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Based upon record review and interview, the facility failed to ensure that nursing assessed 2 of 2 (#1, #2) patients when they experienced a change in condition. Nursing failed to notify the physician of the change of condition of 2 of 2 (#1, #2) patients. Nursing also failed to ensure a physician's order was obtained for interventions initiated with a change of condition for 2 of 2 (#1,#2) patients reviewed. Physician #1 failed to provide evaluation and direction for care for 1 of 2 (#2) patients reviewed.


REFER TO TAG A144

Based upon record review and interview, the medical staff failed to ensure 1 of 3 physicians (Staff #1) provided quality care to 2 of 2 (#1, #2) patients reviewed. Patient #1 had a change in condition and there was no physician available to evaluate patient and direct care. Patient #2 was admitted to the services of staff #1 but patient was not seen by staff #1 for 5 days. The medical staff failed to ensure the medical staff bylaws, rules and regulations, included provision for the utilization and appointment of 1 of 1 physician assistants. The facility utilized a physician assistant in the emergency department on weekends who had not been appointed by the medical staff and did not have a supervising physician that was appointed to the facility's medical staff.



REFER TO TAGS - A338, A347

Based upon record review and interview, the governing body failed to ensure 1 of 3 physicians (Staff #1) provided quality care to 2 of 2 (#1, #2) patients reviewed. Patient #1 had a change in condition and there was no physician available to evaluate patient and direct care. Patient #2 was admitted to the services of staff #1 but patient was not seen by staff #1 for 5 days.

Review of medical record for patient #2 revealed patient was admitted to the service of staff #1 on 2/23/11 with Cervical Spinal Fracture from a fall. Patient was in a hard plastic cervical collar and was requiring pain medication for pain control. The Emergency Room physician, Staff #2 requested transfer to a higher level of care at 2 acute care facilities but unable to negotiate the transfer so staff #2 admitted the patient to the services of staff #1. Further review of the medical record revealed physician progress notes written by Staff #2 on 2/24/11 and 2/25/11. On 2/26/11 and 2/27/11, patient #2 was seen by the Physician Assistant that was working in the emergency department. A progress note was written by the Physician Assistant only on 2/26/11. The Physician Assistant was not appointed by the medical staff, did not have a collaborative agreement with a supervising physician in this facility, and the physician listed on the Texas Medical Board Website as his supervising physician practices 180 miles from this facility. Review of nurses notes for 2/28/11 revealed patient was seen by staff #1. New telephone orders were written by the charge nurse for staff #1 but no physician progress notes were written by staff #1. The patient was hospitalized for 5 days before being transferred to another facility and staff #1, who was her attending physician, did not visit the patient until the 5th day.

Review of medical record #1 revealed patient was admitted to the facility on 2/9/11 with a diagnosis of acute exacerbation of chronic obstructive pumonary disease. Admitting orders were for Oxygen per nasal cannula at 3 liters/minute, hand held nebulizer treatments every 8 hours, and antibiotics. On 2/10/11, patient began responding to treatment. Patient was exhausted with minimal activity. On 2/11/11 at 1:30 am, patient was requesting water pitcher to be filled. At 3:30 am, patient again requested water pitcher to be filled and breathing treatment given. At 5:30 am, patient wanted water pitcher filled and patient was instructed he was drinking too much. At 7:30 am, patient was sitting up in bed, alert and oriented, patient conversing, no complaints. Patient was seen by PA and physician (staff #3) approximately 8am on 2/11/11. Orders were written for additional labs and an EKG to be done in am (2/12/11), and to change IV fluids to 3% Normal Saline, 500 cc @ 100 cc/hour then Normal Saline @ keep vein open rate.

