09353 Based on record review, interview with clinical and administrative staff, and review of policy and procedure, the hospital failed to ensure the protection and promotion of patient rights for patients related to discharge option, alternative physicians, or a second opinion, grievances being responded to timely, and the right privacy of personal data. These failures demonstrates systemic noncompliance with the condition of patient's rights. 1. The hospital failed to ensure patient rights for discharge options for 1 patient. Patient #2 was being discharged despite the daughter's request for a different physician. This resulted in a delay of services. (Refer to A117 for details.) 2. The hospital failed to ensure grievances were referred and processed in a timely manner for 3 patients. Patient #2's grievance had no letter of resolution. Patient #15's grievance had a letter of resolution sent 29 days after initiation. Patient #16's complaint had a letter of resolution sent 26 days after initiation. (Refer to A120 for details.) 3. The hospital failed to ensure a rapid response was responded to timely for 1 patient. The hospital also failed to provide a new doctor in a timely manner in response to the request from Patient #2's representative. (Refer to A131 for details.) 4. The hospital failed to protect patients' rights for personal privacy on 3 (2nd, 3rd, 4th) of 4 floors of the hospital. Potentially individually identifiable health information was posted to computer boards on multiple units. (Refer to A143 for details.)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 09353 Based on a record review and staff interview, the hospital failed to ensure patient rights for discharge options for 1 (Patient #2) of 11 patient records reviewed. Patient #2 was being discharged despite the daughter's request for a different physician. This resulted in a delay of services. The findings included: 1. Review of clinical records revealed Patient #2 had been hospitalized 3 times within a short period of time. The first admission was 4/29/18 through 4/30/18. The patient was readmitted [DATE] through 5/11/18. She was readmitted [DATE] complaining of chest pain and stomach pains. The patient was placed on observation status. The original plan was for the patient to return to the skilled nursing facility where she had been prior to the hospital admission. On 5/14/18 a pending discharge was written by the hospital. The patient's daughter did not want the patient discharged as she felt the patient needed additional workup. No physician visited the patient on 5/14/18. 2. In an interview on 7/2/18 at 1:56 p.m., the Patient Safety Officer and [NAME] President of Nursing both agreed the daughter was requesting a different doctor, but the order was already written for discharge. They explained Patient #2 initially made no objection to the discharge, but when transport arrived in the late afternoon to take the patient, she refused. The Chief Nursing Officer (CNO) told the staff to keep the patient in the hospital. On 5/13/18 at 8 p.m. orders were written to keep the patient. The new doctor did not see the patient until on 5/15/18 at approximately 1:30 p.m. 3. In an interview on 7/3/18 at 10:11 a.m., Case Manager (CM) HH and the Director of Case Management indicated the patient was admitted to the hospital under observation status. They said the patient had no rights about appealing the discharge as the patient was under observation status. When questioned, both case managers admitted the patients are given the same rights statements whether they are under observation status or admitted to the hospital. CM HH indicated they were waiting for a physical therapy evaluation to enable the patient's insurance to pre-certify the patient for nursing home placement.

09353 Based on a grievance record review and staff interview, the hospital failed to ensure grievances were referred and processed in a timely manner for 3 (Patient #2, #15, and #16) of 3 grievances reviewed. Patient #2's grievance had no letter of resolution. Patient #15's grievance had a letter of resolution sent 29 days after initiation. Patient #16's complaint had a letter of resolution sent 26 days after initiation. The findings included: 1. The hospital policy Patient Grievance & Complaint Management P-10-003-RI (reviewed 1/17) differentiates between complaints and grievances. A complaint is an issue that can be resolved promptly by staff members who are present at the time of the complaint. A patient grievance was defined as a written or verbal complaint that cannot be resolved immediately. All written complaints are identified as grievances. This type of grievance requires investigation and/or if it requires further actions. Under the grievance resolution process: 2. Upon receipt of a grievance staff will confer with the appropriate department manager to review, investigate and resolve with the patient and/or patient representative within seven days of receipt of the grievance . 5. In resolution of a grievance, a written notice of the decision must be provided to the complainant that contains the name of the facility contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion. 2. Review of Patient #2's grievance dated 5/16/18 revealed it was documented on a Follow Up Form. No letter of resolution had been sent. 3. Review of Patient #15's grievance dated 5/24/18 revealed the Chief Nursing officer contacted the complainant on 5/30/18. The resolution letter to the complainant was dated 6/22/18, 29 days after initiation. 4. Review of Patient #16's complaint dated 5/18/18 revealed a note on the grievance dated 5/21/18 asking staff to reach out to the patient. On 5/21/18, a physician was asked to contact the patient. The resolution letter to the complainant was dated 6/13/18, 26 days after initiation. 5. In an interview on 7/3/18 at 11:00 a.m., the Patient Safety Officer confirmed the missing and late dates of the resolution letters.

