the medical record for Patient #14 revealed a 61 year old male admitted to the hospital on 07/29/11 with respiratory failure and was on ventilatory support. Review of the Physician's Orders dated/timed 07/29/11 at 1730 (5:30pm) revealed an order for telemetry monitoring. Review of the Telemetry documentation for Patient #14 revealed no documented evidence of a telemetry strip for 08/02/11- 7A shift; 08/0311- 7A shift; 08/06/11 - no documented evidence the nurse reviewed the strip for the 7A shift; 08/14/11 - 7A shift; 08/09/11- 7A shift; 08/12/11 -7A shift; 08/13/11 - 7A shift and 08/14/11- 7A shift.

Review of the hospital policy titled "Cardiac Monitoring", policy number 9-6.14.0 revised 10/09 and submitted by DON (director of nursing) S2 as their current policy for telemetry, revealed, in part, "...Cardiac monitoring telemetry and/or hardwire will be initiated with a physician's order. ... Documentation The cardiac rhythm displayed on the cardiac monitor will be documented on the Daily Nurses Notes each shift by the nurse completing the assessment. Any subsequent rhythm changes will be noted in a narrative nurses' note. A rhythm strip will be printed and placed in the patient's medical record upon admit, upon initiation of cardiac monitoring, every shift, prn rhythm changes/chest pain/shortness of breath and upon discontinuation of cardiac monitoring. The documented strip will include a description of the tracing, including heart rate, rhythm, identification of any ectopy and the signature of the nurse or tech analyzing the strip. Rhythm strip analysis may also include intervals of PR and QRS...".

C) Weights (#4, #5, #7, #14)

Patient #4: Review of the medical record for Patient #4 revealed an 82 year old male admitted to the hospital on 07/29/11 for an infected left knee. Review of the Physician's Orders dated 07/29/11 (no time documented) revealed an order to weigh the patient on admit and weekly. Review of the Weight Flow Sheet for Patient #4 revealed the following: 07/29/11 at 2045 (8:45pm) - 136.9; 08/05/11 - no documentation a weight had been taken; and 08/12/11 at 2200 (10:00pm) - 135.4.

Patient #5: Review of the medical record for Patient #5 revealed a 55 year old female admitted to the hospital on 05/05/11 for pneumonia, weakness, debility and multiple decubitus. Review of the Physician's Orders dated 05/05/11 at 1940 (7::40pm) revealed an order to weight the patient on admit and then daily. Review of the Weight Flow Sheet for Patient #5 revealed no documented weight for 05/14/11 or 05/23/11.

Patient #7: Review of Patient #7's medical record revealed he was admitted on 07/28/11 with diagnoses of multiple infected wounds, stage IV sacral decubitus, left foot Osteomyelitis, paraplegic secondary to motor vehicle accident, right hip disarticulation, neurogenic bladder with suprapubic catheter, colostomy, and gastroesophageal reflux disease. Review of the "Admit Orders", dated 07/28/11 with no documented evidence of the time of the order, revealed an order to weigh the patient upon admit and weekly. Review of the "Weight Flow Sheet" revealed Patient #7 was weighed on admit (7/28/11) and on 08/13/11. There was no documented evidence Patient #7 was weighed weekly as ordered.

Patient #14: Review of the medical record for Patient #14 revealed 61 year old male admitted to the hospital on 07/29/11 for respiratory failure. Review of the Physician's Orders dated/timed 07/29/11 at 1730 (5:30pm) revealed an order to weigh the patient on admit and weekly. Review of the Weight Flow Sheet for Patient #14 revealed the following; 07/29/11 at 1730 (5:30pm) - 143.1; 08/06/11 at 1430 (2:30pm) - 110 comment: will reweigh; 08/07/11 0500 (5:00am) 130.9 comment: decreased edema; and 08/15/11 at 0500 (5:00am) - 144 comment: weight similar to admit. Review of the Nursing Daily Flowsheet and the Physician Progress Notes dated 07/29/11 through 08/07/11 revealed no documented evidence Patient #14 had been assessed as having edema. Review of the Physicians' Orders revealed no documented evidence Patient #14 had a diuretic ordered.

Review of Policy Number: 9-5.2.0 titled "Weights" last revised 07/09 and submitted by the hospital as the one currently in use revealed..... "Policy: Weights will be done by CNAs (Certified Nursing Assistants) or designated personnel and the nurse will review/verify weight before recording on the Weight Flow Sheet. If there is a five pound discrepancy in the weight, the patient is to be re-weighed. If the weight discrepancy cannot be accounted for, the nurse will make a narrative entry on the Weight Flow Sheet with an explanation".

D) Assessment of vital signs (#6, #17):

Patient #6: Review of Patient #6's medical record revealed he was admitted on 08/15/11 at 7:10pm with diagnoses of pneumonia, sepsis, and acute renal failure. Review of the "Admit Orders" revealed an order for vital signs every 4 hours if on telemetry. Review of Patient #6's "Graphic/I&O (intake and output) Sheet" revealed no documented evidence his vital signs were assessed at 12:00am on 08/16/11.

