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Based on record review and interview the hospital failed to ensure the hospital policy for DNR (Do Not Resuscitate) was followed as evidenced by 1 (#1) patient in a total sample of 30 (#1 - #30) with a DNR order was 1) not a verbal order and 2) included documentation in the physician's progress notes of how the decision was reached and who was present for the discussion. Findings:

Patient #1

Review of a hospital policy titled "Do Not Resuscitate", policy number N-201, effective 01/08, prior version date 4/04, presented as current hospital policy, revealed in part: "Purpose: To establish procedures when decisions concerning "Do Not Resuscitate" ("DNR") orders must be made...1. If the patient is incompetent, the patient's attending physician and a consulting physician must determine if a DNR order is medically appropriate, based on...presence or lack thereof of an advanced directive. 2. If the...patient has an advanced directive indicating a desire for DNR status in certain circumstances, the attending 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, the 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 documentation of such discussions shall include at least the following information: persons present, information conveyed by the physician, and decision of the family or legal guardian. 3...If the patient is not competent, the patient's family or legal guardian must consent to the entry of the DNR order. In either case the attending physician must indicate in the patient's medical record that consent has been obtained and the manner in which it was obtained...6...Verbal orders may not be implemented..."


Review of the medical record for patient #1 revealed the following: "Needs continued wound care for his sacral and bilateral lower extremity decubitis and IV antibiotics." The medical history for patient #1 included: Alzheimer's and Dementia...He is alert and talkative but disoriented...DNR (Do Not Resuscitate).

Review of the admission assessment dated 4/12/13 signed by S2DON revealed the following: "Neuromuscular...Level of Consciousness: Alert...Orientation: Person..."

Review of the medical record for patient #1 revealed a "Consent for Life-Sustaining Procedure" from the nursing home where patient #1 resides. Review of the document revealed it was signed by patient #1 on 04/19/12 with a check mark next to "I understand that CPR (cardiopulmonary resuscitation) constitutes an extraordinary measure and should not be performed on this resident....".

Review of the H&P (History and Physical) revealed S8Physician documented in the H&P that patient #1 is a DNR. Review of the physician's progress notes revealed no documentation in progress notes of how the DNR decision was obtained. Review of the physician's admission orders revealed the DNR order is a verbal order.

In an interview on 4/16/13 at 11:00 a.m. with S2DON she stated that the DNR order needs to be documented in progress notes and cannot be a verbal order. She further stated that there should be documentation in progress notes by physician of how the decision was reached and who was present.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by 1) failing to ensure patient wounds/pressure ulcers were measured upon admission and weekly thereafter per hospital policy for 3 (#1,#9,#29) of 30 (#1 - #30) sampled patients as evidenced by no documented measurements, and 2) failing to ensure admission orders were ordered by a licensed practitioner responsible for the care of the patient.

1) Failing to ensure patient wounds/pressure ulcers were measured upon admission and weekly thereafter per hospital policy.

Review of a hospital policy titled "Wound Documentation", policy number N-210, effective 01/08, prior version: 4/04, presented as current hospital policy revealed in part: "Purpose: To provide consistent documentation through assessment by licensed personnel of wound healing progression or need for a change in treatment...Procedure: 1. The licensed nurse will measure...the patient's wounds..."

Patient #1

Review of the medical record for patient #1 revealed: "Needs continued wound care for his sacral and bilateral lower extremity decubiti and IV antibiotics. Hx: CRI (chronic renal insuffiencey), Alzheimer's, Dementia, OA (osteoarthritis), GERD (gastroesophageal reflux disorder), BPH (benign prostatic hypertrophy), DM (Diabetes Mellitus) Type II, Anemia, CKD (chronic kidney disease), Depression, PVD (peripheral vascular disease). Surgical History: L (left) Total Knee (replacement). He is alert and talkative but disoriented. Diagnosis: Sacral decubitis with associated cellulitis. Currently on Zosyn. Multiple decubiti of heels, dorsum of right foot and right malleolus. Currently undergoing wound care. UTI (urinary tract infection). Protein and calorie malnutrition. On Clinimix per PICC (peripherally inserted central catheter). Bedbound. DNR."

Review of the assessment of the Sacral decubitis stage II-III wound assessment dated 4/12/13 revealed there was no measurement of the size of the sacral decubitis wound documented.

Patient # 9
Review of the medical record for patient #9 revealed he was admitted to the hospital on 3/21/13 with the diagnosis of COPD (Chronic Obstructive Pulmonary Disease) Exacerbation, Type II DM (Diabetes Mellitus), Anemia & Stage I Decubitus Ulcer on right upper posterior thigh.