A telephone interview was conducted with the patient's wife on 3/1/11 at 1:30 pm. The patient's wife reported on 2/10/11 she was at the hospital that evening and her husband had a good day and was responding to treatment and he told her to go home and get a good night's sleep because he would probably be coming home the next day and she would have to care for him. The wife went home and returned at approximately 9:45 am. The wife reported when she walked in the room her husband was breathing very shallow and rapid and was unresponsive to verbal stimuli and she tried shaking him to arouse him without success. The wife reported she went to the nurse's station and asked what had happened to her husband and the nurse told her he was alright earlier that morning but the night nurses told that he had a very bad night. The wife reported she asked the nurses to call staff #3 (physician) but they did not call him. The wife reported she went to the Emergency Room and requested staff #2 to go evaluate her husband but he did not. The wife reported that approximately 12:30 pm, Staff #3 came to the patient's room and informed the patient's family that he had been relieved of his duties and he suggested that the family have the patient transferred to another facility. The wife reported at that time she asked staff #3 to evaluate the patient but staff #3 told the wife he was not allowed. The wife then went back to the emergency room and begged staff #2 (Emergency Room physician) to evaluate her husband. The wife reported he came to the room and stuck his head in the door and looked at the patient but did not evaluate him and turned and walked away. The wife further reported that approximately3:00 pm, staff #1 arrived and evaluated the patient. Staff #1 told the wife that the patient was too critical to move and discussed the patient's living will and advanced directives. Wife reported family agreed to honor patient's living will and not utilize any heroic measures. Staff #1 ordered arterial blood gases and increased hand held nebulizer treatments to every 2 hours.

Review of nurse notes for patient #1on 2/11/11 at 9:55 am revealed "patient given xanax as ordered per wife's request. Review of nurse notes on 2/11/11 at 1200 noon revealed "patient sleeping soundly but arousable (night shift reported patient awake most of night). 12:30 pm - Dr (staff #3) in to see patient and family and notified them of his dismissal.. Family has requested transfer to another facility, initial contact made and staff #2 notified. Patient not verbally responding at present; family anxious and concerned. 1:30 pm - Spoke with staff #1 regarding taking over care of patient per the administrator's instructions. 2:40pm - Staff #1 in to see patient; new orders written. 15:00 - Blood gases obtained and patient placed on BIPAP set @ 18/5 per respiratory therapy.

Review of physician's orders revealed blood gases were ordered and change in IV fluids but there was no written order for BIPAP. Review of respiratory therapy progress notes dated 2/11/11 at 3:30 pm. revealed "Patient placed on BIPAP @ 16/5 with oxygen bleed-in @5 L/min."

Review of physician's progress notes revealed the final progress note written by staff #3 (physician) on 2/11/11: "Having been removed from medical staff by administrator, further orders will be from whomever he designates effective immediately per administrator." Staff #1 did not write any progress notes from 2/11/11-2/13/11.

Based upon record review and interview, the facility failed to ensure that nursing assessed 2 of 2 (#1, #2) patients when they experienced a change in condition. Nursing failed to notify the physician of the change of condition of 2 of 2 (#1, #2) patients. Nursing also failed to ensure a physician's order was obtained for interventions initiated with a change of condition for 2 of 2 (#1,#2) patients reviewed. Physician #1 failed to provide evaluation and direct care for 1 of 2 (#2) patients reviewed.

A telephone interview was conducted with the wife of patient #1on 3/1/11 at 1:30 pm. The patient's wife reported on 2/10/11 she was at the hospital that evening and her husband had a good day and was responding to treatment and he told her to go home and get a good night's sleep because he would probably be coming home the next day and she would have to care for him. The wife went home and returned at approximately 9:45 am. The wife reported when she walked in the room her husband was breathing very shallow and rapid and was unresponsive to verbal stimuli and she tried shaking him to arouse him without success. The wife reported she went to the nurse's station and asked what had happened to her husband and the nurse told her he was alright earlier that morning but the night nurses told that he had a very bad night. The wife reported she asked the nurses to call staff #3 (physician) but they did not call him. The wife reported she went to the Emergency Room and requested staff #2 to go evaluate her husband but he did not. The wife reported that approximately 12:30 pm, Staff #3 came to the patient's room and informed the patient's family that he had been relieved of his duties and he suggested that the family have the patient transferred to another facility. The wife reported at that time she asked staff #3 to evaluate the patient but staff #3 told the wife he was not allowed. The wife then went back to the emergency room and begged staff #2 (Emergency Room physician) to evaluate her husband. The wife reported he came to the room and stuck his head in the door and looked at the patient but did not evaluate him and turned and walked away. The wife further reported that approximately3:00 pm, staff #1 arrived and evaluated the patient. Staff #1 told the wife that the patient was too critical to move and discussed the patient's living will and advanced directives. Wife reported family agreed to honor patient's living will and not utilize any heroic measures. Staff #1 ordered arterial blood gases and increased hand held nebulizer treatments to every 2 hours.