Patient #17 (Off site Campus A): Review of Patient #17's medical record revealed the patient was admitted to the hospital on 8/15/2011 with admission orders (no documented time) which included an order for Coreg 12.5 milligram by mouth two times per day. Review of Patient #17's Medication Administration Record (MAR) revealed a Pharmacy cue indicating "Coreg. . . Record Apical Pulse on MAR, hold if
Review of the hospital's Drug Reference Book titled, "Mosby's 2012 Nursing Drug Reference, 25th Edition" presented by the hospital as current revealed in part, "(page 251 - 253) Coreg. . . Nursing Considerations. . . Administer: Pulse: if < 50 (less than 50), hold product, call prescriber."


2. Failing to notify the licensed practitioner of a change in a patient's condition (#7, #20). Findings:

Patient #7: Review of Patient #7's medical record revealed he was admitted on 07/28/11 with diagnoses of multiple infected wounds, stage IV sacral decubitus, left foot Osteomyelitis, paraplegic secondary to motor vehicle accident, right hip disarticulation, neurogenic bladder with suprapubic catheter, colostomy, and gastroesophageal reflux disease. Review of the "Drug Levels and Screens" revealed Patient #7's Vancomycin Trough was 22.6, a critical result, on 08/04/11 at 9:47am. Further review revealed the critical result was reported to LPN (licensed practical nurse) S26 on 08/04/11 at 10:26am. Further review of the entire medical record revealed no documented evidence that LPN S26 notified the RN (registered nurse) or the physician of the critical lab value.

In a face-to-face interview on 08/19/11 at 12:30pm, DON S2 could offer no explanation for the LPN not informing the RN of the critical lab value.

Patient #20: Review of Patient #20's medical record revealed the patient was admitted to the hospital on 7/26/2011. Further review revealed Patient #20's pulse as 42 on the graphic sheet for 8/04/2011 at 8:00 a.m. Further review revealed nursing documentation by LPN (Licensed Practical Nurse) S27 dated 8/04/2011 at 8:00 a.m. indicating, "Assessment completed per flow sheet, V/S (vital signs) stable as documented per graphic. . ."

During a face to face interview on 8/18/2011 at 1450 (2:50 p.m.), Licensed Practical Nurse S27 indicated that 42 was not a normal heart rate. S27 indicated that she (S27) would typically re-assess a heart rate that low and notify the Charge Nurse and the patient's doctor. S27 indicated she could not recall the events that occurred on 8/18/2011; however, documentation failed to show that Patient #20 had been evaluated for a low pulse of 42.

During a face to face interview on 8/18/2011 at 1500 (3:00 p.m.), Director of Nursing S14 at Offsite Campus A indicated she (S14) would expect the Licensed Practical Nurse providing care to Patient #20 to have re-evaluated the patient by taking an Apical Pulse and documenting the findings. S14 further indicated if any patient; to include Patient #20, had a heart rate of less than 50, she (S14) would expect that nurse assigned to the care of the patient to inform the Charge Nurse and the Patient's Physician.

Review of the hospital policy titled, "Patient Assessment/Re-assessment, #9-1.1.0" presented by the hospital as current revealed in part, "Any significant change in the patient's condition should elicit a reassessment of the patient (documented in the narrative notes) within one hour. The registered nurse is responsible for ensuring that the physician is notified of all significant changes in patients condition.


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25065

Based on record review and interview, the hospital failed to ensure: 1) patient care plans were developed and updated with changes in condition for 6 of 20 sampled patients (#3, #4, #5, #6, #7, #14) and 2) physician orders were implemented for medications, accuchecks, and labs for 2 of 20 sampled patients (#6, #7). Findings:

1) Patient care plans were developed and updated with changes in condition:

Patient #3
Review of the medical record for Patient #3 revealed a 44 year old male admitted to the hospital on 08/01/11 with respiratory failure on ventilator support and severe cardiomyopathy. Further review revealed #3 had a history of atrial fibrillation, liver disease congestive heart disease and alcohol abuse. Review of the Nursing Care Plan for Patient #3 dated 08/01/11 (at the time of admit) revealed ineffective breathing patterns as an identified problem. Further review revealed the short term goals as "the patient will demonstrate an effective respiratory rate, depth, and pattern as evidenced by eupnea, normal skin color, and regular respiratory rate/pattern. Nursing interventions included: teach/assist with the use of incentive spirometry; schedule activities to provide adequate rest; cough and deep breath every two hours; provide reassurance and stay with the patient during acute episodes of respiratory distress; and increase activity as tolerated to promote maximum diaphragmatic excursion. According to the documentation on the care plan for ineffective breathing patterns the problem was resolved on 08/06/11 when Patient #3 was extubated. Review of the Weight Flow Sheet dated 08/01/11 through 08/17/11 revealed Patient #3 experienced a 6 pound weight loss from 08/01/11 though 08/07/11 and a 18 pound weight loss from 08/07/11 through 08/14/11. Review of the Care Plan for Patient #3 revealed no documented evidence weight loss was recognized as a problems or was any interventions implemented.

Patient #4
Review of the medical record of Patient #4 revealed an 82 year old male admitted to the hospital on 07/29/11 with a left infected knee. Further review revealed a history of hypothyroidism, dementia and Alzheimer's type psychosis. Review of the Nutritional Assessment dated 08/01/11 performed by Dietitian S29 revealed problems identified a decreased oral intake, inconsistent oral intake, dentition, underweight, and decrease in mental status requiring assistance with meals. Review of the Care Plan dated 07/29/11 for Patient #4 revealed impaired skin integrity, potential for infection and anxiety were the problems identified. Interventions for impaired skin integrity were to maintain adequate nutrition and hydration which continued to be updated and checked off on 08/05/11 and 08/13/11; however no specific intervention were documented as implemented to meet the needs of the identified problems of decreases oral intake, assistance with meals, and increase in oral intake.