Review of the wound assessment form dated 3/21 revealed patient #9 had a stage I decubitus to right posterior thigh, with an order written on 3/21/13 which reads, " apply bbp (boudreaux's butt paste) bid (twice a day); leave ota (open to air)", and a stage II decubitus to left buttocks as documented on the wound assessment form dated 4/12/13. Further review of the wound assessment forms dated 3/21/13, 3/24/13, & 4/12/13 revealed there was no documented measurement of the size of the decubitus for patient #9 in his medical records.

Patient #29

Review of the medical record for patient #29 revealed she was admitted to the hospital on 12/27/12 with the diagnosis of COPD ( Chronic Obstructive Pulmonary Disease) Exacerbation, Pneumonia, Recent Respiratory Failure & Intubation, UTI (urinary tract infection), & Protein Calorie Malnutrition.

Review of the wound assessment forms dated 12/27/13 & 1/1/13 revealed she had a wound on her buttock which the nurse staged as redness and did not document the size. Further review of the wound assessment form dated 1/21/13 revealed she had a stage II decubitus wound on her buttock with no documented size.

In an interview on 4/16/13 at 1:00 a.m. with S2DON, she stated that all decubitis wounds should be measured.

2) Failing to ensure admission orders were ordered by a licensed practitioner responsible for the care of the patient.

Review of the Hospital Policy titled Routine Admission Orders, Policy No. N-209, Effective Date: 01/08 revealed in part:
2. As per MEC approval Routine Admit Orders may be initiated by the admission RN based on orders from transferring facility.
A review was made of the document titled Crowley Rehab Hospital Routine Admission Orders. Review of the top of the document revealed the following statement: Admit Orders for Crowley Rehab Hospital (Please check appropriate orders). Beneath the statement were 42 potential orders with boxes to the left of them to place a check mark if the orders were to be implemented. Further review revealed a line at the bottom of the document for a physician's signature.
Review of the hospital's policies and procedures revealed no protocols or policies on routine admission orders or standing admission orders approved by the MEC (medical executive committee).
In an interview on 4/16/13 at 2:30 p.m. with S2DON, she stated when a patient was admitted to the hospital, the Crowley Rehab Hospital Routine Admission Orders sheet was completed by the admission nurse based on the discharge information from the patient's previous hospital. She stated the form had 42 potential orders that could be checked by the nurse to initiate the orders. S2DON said the admit nurse would go over some of the items on the admission order checklist with the physician when they called to get admission orders, but not all 42 of the orders on the list. S2DON said without consulting the admitting physician on specifically which of the other remaining orders to select, the nurses would select the other orders based on the previous treatment from the discharging hospital or the usual treatment at the hospital. S2DON said some of the orders were checked because they were common sense. S2DON verified the orders were not truly standing orders because there were no protocols or approved policies and procedures to aid in the nurse's selection of the orders. S2DON verified that by the nurse selecting certain orders and placing a check mark next to the orders without the physician specifying the order made them appear to all be ordered by the physician since it was written at the bottom of the form that a physician's telephone order had been obtained. S2DON said the physician would come in later to sign the orders, usually within 24 hours. S2DON also said the nurse liaison would assess the patient before they were admitted and speak to the physicians at the other hospitals about the patients care, but did not write verbal orders for medications or care. S2DON stated she could agree that the nurse picking and choosing some of the orders could potentially be problematic.











31206

Based on interview and record review, the hospital failed to ensure medical records were promptly completed within 30 days of a patients discharge and follow medical staff bylaws for discipline of staff physicians with delinquent medical records for 5 (S4, S5, S6, S8, S9) of 8 staff physicians.

Findings:

Review of the HIM Policy and Procedure titled Discharge Summaries, Policy No. HIM-04 revealed in part:
Policy: The attending physician will develop a Discharge Summary to be included in the patient's record within 30 days of discharge. The chart will be considered complete when the discharge summary is filed in the chart and is signed by the physician and all physician orders are signed.

Review of the Medical Staff Bylaws revealed in part:
Section 3. Automatic Suspension: a. A temporary suspension in the form of withdrawal of a practitioner's admitting privileges, effective until medical records are completed, shall be imposed automatically on the 5th day from warning of delinquency for failure to complete medical records within 30 days of a patient's discharge.
m. Each medical record shall be complete within 30 days after the discharge of the patient or the record becomes delinquent. On a continuous basis, the medical director shall review incomplete records. At this time, any physician who has any delinquent charts shall be notified by phone. If the records are still incomplete two weeks after being notified, he shall automatically suffer suspension of admitting privileges. He shall be notified of such suspension in writing by the medical record director. Privileges may be restored by the Chief Medical Officer when he has been notified by the medical record that the delinquent records have been completed.

