HospitalInspections.org

Based on record review and interviews, the hospital failed to meet the requirements of the Condition of Participation for Patient Rights as evidenced by:

1) Failing to ensure a safe environment was maintained by: 1) having the electronic nurse call system that audibly transmitted calls from the patients' rooms to the nurse's station not functioning and replaced by a bedside table bell that could not be heard by nursing staff during a fire drill when patients' room doors were closed and the alarm was sounding at 9:55am on 10/20/10; 2) having an unlocked medication storage cart in the hallway accessible to the public on 10/14/10 at 10:10am and 10/15/10 at 2:25pm; 3) having expired emergency drugs stored in the crash cart and available for use and having the crash cart and respiratory box contents stored in a disorganized fashion that would make locating drugs and equipment needed in an emergent situation difficult to find; and 4) having patient care equipment in non-working order available for staff to use for patient care (see findings in tag A0144);

2) Failing to follow the hospital policy for grievances for 4 of 4 patients (#1, #6, #9, #10) and/or family who submitted grievances (documented by the hospital for the time period of 08/01/10 through 10/20/10) by having no documented evidence the grievances had been reviewed or investigated (see findings in tag A0119);

3) Failing to follow the hospital policy for grievances for 4 of 4 patients (#1, #6, #9, #10) and/or family who submitted grievances (documented by the hospital for the time period of 08/01/10 through 10/20/10) by having no documented evidence the grievances had been investigated and the complainant notified in writing of the decision or resolution within 10 days of receipt of the grievance (see findings in tag A0122);

4) Failing to: a) develop policies and procedures for obtaining a consent for admission and treatment which resulted in 1of 1 patient who refused to sign the consent for admission and treatment from a total of 10 sampled patients (#4) to not have the unsigned consent witnessed by two staff members and b) obtain a consent for treatment for 1 of 10 sampled patients (#8) (see findings in tag A0131); and

5) Failing to ensure that patients' medical records were kept confidential by having patient MARS (medication administration record) face-up on the desk in the back nursing station that was open and accessible to the public with no personnel present in the nursing station for 1 of 10 sampled patients and 4 of 11 random patients (#7, R7, R9, R12, R13) (see findings in tag A0147).

An immediate jeopardy situation was identified on 10/20/10 at 10:05am and reported to Administrator S1. The immediate jeopardy situation was a result of failing to have a functional, audible electronic call system in the hospital since 09/11/10. The hospital was utilizing bedside table bells for patients to notify nursing personnel when the patient had a need for assistance. During a fire drill conducted on 10/20/10 with DHH (Department of Health and Hospitals) surveyors present and the alarm sounding, each patient's door to their room was closed for approximately 5 minutes with no means to hear a patient use the bedside bell if the patient had an emergent need.

A corrective action plan was submitted by the hospital on 10/22/10 at 10:45am to address the immediate jeopardy situation. The corrective action plan included the following:
1) Each patient was immediately checked, and each patient room was walked through by hospital staff to check for patient safety. The patient safety checks were documented on the hand-written log.
2) Administrator S1 contacted Company B and explained the emergent situation.
3) On 10/20/10 at 2:30pm Administrator S1 was notified that Technician S51 with Company B was enroute to the hospital. S51 inspected the nurse call system and determined minor problems existed which could be corrected by the following day (10/21/10).
4) Observation on 10/22/10 at 10:45am, with Director of Nursing (DON) S21 and Technician S51 from Company B present, the nurse call system was checked and determined to be functional and audible from each patient room and each nursing station. Further observation revealed the nurse call system in each patient bathroom was functional.
5) Review of the "Quality Monitoring Nursing Response To Nursing Call System" revealed the standard of excellence was that the nursing call system would operate at 100% (per cent) in response to patient calls for service. The indicators included: 1) Individual patient call system, when pressed for need of service from the patient room, will light up at the nursing station panel; 2) Individual patient call system, when pressed for need of service from the patient room, will light up above the patient door; 3) Individual patient call system, when pressed for need of service from the patient room, will provide audio sound to nursing station; and 4) Individual patient call system, when pressed from the nursing station, will provide audio sound to patient room. The expected performance threshold was 100%. Beginning 10/22/10 daily monitoring will be conducted for 30 consecutive days or until 100% compliance for 30 consecutive days. Once 100% compliance is reached for 30 consecutive days, monitoring will be conducted once per week for 3 months and then monthly. The charge nurse and/or the DON is to collect data and assure compliance. The DON is to compare the data with the threshold and notify the Administrator when the threshold is exceeded. Monitoring results are to be communicated to the Administrator and the Performance Improvement (PI) Committee/Safety Committee. Director of Nursing S21 and Administrator are responsible for implementing and monitoring and recommended PI actions, and DON S21 is responsible to report action results to the PI Committee.
6) A "Quality Monitoring Life Safety - Nurse Call System" tool was developed for checking and documenting the results of each patient room and bathroom call system test.
7) A note was left at the nursing station with contact numbers for Company B and Technician S51 with Company B. Further observation of the note revealed the following hand-written directions signed by Administrator S1: "In an event the patient call system is non-operational, you must: 1) contact the Director of Nursing (DON S21's name and cell phone number); 2) complete an incident/occurrence report listing all room and bed numbers; 3) notify Administrator S1 (S1's cell phone listed); 4) contact Company B: see above (for phone numbers).

As a result of the hospital's implementation of the action plan, the immediate jeopardy situation was removed on 10/22/10 at 10:45am. The hospital's noncompliance remains at the condition level.

Based on record review and interview the hospital failed to meet the Condition of Participation for Quality Assurance as evidenced by:

Failing to to develop, implement and maintain an ongoing quality assessment/performance improvement program by failing to ensure the safety of patients by failing to monitor equipment used for patient care as evidenced by: 1) having the electronic nurse call system that audibly transmitted calls from the patients' rooms to the nurse's station not functioning and replaced by a bedside table bell that could not be heard by nursing staff during a fire drill when patients' room doors were closed and the alarm was sounding at 9:55am on 10/20/10; 2) having an unlocked medication storage cart in the hallway accessible to the public; 3) having the emergency drugs stored in the crash cart expired and available for use and having the crash cart and respiratory box contents stored in a disorganized fashion that would make locating drugs and equipment needed in an emergent situation difficult to find; and 4) having patient care equipment in non-working order. (See findings at Tag A0276);

Failing to ensure their Quality Assurance/Performance Improvement program was maintained during the change in ownership and leadership as evidenced by three QA/PI Directors named within 3 months with no one presently serving in the position and inability of the hospital to present any QA/PI data (See findings at Tag A0310).

Based on observation, record review, and interviews, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by:

1) Failing to ensure a RN (registered nurse) was immediately available for bedside care of any patient by having 1 RN to cover 2 separate nursing units for 12 of 14 days reviewed from 10/01/10 through 10/14/10 (see findings in tag A0392);

2) Failing to ensure the RN made nursing assignments according to the needs of the patients and the competency and skill of the nursing staff as evidenced by assigning nursing staff who had no documented assessment of competency and/or experience in the care of patients with psychiatric behaviors for 28 of 28 staff members providing direct patient care (S2, S11, S14, S15, S16, S17, S18, S19, S20, S21, S22, S23, S24, S25, S26, S27, S28, S29, S30, S31, S32, S35, S36, S37, S38, S39, S40, S41) (see findings in tag A0397);

3) Failing to ensure the RN supervised and evaluated each patient's care as evidenced by: a) failing to develop and implement a system to ensure the RN assessed patients with a change in condition (fall, hypoglycemia) for 2 of 10 sampled patients (#2, #3) and b) failing to develop and implement a system designating the frequency at which RNs were to measure and stage wounds which resulted in 3 of 6 patients reviewed with wounds from a total of 10 sampled patients failing to have wound assessments by the RN upon admission and/or weekly thereafter (#2, #3, #8) (see findings in tag A0395); and

4) Failing to ensure: a) each patient had an individualized nursing care plan that included patients' identified needs, nursing interventions to respond to those needs, measurable goals, and was updated with changes in patient condition for 8 of 10 sampled patients and 2 random patients (#3, #4, #5, #6, #7, #8, #9, #10, R5, R6) and b) nurses implemented physician's orders for medications (#3, #10), accuchecks (#2), weights (#1, #6, #8, #9, #10), wound care (#2), and intake and output (#10) for 7 of 10 sampled patients (see findings in tag A0396).

Based on record review and interview, the governing body failed to ensure the chief executive officer developed criteria for admission to the hospital. Findings:

Review of the "Governing Body Bylaws", adopted as effective 08/01/10 and submitted by Administrator S1 as their current governing body bylaws, revealed, in part, "...The Governing Body hereby adopts the following as the primary purposes and goals of the Hospital: 1. To establish, maintain, and operate a LTCH (long term care hospital) for the care of persons suffering from medically complex illnesses, physical injuries, and/or psychiatric infirmities that meet criteria adopted by this Governing Body and who would benefit from the services offered at the Hospital ...". Further review of the entire bylaws revealed no documented evidence of established criteria for admission.

Review of the Governing Body Meeting Minutes for 08/01/10, submitted by Administrator S1 as the only governing body meeting since the change of ownership, revealed the long term acute care hospital pre-screening forms (page 2 and page 6) were approved by the governing body. Further review revealed the approval of the hospital policies and procedures was tabled until the next meeting.

In a face-to-face interview on 10/15/10 at 9:40am, CEO (chief executive officer) S58 indicated the governing body met on 08/01/10 and confirmed the meeting minutes were the minutes presented by Administrator S1.

In a face-to-face interview on 10/20/10 at 3:15pm, Medical Director S13 confirmed the hospital did not have admission criteria developed as of the time of this interview. She indicated she had presented admission criteria protocols that she had obtained from other LTACs (long term acute care hospitals) to CEO (chief executive officer) S58. S13 further indicated she had requested a Medical Executive Committee meeting for this month at which time she would present the issue of needing admission criteria established. She could offer no explanation for this not being addressed before now.

Based on record review and interview, the governing body failed to ensure all patients were under the care of a physician by having a patient admitted and care provided without having physician orders for 1 of 10 sampled patients (#2). Findings:

Review of Patient #2's medical record reviewed he was admitted on 08/16/10 at 3:30pm with no documented evidence of physician admission orders until 08/17/10 at 8:30am. Further review revealed his admitting diagnosis was renal failure.

In a face-to-face interview on 10/15/10 at 3:05pm, RN (registered nurse) Consultant S10 confirmed Patient #2's physician's admit orders were not received until 08/17/10 at 8:30am, and Patient #2 arrived and was treated at the hospital on 08/16/10 at 3:30pm.

In a face-to-face interview on 10/20/10 at 3:15pm, Medical Director S13 indicated that patients come to the hospital with physician orders. When the surveyor informed S13 that Patient #2 did not have physician orders for admission until the day after he arrived at the hospital, S13 indicated she didn't know about that occurrence.

In a face-to-face interview on 10/20/10 at 4:00pm, Medical Director S13, after reviewing Patient #2's medical record, indicated hospice patients were admitted with orders from the hospice nurse. When the surveyor asked if S13 meant the hospice nurse was obtaining orders from the hospice physician who was credentialed and privileged at Meadowcrest Specialty Hospital, S13 did not answer the question. She indicated she gave the admit orders on 08/17/10.

Review of the "Governing Body Bylaws", adopted as effective 08/01/10 and submitted by Administrator S1 as their current governing body bylaws, revealed, in part, "...The Governing Body looks to the Medical Staff for activities contributory to the preservation and improvement of the quality and efficiency of patient care provided by the Hospital, including the establishment and pursuit of the following policies, practices, and procedures: ...b) That, except in emergencies or grant of special privilege, only members of the Medical Staff shall admit patients to the Hospital. ...d) That each patient's medical condition should be the responsibility of a physician member of the Medical Staff ...".

Based on record review and interview the hospital failed to: 1) ensure the contracted pharmacy services included 24 hours/7-days a week service for all drugs; 2) ensure all pharmacy policies and procedures were reviewed and/or revised annually by the pharmacist; and 3) ensure the pharmacist was responsible for monitoring of drug administration including accurate hospital narcotic records, availability of expired medications for use by patients, and administering medications ordered for specific patients to other patients. Findings:

1) ensure the contracted pharmacy services included 24 hours/7-days a week service for all drugs
Review of the of the Pharmacy contract dated 04/01/09 revealed.... A) Routine Services and Delivery. During Pharmacy's usual hours of operation, Pharmacy shall provide pharmaceuticals and routine pharmaceutical services to inpatients of the hospital. Pharmacy shall provide pharmaceuticals to the hospital after receipt of a request (usually same day), except for circumstances and conditions beyond its control. If for any reason Pharmacy is unable to deliver requested item(s), Pharmacy shall promptly notify Hospital. Pharmacy will at all times use its best effort and deliver all ordered drugs and supplies. B) Emergency Services: Hospital shall have available Emergency services 24-hour per day, seven (7) days per week their Hospital stock, stored in Med Dispense machines. If for any reason pharmacy is unable to deliver such emergency requested pharmaceutical(s), Pharmacy shall notify Hospital of its inability to deliver such items and assist Hospital to obtain the required item, if not available in stock, then from a nearby pharmacy".

Review of the Occurrence Reports dated 09/20/10 through 09/28/10 revealed the following medications unavailable from the pharmacy for administration: Random Patient 11 three doses of Restoril 15mg; Random Patient 14 one dose of Restoril 15mg; and Random Patient 15 Lasix 80mg IV. Further review revealed the physician had been notified and no new orders given for a substitution nor was there any documented evidence of any actions taken to obtain the medication from another pharmacy either by the hospital or the contracted pharmacy.

In a face to face interview on 10/14/10 at 1:20pm Pharmacist S4 indicated that when the hospital was purchased by the new owners in August of this year (2010) no changes were made to the contract.

In a face to face interview on 10/15/10 at 10:00am CEO S58 indicated he assumed the pharmacy contract that was in place when he purchased the hospital; however he was currently in the process of changing pharmacies.

2) ensure all pharmacy policies and procedures were reviewed and/or revised annually by the pharmacist;
Review of the medication policies contained in the hospital manual section titled "Pharmacy" revealed the last review/revision date on the polices and procedures were 03/07 (3 years and two different owners ago).

Review of the Pharmacy contract dated 04/01/09 and assumed by the present ownership of the hospital revealed no documented evidence development, implementation, review or revisions of policies were included as part of the pharmacy contract.

In a face to face interview on 10/14/10 at 1:20pm Pharmacist S4 indicated policies and procedures were not part of his contract.

3) ensure the pharmacist was responsible for monitoring of drug administration including accurate hospital narcotic records, availability of expired medications for use by patients, and administering medications ordered for specific patients to other patients (See findings at Tag A0509).

Based on record review and interview the hospital failed to follow their policy and procedure for grievances for 4 of 4 patients and/or family who submitted grievances (documented by the hospital for the time period of 08/01/10 through 10/20/10) as evidenced by no documented evidence the grievances had been reviewed or investigated (#1, #6, #9, #10). Findings:

Patient #1
Review of the Occurrence Report, which the hospital used for documenting grievances, dated 08/7/10, revealed the daughter of Patient # 1was concerned about the treatment her father had been receiving and had spoken to MD S13. Further review of the Occurrence Report revealed no documented evidence the grievance had been investigated

Patient #6
Review of the Occurrence Report, which the hospital used for documenting grievances, dated 08/9/10, revealed Patient # 6 informed the hospital a CNA had not cleaned her perineal area. Further review of the Occurrence Report revealed no documented evidence the grievance had been investigated.

Patient #9
Review of the Occurrence Report, which the hospital used for documenting grievances, dated 08/5/10, revealed the son of Patient # 9 informed the hospital about RN S11, who had on two occasions refused to speak to him about his mother (#9). Further review of the Occurrence Report revealed no documented evidence the grievance had been investigated.

Review of a grievance in the form of a letter submitted to the hospital by the brother of Patient #9 revealed concerns he was having with the poor care his sister was receiving and her apparent deteriorating condition and the treatment of the staff when he requested to stay with his sister (lived out of state). Further review of the letter revealed a handwritten notation made by Administrator S1 indicating S12, the now terminated Director of Nursing (DON), had failed to call #9's brother, so she (S1) scheduled a meeting to discuss his issues on 08/23/10. Further review of the submitted information revealed no documented evidence of any investigation, action taken, or written documentation submitted to the brother of Patient #9.

Patient #10
Review of the Occurrence Report, which the hospital used for documenting grievances, dated 08/09/10, revealed Patient #10 informed the hospital a CNA had not bathed her and only splashed water on her and she (the patient) still had bodily odor. Further review of the Occurrence Report revealed no documented evidence the grievance had been investigated.

In a face to face interview on 10/19/10 at 11:00am Administrator S1 indicated that since she had been hired all events (medication variances, complaints, grievances) were being documented on the hospital's "Occurrence Reports". Further, she indicated there had been four documented grievances since her employment in August 2010 and verified the hospital had not followed its policy and procedure for grievances. S1 indicated grievances had been identified as one of the problem area after acquiring ownership of the hospital and recognized no documented evidence could be submitted indicating an investigation had been performed in each of the four documented grievances.

Review of Policy No. I-A.1.11 titled "Patient Rights/Organizational Ethics" revealed .....Procedure for Grievance: 1. Each issue defined as a grievance will be followed up with a written acknowledgement within ten (10) days of receipt from the Patient Advocate (Social Worker) or Case Manager. Risk Management is notified of all patient verbal or written grievances. In it's resolution of a grievance, Administration, in conjunction with Risk Management, provides the patients with writeen notice of its decision (not to exceed 30 days)..."

Based on record review and interview the hospital failed to follow their policy and procedure for grievances resulting in 4 of 4 grievances (documented by the hospital for the time period of 08/01/10 through 10/20/10) failing to be investigated and the complainant notified in writing within 10 days of receipt of the grievance (#1, #6, #9, #10). Findings:

Patient #1
Review of the Occurrence Report, which the hospital used for documenting grievances, dated 08/7/10, revealed the daughter of Patient # 1 was concerned about the treatment her father had been receiving and had spoken to MD S13. Further review of the Occurrence Report revealed no documented evidence the grievance had been investigated, a written response had been sent to the complainant (the daughter of Patient #1), or the complainant had been notified in writing of a decision or resolution.

Patient #6
Review of the Occurrence Report, which the hospital used for documenting grievances, dated 08/9/10, revealed Patient # 6 informed the hospital a CNA who had not cleaned her perineal area. Further review of the Occurrence Report revealed no documented evidence the grievance had been investigated, a written response had been sent to the complainant (Patient #6), or the complainant had been notified in writing of a decision or resolution.