Patient #5
Review of the medical record of Patient #5 revealed a 55 year old female admitted to the hospital on 05/05/11 with pneumonia, weakness, debility and multiple decubitus. Further review revealed a history of DM (Diabetes Mellitus) HTN (Hypertension), Anemia, Obesity and CAD. Review of the Nursing Admission History and Assessment dated 05/05/11 revealed Patient #5 was very weak, bedbound, needed assistance with ADLs (Activities of Daily Living), and experienced dysphagia (chokes, coughs with meals). According to the Assessment care plans initiated were for infection, altered nutrition, and mobility. Review of the Care Plan for Patient #5 dated 05/05/11 revealed problems identified were for impaired physical mobility, alteration in comfort-pain and potential for infection. Further review revealed no documented evidence interventions were implemented for problems identified concerning nutrition. According to documentation on the care plans at the time Patient #5 was discharged on 06/01/11 all of her problems were resolved. Review of the Discharge Summary dated 08/03/11 for Patient #5 revealed.... She (#5) had a slow but progressing improving course in terms of her activities of daily living and improving her trunk strength. She was eventually considered mentally stable for transfer to an inpatient rehabilitation unit on 06/01/11 in improving condition".

Patient #6
Review of Patient #6's medical record revealed he was admitted on 08/15/11 at 7:10pm with diagnoses of pneumonia, sepsis, and acute renal failure. Review of the H&P (history and physical) dictated on 08/16/11 by Physician S21 revealed Patient #6 had been "requiring some dialysis which is on hold for now", and he had a diagnosis of "Acute on chronic kidney disease, Stage IV". Review of the Plan of Care revealed Patient #6 was care planned for risk for injury, impaired skin integrity, and potential for infection. There was no documented evidence that a care plan was initiated for renal failure and pneumonia.

Patient #7
Review of Patient #7's medical record revealed he was admitted on 07/28/11 with diagnoses of multiple infected wounds, Stage IV sacral decubitus, left foot osteomyelitis, paraplegia, right hip disarticulation, neurogenic bladder, chronic pressure ulcers, and gastroesophageal reflux disease. Review of the Plan of Care revealed Patient #7 was care planned for potential for infection, impaired physical immobility, and impaired skin integrity. Review of the lab results revealed Patient #7's vancomycin trough on 08/04/11 was at a critical value resulting in the dose of Vancomycin to be adjusted. Further review revealed no documented evidence Patient #7's care plan was revised for this change in condition. Review of the "Interdisciplinary Team Conference" documented on 08/04/11 revealed no documented evidence of an update to the location and condition of the wounds, the wound care treatment, and changes in lab values.

Patient #14
Review of the medical record for Patient #14 revealed a 61 year old male admitted to the hospital on 07/29/11 for respiratory failure on ventilatory support and sepsis post sinus surgery. Further review revealed a history of chronic pain syndrome with an implanted analgesic pump, subdural hematoma, back surgery and HTN (Hypertension). Review of the Physician's Progress Notes for Patient #14 revealed the following: 08/02/11 #14 was weaned off ventilator and breathing was unlabored. Further review the patient' lungs were clear of wheezing, positive for rales with a few rhonchi. Patient #14 was to continue with oxygen via the use of a T-Tube; 08/05/11 GI (Gastrointestinal) Consult ordered for anemia, GI bleed, abdominal pain, and bloody bowel movement; 08/09/11 Swallow Study indicated silent aspiration occurring. Pt. NPO ice chips 3 ounces twice daily with continued Dysphagia treatment by speech therapy. Review of the Plan of Care for Patient #14 dated 07/29/11 revealed ineffective breathing patterns as an identified problem. Further review revealed the short term goals as "the patient will demonstrate an effective respiratory rate, depth, and pattern as evidenced by eupnea, normal skin color, and regular respiratory rate/pattern. Nursing interventions included: teach/assist with the use of incentive spirometry; schedule activities to provide adequate rest; cough and deep breath every two hours; provide reassurance and stay with the patient during acute episodes of respiratory distress; and increase activity as tolerated to promote maximum diaphragmatic excursion. Re-evaluation of the nursing care plan on 08/05/11 revealed #14 was extubated (no date given); however interventions continued to include monitor readiness to wean and oral hygiene every four hours and prn (as needed). Potential for Infection was also identified as an identified problem on 07/29/11 with the intervention of encouragement of high protein/high carbohydrate foods/fluids as indicated. Review of the Nutritional Assessment for Patient #14 revealed as follows: 08/01/11 Patient on tube feedings due to respiratory status (ventilatory support); 08/08/11 weight loss of 12 pounds in one week. Tube feedings being held due to GI testing. TPN started. 08/15/11 Weight gain of 12 pounds in one week. Tube feedings began again and TPN discontinued. 08/18/11 Bolus tube feedings of Fibersource implemented.