Review of a document of a meeting with the Medical Director dated 1/10/13 revealed the following in part:
Medical Records Director discussed the delinquency rate for the facility. Some of the medical records that need attention backdate to 2011. Very concerned if State visits, facility is not in compliance. Weekly reminders have been sent to each physician regarding their delinquent record status. Requesting assistance from Medical Director and new owners to discuss with those physicians (S4Physician, S5Physician and S6Physician) whose charts need further documentation to get this issue resolved. Medical Director indicated he will discuss with physicians and bring this to the attention of new owners.

Review of a list of delinquent medical records by physician revealed the following delinquencies and the dates the medical records became delinquent:

S6Physician:
Signatures delinquent (10) - 6/22/11, 8/26/11, 10/11/11, 11/29/11, 12/29/11, 1/13/12, 3/19/12, 6/14/12, 6/18/12, 12/17/12.
Discharge Summaries delinquent (6) - 3/9/12, 5/21/12, 7/18/12, 8/28/12, 11/27/12, 1/23/13.

S5Physician:
Signatures Delinquent (3) - 12/12/11, 5/11/12, 3/6/13.
Discharge Summaries delinquent (24) - 2/6/12, 2/13/12, 2/29/12, 3/20/12, 3/29/12, 6/29/12, 7/6/12, 7/31/12, 8/2/12, 9/24/12, 10/11/12, 10/26/12, 11/20/12, 12/10/12, 12/17/12, 1/3/13, 1/18/13, 1/21/13, 1/22/13, 1/22/13, 1/24/13, 2/4/13, 2/13/13, 2/26/13.
History and Physical delinquent (5) - 7/26/12, 1/22/13, 2/4/13, 2/13/13, 2/26/13.

S4Physician:
Signatures delinquent (3) - 6/22/12, 7/2/12, 3/15/13.
Discharge Summaries delinquent (8) - 7/23/12, 7/25/12, 9/9/12, 11/27/12, 1/25/13, 2/13/13, 2/26/13, 3/2/13.

S8Physician:
Signature delinquent (1) - 3/13/13
Discharge Summaries delinquent (1) - 3/8/13

S9Physician: Signature delinquent (1) - 3/4/13

In an interview on 4/17/13 at 8:49 a.m. with S7MR, she stated she had 8 active physicians on staff at the hospital. S7MR said when physician ' s had deficient medical records, they were faxed a notice weekly with their deficiencies to be corrected listed. S7MR stated if the deficiencies were over 30 days old, she notified S1Administrator verbally. S7MR said she did not have written notification of her telling the administrator about the delinquencies. S7MR also said her delinquency rate for 2013 was 42%. S7MR was unable to present a HIM policy on the procedure for notifying physicians about their delinquencies or the consequences of having delinquent medical records.

In an interview on 4/17/13 at 9:10 a.m. with S1Administrator, he said S7MR reported delinquent medical records by physician to him verbally. He said he would talk to the physicians personally to try and get them to bring their charts up to date, but did not send any formalized letters. S1Administrator said he made the governing body aware of the delinquencies, but nothing had been done to reprimand the physicians. He said until December 2012, the two major physician offenders of delinquent medical records were on the governing body of the hospital, so that is why they did not have their privileges suspended as indicated in the medical staff bylaws.

Based on record review and interview, the hospital failed to ensure all entries in patient ' s medical records were dated and timed by the person responsible for providing or evaluating the service provided for 7 (#1, #3, #4, #5, #6, #7, #8) of 9 patients with focused dating, timing, and authentication of medical record entries in a total sample of 30 (#1 - #30).
Findings:.
Review of the Medical Staff Bylaws revealed in part:
d. All clinical entries in the patient ' s medical record shall be accurately dated and authenticated. Authentication means to establish authorship by written signature of identifiable initials.

Patient #1

Review of the medical record for patient #1 revealed: "Needs continued wound care for his sacral and bilateral lower extremity decubiti and IV antibiotics. Hx: CRI (chronic renal insuffiencey), Alzheimer's, Dementia, OA (osteoarthritis), GERD (gastroesophageal reflux disorder), BPH (benign prostatic hypertrophy), DM (Diabetes Mellitus) Type II, Anemia, CKD (chronic kidney disease), Depression, PVD (peripheral vascular disease). Surgical History: L (left) Total Knee (replacement). He is alert and talkative but disoriented. Diagnosis: Sacral decubitis with associated cellulitis. Currently on Zosyn. Multiple decubiti of heels, dorsum of right foot and right malleolus. Currently undergoing wound care. UTI (urinary tract infection). Protein and calorie malnutrition. On Clinimix per PICC (peripherally inserted central catheter). Bedbound. DNR."