Patient #9
Review of the Occurrence Report, which the hospital used for documenting grievances, dated 08/5/10, revealed the son of Patient # 9 informed the hospital about RN S11, who had on two occasions refused to speak to him about his mother (#9). Further review of the Occurrence Report revealed no documented evidence the grievance had been investigated, a written response had been sent to the complainant (the son of Patient #9), or the complainant had been notified in writing of a decision or resolution.

Review of a grievance in the form of a letter submitted to the hospital by the brother of Patient #9 revealed concerns he was having with the poor care his sister was receiving and her apparent deteriorating condition and the treatment of the staff when he requested to stay with his sister (lived out of state).
Further review of the letter revealed a handwritten notation made by Administrator S1 indicating S12 the now terminated Director of Nursing (DON) had failed to call #9's brother, so she (S1) scheduled a meeting to discuss his issues on 08/23/10. Further review of the submitted information revealed no documented evidence of any investigation, action taken, or written documentation submitted to the brother of Patient #9.

Patient #10
Review of the Occurrence Report, which the hospital used for documenting grievances, dated 08/09/10, revealed Patient # 10 informed the hospital a CNA had not bathed her and only splashed water on her and she (the patient) still had bodily odor. Further review of the Occurrence Report revealed no documented evidence the grievance had been investigated, a written response had been sent to the patient, or the patient had been notified in writing of a decision or resolution.

In a face to face interview on 10/19/10 at 11:00am Administrator S1 indicated that since she had been hired all events (medication variances, complaints, grievances) were being documented on the hospital's "Occurrence Reports". Further she indicated there had been four documented grievances since her employment in August 2010 and verified the hospital had not followed its policy and procedure for grievances. S1 indicated grievances had been identified as one of the problem area after acquiring ownership of the hospital and recognized no documented evidence could be submitted indicating an investigation had been performed in each of the four documented grievances.

Review of Policy No. I-A.1.11 titled "Patient Rights/Organizational Ethics" revealed .....Procedure for Grievance: 1. Each issue defined as a grievance will be followed up with a written acknowledgement within ten (10) days of receipt from the Patient Advocate (Social Worker) or Case Manager. Risk Management is notified of all patient verbal or written grievances. In it's resolution of a grievance, Administration, in conjunction with Risk Management, provides the patients with writeen notice of its decision (not to exceed 30 days)..."

Based on record review and interview the hospital failed to follow their policy and procedure for grievances resulting in 4 of 4 patients and/or family who submitted grievances (documented by the hospital for the time period of 08/01/10 through 10/20/10) failing to receive written notice of a decision/resolution within 30 days of the date the grievance was submitted (#1, #6, #9, #10). Findings:

Patient #1
Review of the Occurrence Report, which the hospital used for documenting grievances, dated 08/7/10, revealed the daughter of Patient # 1 was concerned about the treatment her father had been receiving and had spoken to MD S13. Further review of the Occurrence Report revealed no documented evidence the grievance had been investigated, a written response had been sent to the complainant (the daughter of Patient #1), or the complainant had been notified in writing of a decision or resolution.

Patient #6
Review of the Occurrence Report, which the hospital used for documenting grievances, dated 08/9/10, revealed Patient # 6 informed the hospital a CNA had not cleaned her perineal area. Further review of the Occurrence Report revealed no documented evidence the grievance had been investigated, a written response had been sent to the complainant (Patient #6), or the complainant had been notified in writing of a decision or resolution.

Patient #9
Review of the Occurrence Report, which the hospital used for documenting grievances, dated 08/5/10, revealed the son of Patient # 9 informed the hospital about RN S11, who had on two occasions refused to speak to him about his mother (#9). Further review of the Occurrence Report revealed no documented evidence the grievance had been investigated, a written response had been sent to the complainant (the son of Patient #9), or the complainant had been notified in writing of a decision or resolution.

Review of a grievance in the form of a letter submitted to the hospital by the brother of Patient #9 revealed concerns he was having with the poor care his sister was receiving and her apparent deteriorating condition and the treatment of the staff when he requested to stay with his sister (lived out of state).
Further review of the letter revealed a handwritten notation made by Administrator S1 indicating S12 the now terminated Director of Nursing (DON) had failed to call #9's brother, so she (S1) scheduled a meeting to discuss his issues on 08/23/10. Further review of the submitted information revealed no documented evidence of any investigation, action taken, or written documentation submitted to the brother of Patient #9.

Patient #10
Review of the Occurrence Report, which the hospital used for documenting grievances, dated 08/09/10, revealed Patient # 10 informed the hospital a CNA had not bathed her and only splashed water on her and she (the patient) still had bodily odor. Further review of the Occurrence Report revealed no documented evidence the grievance had been investigated, a written response had been sent to the patient, or the patient had been notified in writing of a decision or resolution.

In a face to face interview on 10/19/10 at 11:00am Administrator S1 indicated that since she had been hired all events (medication variances, complaints, grievances) were being documented on the hospital's "Occurrence Reports". Further she indicated there had been four documented grievances since her employment in August 2010 and verified the hospital had not followed its policy and procedure for grievances. S1 indicated grievances had been identified as one of the problem area after acquiring ownership of the hospital and recognized no documented evidence could be submitted indicating an investigation had been performed in each of the four documented grievances.

Review of Policy No. I-A.1.11 titled "Patient Rights/Organizational Ethics" revealed .....Procedure for Grievance: 1. Each issue defined as a grievance will be followed up with a written acknowledgement within ten (10) days of receipt from the Patient Advocate (Social Worker) or Case Manager. Risk Management is notified of all patient verbal or written grievances. In it's resolution of a grievance, Administration, in conjunction with Risk Management, provides the patients with writeen notice of its decision (not to exceed 30 days)..."

Based on record review and interview, the hospital failed to: 1) develop policies and procedures for obtaining a consent for admission and treatment which resulted in 1of 1 patient who refused to sign the consent for admission and treatment from a total of 10 sampled patients (#4) to not have the unsigned consent witnessed by two staff members and 2) failed to obtain a consent for treatment for 1 of 10 sampled patients (#8). Findings:

1) Develop policies and procedures for obtaining consent for admission and treatment:

Review of Patient #4's "Admission Authorizations", which included consent for release of information, consent to hospital care, personal valuables, assignment of insurance benefits, financial agreement and payment guarantee, for Medicare/Medicaid Beneficiaries Only, consent to photograph, notice of physician coverage, and waiver of liability for smoking, revealed a note "pt (patient) refuses to sign". Further review revealed it was witnessed by one employee on 08/10/10 at 10:00pm. Review of Patient #4's "Consent To Medical Treatment And Services To All Patients" revealed a note of "pt refuse to sign". Further review revealed it was witnessed by one employee on 08/10/10 at 10:00pm. There was no documented evidence of two witnesses to Patient #4's refusal to sign consent for treatment.

2) Failed to obtain a consent for treatment:

Review of Patient #8's "Admissions Authorizations", "Notice of Privacy Practices", "Photo Release", and "Consent To Medical Treatment And Services To All Patients" revealed no documented evidence of Patient #8's signature.

In a face-to-face interview on 10/20/10 at 5:30pm, RN (registered nurse) Consultant S10 confirmed the consents for Patients #4 and #8 were not signed and/or witnessed according to the hospital policy. She could offer no explanation for not having a policy and procedure specifically for consent for admission and treatment.

Review of the hospital policy titled "Patient Rights", last revised 03/09 and submitted by Administrator S1 as their current policy for obtaining patient consent, revealed, in part, "...The Primary Care Physician or a Registered Nurse (RN) has been designated by the hospital to be responsible for obtaining consents, verbal or written, and to assure that all required information for the consenting procedure is completed with enough information for the patient and/or designated responsible party to make an appropriate decision. A witness will also be present at the time of obtaining consent which could be but is not limited to another family member, physician or another hospital employee. All consents will be authenticated by signature, time and date as per hospital protocol ...". Further review revealed no documented evidence that this policy addressed consent for treatment and admission.

Based on observation, record review, and interviews, the hospital failed to ensure patients received care in a safe setting by: 1) having the electronic nurse call system that audibly transmitted calls from the patients' rooms to the nurse's station not functioning and replaced by a bedside table bell that could not be heard by nursing staff during a fire drill when patients' room doors were closed and the alarm was sounding at 9:55am on 10/20/10; 2) having an unlocked medication storage cart in the hallway accessible to the public; 3) having the expired emergency drugs stored in the crash cart available for use and having the crash cart and respiratory box contents stored in a disorganized fashion that would make locating drugs and equipment needed in an emergent situation difficult to find; and 4) having patient care equipment in non-working order. Findings:

1) Electronic call system:
In a face-to-face interview on 10/20/10 at 9:50am, Administrator S1 indicated the nursing home next door (Meadowcrest Specialty Hospital was a facility within a facility with the nursing home) was going to hold a fire drill.
Observation on 10/20/10 at 9:55am revealed a loud fire alarm sounding that produced a piercing sound to the surveyor's ears. Further observation revealed the automatic doors had shut, and hospital personnel had closed each patient's room door. While walking in the hallway outside the patient's doors, the surveyor was unable to hear anything other than the piercing alarm that was sounding.
Observation on 10/20/10 at 10:00am revealed the alarm continued to sound with the patient's doors remaining closed with no means to hear a patient use the bedside bell if the patient had an emergent need.

In a face-to-face interview on 10/20/10 at 10:05am, Administrator S2 and RN (registered nurse) Consultant S10 were notified of an immediate jeopardy (IJ) situation.

Review of the hospital policy titled "Disruptive Emergencies", issued 02/07 and included in the Policy and Procedure Manual presented by Administrator S1 as the hospital's Policy and Procedure Manual, revealed, in part, "...3. Communication Outage ... C. Patient call intercom is used in the event any part of the patient intercom system goes out. The following plan is implemented: (1) The Director of Clinical Services and/or Charge Nurse stations non-nursing personnel in or near the patient rooms so that patients' needs can be relayed in a timely manner. (2) Maintenance and Administration are notified as soon as possible. (3) Hand bells are provided to patients who can use them appropriately to replace electronic intercom. (4) Patient rounds are performed continuously to identify needs. The supervisor will assign individuals in other departments to assist in rounds. Needs identified will immediately be reported to nursing staff.

2) Unlocked medication cart:
Observation on 10/14/10 at 10:10am, with Administrator S1 present, revealed the unlocked medication cart located in the hallway next to the nursing station and accessible to the public. Stored in the medication cart were patient-specific prescribed blister-packed medications, stock medications, and a locked drawer that included patient-specific prescribed and stock narcotics.

Observation on 10/15/10 at 2:25pm, with Administrator S1 present, revealed the unlocked medication cart located in the hallway next to the nursing station and accessible to the public.

In a face-to-face interview on 10/14/10 at 10:10am, Administrator S1 indicated the medication storage cart should remain locked when a nurse was not presently using it to obtain patient medication.

Review of the hospital policy titled "Medication Management", issued 02/07 and submitted by Administrator S1 as their current policy for medication management, revealed, in part, "...All medications are properly labeled and stored in the locked medication room/automated pharmacy dispensing machine or sealed crash cart. As appropriate, other medications are stored in the locked medication refrigerator and the medication cart. The medication cart is kept in front of the nurse's station when not in use. Only authorized personnel may have access to these storage areas ...".

3) Emergency crash cart and respiratory box:
Observation on 10/14/10 at 11:20am revealed the crash cart was located in the hallway across from the nursing station with a respiratory box of emergency supplies and a box containing the ambu bag atop the cart. Further observation revealed emergency medications were in their original box and/or a sealed plastic bag. There was no labeling in the drawer to distinguish one medication from the other. Further observation revealed 4 doses of Epinephrine 1:1000 (1 milligram/milliliter) had expired on 10/01/10. Further observation revealed the ambu bag was in the sealed plastic wrap and stored in the original box in which it was received. The surveyor had difficulty opening the box to view the ambu bag which could present a delay if the ambu bag was needed during an emergency. Observation of the respiratory emergency supply box revealed scattered supplies within the box. The surveyor had to reach beneath various supplies to find the laryngoscopes and metal blades in the bottom of the box. Further observation revealed disposable laryngoscope blades in plastic wrap rubber-banded together with no distinguishable way to quickly identify the size of the blade. Observation revealed Respiratory Therapist S38 and Director of Respiratory Therapy S3 were unable to attach the laryngoscope blade to the slim handle laryngoscope.

In a face-to-face interview on 10/14/10 at 11:35am, Director of Respiratory Therapy S3 indicated she was responsible for the organization of and the supplies in the respiratory emergency box. She further indicated the contents of the box were disorganized, and that would present a problem during a cardiac or respiratory emergency.

Review of the hospital policy titled "Crash Cart", issued 02/07 and submitted by Administrator S1 as their current policy for the crash cart, revealed, in part, "...Pharmacy Responsibilities: The crash cart is located in the hospital at the nurse station. Drugs are checked monthly by the responsible contracted pharmacist and if any outdated drugs are found, they are replaced with in-date stock. During this monthly check, drugs nearing their expiration date will be rotated with other pharmacy stock bearing longer expiration dates up to at least a year. ...Nursing Responsibilities: Crash cart is to be checked by a nurse daily to ascertain that the lock is intact and the defibrillator is plugged and in proper working condition, suction works and oxygen tank... Supply Check: The cart is sealed with a break-away lock. ... In the event the seal is broken, all medications and supplies must be checked against the crash cart patient charge list ... and any missing or used must be replaced. Medication replacement is done by contracted pharmacy when a list of medications used is sent to the contracted pharmacy after a code. All supplies are replaced by unit staff from existing floor stock". Further review of the policy revealed no documented evidence regarding the organization of the crash cart contents and the respiratory emergency supply box.
4) Patient care equipment:
Observation on 10/14/10 at 11:50am, with Administrator S1 present, revealed a manual blood pressure cuff on a rolling cart in the hallway outside patients' rooms with part of the appliance used to pump the air into the cuff was hanging from the main rod.

In a face-to-face interview on 10/14/10 at 11:50am, Billing and Supply Specialist S49 indicated the blood pressure machine was broken and should not be in the hall accessible for use.

Continued observation on 10/14/10 at 11:50am revealed a Dinamap blood pressure machine with a disposable cuff that was soiled/stained.

In a face-to-face interview on 10/14/10 at 11:50am, Interim DON (director of nursing) S2 indicated the cuff should not be on the machine, because it was soiled. She further indicated each patient had their own blood pressure cuff in their room, and there was no reason to have a soiled cuff on the machine.

Observation of the general supply room on 10/14/10 at 12:00pm, with Administrator S1, Interim DON S2, and Billing and Supply Specialist S49 present, revealed the following equipment with expired inspection stickers:
Baxter K Module (no one present knew the purpose of the equipment) - inspection due 05/10;
Micro Macro enteral feed - inspection due 05/10; and
Quantum Flexaflow - inspection due 10/08.

Further observation revealed no evidence of a label indicating that the equipment was not to be used.

Review of the PM (afternoon) Work Order (equipment checks by biomedical personnel) performed by Company A with a start date of 06/01/10 and an end date of 08/31/10, presented by Administrator S1, revealed the total number of PM work orders performed was 88. Further review revealed 54 of the 88 pieces of equipment were due to be checked on 06/30/10 and not performed until 07/30/10. The equipment included IV (intravenous) pumps, mattress pumps, patient beds, defibrillator, thermometer, TM Transmitter, K Pump, electrical panels, ultrasound unit, paraffin bath, gel warmer, hydrocollator, stand-up scale, oxygen concentrator, feeding pumps, pulse oximeter, wall suction, x-ray viewer, analyzer, and a nebulizer.

In a face-to-face interview on 10/22/10 at 9:50am, Administrator S1 indicated she was not able to locate any biomedical check logs, so she had to call the company to send her a copy of their last PM check. She could offer no explanation for the equipment checks not being checked by the due date, since these were done prior to her employment.

Review of the hospital policy titled "Defective Equipment Tagging And Removal", issued 02/07 and included in the Policy and Procedure Manual presented by Administrator S1 as the hospital's Policy and Procedure Manual, revealed, in part, "...1. When any piece of equipment that is used or may come into contact with any patient, visitor or employee is deemed not to be operating properly or has been broken damaged, it should be removed immediately from service and a Danger Tag attached securely to the item. Associated items, such as tubing or electrical leads, should be kept with such equipment. 2. The equipment should be returned to the department responsible for the repair of the item, which will be responsible for removing the tag after the repairs are completed. It is important to note on the tag what the problem is and to sign and date it ...".

Review of the policy titled "Biomedical Services", issued 02/07 and included in the Policy and Procedure Manual presented by Administrator S1 as the hospital's Policy and Procedure Manual, revealed, in part, "...Biomedical Services will be responsible for preventive maintenance to the facility's medical equipment. Preventive maintenance logs will be maintained and made available to the facility. ...Biomedical Services department is responsible for providing incoming inspection, preventive maintenance, safety inspection, corrective maintenance and pre-purchase evaluation services on patient care equipment throughout the hospital, to accomplish the above policy...".

Based on observation, record review, and interview, the hospital failed to ensure that patients' medical records were kept confidential by having patient MARS (medication administration record) face-up on the desk in the back nursing station that was open and accessible to anyone walking by with no personnel present in the nursing station for 1 of 10 sampled patients and 4 of 11 random patients (#7, R7, R9, R12, R13). Findings:

Observation on 10/15/10 at 1:20pm revealed the back nursing station had no personnel present. The nursing station opened into the patient day room/dining room and had a walk-through from the day room/dining room to the public hallway that led to patient rooms. Further observation revealed the MARs for Patients #7, #R7, #R9, #R12, and #R13 were face-up on the desk in the nursing station.

In a face-to-face interview on 10/15/10 at 1:50pm, Interim DON (director of nursing) S2 indicated the MARs should not have been left in public view on the desk in the nursing station.

Review of the hospital policy titled "Patient Rights", last revised 03/09 and submitted by Administrator S1 as their current policy for obtaining patient consent, revealed, in part, "...3. Privacy and Confidentiality The patient has the right, within the laws, to personal and informational privacy, as manifested by the following rights: ...To have his medical record read only by individuals directly involved in his treatment or in the monitoring of its quality and by other individuals only on his written authorization or that of his legally authorized representative. To expect all communications and other records pertaining to his care, including the source of payment for treatment, to be treated as confidential ...".