Review of nurse notes on 2/11/11 at 7:30 am revealed "Received patient sitting up in bed, awake, alert and oriented. Oxygen at 3L/min via nasal cannula. Leg bag in place, Left forearm IV without redness or swelling. Patient conversing, no complaints. Review of nurse notes on 2/11/11 at 9:55 am revealed "patient given xanax as ordered per wife's request." Patient's vital signs documented at 10:00 am were 97.8, pulse-55, respirations-22, blood pressure-119/55. There was no assessment documented for the patient's change of condition reported by the wife. Review of nurse notes on 2/11/11 at 1200 noon revealed "patient sleeping soundly but arousable (night shift reported patient awake most of night). 12:30 pm - Dr (staff #3) in to see patient and family and notified them of his dismissal. Family has requested transfer to another facility, initial contact made and staff #2 notified. Patient not verbally responding at present; family anxious and concerned. There was no documentation of nursing assessment when patient #1 experienced this change of condition. There was no documentation of the physician (staff #1) being notified of change of condition.

Review of the medical record of patient #2 revealed patient was hospitalized on 2/23/11 due to a fractured cervical vertebrae. Patient was placed in a hard plastic cervical collar and was admitted to stabilize blood pressure and pain management.

Review of nurses' notes dated 2/25/11 at 8:00 am revealed initial shift assessment that "patient was alert and oriented. Respirations even and non-labored, lungs clear to auscultation. O2(oxygen) at 3 L/min. Abdomen soft and NTND (non-tender non-distended) with BS (bowel sounds) present in 4 quadrants. Hard C-collar in place. Denies needs."
At 1:30 pm, "Patient vomiting at this time. Given Zofran 4 mg. IV." At 7:00 pm on 2/25/11, patient assessment revealed vital signs were 97.4, pulse-51, respirations-20, blood pressure-170/71. Respirations were regular and lung sounds were diminished in right and left lungs, patient voiced no complaints, resting quietly, c-collar in place. On 2/26/11 at 7:30 am, the initial assessment revealed vital signs-temperature 97.7, pulse-50, respirations-18, blood pressure-157/71. Respirations were regular, lung sounds were clear on the right and upper left lobe with crackles in the left lower lobe, heart rate was 48 beats per minute with bradycardic rhythm. Further review of nurses notes, physician progress notes, and physician orders revealed physician was not notified of the change in lung sounds on assessment. Notification of physician would be warranted due to the patient having a vomiting episode the day before. Review of the nursing assessment done at 8:40 pm for the 7pm-7am shift revealed patient now had wheezes in the right lung and crackles in the left lung. Vital signs were temperature-98, pulse-46, respirations-18, blood pressure-166/70. No notification of physician due to change in lung sounds was done. Review of physician progress note revealed patient was seen by the Physician Assistant at 4:30 pm and documented lungs were clear to auscultation. Review of summary of nursing shift assessment on 227/11 at 7:30 am revealed patient "Awake, oriented to time, place, and name. Hard of hearing. Follows simple verbal commands. Lungs clear to auscultation. Respirations unlabored. O2 at 3 L/min in use. Heart rate irregular, no edema, TED hose on, c-collar in place.