Patient #15
Review of the medical record for Patient #15 revealed a 76 year old female admitted to the hospital on 08/08/11 for respiratory failure and sepsis. Review of the Physician's Admit Orders revealed Patient #15 was a "Full Code" Status. Review of the Progress Notes dated 08/14/11 revealed the attending physician, Pulmonologist and Nephrologist all agreed further treatment would be futile and an order was written for a DNR (Do Not Resuscitate) for #15. Review of the Plan of Care for Patient #15 revealed no documented evidence the plan of care was revised to include interventions to reflect the change in the treatment plan.

In a face to face interview on 08/19/11 at 12:30pm, DON (director of nursing) S2 could offer no explanation when informed that review of care plans revealed the care plans were not individualized for each patient, the interventions were not individualized, and the goals were not stated in measurable terms.

Review of the hospital policy titled "The Nursing Process - Care Planning", policy number 9-1.2.0 effective 07/07 and submitted by DON S1 as the current policy for care planning, revealed, in part, "...The nursing plan of care provides a collaborative/systematic method of individualized care that focuses on the patient's response to an actual or potential alteration in health based on patient assessment. ... It communicates pertinent patient problems/needs, delineates appropriate medical and nursing interventions to meet these needs, and documents the effectiveness of those interventions in the medical record. ... a written plan of care developed and initiated within 24 hours of admission by an RN (registered nurse). ... The patient's plan of care shall be reviewed and updated at least weekly by an RN or LPN (licensed practical nurse). The plan of care will be reviewed/updated as needed as a result of ongoing assessment and interdisciplinary rounds... The plan of care shall include: 1) Actual and Potential Problems/Needs ... 2) Nursing Intervention ... 3) Expected Outcomes ... expected outcomes are specific and provide goals for addressing patient problems/needs. 4) Resolution at Discharge...".

2) Physician orders were implemented for medications, accuchecks, and labs:

Patient #6
Review of Patient #6's medical record revealed he was admitted on 08/15/11 at 7:10pm with diagnoses of pneumonia, sepsis, and acute renal failure. Review of the "Admit Orders" dated 08/15/11 at 7:10pm revealed orders to draw a CBC (complete blood count), CMP (complete metabolic profile), and a Pre-albumin in the morning. Review of the lab results revealed no documented evidence a CBC, CMP, and Pre-albumin had been performed and resulted for Patient #6 on 08/16/11. Review of the "Capillary Blood Glucose Scale", with no documented evidence of the date or time the verbal order was received, revealed an order to to perform a CBG (capillary blood glucose) check ac and hs (before meals and at bedtime). Review of the medication administration records (MARs) revealed no documented evidence of the date for each hand-written MAR, and there was no way to determine which day and time the CBG that was documented had been performed.

Patient #7
Review of Patient #7's medical record revealed he was admitted on 07/28/11 with diagnoses of multiple infected wounds, Stage IV sacral decubitus, left foot osteomyelitis, paraplegia, right hip disarticulation, neurogenic bladder, chronic pressure ulcers, and gastroesophageal reflux disease. Review of Patient #7's "Medication Reconciliation Form" recorded on 07/28/11 at 11:00am revealed Invanz 1 gram (gm) IVPB (intravenous piggyback) was to be administered every 24 hours, and Vancomycin 1 gram IVPB was to be administered every 8 hours. Review of the "Physician's Routine Orders" revealed a verbal order received 07/28/11 at 6:25pm to clarify that the last dose of Vancomycin was given at 6:00pm on 07/28/11, and the last dose of Invanz was given at 9:00pm on 07/27/11. Further review revealed an order on 07/28/11 at 7:35pm for MVI (multivitamins) one by mouth every day and Proteinix 2 teaspoons every day. Further review revealed an order on 07/29/11 at 10:45am to increase Proteinix to 30 ml (milliliters) by mouth twice a day.

Review of Patient #7's MARs revealed the following:
07/28/11 at 7:00am to 07/29/11 at 6:59am - Invanz was documented to be given at 9:00am rather than 9:00pm as previously administered prior to admission; no documented evidence Invanz administered as ordered at 9:00pm on 07/28/11;
07/29/11 to 07/30/11 - no documented evidence Vancomycin administered at 2:00am as ordered; Invanz administered at 9:00am on 07/29/11;
07/30/11 to 07/31/11 - Invanz administered at 9:00am;
08/01/11 to 08/02/11 - no documented evidence MVI administered at 9:00am as ordered;
08/04/11 to 08/05/11 - no documented evidence Proteinix administered at 9:00pm as ordered;
08/05/11 to 08/06/11 - Invanz administered at 9:00am;
08/06/11 to 08/07/11 - MAR has Invanz to be administered every 24 hours at 9:00pm; Invanz administered at 9:00pm, which was 36 hours since the previous time of administration.

In a face-to-face interview on 08/19/11 at 12:30pm, DON S2 could offer no explanation for the medications, accuchecks, and labs not being performed/administered as ordered.

Review of the hospital policy titled "Medication Administration", policy number 9-4.13.0 revised 04/10 and submitted by DON S2 as the current medication administration policy, revealed, in part, "...If the medication is ordered and not preprinted on the MAR, the nurse shall transcribe the order onto the MAR utilizing the standard drug administration times for scheduling. ... The nurse shall document on the MAR or in the nurses' narrative notes, if necessary, the reason the drug was not given and the physician must be notified if a medication or treatment is held without a specific order to hold the medication or treatment. ... Medications may be given 30 minutes before or after the scheduled time...".