Review of the assessment of the Sacral decubitis stage II-III wound assessment dated 4/12/13 revealed there was no time documented on wound care assessments.

In an interview on 4/16/13 at 1:00 a.m. with S2DON she stated that medical record entries should be dated and timed.

Patient #2
Review of the medical record for Patient #2 revealed he was an 86 year old male admitted to the hospital on 3/22/13 with the diagnosis of CHF (Congestive Heart Failure) Exacerbation, Diastolic Dysfunction, Hypoalbumineria, & Pancytopenia.

Review of the medical record for Patient #2 revealed the physician had authenticated the following verbal orders, but did not time or date the entries:

Admission telephone orders dated 3/22/13 at 1220.
Admission telephone orders dated 3/22/13 at 1220.
Medication clarification order & diet order dated 3/24,4/1,4/11, & 4/12/13

Review of the medical record for Patient #2 revealed the physician had authenticated the following orders, but did not time the entries :
Medication orders dated 3/22, 3/23, 3/24, 4/10, & 4/15/13.

In an interview on 4/16/13 at 3:30 p.m. with S2DON, she verified the above mentioned missing times and or date on Patient #2 ' s medical record.



Patient #3
Review of the medical record for Patient #3 revealed she was a 61 year old female admitted to the hospital on 4/10/13 with diagnosis including CHF, left pleural effusion, Dyslipidemia, Mental Retardation, GERD, Electrolyte Abnormalities and Severe Scoliosis.
Review of the medical record for Patient #3 revealed the physician had authenticated the following verbal orders, but did not time or date the entries:
Admission telephone orders dated 4/10/13 at 1715.
Admission telephone medication orders dated 4/10/13 at 1715.
Review of the medical record for Patient #3 revealed the wound assessment on 4/10/13 had not been timed.
Review of the nutritional assessment for Patient #3 dated 4/14/13 revealed the entry had not been timed.
Review of the nutritional evaluation for Patient #3 dated 4/12/13 revealed the evaluation had not been timed.
In an interview on 4/16/13 at 2:00 p.m. with S2DON, she verified the above mentioned times were not on the entries in the medical record for Patient #3. S2DON also verified the missing times were errors. S2DON was unable to locate a policy on the hospital requiring dates and times on all entries in the medical record.

Patient #4

Review of the medical record for patient #4 on 4/16/13 revealed she was a 58 year old female admitted on 04/05/13 for Infected transverse abdominal wound status post hernia repair with multiple complications, post-op pneumonia, severe protein calorie malnutrition, debility, and dysphagia.

Review of the medical record for patient #4 revealed the following medical record entries were not dated and/or timed and/or authenticated by the physician:

The Admission Orders were taken as a verbal order on 04/05/13 by S2DON from S5Physician and were not authenticated by the physician.

Physician's Progress Notes dated 04/7/13, 4/8/13, 4/9/13, 4/14/13 were not timed by the physician.

PT (physical Therapy) notes for 04/08/13, 04/10/13, 04/12/13, and 04/15/13 were not timed.

Speech Pathology notes from 04/09/13 were not timed.

The Nutritional Assessment and Evaluation forms were not timed.

In an interview on 04/16/13 at 1:30 p.m. with S2DON she confirmed the above entries in the medical record were not timed.
Patient #5
Review of the medical record for Patient #5 revealed she had been admitted to the hospital on 3/25/13 with diagnosis which included a stage 4 decubitus ulcer to her sacrum and a stage 3 ulcer to her ankle.
Review of the physician ' s telephone order dated 6/9/13 at 1940 revealed an order for NS (normal saline) 500 cc (milliliters) over 8 hours IV (intravenous). Further review revealed the physician had authenticated the order but had not timed or dated his signature.
Review of a document in Patient #5 ' s medical record dated 4/10/13 titled Notice of Approaching Soft Stop-All Drugs revealed a continuation order for Tigecycline 50 mg (milligrams) IV q (every) 12 hours. Further review revealed the physician had signed the order, but had not timed his signature.
Review of a document in Patient #5 ' s medical record dated 4/11/13 titled Notice of Approaching Soft Stop-All Drugs revealed a continuation order for Ciprofloxacin 500 mg oral BID (twice per day). Further review revealed the physician had signed the order, but had not timed his signature.
In an interview on 4/16/13 at 2:04 p.m. with S2DON, she verified the above mentioned missing times on the entries in Patient # 5 ' s medical record and stated they were errors.