09353 Based on a grievance record review and staff interview, the hospital failed to ensure grievances were resolved and resolution communicated in a timely manner for 1 (Patient #2) of 3 grievances reviewed. Patient #2's grievance had no letter of resolution. The findings included: 1. The hospital policy Patient Grievance & Complaint Management P-10-003-RI (reviewed 1/17)differentiates between complaints and grievances. A complaint is an issue that can be resolved promptly by staff members who are present at the time of the complaint. A patient grievance was defined as a written or verbal complaint that cannot be resolved immediately. All written complaints are identified as grievances. This type of grievance requires investigation and/or if it requires further actions. Under the grievance resolution process: 2. Upon receipt of a grievance staff will confer with the appropriate department manager to review, investigate and resolve with the patient and/or patient representative within seven days of receipt of the grievance . 5. In resolution of a grievance, a written notice of the decision must be provided to the complainant that contains the name of the facility contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation, and the date of completion. 2. Review of Patient #2's grievance follow-up form dated 5/16/18 revealed no letter of resolution had been sent. 3. In an interview on 7/3/18 at 11:00 a.m., the Patient Safety Officer confirmed the missing resolution letter.

09353 Based record review and staff interview, the hospital failed to ensure a rapid response was responded to timely for 1 (Patient #2) of 3 patients identified as having had rapid response teams. The hospital failed to provide a new doctor in a timely manner in response to the request from Patient #2's representative. The findings included: 1. The hospital policy Patient Rights and Responsibilities P-10-008-RI (revised 5/8) was reviewed. Additional patient rights include to get the opinion of another physician, including specialists, at the request and expense of the patient. Record review revealed Patient #2 was readmitted to the hospital on 5/12/18. The patient had been complaining of chest pain and stomach pain. The hospitalist had discharged the patient on 5/14/18, but the patient's daughter was requesting an different doctor. On 7/2/18 at 1:56 p.m., the Patient Safety Officer and [NAME] President of Nursing agreed the daughter was requesting a different doctor, but the order was already written for discharge. The patient had initially made no objection to the discharge, but when transport arrived in the late afternoon, she refused the transport. The Chief Nursing Officer (CNO) told the staff to keep the patient in the hospital. At 8 p.m. on 5/14/18 an order was written to keep the patient. The new doctor did not see the patient until on 5/15/18 at approximately 1:30 p.m. 2. On 7/2/18 at about 2:00 p.m., the CNO explained on 5/15/18, the daughter arrived at the hospital and spoke with the CNO. The daughter expressed to the CNO that her mother (Patient #2) was declining. The CNO went to the patient's room at 12:30 or 1 p.m. The staff nurse indicated to the CNO that the daughter was requesting a rapid response call. The CNO told the nurse to call the rapid response team (rapid response is a means to get additional help to the patient's bedside to improve patient outcomes). The record showed on 5/15/18 at 2:14 p.m., the rapid response was called when staff were unable to get the patient's blood pressure. Shortly thereafter, a code was called for cardiac arrest; the patient was transferred to intensive care. 3. In the Hospital policy for Rapid Response Team (dated 10/16), under procedure, a staff member, patient family, or visitors may initiate the Rapid Response Team. On 7/3/18 at 2:35 p.m., Staff Nurse F said has been here 8 months, had called it once. She said if the family requested she would assess the patient. If she did not think it necessary she would get the charge nurse for the 2nd opinion and they would determine if rapid response should be called. On 7/3/18 at 2:48 p.m., Staff Nurse G confirmed the same information and would get the charge nurse to determine the need for a rapid response call. 4. On 7/5/18 at about 3:00 p.m., the Patient Safety Officer said in reviewing this case, she thought things could have done been better. The doctor who discharged Patient #2 from his care on the morning of the 14th did not see her and she was not seen by another doctor until the 15th in the afternoon when she was seen by the new doctor.

30077 Based on observation, staff and family interview, the hospital failed to protect patients' rights for personal privacy on 3 (2nd, 3rd, 4th) of 4 floors of the hospital. Potentially individually identifiable health information was posted to computer boards on multiple units. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) offers guidance on privacy of health information. The findings included: Summary of the HIPAA Privacy Rule defines individually identifiable health information as information, including demographic data, that relates to: * the individual's past, present or future physical or mental health or condition, * the provision of health care to the individual, or * the past, present, or future payment for the provision of health care to the individual, and that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual. Individually identifiable health information includes many common identifiers (e.g., name, address, birth date, Social Security Number). (downloaded from https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html) On 7/2/18 at 10:00 a.m., observations during a tour included on the 2nd, 3rd and 4th floors, computer boards were located across from nursing stations and in patient hallways. The computer boards posted confidential information including, the first 3 letters of patient last names and their first initial, the room and bed number, date of birth, if the patient was on isolation precautions, and if the patient was a full code or had a Do Not Resuscitate (DNR) order. On 7/5/18 at 1:25 p.m., the Patient Safety Officer said, the computer board tells you who is on fall precautions, and each symbol means something. It shows information so the staff can see; if you were a CNA (certified nursing assistant) you could look at that before you run in to the room if it was not your patient. On 7/3/18 at 3:24 p.m., Registered Nurse (RN) Staff A acknowledged that anyone walking by here could see the computer board. It has a lot of information on it. The RN stated, There is an icon for the camera; I think one is for respiratory medications; and the triangle is a fall risk. In an interview on 7/3/18 at 3:30 p.m., the sister of Patient #13 stated, I can see on the computer board who everybody's physician is, which nurse is assigned, who is the aide, what kind of diet they are on, if they are a full code or DNR. She said she could not imagine how someone might feel if they are looking at this and found something upsetting, like their family member is a DNR. She stated, That really should not be on there. (Photos on file)

