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Based on interview with the Director of Case Management, record review, and review of the Health Care Decisions Policy, the Long-Term Acute Care Hospital (LTACH) failed to ensure that advanced directives were properly executed and/or available in the medical record for 1 patient (Patient #14) of 7 patients (Patients #10 th 17).

Findings include:

The Policy/Procedure Titled Health Care Decisions indicated that the Admissions Coordinator, Case Manager/Social Worker or nursing representative admitting the patient will ask the patient/designated representative whether or not the patient had completed an advanced directive. If an advanced directive exists, then the patient/designated representative will be asked to bring a copy for placement in the medical record.

The LTACH's Admissions Packet contained a form titled Advance Directives with areas to indicate if an advanced directive existed, if a copy was/was not placed in the medical record, if the patient wanted more information regarding advance directives, and an area to list the individuals the patient designated through a legally executed document to act as surrogate decision maker in the event the patient became capacitated.

The Surveyor interviewed the Case Management Director with the chief clinical officer (CCO) present on 2/7/12 at 10:30 A.M. The Case Management Director said the admissions office was responsible for bringing the admission packet, which contained information regarding Advance Directives, to the Unit for completion. The Case Management Director said the Case Managers were responsible for following up on advanced directive concerns.

The Admission Face Sheet indicated the LTACH admitted Patient #14 in August, 2010.

The Advance Directives form did not indicate if an advanced directive existed or if a copy was/was not placed in the medical record. The form indicated that through a legally executed document, Patient #14's spouse was the surrogate decision maker if Patient #14 became incapacitated.

The Director of Case Management said a copy of the advanced directive could not be located at the time of the survey.

Based on interview with Unit Manager #1, review of the Restraint Assessment and Order Sheets and the Restraint Flow Sheets indicated that the LTACH failed to ensure that a Restraint Assessment and Order Sheet was completed 11/10/11, 12/2/11, 12/3/11, 12/9/11 and 1/4/12 for one of three patients (Patient #1).

Findings include:

The Admission Face Sheet indicated that the LTACH admitted Patient #1 in October, 2011.

The Physician Progress Note, dated 10/18/11, indicated that Patient #1 suffered from a stroke and respiratory failure requiring a tracheostomy (tube inserted surgically through the neck directly into the trachea) and mechanical ventilation (provision of breaths by a ventilator connected to the tracheostomy). The Physician Progress Note indicated that Patient #1 received intravenous antibiotic therapy. The Progress Note indicated that Patient #1 required physical restraints to prevent sudden decannulation (removal of the tracheostomy).

The Restraint Assessment and Order Sheets, dated 10/18/11 to 1/20/12, indicated that the physicians ordered wrist restraints or hand mitts to prevent dislodging of medically necessary tubes. The physicians renewed the time-limited orders every 24 hours.

The Restraint Flow Sheets, dated 10/18/11 to 1/20/12, indicated that nursing staff applied bilateral mitts or wrist restraints on the following dates with a completed Restraint Assessment and Order Sheet:

1) bilateral mitts on 11/10/11 from 7:00 A.M. until 11:00 P.M.
2) bilateral wrist restraints on 12/2/11 from 4:00 P.M. until 11:00 P.M.
3) bilateral wrist restraints on 12/3/11 from 12:00 A.M. until 11:00 P.M.
4) bilateral wrist restraints on 12/9/11 from 8:00 A.M. until 3:00 P.M.
5) bilateral mitts on 12/29/11 from 7:00 A.M. until 3:00 P.M.
6) bilateral mitts on 1/4/12 from 12:00 a.m. until 6:00 A.M.

The Surveyor interviewed Unit Manager #1 on 12/6/12 and throughout the survey as needed. The Surveyor spoke with Unit Manager #1 regarding the missing Restraint Assessment and Order Sheets. Unit Manager #1 said the Restraint Assessment and Order Sheets for 11/10/11, 12/2/11, 12/3/11, 12/9/11 and 1/4/12 could not be located.

Based on interviews with Patient #1, Unit Manager #1 and the Evening Supervisor, review of the Long-Term Acute Care Hospital's (LTACH) Complaint/Event Log, and the Event Reporting System Policy, the Hospital failed to ensure that missing personal items were reported per Policy for one of one patients (Patient #10).