Based on observation, record review, and interview, the hospital failed to ensure a RN (registered nurse) was immediately available for bedside care of any patient by having 1 RN to cover 2 separate nursing stations for 12 of 14 days reviewed from 10/01/10 through 10/14/10. Findings:

Observation on 10/14/10 at 12:00pm revealed a nursing station and medication room for the front hall that included 12 patient rooms with a total of 20 licensed patient beds. There were 10 patients present on 10/14/10. Further observation revealed at the end of this hall was an unlocked door that led to a second nursing station and medication room. This nursing unit had 6 patient rooms with a total of 7 licensed beds. There were 7 patients present on 10/14/10.

Observation on 10/15/10 at 1:20pm revealed no staff member was in the nursing station in the back unit. Patient #7 was heard to be crying "please help me, please, please, nurse, nurse ...Oh Lord, help me help me, ow, somebody please help me, ow". After hearing Patient #7 continue to cry for approximately 3 minutes, the surveyor was able to locate LPN (licensed practical nurse) S23 in a patient's room performing IV (intravenous) site care. At 1:24pm LPN S23 went to the room of Patient #7, and Patient #7 informed her that her heel and foot were hurting. LPN S23 then called RN S20 from the other nursing unit to come to administer IV pain medication.

In a face-to-face interview on 10/15/10 at 1:30pm, LPN S23 confirmed she was scheduled to cover the back nursing station with a certified nursing assistant.

Review of the nursing staffing pattern prepared by DON (Director of Nursing) S21 and RN Consultant S10 revealed there was 1 RN covering both nursing units on the day shift (7:00am-3:00pm) on 10/06/10, 10/07/10, 10/08/10, 10/09/10, 10/11/10, and 10/12/10. Further review revealed there was 1 RN covering both nursing units on the evening (3:00pm-11:00pm) and night (11:00pm-7:00am) shifts on 10/01/10, 10/02/10, 10/04/10, 10/06/10, 10/07/10, 10/08/10, 10/09/10, 10/10/10, 10/11/10, 10/12/10, 10/13/10, and 10/14/10.

In a face-to-face interview on 10/19/10 at 3:05pm, RN S60 indicated she had been a RN for 2 years. She further indicated her experience prior to coming to Meadowcrest Specialty Hospital 6 months ago had been in pediatrics. S60 indicated some of her responsibilities as the RN charge nurse were to check the code cart, obtain report on the patients, check lab results, make rounds with the physicians, ensure the physician orders were carried out, assist with starting IVs, set up appointments for PICCs (peripherally inserted central catheters), perform the initial admission assessments, perform wound care if needed, hang blood, push IV medications, measure wounds to determine progress of wounds, and assess all patients. She indicated that when she assessed patients, she only documented in the patient's record if there were abnormal findings, therefore she confirmed that the chart would not reveal that she had performed an assessment otherwise. S60 indicated that at the beginning of her employment she had difficulty getting all her duties completed, but she now feels that she has adapted. She further indicated if she needed help, she would ask for it, or she would report to the next shift what had not been done. S60 indicated she felt comfortable with being the only RN with 15 patients; she indicated there had not been a number of patients yet where she did not feel comfortable as the only RN.

In a face-to-face interview on 10/19/10 at 3:15pm, DON (director of nursing) S21 indicated "if the LPN was educated", and the staffing had the LPN with no more than 6 patients to 1 LPN, then she would be comfortable with the RN with a census of 20 patients to 1 RN. She further indicated patient acuity would make a difference in staffing a nursing unit, and she confirmed that the hospital's staffing plan did not include a means of measuring patient acuity.

In a face-to-face interview on 10/22/10 at 9:35am, DON S21 indicated she was not aware that a RN was required to be scheduled and immediately available for direct patient care at each nursing station in the hospital.

Review of the hospital policy titled "Staffing Plan", issued 02/07 and submitted by DON S21 as their current staffing plan, revealed, in part, "...Patient care areas are those departments that provide direct patient services/care. Patient care areas addressed by this policy include: 1. Nursing ... The Administrative team provides leadership for preparing the staffing plan. The Administrative team and specifically the Director of Clinical Services has the authority and responsibility for taking all responsible steps to assure that quality patient care is provided. S/he is accountable to ensure a sufficient number of qualified registered nurses are on duty at all times to give patients the nursing care that requires the judgement and specialized skills of a Registered Nurse. ... The DCS (director of clinical services) ha-s round-the-clock responsibility for the patient care requirements of her/his nursing unit. S/he will coordinate, forecast, and plan to provide adequate staffing for each twenty-four hour period. ...The facility staffing plans include staffing patterns at various census levels that are built from historical trends, benchmark data, and practice guidelines. ... Acuity that deviates from the projected needs is assessed and accommodated in the shift-to-shift allocation of staff. In addition to acuity, including patient diagnosis, age, functioning of the patients, and co-occurring conditions are considered ... Staffing: 1. All patient care areas are staffed based upon: a. Expertise and skill levels of the scheduled personnel. B. Special needs identified by staff and/or DCS ...". The Director of Clinical Services was the title the hospital gave to the position of director of nursing.

Based on record review and interviews, the hospital failed to ensure the RN (registered nurse) supervised and evaluated each patient's care as evidenced by: 1) failing to develop and implement a system to ensure the RN assessed patients with a change in condition (fall, hypoglycemia) for 2 of 10 sampled patients (#2, #3); 2) failing to develop and implement a system designating the frequency at which RNs were to measure and stage wounds which resulted in 3 of 6 patients reviewed with wounds from a total of 10 sampled patients failing to have wound assessments by the RN upon admission and/or weekly thereafter (#2, #3, #8); 3) failing to develop and implement a system to ensure the RN provided direct patient care as required by the hospice agreement for 1 of 1 hospice patient reviewed from a total of 10 sampled patients (#2); and 4) failing to develop and implement a system for reassessment of the effectiveness of medications administered for 1 of 10 sampled patients (#3). Findings:

1) Develop and implement a system to ensure the RN assessed patients with a change in condition:
Patient #2
Review of Patient #2's medical record reviewed he was admitted on 08/16/10 at 3:30pm with no documented evidence of physician admission orders until 08/17/10 at 8:30am. Further review revealed his admitting diagnosis was renal failure.

Review of Patient #2's history and physical examination revealed diagnoses of acute febrile illness with urinary tract infection, right great toe cellulitis, hypertension, Type 2 diabetes with hyperglycemia, and dementia with behavioral disorder, agitation, and chronic psychosis.

Review of Patient #2's "Physician's Orders" dated 08/17/10 at 8:30am revealed an order for accu checks before meals and at bedtime using the hospital's sliding scale protocol. Review of the sliding scale protocol revealed for a blood sugar of 40 to 50 juice with sugar was to be given; check blood sugar in 20 minutes, and repeat treatment if necessary. Further review revealed the physician was to be called if there was no response to treatment.

Review of Patient #2's "Nurses Notes" for 08/19/10 at 10:00pm revealed documentation by LPN (licensed practical nurse) S25 that the blood sugar was 49, and she gave Patient #2 2 cups of orange juice with sugar. Further review revealed LPN S25 rechecked the blood sugar at 10:25pm, and it was 48. LPN S25 gave Patient #2 1 cup of whole milk. Further review revealed no documented evidence that LPN S25 notified a RN and the physician of the change in Patient #2's blood sugar and followed the sliding scale protocol of the hospital.

In a face-to-face interview on 10/20/10 at 5:30pm, RN Consultant S10 and DON (director of Nursing) S21 could offer no explanation for the LPN not notifying the RN of Patient #2's change in condition, not following the hospital's sliding scale protocol, and not notifying the physician when the initial treatment of the low blood sugar was not successful in raising the blood sugar.

Patient #3
Review of Patient #3's medical record revealed he was admitted on 09/30/10 with diagnoses of Rhabdomyolysis, Major depression secondary to spinal cord injury, Encephalopathy, GERD (gastroesophageal reflux disease), Multiple Infected Wounds, Hypertension, and a history of Osteoarthritis, Cardiomegaly, Chronic Pain, and back surgery.

Review of Patient #3's "24 Hour Patient Record" for 10/05/10 at 7:00am through 7:00am on 10/06/10 revealed the 7:00pm assessment of his mental status was alert and oriented times 1. The "Fall Assessment" revealed a score of 39, with written direction on the nursing note of "If 15 or more points: Must be placed on Fall Alert (high risk for falls). Fall alert observe pt. (patient) q (every) 1 hour during the day, and q 30 minutes at night ..." . Review of the "Restraint & (and) Fall Observation" section of the nursing note for 10/05/10 revealed he was observed hourly until 6:45pm; he was then observed hourly from 8:00pm until 12:00am. Review of the "Nurses Notes" for 10/05/10 at 12:00am revealed documentation by RN S15 that Patient #3 was found on the floor, and the patient reported that he rolled off the bed onto the floor. Review of the nurses' notes revealed "v/s (vital signs) stable denies any pain ...". There was no documented evidence of the vital signs and a head-to-toe assessment including a neurological assessment by the RN at the time of the fall and at intervals throughout the night. Review of the entire fall observation documentation revealed no documented evidence Patient #3 was observed every 30 minutes throughout the night as per policy prior to and after the fall.

In a face-to-face interview on 10/20/10 at 5:30pm, RN Consultant S10 and DON S21 could offer no explanation for Patient #3 not having a complete head-to-toe assessment including a neurological assessment by the RN after experiencing a fall and not being reassessed throughout the night.

Review of the hospital's policy titled "Fall Prevention Protocol", issued 02/07 and submitted by Administrator S1 as their current policy for fall prevention, revealed no documented evidence of the level and frequency of observation required based on the fall assessment score as noted on the nurses' notes for a patient on fall alert.

Review of the hospital policy titled "Change In Patient Condition", last revised 02/09 and submitted by Administrator S1 as their current policy for assessment of the patient with a change in condition, revealed, in part, "...The following could describe a significant change in patient condition. This list is not meant to exclude other possibilities, but rather to describe the most common causes for significant changes in condition. Any single finding does describe a significant change in condition and requires Assessment, Documentation, and Notification. Change in mental status ... Change in heart rate from baseline ... New onset arrhythmia ... Acute chest pain ... Change in BP (blood pressure), Pulse oximetry ... Change in respiratory rate or increased work of breathing ... Acute onset of pain ... A complete head to toe assessment will be performed along with consultation as appropriate among the clinical team. It is the responsibility of the Charge RN to ensure that the process to assess the patient occurs in a timely fashion, and gather other relevant data. ... Data to be obtained includes, but is not limited to: A complete set of vital signs including accurate temp (temperature) ... A rhythm strip ... Pulse ox (oxygen) reading ... Finger stick glucose ... A complete pain assessment per policy ... Review and validation of current labs, medications and IV (intravenous) fluids, tube feeding orders. ... The complete assessment should appear on the nursing flow sheet ...". Review of the entire policy revealed no documented evidence that the RN was responsible to perform the assessment, only that she/he had to ensure the process to assess occurred in a timely fashion and gathered data.

2) RNs assessed, measured and staged wounds upon admit and weekly:
Patient #2
Review of Patient #2's medical record revealed he was admitted on 08/16/10 at 3:30pm with no documented evidence of physician admission orders until 08/17/10 at 8:30am. Further review revealed his admitting diagnosis was renal failure, and he was to be a patient of Company of D (hospice).

Review of Patient #2's history and physical examination revealed diagnoses of acute febrile illness with urinary tract infection, right great toe cellulitis, hypertension, Type 2 diabetes with hyperglycemia, and dementia with behavioral disorder, agitation, and chronic psychosis.

Review of Patient #2's medical record revealed no documented evidence of a head-to-toe RN assessment upon admit that included an assessment of skin integrity and wounds. Review of the nursing note of 08/16/10 at 3:30pm by RN S20 revealed Patient #2 arrived via ambulance stretcher. Further review revealed "wound to sacral area, redness noted around. Dressing to R (right) toe due to toe nail removal". Review of the daily nursing notes for the entire admission revealed no documented evidence of an assessment of the wound to the sacrum.

Review of the "Comprehensive Nursing Assessment" from Company D of 08/17/10 performed by RN S56 of Company D revealed a stage II wound to the right great toe that was pink/red, no odor, and had serosanguineous drainage. Further review revealed no documented evidence of wound measurements. Review of the wound assessment by RN S56 of Company D on 08/24/10 revealed stage II wound to the right great toe, stage II wound to the right forearm, and a stage II wound to the sacrum. There was no documented evidence of measurements of any of the wounds. Review of the wound assessment by RN S56 of Company D on 08/31/10 revealed a stage II wound to the sacrum, a stage I wound to the right hip, and a stage II wound to the right ear. There was no documented evidence of a measurement of any of the wounds.

Review of the "Initial Wound/Skin Evaluation" dated 08/17/10 at 12:25pm, with no documented evidence of the signature and title of the person assessing the skin, revealed a Stage 2 wound to the sacrum that was 5.5 x 5 x 0 (5.5 centimeters long by 5 centimeters wide with no depth), no tunneling, no undermining, 100% (per cent) red tissue, with scant bloody drainage and no odor. Review of the "Weekly Wound Assessment" performed on 08/25/10 at 10:00am, with no documented evidence of the signature and title of the person assessing the wound, revealed a "Stage 2 pressure ulcer with small eschar" that was 6 x 5.3 x 0, no tunneling, no undermining, no granulation, small amount of bloody exudate with no odor, beefy red wound bed with black eschar, red surrounding skin, and bruised wound edges. Further review of the medical record revealed 2 pictures of sacral wounds with no documented evidence of the date, time, and signature of the person taking the pictures and performing the assessment.

Review of the "Braden Scale For Predicting Pressure Sore Risk" revealed the assessments were performed by the LPN on 08/17/10, 08/25/10, 09/01/10, and 09/08/10 rather than a RN.

Review of the "Case Management/Multi-Disciplinary Team Conference" documentation of wound care revealed the following:
08/19/10 - sacral stage 1 progressing to stage 2 - by LPN S57;
08/26/10 - sacral stage 2 with eschar with increased drainage and tissue bruising - by LPN S57;
09/02/10 0 sacral necrotic wound declining poss (possible) r/t (related to) poor nutrition; stage 1 to left hip, right hip - by LPN S57;
09/08/10 0 sacral wound declining - currently completely necrotic with foul odor - "pt (patient) needs debridement; also multiple skin tears to right arm and left shoulder, stage 1 to right hip resolving - by LPN S57;
09/15/10 - declining sacral decubitus ulcer with eschar to surface, foul odor noted; new area on right ischium, redness noted with slight edema; multiple skin tears to bilateral upper extremities and bilateral lower extremities - by LPN S57; and
09/22/10 - sacral necrotic wound continues to worsen - by LPN S57. Further review revealed no documented evidence of a report to the RN and subsequent assessment by a RN of the continuing decline of sacral wound.

Review of the "Hospice and Nursing Facility Residential Agreement" with Company D revealed, in part, "...The facility staff will care for the inpatient hospice patient following the hospice plan of care which will be provided to the facility by Company D. ... Facility staff must include a registered nurse available 24 hours a day who provides direct care. ...Each staffing shift must provide a Registered Nurse ... who provides direct patient care to Company D's patient. ...Appendix A Inpatient Care Policy ... The RN Case Manager will coordinate daily visits to review and update the patient's inpatient plan of care...".

In a face-to-face interview on 10/15/10 at 3:05pm, RN Consultant S10 confirmed there was no evidence of an assessment of the toe wound by the RN and that all assessments were of the sacral wound. She further confirmed there was no weekly assessment of Patient #2's wounds by a RN.

Patient #3
Review of Patient #3's medical record revealed he was admitted on 09/30/10 with diagnoses of Rhabdomyolysis, Major depression secondary to spinal cord injury, Encephalopathy, GERD (gastroesophageal reflux disease), Multiple Infected Wounds, Hypertension, and a history of Osteoarthritis, Cardiomegaly, Chronic Pain, and back surgery.

Review of the initial nursing admission assessment revealed no documented evidence of the assessment, staging, and measurement of wounds.

Review of the "Skin Integrity Diagram", with no documented evidence of the date of assessment and the signature of the person documenting the assessment, revealed 10 identified wounds.

Review of the "Initial Wound Care Evaluation" documented by RN S11 on 10/01/10 at 12:10pm revealed the following: "left groin 100% (per cent), no odor, no drainage, 4x0.5 cm (centimeters); maceration bilateral groins; gluteal fold 9x1 cm, no depth, scant SS (serosanguineous) discharge; right groin 6x1 100% red, no odor, no drainage; right ischium 10x6 100%, no odor, no drainage; right lower buttock 2 cmx6 cm 100%, scant serosanguineous drainage; right lower lateral buttock 3x4; right lower lateral buttock 1x3; left heel 4x6.5; right second toe 0.5x1 scab " . Further review of the record revealed 10 pictures with a date in the photo of " 10/11 " with hand-written note below each photo of " folds of leg, sacrum, mid chest, (1 photo without notation), left foot, right chest, right leg, left foot, right breast, sacrum". Further review revealed no documented evidence of the time and signature of the person documenting the photos.

Review of the "Weekly Wound Assessment" for 10/05/10 revealed RN S17 documented the right buttock pressure ulcer as 9cm (length) x 10.5cm (width) with no documented evidence of depth with 70% necrosis with no odor, no exudates, black wound bed, dark red surrounding skin color, and macerated wound edges. There was no documented evidence of a RN assessment of the wounds previously identified on 10/01/10.
Review of the "Weekly Wound Assessment" for 10/12/10 performed by RN S17 revealed wounds to the ischium, right chest, gluteal fold, and lower right buttock. Further review revealed 4 photos with no documented evidence of the description of where the wounds were located, the time of the photos, and the signature of the person taking and assessing the photos. There was no documented evidence of the assessment of the wounds identified on 10/01/10 to the bilateral groins, right lower lateral buttock, and right second toe.

Review of the medical record revealed 6 wound photos with no documented evidence of the date, time, location of wounds, and the signature and assessment of the person documenting the wounds by photos.

In a face-to-face interview on 10/18/10 at 10:20am, LPN S9 indicated she had taken photos that were in Patient #3's record and confirmed she did not sign the form indicating she had documented the photos. After review of the record, LPN S9 confirmed the photos and the measurements documented didn't match, and wound assessments were not performed weekly.

Patient #8
Review of Patient #8's medical record revealed he was admitted on 09/09/10 with diagnoses of infected heel ulcer, restless leg syndrome, altered mental status, hemiparesis, neurogenic bladder, major depressive affective disorder, hepatitis C, anemia, and alcohol abuse. Further review revealed he was discharged on 10/05/10.