25065

Based on record review and interview the hospital failed to develop and implement a process for assessing skills competency for the nursing staff as evidenced by relying on self-assessment to determine competency for 2 of 2 (S10, S11) sampled personnel files. Findings:

Review of the Self- Skill Assessment provided by Agency LPN S10 revealed she was proficient in all areas of practice. Further review of the personnel file for LPN S10 revealed no documented evidence the hospital had performed any competency assessment on S10.

Review of the Hospital Orientation - General/Nursing for LPN S11 dated 07/29/10 revealed she had performed a self-evaluation for competency with the following results: NP (Need Practice) for use of the Doppler, reading of telemetry strips, responsibilities during a cardiopulmonary resuscitation, use and maintenance of a crash cart, chest pain protocol, assistance with insertion of a central line, use of a Baker-Wong pain scale, Hypo/Hyperglycemia protocol, quick tie release for soft limb holders and Self-release lap buddy. Further review of the orientation form which provided a space for re-assessment at the 90-day employment time period was left blank. There was no additional documentation in the personnel record of LPN S11 to indicate steps were take by the hospital to improve efficiency in performance in the identified areas needing additional practice.

In a face to face interview on 08/19/11 at 12:30pm RN S2 DON (Director of Nursing) indicated a problem was recognized with the process of allowing the nursing staff to perform self-assessments and changes needed to be made. S2 verified no corrective action has been implemented at present.

Based on record review and interview the hospital failed to ensure all blood transfusions were administered according to hospital policy and procedure as evidenced by the physician failing to include in the order for blood administration the rate and the nurse failing to obtain clarification of the order for the rate for 2 of 3 patients (#14, #15) receiving blood out of 20 sampled medical records. Findings:

Patient #14
Review of the medical record for Patient #14 revealed a 61 year old male admitted to the hospital on 07/29/11 with a diagnosis of respiratory failure. Further review revealed a history of sinus surgery, thromocytopenia, back surgery and an implanted analgesia pump. Review of the Physician's Orders dated 08/05/11 at 0810 (8:10am) revealed.... "Transfuse 2 u (units) PRBC (Packed Red Blood Cells) today and 08/07/11 at 1240 (12:40pm) Type and crossmatch 2 units of PRBC (Packed Red Blood Cells) and transfuse". Further review of the Physician's Orders revealed no documented evidence the orders were clarified to obtain a rate of administration.

Review of the Transfusion Form for Patient #14 dated 08/05/11 revealed unit #1 of PRBC was started at 1115 (11:15am) and completed at 1410 (2:10pm) 2 hours and 55 minutes and Unit #2 1425 (2:25pm) and completed at 1645 (4:45pm) (2 hours and 20 minutes). Further review of the Transfusion Form dated 08/07/11 revealed Unit #1 was started at 1520 (3:20pm) and completed at 1845 (6:45pm) 3 hours and 25 minutes and Unit #2 started at 2100 (9:00pm and completed at 2330 (11:30pm) 2 hours 30 minutes

Patient #15
Review of the medical record for Patient #15 revealed a 76 year old female admitted to the hospital on 08/09/11 with respiratory failure and sepsis. Review of the Physicians' Orders dated/timed 08/13/11 at 3pm revealed an order to transfuse 2 units FFP (Fresh Frozen Plasma) today. Further review of the Physicians' Orders revealed no documented evidence the order had been clarified by the nurse for the rate of administration before administration.

Review of the Transfusion Form for Patient #15 dated 08/13/11 revealed the FFP was started at 1745 (5:45pm) and completed at 1800 (6:00pm) administered within 15 minutes.

In a face to face interview on 08/19/11 at 12:30pm RN S2 DON (Director of Nursing) indicated the rate of flow should have been clarified before any blood was administered.

Review of Policy Number: 9-4.17.0 titled "Blood and Blood Components" last revised 10/09 and submitted by the hospital as the one currently in use, revealed...... "Procedure: .... A physician's order shall be written for all transfusions of blood/blood components specifying: type of components: red blood cells, platelets, fresh frozen plasma or cryoprecipitate, number of units to be administered, rate of administration and pre-medications."

Based on observation, record review, and interview the hospital failed to: 1) implement a system to ensure medical records were promptly completed as evidenced by failing to suspend physicians with delinquent medical records greater than 60 days (S15, S16, S17, S18, S19, S20, S21) and require automatic resignation after 90 days (S22, S23, S24, S25) for 11 of 303 physicians on staff at the hospital and 2) ensure medical records were stored in a manner to protect them from water damage. Findings:

1) Failing to implement a system to ensure medical records were promptly completed:
Review of the data presented by RHIA (registered health information administrator) S8 revealed the delinquency rate for medical records at the main campus was as follows: February 81% (percent), March 100%, April 97%, May 92%, and June 79%.

Review of the "Chart Deficiency Listing By Physician", presented by RHIA S8 as the current list of physicians who were delinquent with completion of medical records, revealed Physicians S15, S16, S17, S18, S19, S20, and S21 had medical records delinquent greater than 60 days and should be suspended according to the medical staff bylaws. Further review revealed Physicians S22, S23, S24, and S25 had medical records delinquent greater than 90 days and should have automatic resignation according to the medical staff bylaws.