Patient #6
Review of the medical record for Patient #6 revealed she had been admitted on 4/1/13 with diagnosis which included Status post incision and drainage of the right great toe, chronic debility, Great toe gangrene, peripheral vascular disease and HTN.
Review of a document in Patient #6 ' s medical record dated 4/9/13 titled Notice of Approaching Soft Stop-All Drugs revealed a continuation order for Piperacillin/Tazobactam 3.375 mg IV q 8 hours. Further review revealed the physician had signed the order, but had not timed or dated his signature.
Review of the documents in Patient #6 ' s medical record titled Hospital Wound Assessment Form dated 4/1/13, 4/7/13, and 4/14/13 revealed they had been signed by a nurse, but no time had been written as to when the assessments had been completed.
In an interview on 4/16/13 at 2:08 p.m. with S2DON, she verified the above mentioned missing times on Patient #6 ' s medical record.

Patient #7

Review of the medical record for patient #7 revealed she was a 66 year old female who was admitted on 2/13/13. Admission diagnosis included L lateral decubitis with infection s/p debridement, uncontrolled DMII, HTN (Hypertension), CVA (cerebrovascular accident-stroke) (with) L weakness, Vertigo, Morbid Obesity, Hypoalbuminemia, UTI.
Further review revealed the following orders were not dated and/or time and or authenticated:
The Admission Orders (3 pages) were not authenticated by by S4Physician.
The physician's order dated 2/17/13 (pro-shot, multivitamin, vitamin C, Zinc) had no documented time the order was written.
The physician's order dated 02/19/13 for Duragesic Patch had no time the order was written by the physician.
The physician's order dated 2/21/13 for Duragesic patch had no time the order was written by the physician.
The physician's order dated 2/24/13 at 1740 Verbal Order was not authenticated by the physician (S9Physician) who gave the verbal order.
The physician's Verbal Orders dated 3/4/13 at 1745, 1820, 1855 were not authenticated by the physician who gave the verbal order.
The physician's Discharge Order dated 03/14/13 was not authenticated.
The physician's progress notes dated 2/17/13, 2/18/13, 2/19/13, 2/20/13 were timed.
The Discharge Summary was not signed by S4Physician.
In an Interview on 4/17/13 at 10:20 a.m. with S2DON she confirmed the above findings.

Patient #8

Review of the medical record for patient #8 on 4/16/13 revealed he was an 89 year old male admitted on 02/14/13 with admission diagnosis that included Bilateral Pneumonia, CHF (congestive heart failure) exacerbation, COPD (chronic obstructive pulmonary disease) exacerbation with hypercapnea, Malnutrition with hypoalbuminemia, and debility.
Review of the medical record for patient #8 revealed the following orders were not dated or timed and or authenticated:
The admission orders were taken as a verbal order from S8Physician and were not timed.
The discharge summary dictated by S8Physician was not signed.
Review of the PT documentation revealed an initial evaluation was performed on 02/15/13. Further review of the medical record revealed patient #8 received PT services on 02/18/13, 02/20/13, 02/22/13, 02/25/13, 02/27/13, 03/01/13, and 03/05/13. None of the PT documentation was timed.

Review of the OT documentation revealed an initial evaluation on 02/19/13. Further review of the medical record revealed patient #8 received OT services on 02/27/13, 03/04/13, 03/07/13, and 03/12/13. None of the OT documentation was timed.

In an interview on 04/16/13 at 1:30 p.m. with S2DON she confirmed the above entries in the medical record were not timed.

Patient #9

Review of the medical record for patient #9 revealed a 74 year old male admitted to the hospital on 3/21/13 with the diagnosis of COPD (Chronic Obstructive Pulmonary Disease) Exacerbation, Type II DM (Diabetes Mellitus), Anemia & "Stage I Decubitus Ulcer on right upper posterior thigh.

Review of the medical record for patient #9 revealed the following orders were not dated or timed and or authenticated by S9 Physician:
Verbal orders dated 3/22, 4/4, 4/5/13 were all authenticated by S9 Physician, entries were not date and or time by S9 physician.
Verbal order dated 3/23/13 were authenticated by S4 Physician, entry was not date or time by S4 Physician.
Wound assessment dated 3/21, 3/24, & 3/31 were signed & dated by S9 Physician documented time of assessment.
Wound assessment of right & left buttock decubitus dated 4/12/3 were not authenticated, dated or signed by S9 Physician.