Review of the admit nursing assessment performed on 09/09/10 at 5:00pm by LPN S34 revealed no documented evidence of an assessment of the heel ulcer including measurements and staging by a RN. Further review revealed the heel ulcer was assessed by the RN on 09/10/10, and there was no documented evidence of another RN assessment of the heel ulcer for the entire admission.

In a face-to-face interview on 10/20/10 at 5:30pm, RN Consultant S10 and DON S21 could offer no explanation for Patient #8 not having an assessment of his heel ulcer by the RN after the initial assessment, which was from 09/10/10 to 10/05/10.

Review of the hospital policy titled "Initial Assessment", last revised 03/09 and submitted by Administrator S1 as their current policy for the RN admission assessment, revealed, in part, "...A registered nurse is responsible for completing the initial patient physical assessment. The first page of the initial assessment (including vital signs, listing medications, identifying allergies and assistive devices, reviewing health history) may be completed by an LPN. 2. Initial nursing assessment is initiated within 2 hours of admission and completed within 8 hours. ... 5. Initial Wound Care assessment is to be completed by the RN ...".

Review of the hospital policy titled "Photographic Method of Wound Measurement", issued 02/07 and submitted by Administrator S1 as their current policy for wound assessments, revealed, in part, "...2. For consistency, use the same camera and type of film for all photos of the same wound. ...3. Document the distance of the camera from the wound when taking the initial photo, and use this same distance for subsequent photos. ... 6. Include a disposable centimeter rule in the photo for size reference, and write the date of the photo and some identifying number on it so that photos are maintained correctly for that patient. 7. Attach the photo to a wound documentation form, and include written description of the wound including measurements of size and depth, color, odor, phase of healing, presence of necrotic and granulation tissue ...Note: When using photographic records of wounds, be aware that the dimensions of the wound will still have to be measured via some other method in order to accurately track changes in wound size...".

Review of the entire wound care policies and procedures revealed no documented evidence of the frequency wound assessments were to be performed, as well as which discipline was responsible to perform the assessment.

Review of the Louisiana State Board of Nursing's "Declaratory Statement Scope of Practice For Registered Nurses - Wound Care Management" revealed, in part, "Registered nurses render care that is directed towards the prevention and treatment of wounds. ... Nursing care of skin/wound conditions involves the identification, assessment, management, and ongoing evaluation of patients with alterations in skin/tissue integrity, that includes but is not limited to draining wounds, pressure ulcers, and vascular ulcers... Scope of Practice - The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, teaching, evaluation, and supervision are the major responsibilities of the registered nurse in the practice setting. The registered nurse is responsible for performing a nursing assessment and physical examination for preventative and restorative nursing and for providing patient/family teaching. ... The registered nurse initiates appropriate wound preventative measures, stages wounds and collaborates with the wound care team in the implementation and evaluation of nursing interventions as prescribed by an authorized prescriber. ... The registered nurse may delegate to a licensed practical nurse wound care interventions in any situation when the registered nurse has deemed the patients status is stable, the intervention is based on a relatively fixed and limited body of scientific knowledge, can be performed by following a defined nursing procedure with minimal alteration, responses of the individual to the nursing care are predictable and changes in the patient's clinical condition are predictable. Furthermore, the patient's medical and nursing orders are not subject to continuous change or complex modification, appropriate RN supervision is available, and provided that the LPN has been adequately trained and demonstrates competency in the performance of the specific nursing intervention and this said training and competence is documented in the LPN's file...".
3) Develop and implement a system to ensure the RN provided direct patient care as required by the hospice agreement:
Review of Patient #2's medical record revealed he was admitted on 08/16/10 at 3:30pm with no documented evidence of physician admission orders until 08/17/10 at 8:30am. Further review revealed he was to be a patient of Company of D (hospice), and his admit diagnosis was renal failure.

Review of Patient #2's history and physical examination revealed diagnoses of acute febrile illness with urinary tract infection, right great toe cellulitis, hypertension, Type 2 diabetes with hyperglycemia, and dementia with behavioral disorder, agitation, and chronic psychosis.

Review of Patient #2's medical record revealed no documented evidence of a head-to-toe RN assessment upon admit. Review of the entire medical record revealed the nursing care was provided by LPNs for the majority of the patient's stay.

In a face-to-face interview on 10/15/10 at 3:05pm, RN Consultant S10 confirmed most of the patient care was provided by LPNs.

Review of the "Hospice and Nursing Facility Residential Agreement" with Company D revealed, in part, "...The facility staff will care for the inpatient hospice patient following the hospice plan of care which will be provided to the facility by Company D. ... Facility staff must include a registered nurse available 24 hours a day who provides direct care. ...Each staffing shift must provide a Registered Nurse ... who provides direct patient care to Company D's patient. ...Appendix A Inpatient Care Policy ... The RN Case Manager will coordinate daily visits to review and update the patient's inpatient plan of care...".

4) Develop and implement a system for reassessment of the effectiveness of medications administered: (#3)
Review of Patient #3's medical record revealed he was admitted on 09/30/10 with diagnoses of Rhabdomyolysis, Major depression secondary to spinal cord injury, Encephalopathy, GERD (gastroesophageal reflux disease), Multiple Infected Wounds, Hypertension, and a history of Osteoarthritis, Cardiomegaly, Chronic Pain, and back surgery.

Review of Patient #3's medical record revealed physician orders on 09/30/10 at 4:30pm for Tylenol 650 mg (milligrams) orally every 4 hours alternating with Motrin for elevated temperature. Review of the MAR (medication administration record) revealed Tylenol was administered on 10/01/10 at 10:30am. Review of the "Vital Signs And Weight Record" and the nurses' notes revealed the temperature was not reassessed until 12:00pm, 1 and ? hours after the Tylenol was administered.

Review of Patient #3's "Nurses Notes" and MAR revealed he received Darvocet for pain on 10/02/10 at 9:20am. Further review revealed the assessment for effectiveness of the pain medication was performed at 11:00am, more than 1 hour after the medication was administered. Further review revealed Patient #3 was medicated for pain on 10/04/10 at 11:20am, 9:00pm, and at 6:00am on 10/05/10 with no documented evidence of an assessment of the effectiveness of the pain medication. Further review revealed he was medicated for pain on 10/06/10 at 9:30am and 4:00pm with no documented evidence of an assessment of the effectiveness of the pain medication. Further review revealed Patient #3 was medicated for pain on 10/08/10 at 9:00pm and was not assessed for effectiveness of the pain medication until 12:00am, 3 hours after administration. Further review revealed he received pain medication on 10/09/10 at 10:00am with no documented evidence of an assessment for effectiveness of the medication, and he was medicated at 6:35pm and not assessed for effectiveness until 11:00pm, more than 4 hours after administration of the medication.

In a face-to-face interview on 10/20/10 at 5:30pm, RN Consultant S10 and DON S21 could offer no explanation for the effectiveness of medication not being assessed by the nursing staff. They could offer no explanation for the hospital policy not identifying the amount of time the assessment should take place after the medication had been administered.

Review of the hospital policy titled "Nursing Documentation Guidelines", issued 02/07 and submitted by Administrator S1 as their current policy for documentation of medication administration, revealed, in part, "...The patient that has pain is re-assessed each shift and as needed and after the administration of pain medication to assess relief of pain and effectiveness of analgesics...". Further review revealed no documented evidence of the time the assessment should be done once pain medication was administered.

Review of the hospital policy titled "Medication Management", revised 09/08 and submitted by Administrator S1 as their current policy for medication administration, revealed, in part, "...Each patient's response to their medication is monitored according to the clinical needs and addresses the patient's response to the prescribed medication and actual or potential medication-related problems. Monitoring a medication's effect includes the following: gathering the patient's own perceptions about side effects, referring to information in the patient's medical record such as lab values, clinical response, and medication profile...". Further review revealed no documented evidence of the time the assessment should be done once pain medication was administered.

Based on record review and interviews, the hospital failed to: 1) ensure each patient had an individualized nursing care plan that included patient's identified nursing needs, nursing interventions to respond to those needs, measurable goals, and was updated with changes in patient condition for 7 of 10 sampled patients and 2 random sampled patients (#3, #4, #5 #6, #8, #9, #10, R5, R6) and 2) ensure nurses implemented physicians' orders for medications (#3, #10), accuchecks (#2), weights (#1, #6, #7, #8, #9, #10), wound care (#2) Intake and Output (I&O) (#10) for 8 of 10 sampled patients. Findings:

1) Individualized nursing care plan that included patient's identified nursing needs, nursing interventions to respond to those needs, measurable goals, and was updated with changes in patient condition:
Patient #3
Review of Patient #3's medical record revealed he was admitted on 09/30/10 with diagnoses of Rhabdomyolysis, Major depression secondary to spinal cord injury, Encephalopathy, GERD (gastroesophageal reflux disease), Multiple Infected Wounds, Hypertension, and a history of Osteoarthritis, Cardiomegaly, Chronic Pain, and back surgery.
Review of Patient #3's "Plan of Care" revealed the RN identified the following patient problems on 09/30/10: alteration in mental status, potential for, alteration in skin, alteration in sleep patterns, and potential for physical injury/fall risk. Further review revealed no documented evidence as to what each problem was related. Further review revealed no documented evidence of specific, measurable goals, interventions to be implemented to reach the goals and/or expected outcomes, a target date for meeting the goal, the date the problem was resolved or an update of the care plan.
Further review of Patient #3's medical record revealed he had a weight loss of 20.2 pounds in 17 days and experienced a fall on 10/06/10. Both of these occurrences had no documented evidence of an update to Patient #3's care plan.

Patient #4
Review of Patient #4's medical record revealed he was admitted on 08/10/10 with diagnoses of COPD (chronic obstructive pulmonary disease), CHF (congestive heart failure), diabetes, sepsis, hypertension, anemia, altered mental status, substance abuse, peripheral vascular disease, ischemic heart disease, penile trauma, and right toe amputee.

Review of the Plan of Care for Patient #4 revealed it was initiated on 08/10/10. Further review revealed the following identified problems: knowledge deficit related to disease process and smoking cessation; potential for anxiety related to hospitalization and perceived health status; alteration in comfort related to illness/surgery and back/leg pain; potential for alteration in air exchange related to loss of functioning lung tissue; potential for infection related to invasive lines; potential for alteration in sleep patterns related to comfort, environment, anxiety, and pain; and potential for physical injury/fall related to unsteady gait and altered mental status. Further review revealed no documented evidence of specific, measurable goals, interventions to be implemented to reach the goals and/or expected outcomes, a target date for meeting the goal, the date the problem was resolved or an update of the care plan before discharge.

Patient #5
Review of the medical record for Patient #5 revealed she was admitted to the hospital on 08/26/10 with the diagnosis of status post CVA (Cerebral Vascular Accident) with left hemiparesis, depression, and mental retardation.

Review of the Plan of Care for #5 dated 08/26/10 revealed the following identified problems:
Self care deficit; alteration in skin integrity; alteration in sleep patterns; potential for physical injury/fall risk; anxiety; alteration in mental status and alteration in comfort. Further review revealed no documented evidence of specific, measurable goals, interventions to be implemented to reach the goals and/or expected outcomes, a target date for meeting the goal, the date the problem was resolved or an update of the care plan before discharge.

Patient #6
Review of the medical record for Patient #6 revealed she was admitted to the hospital on 08/06/10 with the diagnoses of HTN (Hypertension), CAD (Coronary Artery Disease), Exacerbation of CHF (Congestive Heart Failure), Dilantin Toxicity and Hypothyroidism.

Review of the Plan of Care for #6 dated 08/06/10 revealed the following identified problems: anxiety related to hospitalization; alteration in comfort due to pain;
Alteration in sensory perception related to sight and hearing; potential for infection related to invasive lines; alteration in tissue perfusion related to hemodynamic instability and hypertension; self care deficit related to decreased strength and endurance and sensory deficits; alteration in skin integrity related to decreased mobility, chronic illness and incontinence; alteration in communication related to hearing problems and visual impairments; alteration in sleep patterns related to anxiety; and potential for physical injury/fall risk related to weakness. Further review revealed no documented evidence the plan had been individualized to address the type of hearing problems, visual impairment, location of pain and number and type invasive lines, any interventions had been initiated or that any of the identified problems had been resolved before #6 was discharged from the hospital.

Patient #8
Review of Patient #8's medical record revealed he was admitted on 09/09/10 with diagnoses of infected heel ulcer, restless leg syndrome, altered mental status, hemiparesis, neurogenic bladder, major depressive affective disorder, hepatitis C, anemia, and alcohol abuse.

Review of the Plan of Care initiated on 09/09/10 for Patient #8 revealed the following identified problems: knowledge deficit related to medication management; anxiety related to hospitalization; alteration in mental status related to medication; alteration in comfort related to pain; alteration in air exchange related to infection; potential for infection related to wounds; alteration in tissue perfusion related to wound; self care deficit related to decreased strength and endurance and altered mental status; alteration in skin integrity related to decreased mobility and wound; and potential for physical injury/fall risk related to unsteady gait and weakness. Further review revealed no documented evidence of specific, measurable goals, interventions to be implemented to reach the goals and/or expected outcomes, a target date for meeting the goal, the date the problem was resolved or an update of the care plan before discharge.

Patient #9
Review of Patient #9's medical record revealed she was admitted on 08/02/10 with diagnoses of anemia, insulin dependent diabetes mellitus, gastroesophageal reflux disease, peripheral vascular disease, insomnia, and rheumatoid arthritis.

Review of the Plan of Care initiated on 08/02/10 for Patient #9 revealed the following identified problems: alteration in comfort related to illness/surgery; potential for infection; alteration in skin integrity related to wound; and potential for physical injury/fall risk related to unsteady gait and weakness. Further review revealed no documented evidence of specific, measurable goals, interventions to be implemented to reach the goals and/or expected outcomes, a target date for meeting the goal, the date the problem was resolved or an update of the care plan before discharge. There was documentation that the problem of alteration in skin integrity related to wound was resolved on 08/18/10. Further review revealed alteration in mental status related to orientation and self care deficit related to altered mental status were identified as problems on 08/13/10 with no documented evidence of specific, measurable goals, interventions to be implemented to reach the goals and/or expected outcomes, a target date for meeting the goal, the date the problem was resolved or an update of the care plan before discharge.

Patient #10
Review of the medical record for Patient #10 revealed she was admitted to the hospital on 08/05/10 with the admit diagnosis of CHF (Congestive Heart Failure), HTN (Hypertension) and CVA (Cerebral Vascular Accident) with a history of Seizure Disorder, Anxiety, SOB (Shortness of Breath) and Major Depression.

Review of the Plan of Care initiated on 08/05/10 for Patient #10 revealed the following identified problems: knowledge deficit related to disease process; alteration in comfort related to illness, pain and fluid excess; potential for alteration in air exchange related to loss of functioning lung tissue; potential for infection related to invasive lines; alteration in tissue perfusion related to pulmonary congestion, edema, decreased cardiac output; self care deficit related in decreased strength and endurance; potential nutrition risk factors identified for knowledge deficit related to cardiac diet and fluid restriction; and potential for physical injury/fall risk related to unsteady gait and weakness. Further review revealed no documented evidence any interventions had been initiated or that any of the identified problems had been resolved before #10 was discharged from the hospital. In addition there was no documented evidence problems related to and intervention for the care of a chronic indwelling urinary catheter were identified and implemented. According to the documentation in the Physician's Progress Notes dated 09/06/10 (32 days since admit) revealed ... "Assessment: 1. We will also check for how long the Foley catheter has been there and replace the Foley catheter if it is greater than 30 days". Further review of Patient #10's medical record revealed he had an indwelling foley catheter which had not been identified on the care plan.

Random Patient R5
Review of the medical record for Random Patient R5 revealed he was admitted to the hospital on 09/29/10 with the diagnosis a UTI (Urinary Tract Infection), Multiple Decubitus Ulcers, Uncontrolled Diabetes, Depression and HTN (Hypertension).

Review of the Plan of Care initiated on 09/29/10 for R5 revealed the following identified problems: anxiety; pain; potential for infection; and potential for physical injury/fall risk due to paraplegia. Further review revealed no documented evidence the identified problems for R5 had been individualized to address his needs and expected outcomes specific or that any interventions had been developed or implemented.

Random Patient R6
Review of the medical record for Random Patient R6 revealed she was admitted to the hospital on 09/17/10 with the diagnoses of Malnutrition, Urinary Tract Infection and Anemia with a history of chronic atrial fibrillation, depression and anxiety.

Review of the Plan of Care initiated on 09/17/10 for Random Patient R6 revealed the following identified problems: knowledge deficit related to malnutrition; anxiety related to hospitalization; alteration in mental status related to orientation; alteration in air exchange related to loss of functioning lung tissue; alteration in sensory perception related to sight and hearing; alteration in tissue perfusion related to hypo/hypertension and decreased cardiac output; alteration in bowel elimination incontinence; self care deficit related to sensory deficits; alterations in skin integrity related to decreased mobility, altered nutritional status, incontinence; actual/potential nutrition risk factors identified related to a knowledge deficit for malnutrition and hydration; alteration in communications related to hearing problems and visual impairments; alterations in sleep patterns related to anxiety; and potential for physical injury/fall risk related to weight bearing on BLE (Bilateral Lower Extremity). Further review revealed no documented evidence any interventions had been initiated, any changes implemented to address her continued documented weight loss or that any of the identified problems had been resolved before #10 was discharged from the hospital.

In a face-to-face interview on 10/20/10 at 5:30pm, RN Consultant S10 and Director of Nursing (DON) S21 could offer no explanation for the care plans being incomplete and not updated with changes in the patients' condition.

Review of the hospital policy titled "Individual Plan Of Care", issued 02/07 and submitted by Administrator S1 as their current policy for care plans, revealed, in part, "...All patients will have an individualized plan of care that is individually tailored, integrated and coordinated. ... 1. Each individualized treatment plan is developed through the initial evaluation. 2. The individual treatment plan includes the following information: a. The individual's disease process and presenting needs b. The patient's stated goals. c. The type of treatment and/or services to be provided, and revised when appropriate. e. Measurable goals with the anticipated time frames of accomplishing these goals. e. Objective measures to be used to assess progress and goal attainment. f. Assessment of integration of the individual into the community including accessing community's resources...".