Review of nurses' notes dated 2/27/11at 8:00 am that stated "Having difficulty swallowing secondary to hard C-collar (cervical collar). Suction placed at bedside to use prn." There was no documentation in nurses' notes, physician progress notes or physician orders that physician had been notified and no physician orders were found to suction the patient. At 9:30 pm. "Meds crushed and given in pudding, patient took well." There was no physician order found in medical record to crush patient's medication The next nursing documentation related to difficulty swallowing and suctioning was on 2/28/11 at 6:00 am and the entry stated "Suctioned NT(?) with return thick white secretions and orally thick frothy secretions. 6:30 am Orally suctioned with large amount thich tenacious secretions. 8:00am - Patient awake alert and oriented to self. Respiration even and nonlabored. Required frequent suctioning secondary to increase of secretions." Further review of shift assessment flowsheet timed 8:00 am revealed patient had crackles in both right and left lungs, patient only oriented to person.11:20 am Patient continues to be suctioned periodically as needed. 2:15 pm Patient continues to be suctioned. 4:15 pm Patient unable to take meds by mouth due to increased secretions and difficulty swallowing. 5:40 pm Patient suctioned at this time. 9:30 pm Patient transferred to another facility via ambulance." Review of medication administration record revealed on 2/28/11, patient only received IV medications. Review of nursing intake and output records revealed patient had no oral intake on 2/28/11.

Review of Dietary Consultant notes dated 2/28/11 revealed the following: "Regular diet and IV fluids 60 cc/hr. Wearing large plastic neck collar. Spoke with family member that haws assisted at meals, who told that patient had choking episode yesterday (2/27/11). Staff report no problems with meals until yesterday, and ate little from then on. Staff also report resident is sitting up for all meals, and has no developed secretions and is being suctioned. Chest x-ray done to rule out aspiration, results pending. Nursing told me they are trying to treanfer patient to hospital that can better meet needs. Patient may not be safe to eat or drink. Recommend to MD add 10 meq Potassium to IV fluids every day, Speech therapy screen prior further intake by mouth, and increase IV rate to 75cc/hr if no oral fluids for more than 24 hours." There was a form titled "Communication between Dietary Consultant and attending Physician that listed these recommendations with an area for the physician to sign and agree or disagree with the recommendations and order the recommendations. Physician (Staff #1) did not complete or sign the form to order the recommendations.

Review of physician's orders revealed no order written for suctioning of patient, crushing medications, and no orders written for recommendation by Dietician. Review of physician's progress notes revealed no documented notes related to patient having difficulty swallowing or increased secretions. Further review of the medical record revealed patient #2 was not seen by Physician #1, attending physician, from the time of admission until the day of her discharge (5 days).

Based upon record review and interview, the medical staff failed to ensure the medical staff bylaws, rules and regulations, included provision for the utilization and appointment of 1 of 1 physician assistants. The facility utilized a physician assistant in the emergency department on weekends who had not been appointed by the medical staff and did not have a supervising physician that was appointed to the facility's medical staff.

Review of the Medical Staff Bylaws, Rules and Regulations revealed the section in the Rules and Regulations titled "Specified Professional Personnel or Medical Affiliates." The section contained the following information: "Specified professional personnel or medical affiliates shall be individually authorized and assigned to carry out their professional activities under the supervision of the appropriate attending staff member assigned this responsibility, and shall be subject to the approved policies and procedures of the medical staff and hospital. Specified professional personnel in this facility include CRNA's."

Review of facility policy titled "Mid-Level Practitioners" with adoption date of 4/14/98 revealed the following: "Active medical staff physicians may designate another person or persons to perform for, or on their behalf, certain lawful acts as a mid-level practitioner (MLP) of said physician. Said acts are to be considered as the lawful acts of the physician and said physician shall be directly responsible for the acts of the mid-level practitioner. For purpose of these rules and regulations, mid-level practitioners shall include only Advanced Practice Registered Nurse (ARNP) and Physician Assistant (PA). Further review of policy revealed: Section III Rules and Regulations for MLP: 1. Each MLP will have one specifically designated responsible primary physician, even though they may perform duties under the direction of more than one physician. 2. In no instance will a MLP be assigned or allowed to perform tasks where no competently trained physician is available, even though the MLP may be trained to do those tasks. SECTON IV - Levels of Assignment- 3. Procedures which may be performed by the MLP in an emergency situation, pending the immediate availability of a physician, include: a. Managing cardiac and/or respiratory arrest, including CPR (cardiopulmonary resuscitation); b. Major trauma; c. Initiating electro-defibrillation; d. Intubating; e. ordering and administering blood. SECTION V - "Delineation of Responsibilities"- 1. The medical staff shall be responsible for the following: development of guidelines for the utilization of MLP which will be consistent and compliment the Medical Staff Bylaws and Rules and Regulation . 2. The responsible primary physician shall be responsible for the following: a. Assumes responsibility for the medical care of his/her patients, and shall supervise the MLP in the care of the patients. b. Assumes all responsibility for and countersigns all entries in medical records as documented by the MLP.