In an interview on 04/16/13 at 3:40 p.m. with S2DON she confirmed the above entries in the medical record were not authenticated, date, and or time.











31206

Based on record review and interview the hospital failed to ensure the H&P (history and physical) was on the medical record within 24 hours of admission as evidenced by 3 (#10, #17, #27) of 30 (#1 - #30) H&P's not being on the chart within 24 hours of admission. Findings:

Review of a hospital policy titled "Uniform Content Of Medical Records", policy number: HIM-09, presented as current hospital policy read in part: "Purpose: To ensure uniform content, format, clinical integrity, accuracy and completeness of the medical record based on Medical Staff Bylaws, State, and Federal Guidelines...2. History and Physical Examination:...The H&P must be completed within 24 hours of patient admit..."

Patient #10

Review of the medical record for patient #10 revealed he was admitted on 01/31/13. Review of the H&P revealed it was dictated on 02/01/13 and transcribed on 02/03/13.

In an interview on 04/17/13 at 10:20 a.m. with S2DON she confirmed the H&P could not have been on the medical record until 02/03/13, the day it was transcribed.

Patient #17

Review of the medical record for patient #17 revealed he was admitted on 03/11/13. Review of the H&P revealed it was dictated on 03/12/13 and transcribed on 03/14/13.

In an interview on 04/17/13 at 1:00 p.m. with S7MR she confirmed the H&P could not have been on the medical record until 02/03/13, the day it was transcribed.

Patient #27

Review of the medical record for patient #27 revealed he was admitted on 12/26/12. Review of the H&P revealed it was dictated on 12/27/12 and transcribed on 12/28/12.

In an interview on 04/18/13 at 9:45 a.m. with S7MR she confirmed the H&P could not have been on the medical record until 12/28/12, the day it was transcribed.

Based on record review and interview, the hospital failed to ensure all medical records had a documented discharge summary within 30 days of discharge for 11 (#13,#15, #16, #18, # 19, #21, #24, #27, #28,#29, #30) of 21 discharged patients medical records sampled.
Findings:

Review of the medical staff bylaws presented by the hospital as current revealed the following in part:
Section 3. Medical records
a. The attending physician shall be responsible for the preparation of a complete and legible medical record for each patient. Its content shall be pertinent and current. This record shall include ...summary or discharge note.
g. A discharge clinical resume (summary) shall be written or dictated on all medical records of patients hospitalized over 48 hours. In all instances, the content of the medical record shall be sufficient to justify the diagnosis and warrant the treatment and end result. All summaries shall be authenticated by the responsible physician.
m. Each medical record shall be complete within 30 days after the discharge of the patient or the record becomes delinquent.

Patient #13

Review of the medical record for Patient #13 revealed she had been admitted to the hospital on 1/21/13 with the diagnosis of a Gastrocutaneous fistula and discharged on 2/25/13. Further review revealed Patient #13 had no discharge summary in her medical record.

Patient #16
Review of the medical record for Patient #16 revealed she had been admitted to the hospital on 1/18/13 for wound care and discharged on 2/13/13. Further review revealed Patient #16 had no discharge summary in her medical record.

Patient # 18
Review of the medical record for Patient #18 revealed she had been admitted to the hospital on 1/11/13 with the diagnosis of an acute L4 fracture and discharged to hospice on 2/14/13. Further review revealed Patient #18 had no discharge summary in her medical record.

Patient #21
Review of the medical record for Patient #21 revealed he had been admitted to the hospital on 12/31/12 and discharged on 1/25/13. Further review revealed Patient #21 had no discharge summary in his medical record.

Patient #24
Review of the medical record for Patient #24 revealed he had been admitted to the hospital on 1/17/13 with the diagnosis of a Stage IV decubitus ulcer and discharged on 1/24/13 to a local hospital. Further review revealed Patient #24 had no discharge summary in his medical record.

Patient #27
Review of the medical record for Patient #27 revealed she had been admitted to the hospital on 12/26/12 for continued antibiotic treatment and discharged on 1/21/13. Further review revealed Patient #27 had no discharge summary in his medical record.

Patient #28
Review of the medical record for Patient #28 revealed he had been admitted to the hospital on 12/28/12 with the diagnosis of acute onset renal insufficiency and discharged on 1/23/13. Further review revealed Patient #28 had no discharge summary in his medical record.

Patient #30
Review of the medical record for Patient #30 revealed she had been admitted to the hospital on 2/22/13 with the diagnosis of a diabetic ulcer left heel and discharged on 3/8/13. Further review revealed Patient #30 had no discharge summary in her medical record.