Review of the "Plan of Care" submitted as the one currently in use in the hospital revealed a form requiring the date of the assessment, initials of the nurse implementing/revising the plan of care, date resolved and initials of the nurse and pre-printed patient problems, expected outcomes and interventions. Further review of the forms revealed no documented evidence the goals were developed to include the patient's stated goals, the ability to measure the outcomes of the goals or the ability to assess integration of the individual into the community.

2) Implemented physicians' orders for medications (#3, #10), accuchecks (#2, #4), weights (#1, #6, #8, #10), wound care (#2):
Medications as ordered:
Patient #3
Review of Patient #3's medical record revealed he was admitted on 09/30/10 with diagnoses of Rhabdomyolysis, Major depression secondary to spinal cord injury, Encephalopathy, GERD (gastroesophageal reflux disease), Multiple Infected Wounds, Hypertension, and a history of Osteoarthritis, Cardiomegaly, Chronic Pain, and back surgery.

Review of Patient #3's physician's orders revealed the following orders:
10/01/10 at 9:50am - Ensure 1 can three times a day;
10/02/10 at 6:20pm - Start Vancomycin 1 gram IVPB (intravenous piggyback) daily;
10/04/10 at 4:50pm - Juven twice a day (mix with 8 ounces of water and 2 scoops Benepectin);
10/06/10 at 11:30am - Discontinue Vancomycin;
10/08/10 at 11:25am - Rocephin 1 gram IVPB every day; and
10/13/10 at 12:00pm - Unasyn 3 grams IV every 8 hours; Colistimethate 100 mg (miiligrams) IV every 8 hours; and Imipenem 500 mg IV every 6 hours.

Review of Patient #3's MARs (medication administration record) revealed no documented evidence Vancomycin 1 gram IVPB was administered on 10/06/10 at 9:00am; the order to discontinue Vancomycin was not received until 11:30am on 10/06/10. Further review revealed Rocephin 1 gram IVPB was first administered at 6:00am on 10/09/10, more than 18 hours after the order was received. Review of the MAR revealed no documented evidence Ensure was given on 10/10/10 at 9:00am and 3:00pm, at 9:00am, 3:00pm, and 9:00pm on 10/13/10, and at 9:00am, 3:00pm, and 9:00pm on 10/14/10. Further review revealed the first dose of Colistimethate was not administered until 6:00am on 10/14/10, 18 hours after it was ordered; Imipenem was not administered until 6:00pm on 10/13/10, 6 hours after it was ordered; and Unasyn was not administered until 10:00pm on 10/13/10, 8 hours after it was ordered.

Patient #10
Review of the medical record for Patient #10 revealed she was admitted to the hospital on 08/05/10 with the admit diagnosis of CHF (Congestive Heart Failure), HTN (Hypertension) and CVA (Cerebral Vascular Accident) with a history of Seizure Disorder, Anxiety, SOB (Shortness of Breath) and Major Depression. Review of the verbal Physician's Admit Orders dated 08/05/10 for Patient #10 revealed an order for SS (Sliding Scale) per facility, Lantus 100 units/mL vial 35 units sq (subcutaneously) QHS (every hour of sleep), and Metformin 500mg i tablet po qd (every day). Further review of the nursing notes and the physician's orders revealed no documented evidence the physician had been notified for clarification of orders for administration of insulin and administration of Metformin without the documented diagnosis of Diabetes which were administered to the patient.

Review of the hospital policy titled "Medication Management", revised 09/08 and submitted by Administratr S1 as their current policy for medication administration, revealed, in part, "...Each medication ordered has a documented diagnosis, condition, or indication-for-use. This documentation can be found in the physician's orders, physician's progress notes, and/or the patient's history and physical. ... Routine medications are to be given within 60 minutes of the time ordered...". Further review of the policy revealed no documented evidence timing of initial doses was addressed.

Accuchecks:
Patient #2
Review of Patient #2's medical record revealed a physician's order on 08/17/10 at 8:30am to perform accuchecks ac and hs (before meals and at bedtime) with hospital sliding scale. Further review revealed a physician ' s order on 08/31/10 at 9:10am to decrease accuchecks to every morning.
Review of Patient #2's "Diabetic Record" revealed no documented evidence of accuchecks being performed on 08/28/10 at 6:00am, 09/11/10 at 6:00am, 09/12/10 at 6:00am, and 09/24/10 at 6:00am.

Weights:
Patient #1
Review of the medical record for Patient #1 revealed he was admitted to the hospital on 08/05/10 with the diagnoses of urosepsis, altered mental status and dysphagia. Review of the Physician's Admit Orders dated 08/05/10 revealed #1 was to be weighed on admit and weekly.

Review of the Vital Signs and Weight Record for Patient #1 revealed no documented evidence the patient had been weighed from admit on 08/05/10 through discharge 08/07/10.

Patient #6
Review of the medical record for Patient #6 revealed she was admitted to the hospital on 08/06/10 with the diagnoses of HTN (Hypertension), CAD (Coronary Artery Disease), Exacerbation of CHF (Congestive Heart Failure), Dilantin Toxicity and Hypothyroidism. Review of the Admit Orders dated 08/06/10 revealed the patient was to be weighed on admit and weekly.

Review of the Vital Signs and Weight Record for #6 revealed she was weighed on 08/06/10 at the time of admit and weighed 164.4 pounds. Further review revealed she was weighed 11 days later and weighed 157.6 which was a weight loss of 6.8 pound in 11 days.

Patient #7
Review of the medical record for Patient #7 revealed she was admitted to the hospital on 09/23/10 with the diagnosis of Infected Sacral decubitus and Necrotic Sacral Ulcer and a history of HTN (Hypertension), Hyperlipidemia, Depression, Anemia, Chronic Pain Syndrome and legal blindness. Review of the Physician's Admit Orders dated 09/23/10 revealed Patient #7 was to be weighed on admit and then weekly.

Review of the Vital Signs and Weight Record for #7 revealed she was weighed at the time of admit and weighed 164.8 pounds. Further review revealed no documented weight was recorded untol 10/05/10 (12 days later) at which time #7 weighed 151.1 pounds (a weight loss of 13.7 pounds in 12 days).


Patient #8
Review of Patient #8's medical record revealed he was admitted on 09/09/10 with diagnoses of infected heel ulcer, restless leg syndrome, altered mental status, hemiparesis, neurogenic bladder, major depressive affective disorder, hepatitis C, anemia, and alcohol abuse. Review of the physician admit orders revealed Patient #8 was to be weighed upon admit and then weekly.

Review of the Vital Signs and Weight Record for Patient #8 revealed he was weighed upon admit on 09/09/10 and weighed 269.6 pounds. He was then weighed on 09/14/10 and weighed 263.4 pounds, which was a 6.2 pound weight loss in 5 days. Patient #8 was weighed on 09/28/10, 14 days later and not weekly as ordered, and weighed 245.9 pounds, which was a 23.7 pound weight loss in 19 days.

In a face-to-face interview on 10/20/10 at 8:45am, Registered Dietitian S52 could not explain the weight loss of Patient #8. She indicated some of the documented weight loss may actually be due to inaccurate weights being taken.

Patient #9
Review of Patient #9's medical record revealed she was admitted on 08/02/10 with diagnoses of anemia, hypertension, insulin dependent diabetes mellitus, GERD, peripheral vascular disease, insomnia, and rheumatoid arthritis. Review of the admit physician's orders revealed an order to weigh upon admit and weekly.

Review of the Vital Signs and Weight Record for Patient #9 revealed her weight on 08/02/10 was 138.7 pounds. Patient #9 was weighed on 08/17/10, 08/24/10, and 08/31/10. There was no documented evidence of a weight assessment on 08/09/10 as ordered by the physician to be done weekly.

Patient #10
Review of the medical record for Patient #10 revealed she was admitted to the hospital on 08/05/10 with the admit diagnosis of CHF (Congestive Heart Failure), HTN (Hypertension) and CVA (Cerebral Vascular Accident) with a history of Seizure Disorder, Anxiety, SOB (Shortness of Breath) and Major Depression.

Review of the Physician's Admit Orders dated/timed 08/05/10 at 1550 (3:50pm) for Patient #10 revealed an order for the patient to be weighed on admit and weekly. Further review revealed the order was changed to daily weights on 08/10/10.

Review of the "Vital Signs and Weight Record" for Patient #10 dated 08/05/10 through 09/08/10 revealed no documented evidence a daily weight had been obtained on 08/10/10, 08/12/10, 08/13/10, 08/15/10, 08/22/10, 08/23/10, 08/25/10, 08/26/10, 08/27/10, 08/28/10, 08/29/10, 08/30/10, 09/01/10, 09/02/10, 09/03/10, 09/04/10, 09/05/10, and 09/06/10.

In a face-to-face interview on 10/20/10 at 3:15pm, Medical Director S13 indicated there have been some weight discrepancies, and she had asked staff to recheck patients' weights. She could not explain the documented weight loss.

In a face-to-face interview on 10/20/10 at 5:30pm, RN Consultant S10 and DON S21 could offer no explanation for the weights not being done as ordered by the physician.

Review of the hospital policies and procedures revealed no documented evidence of a hospital policy for obtaining weights.

Wound Care:
Patient #2
Review of Patient #2's medical record reviewed he was admitted on 08/16/10 at 3:30pm with no documented evidence of physician admission orders until 08/17/10 at 8:30am. Further review revealed his admitting diagnosis was renal failure.

Review of Patient #2's history and physical examination revealed diagnoses of acute febrile illness with urinary tract infection, right great toe cellulitis, hypertension, Type 2 diabetes with hyperglycemia, and dementia with behavioral disorder, agitation, and chronic psychosis.

Review of Patient #2's physician orders revealed an order on 08/17/10 at 12:40pm for wet to dry dressing to the sacrum daily. Further review revealed an order on 08/24/10 at 12:10pm for Bactroban ointment to sacral wound daily.

Review of Patient #2's "Medication/Treatment Administration Record" (MAR) revealed no documented evidence wet to dry dressing changes to the sacrum were performed on 08/21/10 and 08/22/10. Further review revealed no documented evidence Bactroban ointment was applied to the sacral wound on 08/28/10, 08/29/10, 09/11/10, and 09/19/10.

I&O
Patient #10
Review of the medical record for Patient #10 revealed she was admitted to the hospital on 08/05/10 with the admit diagnosis of CHF (Congestive Heart Failure), HTN (Hypertension) and CVA (Cerebral Vascular Accident) with a history of Seizure Disorder, Anxiety, SOB (Shortness of Breath) and Major Depression.

Review of the Physician's Orders dated/timed 08/05/10 at 1550 (3:50pm) for Patient #10 revealed an order for I&O (Intake and Output) every shift.

Review of the "Total Intake and Output Record" for Patient #10 dated 08/05/10 through 09/08/10 revealed no documented evidence I&O's had been performed on the following dates and shifts: 08/16/10 7p-7a shift and 09/07/10 7p-7a shift.

In a face-to-face interview on 10/20/10 at 5:30pm, RN Consultant S10 and DON S21 could offer no explanation for medications not being administered as ordered by the physician, and for accuchecks, weights, wound care, and I&Os not being performed as ordered by the physician.

Based on record review and interview the hospital failed to ensure the Registered Nurse (RN) made nursing assignments according to the needs of the patients and the competency and skill of the nursing staff as evidenced by assigning nursing staff who have no documented assessment of competency and/or experience in the care of patients with psychiatric behaviors for 28 of 28 staff members providing direct patient care (S2, S11, S14, S15, S16, S17, S18, S19, S20, 21,S22, S23, S24, S25, S26, S27, S28, S29, S30, S31, S32, S35, S36, S37, S38, S39, S40, S41). Findings:

Review of the census dated 10/17/10 and the medical records of the patients revealed 6 of the 15 patients presently in the hospital were admitted with acute psychiatric behaviors as follows:
R2 was admitted via a PEC (Physician ' s Emergency Certificate) to the hospital on 09/28/10 for treatment of a right hip fracture and gravely disabled with combative behavior.
R3 was admitted to the hospital on 10/05/10 for rehabilitation of a broken left ankle, medication non-compliance and suicidal ideations, agitation and depressed symptoms.
R6 was admitted to the hospital on 09/17/10 for a UTI (Urinary Tract Infection), antibiotic therapy, medication non-compliance and mood disorder disturbances (danger to others by throwing things at staff), verbally abusive.
R8 was admitted to the hospital on 09/18/10 for treatment of multi decubiti, refusing medical care and exhibiting combative and disruptive behavior.
R10 was admitted to the hospital on 10/15/10 for treatment of a UTI and Dementia with Behavioral Disturbances.
R11 was admitted to the hospital on 09/10/10 for treatment of Stage IV decubitus ulcers, a decrease in mental status and an increase in aggressive behavior.

Review of Policy No. I-C.3.03 titled "General LTAC Admission Guidelines" issued 02/07, accepted by the Governing Body (Meeting Minutes dated 08/01/10) and submitted as the ones currently in use revealed patients who are unable to comply with medication regime due to emotional or psychiatric disorder and who require skilled observation and/or monitoring or assessment for titration of psychotropic drugs are considered meeting the criteria for admission (Category 11).

Review of the "Application for Employment" forms, orientation, and competency assessments for the Registered Nurses listed as employed by the hospital revealed no documented evidence of psychiatric experience, assessment of competency in the care of the patient with psychiatric behaviors or competency in the application of restraints for RN S2, S11, S14, S15, S16, S17, S18, S19, S20 and S21 DON (Director of Nursing).

Review of the "Application for Employment" forms, orientation, and competency assessments for the Licensed Practical Nurses listed as employed by the hospital revealed no documented evidence of psychiatric experience, assessment of competency in the care of the patient with psychiatric behaviors or competency in the application of restraints for LPN S9, S23, S24, S25, S26, S27, S28, S29, S30, S31, S32, and S35.

Review of the "Application for Employment" forms, orientation, and competency assessments for the Respiratory Therapists listed as employed by the hospital revealed no documented evidence of psychiatric experience or assessed competency in the care of the patient with psychiatric behaviors for RT (Respiratory Therapist) S3 Respiratory Director, S22, S36, S37, S38, S39, S40 and S41.

Review of the "Application for Employment" forms, orientation, and competency assessments for the Certified Nursing Assistants listed as employed by the hospital revealed no documented evidence of psychiatric experience, assessment of competency in the care of the patient with psychiatric behaviors or competency in the application of restraints for CNA (Certified Nursing Assistant) S42, S43, S44, S45, and S46.

In a face to face interview on 10/20/10 at 2:00pm Administrator S1 indicated S6 (Medical Records and Human Resource Director) was responsible for the personnel records. Further she indicated the records of the present employees had not been reviewed by the new owners and Administrative team to ensure all records contained the required licensure, training and/or competency. The Administrator indicated she had been assured by S12, the recently terminated Director of Nursing (DON) all personnel files were complete.

Review of the sign-in sheet titled CPI non-violent Crisis Intervention Training dated 08/02/10 submitted by the hospital as their documented evidence of training and competency of staff in the care of the patient with psychiatric behaviors, revealed the following topics were discussed: identify patient behavior related to crisis situation; how your non-verbal behavior affects patients; how to set limits without escalating the patient; and safety in numbers. Further review revealed no documented evidence the employees attending the seminar had been assessed for competency in crisis prevention techniques. Review of the credentials of the nurse presenting the CPI Training S7, revealed her instructor's certification had not been renewed since 2006.

Review of the hospital policy titled "Orientation/Reorientation", revised 07/10 and submitted by Administrator as their current policy for orientation, revealed, in part, "...Facility/Hospital orientation for all new employees must include the items below plus all other information required by law, ...CPI certification requirements (all nursing staff must obtain CPI certification) ... All new nursing staff, including PRNs (as needed), will be required to demonstrate proficiency in nursing skills required for their unit ...".

Review of the hospital titled "Job Descriptions and Competencies", revised 07/10 and submitted by Administrator S1 as their current policy for staff competency, revealed, in part, "...The determination of clinical competency must begin prior to hiring an employee via a review of the potential employee's completed application, education and previous work experience; reference checks; personal interviews by the Department Head ... Each supervisor will be responsible for ensuring that the competence of all his/her employees is continuously assessed, demonstrated, maintained and improved. ... Each employee is required to attend Annual Re-orientation for facility-wide ongoing competency assessment. ...The following methods are acceptable means of assessing department specific or unit specific annual competencies: Observation - direct observation by a supervisor, designated evaluator, preceptor or team while the employee demonstrates the skill in the work setting ... Demonstration - return demonstration by the employee during a departmental in-service ... Cognitive - written and/or verbal or demonstration of knowledge ... Documentation review - review of medical record documentation, written reports ...".

Review of the policy titled "Licenses, Certifications, Registrations and Accreditations", revised 07/10 and submitted by Administrator S1 as their current policy for orientation and competency, revealed, in part, "...All employees are required to be certified (re-certified) in Crisis Prevention and Intervention (CPI). The Human Resources Director schedules CPI training sessions periodically throughout the year. These sessions are conducted by certified instructors. An employee must be certified in CPI within six (6) months of employment ...".

Based on record review and interview, the hospital failed to follow its policies and procedures for reporting medication variances by failing to initiate a medication variance report for 13 identified medication variances involving 1 of 10 sampled patients (#3). Findings:

Review of Patient #3's medical record revealed he was admitted on 09/30/10 with diagnoses of Rhabdomyolysis, Major depression secondary to spinal cord injury, Encephalopathy, GERD (gastroesophageal reflux disease), Multiple Infected Wounds, Hypertension, and a history of Osteoarthritis, Cardiomegaly, Chronic Pain, and back surgery.

Review of Patient #3's physician's orders revealed the following orders:
10/01/10 at 9:50am - Ensure 1 can three times a day;
10/02/10 at 6:20pm - Start Vancomycin 1 gram IVPB (intravenous piggyback) daily;
10/04/10 at 4:50pm - Juven twice a day (mix with 8 ounces of water and 2 scoops Benepectin);
10/06/10 at 11:30am - Discontinue Vancomycin;
10/08/10 at 11:25am - Rocephin 1 gram IVPB every day; and
10/13/10 at 12:00pm - Unasyn 3 grams IV every 8 hours; Colistimethate 100 mg (milligrams) IV every 8 hours; and Imipenem 500 mg IV every 6 hours.