In a face-to-face interview on 08/18/11 at 12:10pm, RHIA S8 indicated Physicians S22, S23, and S25 were currently suspended due to delinquent medical records. S8 further indicated no physician had been automatically resigned. After review of the dates of delinquency, S8 confirmed that Physician 25 had a medical record with a discharge date of 11/24/10 which was greater than 90 days, and he should be automatically resigned.

In a face-to-face interview on 08/19/11 at 8:15am, RHIA S8, after review of the delinquency data submitted to the surveyor on 08/18/11, confirmed that Physicians S15, S16, S17, S18, S19, S20, and S21 should be currently suspended and Physicians S22, S23, S24, and S25 should be automatically resigned. S8 indicated Physicians S15 and S16 were on vacation at the time were due to be suspended, and the bylaws allowed for extension. After review of the medical records policy which stated that physicians "will not be placed on suspension while absent due to illness, vacation or leave of absence provided that the practitioner notified the Medical Staff Office prior to the practitioner's absence", S8 confirmed that Physicians S15 and S16 did not notify the Medical Staff Office of their vacation time as required by policy.

In a face-to-face interview on 08/19/11 at 9:50am, Administrator S1, after being presented the data from medical records on the delinquency of medical records, confirmed that Physicians S15, S16, S17, S18, S19, S20, and S21 should be currently suspended and Physicians S22, S23, S24, and S25 should be automatically resigned. S1 indicated that the system for suspension of physicians for delinquent medical records was not working. S1 further indicated the process needed to be taken out of the hands of administration and given to RHIA S8 to handle.

Review of the hospital policy titled "Documentation Completion Time Frames", policy number 5-3.8.0 effective 01/08 and submitted by RHIA S8 as their current policies and procedures for medical records, revealed, in part, "...Delinquent Medical Record: An inpatient medical record that remains incomplete for 30 or more days post discharge. Suspension: Suspension of the practitioner's privileges to admit, consult or perform procedures at The Hospital. ...A. Notification of Incomplete/Delinquent Medical Records 1. The Administrator or his designee shall notify each practitioner with a list of the practitioner's Incomplete and Delinquent Medical Records not less than weekly. 2. A special notice is given to a practitioner once an Incomplete medical record has been Incomplete for twenty-one (21) days. ... 4. Once a medical record remains Incomplete for thirty (30) days, and is determined to be Delinquent, the record will be designated as such on the weekly list provided to the practitioner. The practitioner shall also receive a FIRST NOTICE that he/she has a delinquent medical record and will be given TWO (2) WEEKS to complete the medical record or be placed on suspension at the Hospital. 5. If a record remains Delinquent upon the lapse of the first notice, the practitioner shall be given a SECOND NOTICE that he/she has a Delinquent medical record and will be given ONE week to complete the medical record or be placed on suspension... 6. If the Delinquent medical record is not completed upon the lapse of the SECOND NOTICE, the Health Information Staff will conduct a review of the medical record prior to suspension to affirm that the Delinquent medical record is indeed Incomplete. B. Suspension 1. If the record is still Delinquent upon the lapse of the SECOND NOTICE, the Administrator shall suspend the practitioner's privileges. ... 3. The automatic suspension will remain in effect until the Delinquent medical records have been verified as complete. ...5. Practitioners will not be placed on suspension while absent due to illness, vacation or leave of absence provided that the practitioner notified the Medical Staff Office prior to the practitioner's absence. ... E. Automatic Resignation 1. If a Delinquent medical record remains Incomplete by ninety (90) days post discharge, the practitioner will be sent notice that the practitioner will be deemed to have automatically resigned from the Medical Staff and relinquished all privileges at the Hospital, if the practitioner fails to complete ALL Delinquent AND Incomplete medical records within forty-eight (48) hours. 2. If the practitioner has any Incomplete or Delinquent medical records upon the lapse of the forty-eight (48) hour notice period, the practitioner shall be deemed to have automatically resigned from the Medical Staff and relinquished all privileges at the Hospital...".

Review of the Medical Staff By-Laws dated April 2011 revealed....."B. Suspension: If the record is still Delinquent upon the lapse of the second notice, the Administrator shall suspend the practitioner's privileges. The practitioner will be notified of automatic suspension by phone, as well as by mail to his/her primary office. E. Automatic Resignation: 1. If a Delinquent medical record remind incomplete by ninety (90) days post discharge, the practitioner will be sent notice that the practitioner will be deemed to have automatically resigned from the Medical Staff and relinquished all privileges at the hospital....".

2) Failing to ensure medical records were stored in a manner to protect them from water damage:
Observation on 08/18/11 at 12:10pm of the medical record department, with RHIA S8 present, revealed the room was protected from fire with a sprinkler system. Further observation revealed rolling carts with 37 patient medical records with no means of protection from water damage. Further observation revealed 4 boxes stacked on the floor containing patient medical records.

In a face-to-face interview on 08/18/11 at 12:10pm, RHIA S8 indicated the boxed medical records were to be sent back to the off-site storage. S8 further indicated the 37 charts on the cart were to be processed next week in preparation for off-site storage, and they had been stored on the cart for the previous two weeks. S8 confirmed there was no way to protect the boxed records and the 37 records on the cart from water damage in the event the sprinkler system was activated.

Review of the hospital policy titled "Retention and Destruction", policy number 5-3.6.0 revised 01/09 and submitted by RHIA S8 as their current policies and procedures for medical records, revealed, in part, "...In anticipation of unplanned disasters, the hospital will make every attempt to safeguard health information records, documents, and other storage medium in structurally safe, fire-resistant, and water resistant storage environments...".