Patient #15
Review of the medical record for Patient #15 revealed she was admitted to the hospital on 1/15/13 with the diagnosis of Serve Protein Malnutrition, and discharged on 2/14/13. Further review revealed Patient #15 had no discharge summary in her medical record.

Patient # 19
Review of the medical record for Patient #19 revealed he was admitted to the hospital on 12/3/12 with the diagnosis of Severe Protein Calorie Malnutrition, Pneumonia, Uncontrolled Type II DM (Diabetes Mellitus) and HTN (High Blood Pressure) and discharged on 1/3/13. Further review revealed Patient #19 had no discharge summary in his medical record.

Patient #29
Review of the medical record for Patient #29 revealed she was admitted to the hospital on 12/27/12 with the diagnosis of COPD (Chronic Obstructive Pulmonary Disease) Exacerbation, Pneumonia,UTI (Urinary Tract Infection), and Left Hemiplegia CVA (cerebral vascular accident) and was discharged on 1/22/13. Further review revealed Patient #29 hand no discharge summary in her medical record.

In an interview on 4/18/13 at 9:45 a.m. with S7MR, she stated discharge summaries should be completed on all patients within 30 days of being discharged. S7MR verified the above mentioned records did not include a discharge summary within 30 days of discharge.



31206

Based on observation and interviews, the hospital failed to ensure equipment was maintained to ensure an acceptable level of safety and quality as evidenced by: 1) failing to have preventative maintenance of respiratory equipment and electric patient beds. 2) failing to ensure sanitary storage of clean patient equipment in a room where contaminated patient items were being laundered.
Findings:
1) Failing to have preventative maintenance of equipment.
An observation was made of the respiratory department on 4/16/12 at 10:25 a.m. 2 nebulizer's and 1 Portable Suction machine were noted to not have preventative maintenance stickers on them.

In an interview with S3CRT, she stated the respiratory department of the hospital had 7 nebulizer's and 1 portable suction machine available for patient use. S3CRT stated the equipment had neither been tested by a biomedical engineer before use on patients nor had routine preventative maintenance.

In an interview on 4/16/13 at 10:27 a.m. with S1Administrator, he said the directors of the various hospital departments checked their mechanical equipment for safety. He stated there was no record of a biomedical engineer having tested the suction or nebulizer equipment in the respiratory department.
In an interview on 4/17/13 at 10:00 a.m. with S2DON, she stated the facility did not have a biomedical engineer on staff or contracted to ensure the safety of mechanical equipment before use on a patient or perform preventative maintenance on equipment.
In an interview on 4/18/13 at 9:15 a.m. with S2DON, she stated no routine preventative maintenance (PM) had been performed on the 15 patient beds. She also stated she did not have any manufacturer ' s recommendations for PM for the beds. S2DON also said she did not have a policy on PM for the hospital.

2) Failing to ensure sanitary storage of clean patient equipment in a room where contaminated patient items were being laundered.
Review of the hospital policy and procedure manual revealed no policy for the storage of clean equipment. On 4/18/13 at 10:00 a.m., S2DON verified the hospital did not have a policy on the storage of clean equipment.
An observation on 4/16/13 at 10:30 a.m. of a storage room revealed the following clean patient supplies: 10 wheelchairs, a Geri-chair, 7 IV (intravenous) pumps, 6 slings for patient lifts and 14 walkers. Further observation revealed a washer and dryer in the room.
In an interview with S1Administrator, he stated the medical equipment in the room was clean patient equipment. He also verified dirty patient laundry was taken into the room to be washed and dried.
In an interview on 4/18/13 at 9:00 a.m. with the infection control officer S2DON, she stated contaminated laundry should not be taken into the same room with clean patient equipment.

Based on record review, staff interview, and review of Louisiana Physical Therapy Practice Act and Louisiana State Board Medical Examiners, the hospital failed to ensure that physical therapy (PT) and occupational therapy (OT) services were provided only under the orders of a licensed practitioner by failing to obtain physician's orders for therapy services provided after the initial evaluation by the therapist for 3 (#4, #7, #8) of 30 (#1 - #30) sampled patients. Findings:

Review of the Louisiana Revised Statutes, 37:2401-37:2424 Chapter 29. Louisiana Physical Therapy Practice Act revealed in part the following:
§2418. Authority to practice as a physical therapist or physical therapist assistant
A. A physical therapist or physical therapist assistant licensed in Louisiana is authorized to practice physical therapy as defined in this Chapter. A physical therapist is responsible for managing all aspects of the physical therapy care of each patient. B. Without prescription or referral, a physical therapist may perform an initial evaluation or consultation of a screening nature to determine the need for physical therapy and may perform physical therapy or other services provided in Subsection C of this Section. However, implementation of physical therapy treatment shall otherwise be based on the prescription or referral of a person licensed to practice medicine, surgery, dentistry, podiatry, or chiropractic. C. Except as to an initial evaluation or consultation, as provided in Subsection B of this Section, physical therapy services may be performed without a prescription or by referral only under the following circumstances: (1) To a child with a diagnosed developmental disability pursuant to the child's plan of care. (2) To a patient of a home health care agency pursuant to the patient's plan of care. (3) To a patient in a nursing home pursuant to the patient's plan of care. (4) Related to conditioning or to providing education or activities in a wellness setting for the purpose of injury prevention, reduction of stress, or promotion of fitness.(5) To an individual for a previously diagnosed condition or conditions for which physical therapy services are appropriate after informing the health care provider rendering the diagnosis. The diagnosis shall have been made within the previous ninety days. The physical therapist shall provide the health care provider who rendered such diagnosis with a plan of care for physical therapy services within the first fifteen days of physical therapy intervention..."

Review of the Louisiana State Board of Medical Examiners Subchapter B. Standards of Practice revealed in part the following:
A. This Subchapter provides the minimum standards for occupational therapy practice applicable to all persons licensed to practice occupational therapy in the state of Louisiana.
4915. Individual Program Implementation
A. Implementation of direct occupational therapy to individuals for their specific medical condition or conditions shall be based on a referral or order from a physician licensed to practice in the state of Louisiana.

Patient #4

Review of the medical record for patient #4 on 4/16/13 revealed she was a 58 year old female admitted on 04/05/13 for Infected transverse abdominal wound status post hernia repair with multiple complications, post-op pneumonia, severe protein calorie malnutrition, debility, and dysphagia.

Review of the admission orders, taken as a verbal order from S5Physician by S2DON on 04/05/13 at 1510 revealed an order, #18 on the pre-printed order sheet, that read as follows: "PT/OT full evaluation and treat".

Review of the PT documentation revealed an initial evaluation was performed on 04/08/13. Further review of the medical record revealed patient #4 received PT services on 04/10/13 and 04/15/13. Review of the entire medical record revealed no documented evidence the practitioner responsible for the care of patient #4 reviewed the PT evaluation and ordered PT based upon the evaluation of patient #4.

There was no documentation in the medical record that OT evaluated patient #4 as ordered by the physician.

In an interview on 04/16/13 at 1:30 p.m. with S2DON she confirmed the orders for PT/OT to evaluate and treat patient #4. She further confirmed that OT failed to follow the physicians order to evaluate patient #4.

Patient #7

Review of the medical record for patient #7 revealed she was a 66 year old female admitted on 2/13/13. Admission diagnosis included L lateral decubitis with infection s/p debridement, uncontrolled DMII, HTN, CVA L weakness, Vertigo, Morbid Obesity, Hypoalbuminemia, UTI.
Review of the admission orders, taken as a verbal order from S4Physician by S2DON on 04/05/13 at 1510 revealed an order, #18 on the pre-printed order sheet, that read as follows: "PT/OT full evaluation and treat".
In an interview with on 4/17/13 at 10:20 am. with S2DON she confirmed the above findings.

Patient #8

Review of the medical record for patient #8 on 4/16/13 revealed he was an 89 year old male admitted on 2/14/13 with admission diagnosis that included Bilateral Pneumonia, CHF (congestive heart failure) exacerbation, COPD (chronic obstructive pulmonary disease) exacerbation with hypercapnea, Malnutrition with hypoalbuminemia, and UTI.
Review of the admission orders, taken as a verbal order from S5Physician by S2DON on 04/05/13 at 1510 revealed an order, #18 on the pre-printed order sheet, that read as follows: "PT/OT full evaluation and treat".

Review of the PT documentation revealed an initial evaluation was performed on 02/15/13. Further review of the medical record revealed patient #8 received PT services on 02/18/13, 02/20/13, 02/22/13, 02/25/13, 02/27/13, 03/01/13, and 03/05/13.

Review of the OT documentation revealed an initial evaluation on 02/19/13. Further review of the medical record revealed patient #8 received OT services on 02/27/13, 03/04/13, 03/07/13, and 03/12/13.

In an interview on 04/16/13 at 1:30 p.m. with S2DON she confirmed the orders for PT/OT to evaluate and treat patient #8.

Review of the entire medical record revealed no documented evidence the practitioner responsible for the care of patient #8 reviewed the PT/OT evaluation and ordered PT/OT based upon the evaluation of patient #8