Review of Patient #3's MARs (medication administration record) revealed no documented evidence Vancomycin 1 gram IVPB was administered on 10/06/10 at 9:00am; the order to discontinue Vancomycin was not received until 11:30am on 10/06/10. Further review revealed Rocephin 1 gram IVPB was first administered at 6:00am on 10/09/10, more than 18 hours after the order was received. Review of the MAR revealed no documented evidence Ensure was given on 10/10/10 at 9:00am and 3:00pm, at 9:00am, 3:00pm, and 9:00pm on 10/13/10, and at 9:00am, 3:00pm, and 9:00pm on 10/14/10. Further review revealed the first dose of Colistimethate was not administered until 6:00am on 10/14/10, 18 hours after it was ordered; Imipenem was not administered until 6:00pm on 10/13/10, 6 hours after it was ordered; and Unasyn was not administered until 10:00pm on 10/13/10, 8 hours after it was ordered.

In a face-to-face interview on 10/20/10 at 5:30pm, RN Consultant S10 and DON S21 could offer no explanation for medications not being administered as ordered by the physician. S120 confirmed there was no medication variance report written for the above identified medication variances.

Review of the hospital policy titled "Medication Management", revised 09/08 and submitted by Administrator S1 as their current policy for medication administration, revealed, in part, "...Each medication ordered has a documented diagnosis, condition, or indication-for-use. This documentation can be found in the physician's orders, physician's progress notes, and/or the patient's history and physical. ... Routine medications are to be given within 60 minutes of the time ordered...".

Review of the hospital policy titled "Medication Administration Error", issued 02/07 and submitted by Administrator S1 as their current policy for medication variances, revealed, in part, "...Drug administration errors are written when: ...4. Drug is not given as it is ordered (must give the reason it is not given, except when refused, then see refused medication policy). 5. The primary care physician or on-call physician is not notified when a medication is not given. ... Procedure: When medication is administered improperly or a drug reaction occurs, the following procedure is used: 1. Notify Director Clinical Services or Clinical designee 2. Notify physician immediately. 3. Record occurrence in nurses notes. 4. Complete "Medication Variance" forms and take to the Clinical Director's office. 5. The Clinical Director will file it with the Incident Report form in the Administrative file and in the Nurses file. 6. Patient is to be monitored as per physician's order. 7. Consultant Pharmacist will be notified on next visit on all drug reactions".

Based on record review and interview the hospital failed to ensure accurate medical records were maintained as evidenced by 1) failure to document Diabetes as medical diagnosis on the Admit Orders resulting in sliding scale insulin being ordered without a documented diagnosis for the indicated use of insulin (#10); 2) failure to ensure all medical information contained in dictated physician progress notes, consultations and discharge summaries were reviewed for accuracy by the physician before authentication resulting in incomplete information, inaccurate patient names, and inaccurate patient date of birth and age (#1, #6, #10, R6) for 3 of 10 sampled records and 1 random patient record. Findings:

1) failure to document Diabetes as medical diagnosis on the Admit Orders resulting in sliding scale insulin orders, standing orders for Lantus Insulin, and Tsanding Orders for Oral Hypoglycemics (Metformin) being written and implemented without a documented diagnosis for the indicated use of insulin.
Review of the medical record for Patient #10 revealed she was admitted to the hospital on 08/05/10 with the admit diagnosis of CHF (Congestive Heart Failure), HTN (Hypertension) and CVA (Cerebral Vascular Accident) with a history of Seizure Disorder, Anxiety, SOB (Shortness of Breath) and Major Depression. Review of the Physician's Admit Orders dated 08/05/10 for Patient #10 revealed an order for SS (Sliding Scale) per facility, Lantus 100 units/mL vial 35 units sq (subcutaneously) QHS (every hour of sleep), and Metformin 500mg i tablet po qd (every day). Further review of the nursing notes and the physician's orders revealed no documented evidence the physician had been notified for clarification of orders for administration of insulin and administration of Metformin without the documented diagnosis of Diabetes.

2) failure to ensure all medical information contained in dictated physician progress notes, consultations and discharge summaries were reviewed for accuracy by the physician before authentication resulting in incomplete information, inaccurate patient names, and inaccurate patient date of birth and age

Patient #1
Review of the History and Physical dated 08/05/10 for Patient #1 revealed the assessment of the genittalia/rectum could not be done due to a urinary catheter. Review of the physician ' s Admit Orders dated 08/05/10 revealed no documented orders for the care of a urinary catheter. Review of the Nursing Assessment dated 08/05/10 revealed no documented evidence Patient #1 had a urinary catheter. Review of the Intake and Output Record dated 08/05/10 through 08/07/10 revealed no documented evidence the patient had a urinary catheter and was able to void. Review of the Nurses' Notes dated/timed 08/05/10 1440 (2:40pm) through 2130 (9:30pm) revealed no documented evidence patient #1 had a urinary catheter in place or that it had been removed during this time. 2130 (9:30pm) Nurse reported the patient was assisted to the bathroom.

Patient #5
Review of the medical record for Patient #5 revealed was admitted to the hospital on 08/26/10 with the diagnosis of status post CVA (Cerebral Vascular Accident) with left hemiparesis. Further review of the record revealed #5 signed a "Discharge Against Medical Advise" form on 08/31/10 at 11:10am. Review of the Physician's Orders dated/timed 08/31/10 at 10:25am revealed an order for the Patient to sign out AMA. Review of the Discharge Summary dictated by MD S55 on 08/31/10 revealed no documented evidence Patient #5 signed herself out of the hospital against medical advise. MD S55 documented that the patient improved rapidly with the start of the drug Lexapro, engaged in her physical therapy and was very eager to go home.

Patient #6
Review of the Discharge Summary dated 08/31/10 and dictated by MD S13 for Patient R6 revealed a date of birth as 12/30/1899 and an age of 77 and contained no documented evidence of the disposition and aftercare treatment of the patient. Further review revealed the dictated Discharge Summary had been reviewed for accuracy and signed by MD S13 on 09/08/10. Review of the History and Physical revealed a date of birth as 09/25/1933.

Review of the dictated consultation by MD S53 dated 08/12/10 for Patient #6 revealed no documented date of birth, but a documented age of 34. Further review revealed ..... "History of Present Illness: This is a 34 year old female that has presented originally to Hospital "A" was transferred over here for further management and I was consulted for urinary tract infection. Laboratory Data: White Cell count is 60.2".
Further review revealed the dictated Discharge Summary had been reviewed for accuracy and signed by MD S53 on 08/12/10.

Review of the Laboratory Report of the CBC results obtained 08/07/10 for Patient #6, referred to by MD S53 in the Consultation Summary dated 08/12/10 revealed a WBC of 6.2.

Patient #10
Review of the dictated Physician Progress Note dated 09/02/10 revealed MD S13 signed the document without completing the line left by the transcriptionist for clarification of the dosage for the drug Victoza.

Random Patient R6
Review of the dictated Physician Progress Notes contained in the medical record of Random Patient R6 and dictated by MD S13 revealed a Progress Note in the chart of Random Patient R6 dated 10/05/10, 10/11/10 and 10/12/10 which had no documented evidence of a date of birth, patient # and which contained the name of someone other than the R6.

Review of the dictated Progress Notes contained in the medical record of Random Patient R6 revealed no documented date of birth, patient age or patient number had been included in the progress notes by dictating MD S 13 for the following dates: 09/20/10, 09/21/10, 09/27/10, 09/28/10, 09/29/10, 09/20/10, 10/01/10, 10/04/10, 10/06/10, 10/07/10, 10/08/10, 10/14/10, 10/15/10. 10/18/10, 10/19/10, and 10/20/10. Further review R6 ' s name was misspelled on the following dates 09/27/10, 09/28/10, 09/29/10, 09/20/10, 10/01/10, 10/04/10, 10/06/10, 10/07/10, 10/08/10, 10/14/10, 10/15/10, 10/18/10, 10/19/10, and 10/20/10 resulting in a change in R6's first name.

Review of the dictated Progress Notes contained in the medical record of Random Patient R6 revealed no documented date of birth, patient age or patient number had been included by the dictating MD S50 in the progress notes for the following dates: 10/07/10 and 10/18/10.

Review of the Initial Nutritional Screening found in the closed medical record of Random Patient R6 revealed no documented evidence identifying the information as belonging to R6.

In a face to face interview on 10/20/10 at 3:15pm MD S13 (also Medical Director) reviewed Patient #6's medical record and verified the date of birth was incorrect. Further she indicated the date of birth and patient # is not always put on the dictations. S13 agreed the dictations should be reviewed more closely for accuracy.

Based on record review and observation the hospital failed to meet the Conditions of Participation for Pharmacy as evidenced by:

Failing to ensure the contracted pharmacist was responsible for the hospital-wide pharmacy service as evidenced by: 1) failing to ensure pharmacy policies and procedures were reviewed and revised with input from the pharmacist as evidenced by pharmacy policies last reviewed/revised 02/07; 2) failing to ensure all nursing staff performing the mixing of IV antibiotics were properly trained and monitored for competency; 3) failing to perform monthly checks of the medicine cart for expired drugs, timely and appropriate disposal of medications for discharged or expired patients and security of narcotic and non-narcotic medications stored within the medication cart; 4) failed to ensure the crash cart was ready for emergency use by having expired epinephrine and vials of medications in their original packaging and stored in plastic bags making it necessary for nursing staff to open during an emergency situation; 5) failing to ensure hospital policy and procedure was followed for counting and wasting of narcotics by having only one nurse count and waste narcotics; 6) failing to ensure the narcotic prescribed for a specific patient was not administered to another patient; and ) failing to ensure accurate narcotic record were kept by the nursing staff as evidenced by no documentation of narcotics destroyed by the pharmacist for individual narcotic records. (See findings at Tag A0492);

Failing to have a system in place to accurately track narcotics as evidenced by: 1) failing to develop and implement a policy and procedure for receiving narcotics from the pharmacy, counting of narcotics, proper storage of narcotics until scheduled wastage by the pharmacist and administration of narcotics which addresses the practice of "borrowing" narcotics from patients; 2) failing to ensure individual narcotic records were reconciled and wastage of narcotics were performed by two nurses; and 3) failing to ensure narcotics drugs prescribed for a specific patient were administered to that patient by practicing the habit of "borrowing" narcotics from patient. (See findings at Tag A0494);

Failing to follow their policy and procedure for the security of drugs as evidenced by storing the medication cart containing medications and narcotics unlocked in a hallway by the nurses' station which was accessible to patients, non-nursing staff and the public. (See findings at Tag A0502 and A0503);

Failing to develop and implement a policy concerning the disposing of medication for discharged and/or expired patients, ensure all expired medications were not available for patient use by having expired medications and/or unlabeled opened vials in the medication cart and medication refrigerators; and ensure all medications for discharges or expired patients were not placed in hospital stock and available for patient use. (See findings at Tag A0505); and

Failing to follow their policy and procedure for counting narcotics for 36 of 160 shifts in a period from 08/01/10 through 10/19/10 by having documentation of only one nurse performing the counts; follow their policy and procedure for wasting narcotics by having two have two nurses perform the task, one to waste and one to witness; follow their policy and procedure for narcotic count discrepancy as evidenced by failing to require all staff to remain on the premises, perform a thorough search of the hospital, notify the pharmacist and the appropriate officials after discovering the medication cart was left unlocked, reporting an incident of unresolved missing narcotics to the pharmacist involving 11 Temazapam; and ensure a medication ordered for a patient was administered only to that patient as evidenced by patients being dispensed narcotics prescribed for another patient. (See findings at Tag A0509).

Based on record review and interview the hospital failed to ensure the contracted pharmacist was responsible for the hospital-wide pharmacy service as evidenced by: 1) failing to ensure pharmacy policies and procedures were reviewed and revised with input from the pharmacist as evidenced by pharmacy policies last reviewed/revised 02/07; 2) failing to ensure all nursing staff performing the mixing of IV antibiotics were properly trained and monitored for competency; 3) failing to perform monthly checks of the medicine cart for expired drugs, timely and appropriate disposal of medications for discharged or expired patients and security of narcotic and non-narcotic medications stored within the medication cart; 4) failed to ensure the crash cart was ready for emergency use by having expired epinephrine and vials of medications in their original packaging and stored in plastic bags making it necessary for nursing staff to open during an emergency situation; 5) failing to ensure the narcotic prescribed for a patients was not administered to another patient; and 6) failing to ensure accurate narcotic record were kept by the nursing staff as evidenced by no documentation of narcotics destroyed by the pharmacist for individual narcotic records. Findings:

1) ensure pharmacy policies and procedures were reviewed and revised with input from the pharmacist as evidenced by pharmacy policies last reviewed/revised 02/07
Review of the hospital's policy and procedure manual the section titled "Pharmacy" revealed the last date the medication /pharmacy policies had been reviewed/revised was 02/07.

2) failing to ensure all nursing staff performing the mixing of IV antibiotics were properly trained and monitored for competency; (See findings at Tag A0500).

3) failing to perform monthly checks of the medicine cart for expired drugs, timely and appropriate disposal of medications for discharged or expired patients and security of narcotic and non-narcotic medications stored within the medication cart;

Observation of the unlocked medication cart on 10/14/10 at 10:10am revealed drawer two 60 blister packs of medication prescribed for specific patients who had either been discharged from the hospital or expired filed in with the medication used as "stock" drugs and available for administration to patients in the hospital. Further observation revealed the name of the patient had been in some cases blacked out and the work "stock" written across the top or the patients' names left on the blister pack and the word "stock" written on the top. Review of the blister packs revealed the following list of drugs prescribed to specific patients and being used as stock medications: Divalproex Sodium 250mg and 500mg, Minocycline HCL 100mg, Carbamazepine 200mg, Vitamin D 1000 Units, Phenytoin Sodium Extended 100mg, Benazepril HCL 40mg, Gabapentin 600mg, Benztropine Mesylate 1mg, Potassium Chloride 20 meq, Namenda 5mg, Oyster-Cal 500mg, Enalapril Maleate 5mg and 10mg, Carbidopa-Levodopa 25-250mg, Captopril 25mg, Calcium-Magnesium 500-250mg, Baclofen 10mg, Crestor 10mg, Folic Acid 1mg, Warfarin Sodium 3mg and 5mg, Dipyridamole 75mg, Digoxin 125 mcg, Diltiazem 240mg, Glimepiride 2mg, Bethanechol Chloride 50mg, Amiodarone HCL 200mg, Simvastatin 40mg, Flomax 0.4mg, Nexium 40mg, Lamotrigine 100mg, Pantoprazole Sodium 40mg, Nortriptyline HCL 10mg and 25mg, Phenazopyridine HCL 200mg, Sertraline HCL 25mg and 50mg, Lasix 80mg, Finasteride 5mg and 30mg, Colestipol HCL 1G, Lovastatin 20mg, Klor-Con M10 10meq, Detrol LA 40mg, Lisinopril 2.5mg, and Flavoxate HCL 100mg. Further observation revealed 54 unidentified loose pills on the bottom of the drawer. Drawer three contained bottles of stock medication with the bottom of the drawer having a thick sticky residue as well as an expired bottle of Omega-3 Fish Oil 100mg capsules.

In a face to face interview on 10/14/10 at 10:40am Administrator S1 indicated that the former Performance Improvement Coordinator was responsible for checking the carts; however she is no longer employed at the hospital.

In a face to face interview on 10/14/10 at 1:20pm Pharmacist S4 indicated medications prescribed for a patient cannot be used as a "Stock" medication. Further he indicated his pharmacy tech has the responsibility for inspecting the medication cart and verified the tech should have reported this finding back to the pharmacist. When asked how patients are charged for the medication S4 indicated the medication is charged to the hospital and they in turn charge the patient.

4) failed to ensure the crash cart was ready for emergency use by having expired epinephrine and vials of medications in their original packaging and stored in plastic bags making it necessary for nursing staff to open during an emergency situation;
Observation of the only crash cart in the hospital on 10/14/10 at 10:00am revealed 4 vials of Epinephrine 1:100mg/ml expired as of 10/01/10. Further review revealed all medication in vials still in the packaging and sealed in a plastic bag.

In a face to face interview on 10/14/10 at 10:05am Interim Director of Nursing (DON) S2 indicated the pharmacy is responsible for checking the drugs in the crash cart as well as the nursing staff. Further S2 indicated the medication should not be kept in the packaging, but should be readily available in case of an emergency situation.

5) failing to ensure the narcotic prescribed for a patients was not administered to another patient; (See findings in Tag A0509).

6) failing to ensure accurate narcotic record were kept by the nursing staff as evidenced by no documentation of narcotics destroyed by the pharmacist for individual narcotic records; (See findings at Tag A0494)

Based on record review and interview the hospital failed to have a system in place to accurately track narcotics as evidenced by: 1) failing to develop and implement a policy and procedure for receiving narcotics from the pharmacy, counting of narcotics, proper storage of narcotics until scheduled wastage by the pharmacist and administration of narcotics which addresses the practice of "borrowing" narcotics from patients; 2) failing to ensure individual narcotic records were reconciled and wastage of narcotics were performed by two nurses; and 3) failing to ensure narcotics drugs prescribed for a specific patient were administered to that patient by practicing the habit of "borrowing" narcotics from patient. Findings:

1) failing to develop and implement a policy and procedure for receiving narcotics from the pharmacy, counting of narcotics, proper storage of narcotics until scheduled wastage by the pharmacist and administration of narcotics which addresses the practice of "borrowing" narcotics from patients;
Review of the hospital's policy and procedure manual, section titled "Pharmacy" last revised 02/07, revealed no documented evidence of a policy addressing the following issues: receiving narcotics from the pharmacy, counting of narcotics, proper storage of narcotics until scheduled wastage by the pharmacist and administration of narcotics which addresses the practice of "borrowing" narcotics from patients.

Review of the Pharmacy contract dated 04/01/09 revealed the pharmacy was not responsible for developing policy and procedures for the hospital.

In a face to face interview on 10/15/10 at 3:00pm Administrator S1 indicated that none of the policies have been reviewed or revised as of this time. Since the management and ownership is new, we know there is still more work to be done. Further she indicated the contract with the pharmacy would be changing, and all of these things would be discussed with the new company.