Based on record review and interview, the hospital failed to ensure physician's orders, including verbal orders, were dated, timed, and authenticated promptly by the ordering practitioner for 2 of 20 sampled patients (#19, #20). Findings:

Patient #19:
Review of Patient #19's medical record revealed Read Back Telephone Admit Orders and Medication Reconciliation Form dated 07/25/11 and timed 1615 (4:15 p.m.) were not signed by the physician (24 days after given by the physician). Also Read Back Telephone Orders dated 07/27/11 and timed 0945 (9:45 a.m.) and 1230 (12:30 p.m.) were not signed by the physician (22 days after given by the physician). The findings were confirmed by S14DON at the Offsite Campus A on 08/18/11 at 3:10 p.m.

Patient #20:
Review of Patient #20's medical record revealed physician's orders dated 7/29/2011, 8/08/2011, 8/09/2011 and 8/15/2011 with no documented time that the order was written. Further review revealed Read-Back-Telephone-Orders admission orders for Patient #20 dated 7/26/2011 at 2000 (8:00 p.m.) with authenticating signature by the physician when reviewed on 8/18/2011 (23 days after the verbal order had been given).

This finding was confirmed by Director of Nursing S14 at offsite campus A in a face to face interview on 8/18/2011 at 1500 (3:00 p.m.). S14 indicated the hospital had been working with the physician's in an attempt to reach improvement with dating, timing, and authentication of medical record entries. S14 indicated physicians should be compliant with dating, timing, and authenticating entries.

Review of the hospital policy titled, "Documentation and Authentication, #5-2.3.0" presented by the hospital as current revealed in part, "All orders, including verbal orders must be timed, dated, and authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient and is authorized to write orders. . . All verbal orders will be authenticated within 10 days. . ."





26351

Based on record review and interview, the hospital failed to ensure the dietitian responsible for the nutritional needs of the patients assured food was served at a proper temperature as evidenced by failure to perform random tray checks at least one to two times a week as required by hospital policy. Findings:

Review of the "Nutrition Services Meal Test Tray" data presented by Registered Dietitian (RD) S7 revealed temperatures of test trays were checked on 01/04/11, 01/27/11, 02/01/11, 02/08/11, 02/22/11, 03/01/11, 03/15/11, 03/29/11, 04/05/11, 04/19/11, 04/26/11, 05/17/11, 05/24/11, 06/07/11, 06/21/11, 07/07/11, 07/12/11, and 07/25/11. Further review revealed no documented evidence the food temperatures were checked at least one time a week as required by hospital policy for the weeks of 01/09/11, 01/16/11, 02/13/11, 03/06/11, 03/20/11, 04/10/11, 05/01/11, 05/08/11, 05/29/11, 06/12/11, 06/26/11, 07/17/11, 07/31/11, and 08/07/11.

In a face-to-face interview on 08/18/11 at 10:40am, RD S7 confirmed the test trays were not being checked at least one time a week for proper temperature as required by hospital policy.

Review of the hospital policy titled "Meal Service", policy number 9-2.10.0 revised 10/07 and submitted by RD S7 as their current policy for temperature checks, revealed, in part, "...Random tray checks (at least 1-2 times a week) will be monitored and conducted by Nursing or a designee. A tray check will include monitoring patient food portions, tray accuracy, and temperature checks...".

Based on observation and interview, the hospital failed to ensure all facilities, supplies, and equipment were maintained to ensure an acceptable level of safety and quality. Findings:

Observations on 8/16/11 between 1:30 p.m. and 2:30 p.m. revealed sections of cracks/rips/tears in the vinyl covering of chairs located in patient rooms. The cracks/rips/tears resulted in a non-wipable surface as foam cushioning was exposed on these chairs. The Patient Rooms affected by this finding included, but are not limited to, Patient Room #915, Patient Room #917, and Patient Room #936. This finding was confirmed in an interview with the Director of Nursing at the time of the observation.

Observation of the rehab department on 08/18/11 at 12:00 p.m. with Director of Rehab S5 present revealed the following:
1) the mat on the high-low table had a 3/8 inch tear;
2) the tilt table had five tears to the surface of the mattress with the side and lower edge with ripped and/or worn edges; the handle to manipulate the table had a cracked plastic knob; and
3) the clean closet had 2 walkers not labeled as clean mixed with multiple walkers with a "clean" label attached and 2 walkers broken and unable to be used with no tag attached to indicate they were not to be used.

In a face-to-face interview on 08/18/11 at 12:00 p.m., Director of Rehab S5 indicated the walkers should be labeled with a "clean" tag when they are placed in the clean closet. S5 further indicated the broken walkers should be tagged and separated from those that are ready for use.

An observation on 08/18/11 at 11:00 a.m. was made on the Offsite Campus A of the clean linen cart being stored in the shower room. The shower room consisted of a shower, a sink, and a toilet. The clean linen cart was full of clean linen and the covering over the cart was opened. The observation was verified by S12 (Assistant Administrator). S12 was interviewed on 08/18/11 at 11:25 a.m. He stated the linen cart's location is rotated during the day to keep the cart out of the hallway due to the fire marshall's regulations. The linen cart is usually in the shower room in the early morning and the late evening. The cart does go downstairs in the hospital in the afternoon to get restocked.