Review of the facility's credentialing or personnel file for the Physician Assistant (PA) contained the following expired documents: PA license, Cardiopulmonary Resuscitation (CPR) Expired 9/2010, Advanced Cardiac Life Support (ACLS) expired 9/2010, Pediatric Advanced Life Support (PALS) expired 1/2011. There was no DPS or DEA registration. There was no appointment as a "medical associate" to the medical staff. There was no document indicating who the supervising physician was and no collaborative agreement between a physician and the PA.

Review of "Public Verification/Physician Profile" obtained from the Texas Medical Board Website revealed the PA's primary practice address as a facility in Cameron, Texas and the active supervising physician is on the medical staff at the facility in Cameron, Texas which is located 180 miles from this facility.

An interview was conducted with staff #5 on 3/7/11 at 1:30 pm. Staff #5 reviewed credentialing file for the PA and confirmed the license, CPS, ACLS, and PALS were all expired. Staff #5 also reported Staff #2 was the supervising physician for the PA but staff #5 confirmed there were no documents acknowledging staff #2 as the supervising physician and there was no collaborative agreement between staff #2 and the PA.

An interview was conducted with staff #2 on 3/7/11 at 1:00 pm in the ER. Staff #2 reported he remembered completing a form as supervising physician but he had no idea what happened to it when he completed it. Staff #2 also confirmed there was no collaborative agreement with the PA.

Based upon record review and interview, the medical staff failed to ensure 1 of 3 physicians (Staff #1) provided quality care to 2 of 2 (#1, #2) patients reviewed. Patient #1 had a change in condition and there was no physician available to evaluate patient and direct care. Patient #2 was admitted to the services of staff #1 but patient was not seen by staff #1 for 5 days.

Review of medical record for patient #2 revealed patient was admitted to the service of staff #1 on 2/23/11 with Cervical Spinal Fracture from a fall. Patient was in a hard plastic cervical collar and was requiring pain medication for pain control. The Emergency Room physician, Staff #2 requested transfer to a higher level of care at 2 acute care facilities but unable to negotiate the transfer so staff #2 admitted the patient to the services of staff #1. Further review of the medical record revealed physician progress notes written by Staff #2 on 2/24/11 and 2/25/11. On 2/26/11 and 2/27/11, patient #2 was seen by the Physician Assistant that was working in the emergency department. A progress note was written by the Physician Assistant only on 2/26/11. The Physician Assistant was not appointed by the medical staff, did not have a collaborative agreement with a supervising physician in this facility, and the physician listed on the Texas Medical Board Website as his supervising physician practices 180 miles from this facility. Review of nurses notes for 2/28/11 revealed patient was seen by staff #1. New telephone orders were written by the charge nurse for staff #1 but no physician progress notes were written by staff #1. The patient was hospitalized for 5 days before being transferred to another facility and staff #1, who was her attending physician, did not visit the patient until the 5th day.

Review of medical record #1 revealed patient was admitted to the facility on 2/9/11 with a diagnosis of acute exacerbation of chronic obstructive pumonary disease. Admitting orders were for Oxygen per nasal cannula at 3 liters/minute, hand held nebulizer treatments every 8 hours, and antibiotics. On 2/10/11, patient began responding to treatment. Patient was exhausted with minimal activity. On 2/11/11 at 1:30 am, patient was requesting water pitcher to be filled. At 3:30 am, patient again requested water pitcher to be filled and breathing treatment given. At 5:30 am, patient wanted water pitcher filled and patient was instructed he was drinking too much. At 7:30 am, patient was sitting up in bed, alert and oriented, patient conversing, no complaints. Patient was seen by PA and physician (staff #3) approximately 8am on 2/11/11. Orders were written for additional labs and an EKG to be done in am (2/12/11), and to change IV fluids to 3% Normal Saline, 500 cc @ 100 cc/hour then Normal Saline @ keep vein open rate.