2) failing to ensure individual narcotic records were reconciled and wastage of narcotics were performed by two nurses;
Review of the narcotics logs dated 08/01/10 through 10/19/10 revealed no documented evidence two nurses performed the narcotics counts on the following dates and shifts: 08/02/10 7p-7a; 08/16/10 7p-7a; 08/17/10 7p-7a; 08/19/10 7p-7a; 08/21/10 7p-7a; 08/24/10 7p-7a; 08/25/10 7p-7a; 08/26/10 7a-7p and 7p-7a; 08/27/10 7a-7p; 08/29/10 7a-7p; 08/30/10 7a-7p and 7p-7a; 08/31/10 7p-7a; 09/01/10 7a-7p and 7p-7a; 09/02/10 7p-7a; 09/03/10 7a-7p and 7p-7a; 09/04/10 7p-7a; 09/05/10 7a-7p; 09/07/10 7a-7p and 7p-7a; 09/08/10 7p-7a; 09/10/10 7a-7p and 7p-7a; 09/11/10 7a-7p and 7p-7a; 09/12/10 7a-7p and 7p-7a; 10/12/10 7a-7p; 10/15/10 7a-7p and 7p-7a shifts; 10/16/10 7p-7a; and 10/19/10 7a-7p and 7p-7a shifts.

Review of the policy No F.7.12 revealed a form titled "RT of Destroyed Aliquot (remaining part) Part Record" submitted as the one presently in use revealed when a dosage smaller than the smallest available dose is used, the remaining portion must be destroyed in the presence of a witness and accounted for on this sheet.

The hospital could not submit any RT of Destroyed Aliquot forms for narcotic drugs.

Review of the individual patient narcotic sheets revealed the following:
08/18/10 1000 (10:00am) Alpmazolam 0.5mg tablets 1/2 wasted. No documented evidence the wastage was witnessed by a nurse.
08/28/10 at 0600 (6:00am) Lorazepam 2mg/ml vial 1.5mg wasted. No documented evidence the wastage was witnessed by a nurse.
09/05/10 Lorazepam 0.5mg (no time documented) Pill removed and destroyed due to 1/2 mistakenly fell out to floor. No documented evidence the wastage was witnessed by a nurse.

In a telephone interview on 11/01/10 at 11:45am Pharmacist S4 indicated he was not aware the nurses were not witnessing the wastage even though he acknowledged he signed off on the narcotic's sheets presently being used when he came to the hospital to perform the wastage of all narcotics from discharged and/or expired patients.

3) failing to ensure narcotics drugs prescribed for a specific patient were administered to that patient by practicing the habit of "borrowing" narcotics from patient;
Review of the individual patients' Narcotics Sheets submitted by the hospital for the time period of 08/01/10 through 01/18/10 revealed 100 entries on the individual patient narcotic sheets where the name of the patient for which the medication had been dispensed did not match the name for which the drug had been ordered.

Review of a Memo dated 10/06/10 sent from the Pharmacist to the Nursing Staff indicated the pharmacy would no longer provide stock narcotic medication and therefore would have to have a hard copy of the prescription and the DEA(Drug Enforcement Agency) 222 form before the medication could be filled.

Review of the policy and procedures for medication administration revealed no documented evidence a policy addressing borrowing of patient drugs had been developed and/or implemented by the hospital.

In a telephone interview on 11/01/10 at 11:45am Pharmacist S4 indicated he was not aware the nurses were administering medications specifically ordered for a patient to another patient. Further S4 indicated that cannot be done.

Based on observation and interview the hospital failed to follow their policy and procedure for the security of drugs as evidenced by the nursing medication cart stored in the hallway by the nurses' station which contained patient medications and hospital stock medications being left unlocked when not in attendance/use by a nurse. Findings:

Observation on 10/14/10 at 10:15am of the unlocked medication cart in the hallway by the nurses' station used by the public to get to patient rooms. When opened by RN S2 Interim Director of Nursing (DON) four drawers revealed hospital stock medication and patient specific medications.

In a face to face interview on 10/14/10 at 10:15am Administrator S1 and RN S2 Interim DON both verified the medication cart should never be left unlocked unless being used by a nurse to dispense medication. Further, when the nurse walks away, it should be locked.

Observation on 10/15/10 at 2:25pm in the presence of Administrator S1 and RN S7 DON/Consultant of the medication cart in the hallway by the nurses' station revealed it was unlocked. Further, while the Administrator inquired to the staff who were standing at the nurses' station why this had happened, and LPN walked to the cart, looked at the surveyors, Administrator and consultant, pressed the lock button and without a word went back into the station.

In a face to face interview on 10/15/10 at 2:30pm RN S7 DON/Consultant indicated the issue with the medication cart had been discussed with the staff yesterday after the first incident. Further S7 indicated problems with work ethics among the staff had been identified and needed to be addressed.

Review of Policy No. II-F.7.00 titled "Medication Management" last revised 09/08 revealed.... "C. Storage: As appropriate, other medications are stored in the locked refrigerator and the medication cart. Never leave the medicine cart unlocked".

Based on observation and interview the hospital failed to follow their policy and procedure for the security of scheduled drugs as evidenced by the nursing medication cart stored in the hallway by the nurses' station which contained narcotics drugs being left unlocked when not in attendance/use by a nurse. Findings:

Observation on 10/14/10 at 10:15am of the unlocked medication cart in the hallway by the nurses' station used by the public to get to patient rooms. When opened by RN S2 Interim Director of Nursing (DON) a single lock box was noted and verified by S2 that it contained narcotics.

In a face to face interview on 10/14/10 at 10:15am Administrator S1 and RN S2 Interim DON both verified the medication cart should never be left unlocked unless being used by a nurse to dispense medication. Further, when the nurse walks away, it should be locked.

Observation on 10/15/10 at 2:25pm in the presence of Administrator S1 and RN S7 DON/Consultant of the medication cart in the hallway by the nurses' station revealed it was unlocked. Further, while the Administrator inquired to the staff who were standing at the nurses' station why this had happened, and LPN walked to the cart, looked at the surveyors, Administrator and consultant, pressed the lock button and without a word went back into the station.

In a face to face interview on 10/15/10 at 2:30pm RN S7 DON/Consultant indicated the issue with the medication cart had been discussed with the staff yesterday after the first incident. Further S7 indicated problems with work ethics among the staff had been identified and needed to be addressed.

Review of Policy No. II-F.7.00 titled "Medication Management" last revised 09/08 revealed.... "C. Storage: As appropriate, other medications are stored in the locked refrigerator and the medication cart. Never leave the medicine cart unlocked".

Based on observation, record review and interview the hospital failed to: 1) develop and implement a policy concerning the disposing of medication for discharged and/or expired patients; 2) ensure all expired medications were not available for patient use by having expired medications and/or unlabeled opened vials in the medication cart and medication refrigerators; 3) ensure all medications for discharged or expired patients were not placed in hospital stock and available for patient use. Findings:

1) develop and implement a policy concerning the disposing of medication for discharged and/or expired patients

Review of the Pharmacy Service Agreement effective 04/01/09 with Company "C" revealed.... 1.5 Additional Services; Additional services may be provided by an independent pharmacy consultant to include such services as......inspection of emergency drug storage, hospital or expirations dates; inspection of controlled medications..... Pharmacy makes no claim to provide such services as part of this agreement..." Further review revealed no documented evidence the pharmacy was responsible for development or implementation of policies and procedures for medication inspection, storage, administration or destruction.

Review of Policy No.II.F.7.00 titled "Medication Management" last revised 09/08 and submitted by the hospital as the one currently in use, revealed no documented evidence disposition of medication for patients who have been discharges or expired and expired medications had been addressed.

In a face to face interview on 10/14/10 at 11:00am RN S2 Interim DON indicated she was not aware of any issues with medications from discharged and/or expired patients. Further she indicated she had been in the DON position for a short time and did not know that the pharmacy was not taking care of the unused medications.

2) ensure all expired medications were not available for patient use by having expired medications and/or unlabeled opened vials in the medication cart and medication refrigerators

Observation on 10/14/10 at 10:40am of the unlocked medication cart located in the hallway by the nurses' station revealed the following expired medications: 6 Detrol LA 4mg capsules expired 09/04/10; 13 Lisinopril 2.5mg tablets date of expiration torn off; 8 Flavoxate HCL 100mg tablets expired 08/23/10; 7 Butalbital-APAP-CAFE 50-325-40mg tablets expired 06//27/10; 3 Minocycline HCL 100mg capsules expired 06/15/10;

Observation of the Crash Cart on 10/14/10 at 11:20am revealed 4 ampoules of Epinephrine 1:100 (1mg/ml) that had expired on 10/01/10.

Observation of the medication refrigerator on 10/15/10 at 10:30am located in the medication room behind the nurses' station revealed the following medications with no documented evidence of the date the vial had been punctured: Lantus (1); Novolin R (1); Novolog 70/30 (1); Novolog (2); Novolin 70/30 (1) and Tuberculin Mantoux (2) for a total of 8 vials of medication.

In a face to face interview on 10/14/10 at 1:20pm Pharmacist S4 indicated the nurses and his pharmacy tech check for expired medications; however he did not think his tech had come to the hospital since August 2010 because that is when the pharmacy contract was due to expire.

In a face to face interview on 10/15/10 at 10:30am RN S7 DON/Consultant indicated the labeling of vials had been discussed yesterday with the staff and she is very surprised at this non-compliance.

Review of Policy No. II-F.7.00 titled "Medication Management" last revised 09/08 and submitted by the hospital as the one currently in use revealed no documented evidence labeling of multi-dose vials had been addressed.

3) ensure all medications for discharges or expired patients were not place in hospital stock and available for patient use

Observation on 10/14/10 at 10:30am of the unlocked medication cart located in the hallway by the nurses' station revealed 60 blister packs of medication prescribed for specific patients who had either been discharged from the hospital or expired filed in with the medication used as "stock" drugs and available for administration to patients in the hospital. Further observation revealed the name of the patient had been, in some cases, blacked out and the work "stock" written across the top or the patients' names were left on the blister pack and the word "stock" written on the top. Review of the blister packs revealed the following list of drugs prescribed to specific patients and being used as stock medications: Divalproex Sodium 250mg and 500mg, Minocycline HCL 100mg, Carbamazepine 200mg, Vitamin D 1000 Units, Phenytoin Sodium Extended 100mg, Benazepril HCL 40mg, Gabapentin 600mg, Benztropine Mesylate 1mg, Potassium Chloride 20 meq, Namenda 5mg, Oyster-Cal 500mg, Enalapril Maleate 5mg and 10mg, Carbidopa-Levodopa 25-250mg, Captopril 25mg, Calcium-Magnesium 500-250mg, Baclofen 10mg, Crestor 10mg, Folic Acid 1mg, Warfarin Sodium 3mg and 5mg, Dipyridamole 75mg, Digoxin 125 mcg, Diltiazem 240mg, Glimepiride 2mg, Bethanechol Chloride 50mg, Amiodarone HCL 200mg, Simvastatin 40mg, Flomax 0.4mg, Nexium 40mg, Lamotrigine 100mg, Pantoprazole Sodium 40mg, Nortriptyline HCL 10mg and 25mg, Phenazopyridine HCL 200mg, Sertraline HCL 25mg and 50mg, Lasix 80mg, Finasteride 5mg and 30mg, Colestipol HCL 1G, Lovastatin 20mg, Klor-Con M10 10meq, Detrol LA 40mg, Lisinopril 2.5mg, and Flavoxate HCL 100mg.

In a face to face interview on 10/14/10 at 1:20pm Pharmacist S4 indicated medications prescribed for a patient cannot be used as a "Stock" medication. Further he indicated his pharmacy tech has the responsibility for inspecting the medication cart and verified the tech should have reported this finding back to the pharmacist. When asked how patients are charged for the medication S4 indicated the medication is charged to the hospital and they in turn charge the patient.

Based on record review and interview the hospital failed to: 1) follow their policy and procedure for counting narcotics for 36 of 160 shifts in a period from 08/01/10 through 10/19/10 by having documentation of only one nurse performing the counts; 2) follow their policy and procedure for wasting narcotics by having two nurses perform the task, one to waste and one to witness; 3) follow their policy and procedure for narcotic count discrepancy as evidenced by failing to require all staff to remain on the premises, perform a thorough search of the hospital, notify the pharmacist and the appropriate officials after discovering the medication cart was left unlocked, report an incident of unresolved missing narcotics to the pharmacist involving 11 Temazapam; and 4) ensure a narcotic medication ordered for a patient was administered only to that patient as evidenced by patients being dispensed narcotics prescribed for another patient.

1) follow their policy and procedure for counting narcotics for 36 of 160 shifts in a period from 08/01/10 through 10/19/10 by having documentation of only one nurse performing the count and failing to ensure another nurse witnessed wastage of a narcotic;
Review of the narcotics logs dated 08/01/10 through 10/19/10 revealed no documented evidence two nurses performed the narcotics counts on the following dates and shifts: 08/02/10 7p-7a; 08/16/10 7p-7a; 08/17/10 7p-7a; 08/19/10 7p-7a; 08/21/10 7p-7a; 08/24/10 7p-7a; 08/25/10 7p-7a; 08/26/10 7a-7p and 7p-7a; 08/27/10 7a-7p; 08/29/10 7a-7p; 08/30/10 7a-7p and 7p-7a; 08/31/10 7p-7a; 09/01/10 7a-7p and 7p-7a; 09/02/10 7p-7a; 09/03/10 7a-7p and 7p-7a; 09/04/10 7p-7a; 09/05/10 7a-7p; 09/07/10 7a-7p and 7p-7a; 09/08/10 7p-7a; 09/10/10 7a-7p and 7p-7a; 09/11/10 7a-7p and 7p-7a; 09/12/10 7a-7p and 7p-7a; 10/12/10 7a-7p; 10/15/10 7a-7p and 7p-7a shifts; 10/16/10 7p-7a; and 10/19/10 7a-7p and 7p-7a shifts.

Review of the hospital policy and procedure manual for patient care the section titled "Pharmacy" revealed no documented evidence of a policy for the counting of narcotics.

2) follow their policy and procedure for wasting narcotics as evidenced by no documented evidence the "RT of Destroyed Aliquot Part Record" had been completed or that the process had been performed by two nurses:

Review of the policy No F.7.12 revealed a form titled "RT of Destroyed Aliquot (remaining part) Part Record" submitted as the one presently in use revealed when a dosage smaller than the smallest available dose is used, the remaining portion must be destroyed in the presence of a witness and accounted for on this sheet.

The hospital could not submit any RT of Destroyed Aliquot forms for narcotic drugs.

Review of the individual patient narcotic sheets revealed the following:
08/18/10 1000 (10:00am) Alpmazolam 0.5mg tablets 1/2 wasted. No documented evidence the wastage was witnessed by a nurse.
08/28/10 at 0600 (6:00am) Lorazepam 2mg/ml vial 1.5mg wasted. No documented evidence the wastage was witnessed by a nurse.
09/05/10 Lorazepam 0.5mg (no time documented) Pill removed and destroyed due to 1/2 mistakenly fell out to floor. No documented evidence the wastage was witnessed by a nurse.

In a telephone interview on 11/01/10 at 11:45am Pharmacist S4 indicated he was not aware the nurses were not witnessing the wastage even though he acknowledged he signed off on the narcotic's sheets presently being used when he came to the hospital to perform the wastage of all narcotics from discharged and/or expired patients.

3) follow their policy and procedure for narcotic count discrepancy
Review of Policy No. II-F.7.07 titled Record Keeping" issued 02/07 and submitted by the hospital as the one presently in use revealed ..... " Reporting of Abuse: Reporting abuse and losses of controlled substances shall be reported to the individual for the pharmaceutical services, to the chief executive officer, Louisiana Board of Pharmacy, and the Regional Drug Enforcement Administration (DEA) office, as appropriate".

Review of the Occurrence Report dated 08/10/10 at 0625 (6:25am) written by RN S15 Charge Nurse revealed.... "Narcotic count discrepancy 11 Temazapam missing from narcotic box. Supervisor called." Further review revealed RN S59, former DON, was notified at 0625 (6:00am) and the Administrator notified at 0930 (9:30am). Review of the section titled "Follow-up" revealed, " 08/10/10 11:30 (am or pm not documented) During the 7A-7P narcotic count it was discovered that 11 Restoril/Temazapam was not in the locked box of the medicine cart. The box was found to have a flawed lock that additional meds (medications) inside box prevents box from locking securely. The meds must be completely clear of the lock for the box to lock securely. Med Cart was also unlocked. Nursing staff was instructed to not leave med cart unlocked at any time to prevent risk of medications being taken from the cart". Further review revealed no documented evidence an investigation had been performed, medication had been found, the pharmacist had been notified, the Louisiana Board of Pharmacy notified or the DEA notified. Further review of the Occurrence Report revealed no documented evidence of the missing medication being a stock medication or a medication prescribed for a specific patient.

Review of the Narcotic Sheets submitted by the hospital for the period of 08/01/10 through 10/18/10 revealed no documented evidence Temazapam had been prescribed for any patient during the reported discrepancy date of 08/10/10. Further review of the Narcotics Sheet revealed no documented evidence Temazapam had been included in the hospital's stock of narcotic drugs.

In a face to face interview on 10/19/10 at 4:30pm Administrator S1 reviewed the Occurrence Report for the 11 missing Temazapam and verified there was no documented evidence the staff had been questioned before being allowed to leave the hospital; no further investigation had been performed, the pharmacist had not been contacted nor had any other official. Further S1 indicated the drugs had never been recovered.

In a telephone interview on 11/01/10 at 11:45am Pharmacist S4 indicated he had not been notified of any narcotic discrepancy concerning Temazapam; therefore he had not reviewed or signed off on the narcotics sheet which included the discrepancy. Further after checking his records of narcotics dispensed to the facility S4 indicated between the dates of 08/01/10 and 08/10/10 only 3 Temazapam 15mg had been dispensed to Patient #9 on 08/01/10.

4) ensure medication ordered for a patient was administered only to that patient as evidenced by other patients being dispensed narcotics prescribed for another patient.

Review of the individual patients' Narcotics Sheets submitted by the hospital for the time period of 08/01/10 through 01/18/10 revealed 100 entries on the individual patient narcotic sheets where the name of the patient for which the medication had been dispensed did not match the name for which the drug had been ordered.

Review of a Memo dated 10/06/10 sent from the Pharmacist to the Nursing Staff indicated the pharmacy would no longer provide stock narcotic medication and therefore would have to have a hard copy of the prescription and the DEA(Drug Enforcement Agency) 222 form before the medication could be filled.

Review of the policy and procedures for medication administration revealed no documented evidence a policy addressing borrowing of patient drugs had been developed and/or implemented by the hospital.

In a telephone interview on 11/01/10 at 11:45am Pharmacist S4 indicated he was not aware the nurses were administering medications specifically ordered for a patient to another patient. Further S4 indicated that cannot be done.