Findings include:

The Surveyor interviewed Patient #10 on 2/7/12 at 9:55 A.M. Patient #10 said that in December, 2011 he/she went from the LTACH to a nearby Emergency Department (ED) with several bags of personal belongings and at that time 2 game cartridges were missing. Patient #10 said he/she reported the missing game cartridges to someone at the LTACH, but could not remember who.

The Surveyor interviewed Unit Manager #1 on 2/7/12 at 10:05 A.M. regarding patient valuables. Unit Manager #1 said staff completed an event report when patient personal belongings were missing.

The Policy/Procedure titled Event Reporting System indicated that an event is any occurrence or situation not consistent with the routine operation of the facility. The staff member who identifies the event must enter the event into the Event Reporting System.

The Surveyor reviewed the Patient Complaint Log and the Event Log, dated 8/1/11 to 2/7/12. The Surveyor did not identify a complaint or event report regarding the missing game cartridges or the stuffed monkey.

The Surveyor interviewed Nurse #3 on 2/7/12 at 9:45 A.M. Nurse #3 said that Patient #10 told her that there was game cartridges and a stuffed monkey missing several weeks ago. Nurse #3 said she did not act on the information because Patient #10 told her that he/she reported the missing items to a nurse the night before.

The Surveyor interviewed the Evening Supervisor on 2/7/12 at 3:15 P.M. with the CCO present. The Evening Supervisor said that one evening, some time ago, Patient #10 informed her that 2 game cartridges were missing. The Evening Supervisor said she observed the hand-held gaming system on Patient #10's bedside stand. The Evening Supervisor said she did not complete an event report regarding the missing game cartridges and did not know she was supposed to. The Evening Supervisor said when personal items were missing, she sent an electronic mail (Email) to the Chief Clinical Officer (CCO), Chief Executive Officer (CEO), and/or Unit Manager. The Evening Supervisor said she could not remember if she sent an Email regarding Patient #10's missing game cartridges. The Evening Supervisor said she was not aware of the missing stuffed monkey.

The CEO, CCO, and Unit Manager #1 said they did not receive an Email regarding Patient #10's missing game cartridges.

1) Based on interviews with the Quality and Risk Director and Unit Manager #1, review of Case Management Notes and the Plan of Care, the LTACH failed to implement a plan of care addressing inappropriate behaviors for 1 of 1 patient (Patient #10).

2) Based on interviews with Unit Manager #1, the Rehabilitation Therapy Director, Nurse #1, Nurse #2 and certified nurse aide (CNA) #3 and review of Physician Orders, Physical Therapy Notes, Restorative Aide (RA) Notes, and Nursing Flow Sheets, the LTACH failed to ensure that staff got 1 of 3 patients (Patient #1) out of bed in accordance with the Plan of Care.

Findings include:

1) The Surveyor interviewed the Quality and Risk Director and Unit Manager #1 on 12/6/12 at 4:30 P.M. The Surveyor reviewed the Case Management Notes Notes, dated 11/25/11, The Quality and Risk Director and Unit Manager #1 said the Notes indicated that Patient #10 had a remote history as a sex offender (15 years previous). The Case Management Notes indicated that Patient #10's offense was showing pornographic material to an underage person and did not include physical contact/aggression.

The Case Management Note, dated 11/25/11 at 3:28 P.M., indicated that the Facility placed Patient #10 in a semi-private room without a roommate. The Note indicated that Patient #10 would remain there as a single occupant until a private room was available. The Case Management Note indicated that the Unit Manager (no longer employed at the LTACH) would alert all supervisors.

Observation during the tour of the Chronic Care Unit, conducted on 2/7/12, indicated that Patient #10 was in a semi-private room with another patient.

The Nursing Flow Sheets, dated 11/25/11 to 2/4/12, indicated that Patient #10 spent most of his/her time in bed.

Unit Manager #1 said Patient #10 resided in a private room until 1 week prior to the survey. Unit Manager #1 said Patient #10 remained in bed most of the time, required 2 staff to transfer out of bed, was not independent for mobility, and did not associate with other patients on the Unit. Unit Manager #1 said she had not received any complaints from staff regarding Patient #10 behaving inappropriately.

The electronic Plan of Care provided by the LTACH, dated 11/23/11 to 1/23/12, indicated that it did not address a plan to keep Patient #10 in a private room or a plan to ensure patient/staff safety.