A telephone interview was conducted with the patient's wife on 3/1/11 at 1:30 pm. The patient's wife reported on 2/10/11 she was at the hospital that evening and her husband had a good day and was responding to treatment and he told her to go home and get a good night's sleep because he would probably be coming home the next day and she would have to care for him. The wife went home and returned at approximately 9:45 am. The wife reported when she walked in the room her husband was breathing very shallow and rapid and was unresponsive to verbal stimuli and she tried shaking him to arouse him without success. The wife reported she went to the nurse's station and asked what had happened to her husband and the nurse told her he was alright earlier that morning but the night nurses told that he had a very bad night. The wife reported she asked the nurses to call staff #3 (physician) but they did not call him. The wife reported she went to the Emergency Room and requested staff #2 to go evaluate her husband but he did not. The wife reported that approximately 12:30 pm, Staff #3 came to the patient's room and informed the patient's family that he had been relieved of his duties and he suggested that the family have the patient transferred to another facility. The wife reported at that time she asked staff #3 to evaluate the patient but staff #3 told the wife he was not allowed. The wife then went back to the emergency room and begged staff #2 (Emergency Room physician) to evaluate her husband. The wife reported he came to the room and stuck his head in the door and looked at the patient but did not evaluate him and turned and walked away. The wife further reported that approximately3:00 pm, staff #1 arrived and evaluated the patient. Staff #1 told the wife that the patient was too critical to move and discussed the patient's living will and advanced directives. Wife reported family agreed to honor patient's living will and not utilize any heroic measures. Staff #1 ordered arterial blood gases and increased hand held nebulizer treatments to every 2 hours.

Review of nurse notes for patient #1on 2/11/11 at 9:55 am revealed "patient given xanax as ordered per wife's request. Review of nurse notes on 2/11/11 at 1200 noon revealed "patient sleeping soundly but arousable (night shift reported patient awake most of night). 12:30 pm - Dr (staff #3) in to see patient and family and notified them of his dismissal.. Family has requested transfer to another facility, initial contact made and staff #2 notified. Patient not verbally responding at present; family anxious and concerned. 1:30 pm - Spoke with staff #1 regarding taking over care of patient per the administrator's instructions. 2:40pm - Staff #1 in to see patient; new orders written. 15:00 - Blood gases obtained and patient placed on BIPAP set @ 18/5 per respiratory therapy.

Review of physician's orders revealed blood gases were ordered and change in IV fluids but there was no written order for BIPAP. Review of respiratory therapy progress notes dated 2/11/11 at 3:30 pm. revealed "Patient placed on BIPAP @ 16/5 with oxygen bleed-in @5 L/min."

Review of physician's progress notes revealed the final progress note written by staff #3 (physician) on 2/11/11: "Having been removed from medical staff by administrator, further orders will be from whomever he designates effective immediately per administrator." Staff #1 did not write any progress notes from 2/11/11-2/13/11.

Based upon record review and interview, the facility failed to ensure the history and physical examination was completed and on the medical record within 24 hours on 2 of 2 patient medical records reviewed.

Review of medical record #2 revealed patient was admitted on 2/23/11 by Emergency Room Physician to the services of staff #1(physician). A hand written history and physical examination was found in the physician progress notes dated 2/23/11 completed by staff #2.. Also found in the medical record was a typed document titled History and Physical that was completed by staff #1. The date of dictation was 2/28/11 (date of transfer) and the transcription date was 3/1/11.

Further review of the typed History and Physical revealed statements that clearly indicated the History and Physical was not completed within 24 hours of admission. The Statements were as follows:

"Urinalysis showed bacteria." Review of physician orders revealed the only time a urinalysis was ordered was on 2/26/11.

"I have discussed this with "physician #2" at the time of admission. The plan was discussed with me and I agreed to watch her while she is being treated with Levaquin, blood pressure and pain control, C-Collar, fluids and oxygen." Review of physician orders revealed the Levaquin was ordered on 2/27/11 (day before discharge) for urinary tract infection.