Based on record review and interview, the hospital failed to ensure the dietitian performed and documented nutritional assessments and maintained pertinent data needed to modify therapeutic diets to meet the nutritional needs of patients as evidenced by a patient with a 20.2 pound weight loss in 17 days, a pre-albumin of 6 mg/dl (milligrams per deciliter), and stage IV pressure ulcers with no follow-up nutritional assessment by the dietitian after the initial assessment for 1 of 10 sampled patients (#3). Findings:

Review of Patient #3's medical record revealed he was admitted on 09/30/10 with diagnoses of Rhabdomyolysis, Major depression secondary to spinal cord injury, Encephalopathy, GERD (gastroesophageal reflux disease), Multiple Infected Wounds, Hypertension, and a history of Osteoarthritis, Cardiomegaly, Chronic Pain, and back surgery.

Review of Patient #3's History and Physical performed on 10/01/10 revealed "multiple decubitus ulcers at the back varying stage up to stage IV".

Review of Patient #3's medical record revealed RD (registered dietitian) S52 performed a nutritional assessment on 10/02/10. Further review revealed S52 documented a weight of 248 pounds, pre-albumin of 6, albumin of 2.4, estimated caloric intake of 1800 calories for weight loss, and 128 grams of protein to increase protein. S52's plan was to give Juven 1 pack mixed with 8 ounces of water with 2 scoops of Benepectin twice a day and to follow and monitor patient. Further review of the medical record revealed no documented evidence RD S52 performed a follow-up nutritional assessment as of the date of chart review on 10/18/10, which was 16 days since the initial assessment and Patient #3 has lost 20.2 pounds in this time.

In a face-to-face interview on 10/20/10 at 8:45am, RD S52 indicated she had been seeing patients once a week or more often before the dietary technician was hired, but since that time the dietary technician visited the patient more often. She further indicated she would base the need for her to reassess a patient upon the report by the dietary technician of a patient not eating, having weight loss, or having a low or decrease in a pre-albumin level. After reviewing Patient #3's medical record, RD S52 indicated she felt his weight loss may have been a "scale problem" or possibly fluid loss. She further indicated they had problems with weights being taken accurately, so she often had to ask that a patient be reweighed. She could offer no explanation for not having performed a follow-up visit with Patient #3.

Review of the hospital policy titled "Nutritional Services (General)", issued 02/07 and submitted by Administrator S1 as their current policy for nutritional assessments, revealed, in part, "...The Dietician will be notified upon patient admit after the Nutritional Screening is performed. The Dietary consult will be initiated within 24 hours and completed within 72 hours ...". Further review revealed no documented evidence regarding the dietitian's role in performing reassessment of the nutritional needs of patients.

Based on record review and interview the hospital failed to ensure efficient use of the facility and its services by admitting a patient for treatment and allowing her to go out on passes totaling more than 13 hours in a two day period for 1 of 10 sampled medical record (#5). Findings:

Review of the medical record for Patient #5 was a 39 year old female with a history of moderate to mild mental retardation who suffered a CVA (Cerebral Vascular Accident) which left her with significant numbness and decreased sensation in the upper and lower extremities and left lower extremity weakness. #5 was transferred from a hospital in Florida at the request of her family to be closer to home and was admitted to this facility on 08/26/10.

Review of the Physician's Admit Orders dated 08/26/10 revealed Patient #5 had the following orders: blood cultures, fall precautions, aspiration precautions, vital signs every four hours, urinary catheter, specialty bed overlay, Physical, Occupational and Speech Therapy (PT/OT/ST) consults, a saline lock ordered and medication requiring administration twice a day.

Review of the Nurses' Notes dated 08/28/10 at 1400 (2:00pm) revealed the MD was called concerning a pass for Patient #5 which the family said had already been discussed. 1600 (4:00pm) The patient left on pass. 2300 (11:00pm) Patient returns from pass accompanied by her sister. Review of the Physician's Orders for Patient #5 revealed a late entry for a verbal order to allow Patient #5 to leave on pass was documented after 6:00PM on 06/28/10.

Review of the Nurses' Notes dated 08/28/10 at 12:00 noon patient left on pass. 2200 (10:00pm) Patient returns to facility.

Review of the Medication Administration Record (MAR) revealed Patient #5 missed her ordered 6:00pm medications on 08/28/10 and the 6:00PM medications for 08/29/10 were administered 3 hours late. Further review revealed no arrangements or instructions had been ordered by the physician to ensure patient #5 received her medications on time or had approved for the medications to be administered late.

Review of the PT/OT/ST Notes for 08/28/10 and 08/29/10 revealed Patient #5 revealed no therapies during this time.

In a face to face interview on 10/15/10 at 11:00am, Administrator S1 indicated passes in a long term acute care setting are not appropriate and will have to be addressed with the medical staff.

Based on observation, record review, and interviews, the hospital failed to monitor equipment used for patient care as evidenced by: 1) having the electronic nurse call system that audibly transmitted calls from the patients' rooms to the nurse's station not functioning and replaced by a bedside table bell that could not be heard by nursing staff during a fire drill when patients' room doors were closed and the alarm was sounding at 9:55am on 10/20/10; 2) having an unlocked medication storage cart in the hallway accessible to the public; 3) having the emergency drugs stored in the crash cart expired and available for use and having the crash cart and respiratory box contents stored in a disorganized fashion that would make locating drugs and equipment needed in an emergent situation difficult to find; and 4) having patient care equipment in non-working order. Findings:

1) Electronic call system:
In a face-to-face interview on 10/20/10 at 9:50am, Administrator S1 indicated the nursing home next door (Meadowcrest Specialty Hospital was a facility within a facility with the nursing home) was going to hold a fire drill.
Observation on 10/20/10 at 9:55am revealed a loud fire alarm sounding that produced a piercing sound to the surveyor's ears. Further observation revealed the automatic doors had shut, and hospital personnel had closed each patient's room door. While walking in the hallway outside the patient's doors, the surveyor was unable to hear anything other than the piercing alarm that was sounding.
Observation on 10/20/10 at 10:00am revealed the alarm continued to sound with the patient's doors remaining closed with no means to hear a patient use the bedside bell if the patient had an emergent need.

In a face-to-face interview on 10/20/10 at 10:05am, Administrator S2 and RN (registered nurse) Consultant S10 were notified of an immediate jeopardy (IJ) situation.

Review of the hospital policy titled "Disruptive Emergencies", issued 02/07 and included in the Policy and Procedure Manual presented by Administrator S1 as the hospital's Policy and Procedure Manual, revealed, in part, "...3. Communication Outage ... C. Patient call intercom is used in the event any part of the patient intercom system goes out. The following plan is implemented: (1) The Director of Clinical Services and/or Charge Nurse stations non-nursing personnel in or near the patient rooms so that patients' needs can be relayed in a timely manner. (2) Maintenance and Administration are notified as soon as possible. (3) Hand bells are provided to patients who can use them appropriately to replace electronic intercom. (4) Patient rounds are performed continuously to identify needs. The supervisor will assign individuals in other departments to assist in rounds. Needs identified will immediately be reported to nursing staff.

2) Unlocked medication cart:
Observation on 10/14/10 at 10:10am, with Administrator S1 present, revealed the medication cart located in the hallway next to the nursing station and accessible to the public unlocked. Stored in the medication cart were patient-specific prescribed blister-packed medications, stock medications, and a locked drawer that included patient-specific prescribed and stock narcotics.

Observation on 10/15/10 at 2:25pm, with Administrator S1 present, revealed the medication cart located in the hallway next to the nursing station and accessible to the public unlocked.

In a face-to-face interview on 10/14/10 at 10:10am, Administrator S1 indicated the medication storage cart should remain locked when a nurse was not presently using it to obtain patient medication.

Review of the hospital policy titled "Medication Management", issued 02/07 and submitted by Administrator S1 as their current policy for medication management, revealed, in part, "...All medications are properly labeled and stored in the locked medication room/automated pharmacy dispensing machine or sealed crash cart. As appropriate, other medications are stored in the locked medication refrigerator and the medication cart. The medication cart is kept in front of the nurse's station when not in use. Only authorized personnel may have access to these storage areas ...".

3) Emergency crash cart and respiratory box:
Observation on 10/14/10 at 11:20am revealed the crash cart was located in the hallway across from the nursing station with a respiratory box of emergency supplies and a box containing the ambu bag atop the cart. Further observation revealed emergency medications were in their original box and/or a sealed plastic bag. There was no labeling in the drawer to distinguish one medication from the other. Further observation revealed 4 doses of Epinephrine 1:1000 (1 milligram/milliliter) had expired on 10/01/10. Further observation revealed the ambu bag was in the sealed plastic wrap and stored in the original box in which it was received. The surveyor had difficulty opening the box to view the ambu bag which could present a delay if the ambu bag was needed during an emergency. Observation of the respiratory emergency supply box revealed scattered supplies within the box. The surveyor had to reach beneath various supplies to find the laryngoscopes and metal blades in the bottom of the box. Further observation revealed disposable laryngoscope blades in plastic wrap rubber-banded together with no distinguishable way to quickly identify the size of the blade. Observation revealed Respiratory Therapist S38 and Director of Respiratory Therapy S3 were unable to attach the laryngoscope blade to the slim handle laryngoscope.

In a face-to-face interview on 10/14/10 at 11:35am, Director of Respiratory Therapy S3 indicated she was responsible for the organization of and the supplies in the respiratory emergency box. She further indicated the contents of the box were disorganized, and that would present a problem during a cardiac or respiratory emergency.

Review of the hospital policy titled "Crash Cart", issued 02/07 and submitted by Administrator S1 as their current policy for the crash cart, revealed, in part, "...Pharmacy Responsibilities: The crash cart is located in the hospital at the nurse station. Drugs are checked monthly by the responsible contracted pharmacist and if any outdated drugs are found, they are replaced with in-date stock. During this monthly check, drugs nearing their expiration date will be rotated with other pharmacy stock bearing longer expiration dates up to at least a year. ...Nursing Responsibilities: Crash cart is to be checked by a nurse daily to ascertain that the lock is intact and the defibrillator is plugged and in proper working condition, suction works and oxygen tank... Supply Check: The cart is sealed with a break-away lock. ... In the event the seal is broken, all medications and supplies must be checked against the crash cart patient charge list ... and any missing or used must be replaced. Medication replacement is done by contracted pharmacy when a list of medications used is sent to the contracted pharmacy after a code. All supplies are replaced by unit staff from existing floor stock". Further review of the policy revealed no documented evidence regarding the organization of the crash cart contents and the respiratory emergency supply box.

4) Patient care equipment:
Observation on 10/14/10 at 11:50am, with Administrator S1 present, revealed a manual blood pressure cuff on a rolling cart in the hallway outside patients' rooms with part of the appliance hanging from the main rod.

In a face-to-face interview on 10/14/10 at 11:50am, Billing and Supply Specialist S49 indicated the blood pressure cuff was broken and should not be in the hall accessible for use.

Continued observation on 10/14/10 at 11:50am revealed a Dinamap blood pressure machine with a disposable cuff that was soiled/stained.

In a face-to-face interview on 10/14/10 at 11:50am, Interim DON (director of nursing) S2 indicated the cuff should not be on the machine, because it was soiled. She further indicated each patient had their own blood pressure cuff in their room, and there was no reason to have a soiled cuff on the machine.

Observation of the general supply room on 10/14/10 at 12:00pm, with Administrator S1, Interim DON S2, and Billing and Supply Specialist S49 present, revealed the following equipment with expired inspection stickers:
Baxter K Module (no one present knew the purpose of the equipment) - inspection due 05/10;
Micro Macro enteral feed - inspection due 05/10; and
Quantum Flexaflow - inspection due 10/08.

Further observation revealed no evidence of a label indicating that the equipment was not to be used.

Review of the PM Work Order (equipment checks by biomedical personnel) performed by Company A with a start date of 06/01/10 and an end date of 08/31/10, presented by Administrator S1, revealed the total number of PM work orders performed was 88. Further review revealed 54 of the 88 pieces of equipment were due to be checked on 06/30/10 and not performed until 07/30/10. The equipment included IV (intravenous) pumps, mattress pumps, patient beds, defibrillator, thermometer, TM Transmitter, K Pump, electrical panels, ultrasound unit, paraffin bath, gel warmer, hydrocollator, stand-up scale, oxygen concentrator, feeding pumps, pulse oximeter, wall suction, x-ray viewer, analyzer, and a nebulizer.

In a face-to-face interview on 10/22/10 at 9:50am, Administrator S1 indicated she was not able to locate any biomedical check logs, so she had to call the company to send her a copy of their last PM check. She could offer no explanation for the equipment checks not being checked by the due date, since these were done prior to her employment.

Review of the hospital policy titled "Defective Equipment Tagging And Removal", issued 02/07 and included in the Policy and Procedure Manual presented by Administrator S1 as the hospital's Policy and Procedure Manual, revealed, in part, "...1. When any piece of equipment that is used or may come into contact with any patient, visitor or employee is deemed not to be operating properly or has been broken damaged, it should be removed immediately from service and a Danger Tag attached securely to the item. Associated items, such as tubing or electrical leads, should be kept with such equipment. 2. The equipment should be returned to the department responsible for the repair of the item, which will be responsible for removing for removing the tag after the repairs are completed. It is important to note on the tag what the problem is and to sign and date it ...".

Review of the policy titled "Biomedical Services", issued 02/07 and included in the Policy and Procedure Manual presented by Administrator S1 as the hospital's Policy and Procedure Manual, revealed, in part, "...Biomedical Services will be responsible for preventive maintenance to the facility's medical equipment. Preventive maintenance logs will be maintained and made available to the facility. ...Biomedical Services department is responsible for providing incoming inspection, preventive maintenance, safety inspection, corrective maintenance and pre-purchase evaluation services on patient care equipment throughout the hospital, to accomplish the above policy...".

The hospital could submit no documented evidence any improvement activities had been implemented.

Based on record review and interview the hospital failed to monitor high risk and problem prone areas of care as evidenced by no documented indicators for monitoring of patients admitted with a secondary psychiatric diagnosis, decubitus ulcers, or falls. Findings:

The hospital could submit no indicators to monitor patients exhibiting psychiatric behaviors, wound healing percentages, or effectiveness of their fall prevention program.

Based on record review and interview the hospital failed to ensure their Quality Assurance/Performance Improvement program was maintained during the change in ownership and leadership as evidenced by three QA/PI Directors names within 3 months with no one presently serving in the position and inability of the hospital to present any QA/PI data. Findings:

In a face to face interview on 10/15/10 at 4:00pm Administrator S1 indicated former DON #2 S59 was the QA/PI Director when the new owners took over management of the hospital. Further S1 indicated that when DON S12 was terminated S59 was named the new DON and another nurse was put in the QA/PI position, Interim DON S2; however when S59 was terminated S2 was name DON and another nurse, who is no longer at this facility, was placed into QA/PI. The Administrator indicated no one is in the position at the present time until Monday 10/18/10 when the new DON arrives.

The hospital could not submit any current QA/PI data to the survey team.

Review of the last "Utilization Review" Committee Meeting Minutes dated 07/21/10 revealed the following had been reviewed: blood transfusions, medical records, ventilators and weaning, P&T, complaints, invasive procedures, human resources, and transfers.

Based on record review and interview, the hospital failed to ensure medications were administered as ordered for 2 of 10 sampled patients (#3, #10). Findings:

Patient #3
Review of Patient #3's medical record revealed he was admitted on 09/30/10 with diagnoses of Rhabdomyolysis, Major Depression secondary to spinal cord injury, Encephalopathy, GERD (gastroesophageal reflux disease), Multiple Infected Wounds, Hypertension, and a history of Osteoarthritis, Cardiomegaly, Chronic Pain, and back surgery.

Review of Patient #3's physician's orders revealed the following orders:
10/01/10 at 9:50am - Ensure 1 can three times a day;
10/02/10 at 6:20pm - Start Vancomycin 1 gram IVPB (intravenous piggyback) daily;
10/04/10 at 4:50pm - Juven twice a day (mix with 8 ounces of water and 2 scoops Benepectin);
10/06/10 at 11:30am - Discontinue Vancomycin;
10/08/10 at 11:25am - Rocephin 1 gram IVPB every day; and
10/13/10 at 12:00pm - Unasyn 3 grams IV every 8 hours; Colistimethate 100 mg (milligrams) IV every 8 hours; and Imipenem 500 mg IV every 6 hours.

Review of Patient #3's MARs (medication administration record) revealed no documented evidence Vancomycin 1 gram IVPB was administered on 10/06/10 at 9:00am; the order to discontinue Vancomycin was not received until 11:30am on 10/06/10. Further review revealed Rocephin 1 gram IVPB was first administered at 6:00am on 10/09/10, more than 18 hours after the order was received. Review of the MAR revealed no documented evidence Ensure was given on 10/10/10 at 9:00am and 3:00pm, at 9:00am, 3:00pm, and 9:00pm on 10/13/10, and at 9:00am, 3:00pm, and 9:00pm on 10/14/10. Further review revealed the first dose of Colistimethate was not administered until 6:00am on 10/14/10, 18 hours after it was ordered; Imipenem was not administered until 6:00pm on 10/13/10, 6 hours after it was ordered; and Unasyn was not administered until 10:00pm on 10/13/10, 8 hours after it was ordered.

Patient #10
Review of the medical record for Patient #10 revealed she was admitted to the hospital on 08/05/10 with the admit diagnosis of CHF (Congestive Heart Failure), HTN (Hypertension) and CVA (Cerebral Vascular Accident) with a history of Seizure Disorder, Anxiety, SOB (Shortness of Breath) and Major Depression. Review of the verbal Physician's Admit Orders dated 08/05/10 for Patient #10 revealed an order for SS (Sliding Scale) per facility, Lantus 100 units/mL vial 35 units sq (subcutaneously) QHS (every hour of sleep), and Metformin 500mg i tablet po qd (every day). Further review of the nursing notes and the physician's orders revealed no documented evidence the physician had been notified for clarification of orders for administration of insulin and administration of Metformin without the documented diagnosis of Diabetes before administration of the drugs to patient #10.

In a face-to-face interview on 10/20/10 at 5:30pm, RN Consultant S10 and DON S21 could offer no explanation for medications not being administered as ordered by the physician.

Review of the hospital policy titled "Medication Management", revised 09/08 and submitted by Administrator S1 as their current policy for medication administration, revealed, in part, "...Each medication ordered has a documented diagnosis, condition, or indication-for-use. This documentation can be found in the physician's orders, physician's progress notes, and/or the patient's history and physical. ... Routine medications are to be given within 60 minutes of the time ordered...". Further review of the policy revealed no documented evidence initial dose had been addressed.