An observation on 08/18/2011 at 11:15 a.m. was made on the Offsite Campus A of 2 bags of dirty linen being stored in the clean equipment room. The clean equipment room housed clean mattresses, clean wheelchairs, and chairs. S12 Assistant Administrator confirmed the equipment in the room was clean.

An interview was conducted with S13 (CNA) on 08/18/11 at 11:20 a.m.. S13 stated she had put the 2 bags of dirty linen in the clean equipment room to house the dirty linen until she had more dirty linen to take to the soiled utility room. She went on to stated the soiled utility room was on the other hallway.


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25059


Based on record review and interview, the hospital's infection control officer/officers failed to ensure the implementation of an effective infection control program by failing to incorporate, into the program, a thorough investigation to assist with identifying the cause/source of hospital acquired infections and by failing to incorporate a system that ensures the identification of personnel who fail to comply with proper infection control practices. Findings:

The hospital's "Infection Control Plan" was reviewed. The plan documents under the section of "Epidemiology" "Investigation: Maintain adequate records to identify and investigate problems before they become major concerns. Compile and analyze surveillance data and present deviations from baseline data to the IC Committee and to other appropriate committees, departments or services". The plan also documents "Each Director of Nursing in the LHC Group hospital is responsible for monitoring compliance with all facility policies. Deviation from policies and procedures are dealt with according to current facility policy. Observations of deviation from policy, made during surveillance, by the IC Officer(s) are reported to the Director of Nursing. Routine "walking rounds" are integrated with safety, risk management, and environmental services. Problems identified are referred to the appropriate department, division, or committee for discussion and correction".

Review of the hospital's infection control data for June of 2011 was reviewed with the hospital's Director of Nursing on 8/18/11 at 1:00 p.m. When asked about the hospital acquired infections for June of 2011, the Director of Nursing reviewed the data for the main campus and indicated there were two hospital acquired Central Line infections and one hospital acquired Urinary Tract infection at the hospital's main campus for June of 2011. When asked for data relating to the hospital acquired infections, the Director of Nursing presented a "Patient Infection Control Data Log" for the patients identified as obtaining a hospital acquired infection. Review of the "Patient Infection Control Data Log" revealed no documentation to indicate that a thorough investigation was conducted by the infection control officer in an effort to identify the cause/source of the hospital acquired infection so that measures could be implemented to prevent and/or reduce further infections. When asked to present data relating to an investigation into the cause/source of the hospital acquired infections for the above three cases in June of 2011, the Director of Nursing indicated that she could provide no data to indicate that a thorough investigation was conducted in an effort to obtain the cause/source of the infection.

Review of the hospital's infection control monitoring tools including Hand Hygiene (January through July of 2011) revealed no evidence to indicate the infection control officer had a system in place to identify the identity of personnel who fail to follow proper infection control practices. This resulted in the hospital's inability to identify potential trends with personnel that could potentially affect patient safety in relation to infection control. The data obtained on the "Hand Hygiene Monitor" form (January through July of 2011) revealed there was a circle around the type of healthcare worker, (nurse, therapists, CNA, respiratory therapist or other personnel) observed during the surveillance period. Documentation of hand hygiene in January revealed a CNA (certified nursing assistant) failed to perform hand hygiene before and after patient care on 1/08/11 and a nurse failed to perform hand hygiene on 1/13/11. Documentation of hand hygiene in February revealed a CNA (certified nursing assistant) failed to perform hand hygiene before and after patient care on 2/09/11 and a nurse failed to perform hand hygiene on 2/17/11, 2/22/11, and 2/24/11. Documentation of hand hygiene in May revealed a nurse failed to perform hand hygiene on 5/03/11, 5/04/11, 5/05/11, 5/09/11, and 5/11/11 and a therapist failed to perform hand hygiene on 5/10/11 and 5/16/11. Documentation revealed "other personnel" failed to perform hand hygiene on 6/18/11. There was no system in place to identify the identity of the staff members who were observed failing to perform hand hygiene as documented above. The discipline of the staff member was identified but not the person resulting in the hospital's inability to systematically track repeat violators of effective infection control practices.

Based on record review and interview, the hospital failed to ensure rehabilitation policies provided for the number of staff to be based on the type of patients treated and the frequency, duration, and the complexity of the treatment required as evidenced by having a policy to prioritize patient care in the event of inadequate levels of staffing. Findings:

Review of the hospital policy titled "Patient Treatment Priorities", policy number 12-3.3.0 revised 01/09 and presented by Director of Rehab S5 as their current policies for rehab services, revealed, in part, "...The Rehabilitation Department shall have a plan to prioritize patient care, in the event that staffing reaches inadequate levels, due to loss of staff, reduction in productive hours, sudden increase in patient demand on services, or in times found difficult to secure appropriate numbers of qualified individuals to provide basic care services to patients requiring rehabilitation services. ... 1. All patients enrolled in therapy are to receive some treatment. The number of treatments for some patients may need to be reduced to accommodate the patients...". Further review revealed a list of order of high priority to low priority.

In a face-to-face interview on 08/18/11 at 2:40pm Director of Rehab S5 could offer no explanation for the policy related to prioritizing patient care. S5 indicated he had never prioritized rehab care based on staff needs. S5 confirmed that the policy was not appropriate.