"ASSESSMENT - 1. Status post fall; 2. Cervical fracture; 3. Possible Aspiration Pnuemonia; Urinary Tract Infection." Review of medical record revealed Urinalysis was obtained on 2/27/11 and antibiotics started for Urinary Tract Infection on 2/27/11. Patient record revealed patient began having difficulty swallowing on 2/28/11 (date of discharge) and orders were given for nebulizer treatments and chest x-ray.

During an interview with staff #5 on 3/7/11, the medical record was reviewed. Staff #5 confirmed the typed history and physical examination contained events that occurred during the hospitalization and was not completed within 24 hours of admission.

Review of medical record #1 revealed patient was admitted to the facility on 2/9/11. Review of the history and physical report revealed the report was dictated on 2/10/11 but was transcribed on 2/19/11which was nine days after admission.

Based upon record review and interview, the facility failed to ensure physicans gave verbal orders infrequently on 2 of 2 (#1, #2) patient records reviewed.

Review of medical record #1revealed patient was hospitalized from 2/9/11 - 2/13/11. On 2/11/11 at approximately 2:30 pm, physician #1 assumed care for patient #1 after the dismissal of physician #3. Review of physician's orders revealed 6 telephone or verbal orders written by nursing staff and 1 physician written order from 2/11/11 - 2/13/11.

Review of medical record #2 revealed patient was hospitalized from 2/23/11-2/28/11. Review of physician's orders revealed 7 verbal or telephone orders and 4 physician written orders during the 6 day hospitalization.

An interview was conducted with staff #5 on 3/7/11. Staff #5 reported the problem had been identified but it had not been addressed with the physicians.

Based upon record review and interview, the facility failed to ensure entries in the medical records of 2 of 2 patients (#1, #2) were timed and authenticated by the responsible staff or physician.

Review of patient #1 revealed 12 of 15 physician's orders that were not timed and 3 of 3 physician progress notes that were not timed. In addition, 12 of 15 physician orders were signed off and dated by the nurse but no time was noted.

Review of patient #2 revealed 3 of 4 progress notes and 5 of 11 physician's orders that were not timed. In addition, 7 of 11 physician's orders were signed off and dated by the nurse but no time was noted.

During an interview with staff #5 on 3/7/11 at 11:30 am, staff #5 confirmed the orders and progress notes were not timed.

Based upon record review and interview, the facility failed to ensure physician orders were dated, timed, and authenticated by the physician who gave the orders on 2 of 2 patient medical records reviewed.

Review of medical record of patient #1 revealed 12 sets of physician orders. Further review revealed 6 of the 12 sets were not dated or timed and 2 of 12 were not timed.

Review of medical record of patient #2 revealed 11 sets of physician orders. Further review revealed 6 of 11 sets were not dated, timed, and authenticated by the ordering physician, 2 of 11 sets were not dated and timed, and 1 of 11 sets were not dated.

An interview was conducted with staff #5 on 3/7/11 at 11:30 am. Staff #5 confirmed the orders were not dated, timed, or signed and reported that was an ongoing problem that was being addressed.

Based upon record review and interview, the facility failed to ensure physicians authenticated all verbal orders on 1 of 2 (#2) patient medical records.

Review of patient medical record #2 revealed 6 of 11 verbal or telephone orders that were not authenticated by the physician who wrote the orders.

An interview was conducted with staff #5 on 3/7/11 at 11:30 am. Staff #5 reported being aware of problem with physicians not signing off on verbal and telephone orders.

Based upon record review and interview, the facility failed to ensure the history and physical examination was completed and on the medical record within 24 hours on 2 of 2 patient medical records reviewed.

Review of medical record #2 revealed patient was admitted on 2/23/11 by Emergency Room Physician to the services of staff #1(physician). A hand written history and physical examination was found in the physician progress notes dated 2/23/11 completed by staff #2.. Also found in the medical record was a typed document titled History and Physical that was completed by staff #1. The date of dictation was 2/28/11 (date of transfer) and the transcription date was 3/1/11.