2) The Physician Progress Note, dated 10/18/11, indicated that Patient #1 suffered from a stroke and respiratory failure requiring a tracheostomy (tube inserted surgically through the neck directly into the trachea) and mechanical ventilation (provision of breaths by a ventilator connected to the tracheostomy) and was dependent for mobility.

The Physician Orders and Plan of Care, dated 12/19/11, indicated that Patient #1 was to be out of bed from 10:00 A.M. until 1:00 P.M. and from 4:00 P.M. until 7:00 P.M. and in a wheelchair as part of the restorative program.

The PT Progress Note, dated 12/19/11, indicated that the Physical Therapist trained the Restorative Aide (RA) regarding the treatment plan for Patient #1's restorative care that included being out of bed from 10:00 A.M. until 1:00 P.M. and from 4:00 P.M. until 7:00 P.M. and engaging in lower extremity exercises.

The Staffing/Assignment Sheets, dated 12/19/11 to 2/6/12, indicated that nursing staff to patient ratios did not change on the weekends.

The Surveyor interviewed Unit Manager #1 on 2/6/12 at 9:20 A.M. Unit Manager #1 said nursing staff ratios remained consistent. However, on the weekends, support staff such as rehab staff, were reduced to one staff person.

The Surveyor interviewed the Rehabilitation Therapy Director (Rehab Director) on 2/7/12 at 11:15 A.M. and throughout the survey as needed. The Rehab Director said that from Monday through Friday, there were rehabilitation technicians, and PT staff scheduled. The Rehab Director said that on the weekend, there was one therapist scheduled for each day and they were responsible for providing skilled services. The Rehab Director said the nursing staff performed patients' restorative program when the RA was unavailable.

The Nursing Flow Sheets, dated 12/16/11 to 2/6/12, indicated that Patient #1 did not get out of bed on the following weekends: 12/24-25/11, 12/31/11/and 1/1/12, 1/7-8/12, 1/14-15/12, 1/21-22/12, 1/28-29/12, and 2/4-5/12. The Flow Sheets did not indicate the reason Patient #1 did not get out of bed.

The Surveyor interviewed CNA #2 on 2/6/12 at 2:30 P.M. CNA #2 said the number of nursing staff did not change on the weekend, but there were less Rehab staff scheduled. CNA #2 said that if a patient was alert and oriented and insisted on getting out of bed, then she would get that patient up. CNA #2 said that depending on her patient assignment, she might leave the patients who were not alert and oriented in bed.

Based on interview with the Infection Control Nurse, review of the Surveillance Policy and the Infection Control Surveillance Reports, the LTACH failed to ensure that observed deficient practices regarding hand-hygiene and use of personal protective equipment were addressed with staff identified with the deficient practice.

Findings include:

1) The Policy/Procedure titled Surveillance of Healthcare Associated Infections indicated that walking rounds conducted on the Units allowed the Infection Control Professional to observe staff performance and opportunities for brief, on-the-spot infection prevention and control inservices. The Policy indicated that information may be much more meaningful to staff when presented during their actual performance of hand-hygiene and use of protective equipment.

2) The Surveyor interviewed the LTACH's Infection Control (IC) Nurse on 2/6/12 at 7:55 A.M. The IC Nurse said she conducted unannounced surveillance rounds on different units, different days and at different times.

3) The Observation Tools, dated 12/11/11 to 1/17/12, indicated that:

A) The Observation Tool, dated 1/3/12, indicated that there was 1 observation of of improper use of protective equipment, 2 observations of hand hygiene not performed, and 1 observation of failure to remove gloves before leaving a room and proceeding down the corridor.

B) The Observation Tool, dated 1/4/12, indicated that there was 1 observation of improper use of protective equipment and 1 observation of no hand hygiene after gloves were removed.

C) The Observation Tools, dated 1/12/12, 1/13/12, and 1/17/12, did not indicate the location of the observation, the identity of the Observer, or if there were any findings.

D) The Observation Tool, dated 1/17/12, indicated that there were 3 observations of noncompliance with hand hygiene.

Review of the Observation Tools A, B, C, D indicated that the Observation Tools did not include documentation that on-the-spot infection prevention and control inservices were conducted with the staff person identified with deficient practice.