Further review of the typed History and Physical revealed statements that clearly indicated the History and Physical was not completed within 24 hours of admission. The Statements were as follows:

"Urinalysis showed bacteria." Review of physician orders revealed the only time a urinalysis was ordered was on 2/26/11.

"I have discussed this with "physician #2" at the time of admission. The plan was discussed with me and I agreed to watch her while she is being treated with Levaquin, blood pressure and pain control, C-Collar, fluids and oxygen." Review of physician orders revealed the Levaquin was ordered on 2/27/11 (day before discharge) for urinary tract infection.

"ASSESSMENT - 1. Status post fall; 2. Cervical fracture; 3. Possible Aspiration Pnuemonia; Urinary Tract Infection." Review of medical record revealed Urinalysis was obtained on 2/27/11 and antibiotics started for Urinary Tract Infection on 2/27/11. Patient record revealed patient began having difficulty swallowing on 2/28/11 (date of discharge) and orders were given for nebulizer treatments and chest x-ray.

During an interview with staff #5 on 3/7/11, the medical record was reviewed. Staff #5 confirmed the typed history and physical examination contained events that occurred during the hospitalization and was not completed within 24 hours of admission.

Review of medical record #1 revealed patient was admitted to the facility on 2/9/11. Review of the history and physical report revealed the report was dictated on 2/10/11 but was transcribed on 2/19/11which was nine days after admission.

Based upon record review, nursing failed to ensure a physician's order was obtained for providing suctioning to clear the airway and crushing medications in pudding of 1 of 2 (#2) patients reviewed. Nursing also failed to ensure a physician's order was obtained for oxygen therapy via BIPAP for 1of 2 (#1) patients reviewed.

Review of nurse notes for patient #1on 2/11/11 at 9:55 am revealed "patient given xanax as ordered per wife's request. Review of nurse notes on 2/11/11 at 1200 noon revealed "patient sleeping soundly but arousable (night shift reported patient awake most of night). 12:30 pm - Dr (staff #1) in to see patient and family and notified them of his dismissal.. Family has requested transfer to another facility, initial contact made and staff #2 notified. Patient not verbally responding at present; family anxious and concerned. 1:30 pm - Spoke with staff #1 regarding taking over care of patient per the administrator's instructions. 2:40pm - Staff #1 in to see patient; new orders written. 15:00 - Blood gases obtained and patient placed on BIPAP set @ 18/5 per respiratory therapy.

Review of physician's orders revealed blood gases were ordered and change in IV fluids but there was no written order for BIPAP. Review of respiratory therapy progress notes dated 2/11/11 at 3:30 pm. revealed "Patient placed on BIPAP @ 16/5 with oxygen bleed-in @5 L/min." The BIPAP settings were different in the nurse's notes from what was written in the Respiratory Therapy progress notes.

Review of physician's progress notes revealed Staff #1 did not write any progress notes from 2/11/11-2/13/11 therefore no documentation by Staff #1of the use of oxygen therapy by BIPAP was found.

Review of the medical record of patient #2 revealed nurses' notes dated 2/27/11at 8:00 am that stated "Having difficulty swallowing secondary to hard C-collar (cervical collar). Suction placed at bedside to use prn." The next nursing documentation related to difficulty swallowing and suctioning was on 2/28/11 at 6:00 amand the entry stated "Suctioned NT(?) with return thick white secretions and orally thick frothy secretions. 6:30 am Orally suctioned with large amount thich tenacious secretions. 8:00am - Patient awake alert and oriented to self. Respiration even and nonlabored. Required frequent suctioning secondary to increase of secretions. 11:20 am Patient continues to be suctioned periodically as needed. 2:15 pm Patient continues to be suctioned. 4:15 pm Patient unable to take meds by mouth due to increased secretions and difficulty swallowing. 5:40 pm Patient suctioned at this time. 9:30 pm Patient transferred to another facility via ambulance."

Review of physician's orders revealed no order written for suctioning of patient. Review of physician's progress notes revealed no documented notes related to patient having difficulty swallowing or increased secretions.