30077 Based on observation, policy review, and staff interview, the facility failed to develop a plan of care for 5 (Patients #3, #7, #8, #9 and #10) of 6 patients reviewed for restraint use. The care plan is a source of information for those responsible for the patient. A restrained patient's responsible nurse may not know which interventions to implement in an effort to have restraints removed. The findings included: On 7/2/18 at 10:00 a.m., during a tour of the facility, observed Patients #3, #7, #8, and #10 in soft, bilateral wrist restraints. Patient #9 was in a net bed (canopy netting restricts the patient from leaving the bed). On 7/5/18 at 10:15 a.m., Registered Nurse Staff G said she has given training to the staff for the new computer program they are using. She said when a patient is placed in restraints and the nurse does her assessment, nursing should generate a plan of care for restraints. She attempted to retrieve restraint care plans for Patients #3, #7, #8, #9 and #10 and stated, The care plan isn't there. I do not know why they are not initiating it. I guess I have more training to do. Review of the hospital Patient Restraints and Seclusion policy and procedure revealed use of restraints should clearly reflect a loop of assessment, intervention and evaluation for restraint and seclusion and medications. Patients and families should be involved in care planning to the extent possible and made aware of changes to the plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 30077 Based on interview and record review, the facility and nursing department failed to appropriately supervise the on-going care for 1 (Patient #4) of 10 sampled patients. The findings included: On 8/31/16, a record review of Patient #4's medical chart revealed he was admitted on [DATE], through the Emergency Department (ED). A cardiac alert was completed on his arrival to the ED. Registered Nurse, Staff H said she wrote the name of Patient #4's cardiologist on the form. She said that Patient #4 requested Staff C to be contacted, because he was under his care in the community. On 10/6/16 at 9:45 a.m., the Risk Management and Patient Safety Director said she believes Patient #4 did give the name of his community cardiologist as Staff C. She said Staff C should have been the one notified from the ED. She said the patient should have the choice of which cardiologist to notify and that person should be called. She said Patient #4 probably did tell staff, the nurses, who he wanted for his cardiologist and Staff C wasn't called. On 8/31/16, a review of the Emergency Service Back Up Physician Schedule documented Cardiologist, Staff B was listed as the On Call Cardiologist for 3/24/16 and 3/25/16. On 8/31/16 a review of nursing progress notes dated 3/25/16 at 0702 (7:02 a.m.), Registered Nurse, Staff F documented Advanced Registered Nurse Practitioner, Staff D noted Patient #4 with continued chest pain; stated she will notify Cardiologist Staff B. At 0757 (7:57 a.m.), Registered Nurse, Staff E documented call placed to Cardiologist, Staff B to notify of Troponin level of 30.300, awaiting call back at this time. At 0818 (8:18 a.m.), Staff E documented second call placed to Cardiologist, Staff B to notify of Troponin of 30.300 this a.m., still awaiting call back at this time. On 8/31/16, a review of a physician order dated 3/25/16 at 0847 (8:47a.m.), for Patient #4 documented a consult was requested with Cardiologist, Staff C. On 10/6/16, a review of the policy Chain of Command documented Policy II. Any ordering, attending/covering, or the consulting physician of the appropriate specialty, will be contacted whenever a patient's condition warrants or when there is a question that the change in condition could affect patient safety or an adverse outcome could occur. The Procedure documented (2) notify the charge and or lead clinician of the situation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 17400 Based on reviews of medical records, policies and procedures, Medical Staff By-Laws and Rules, emergency services agreements, emergency room (ER) physician schedules and staff and physician interviews, the facility failed to comply with 42 Code of Federal Regulations (CFR) 489.24, special responsibilities of Medicare hospitals in emergency cases. The facility's on-call surgeon refused to provide necessary stabilizing treatment requested by the ER physician in preparation for an appropriate transfer. The findings include: [NAME] Memorial Hospital has been certified to accept Medicare patients. As a Medicare provider the facility has agreed to comply with 42 CFR 489.24. As part of the agreement the facility must have on-call services available to provide treatment necessary after the initial examination to stabilize individuals with emergency medical conditions. Review of the medical record for Patient #2 shows the patient presented to theER on [DATE] at 10:45 p.m. The patient had a gunshot wound to the abdomen and was determined to be a Priority 1 - in urgent need of care. A bedside ultrasound was done and fluid was seen in the right and left upper quadrant (upper areas) of the abdomen. The ER physician documented that he immediately called the on-call surgeon. The on-call surgeon refused to come to the hospital and treat the patient. After the on-call surgeon repeatedly refused to come in to the hospital, the treating emergency physician transferred the patient to a trauma center (see A-2404) without the requested surgical attendance. The repeated requests for and refusal of the on-call surgeon resulted in a delayed stabilizing decisions prior to transferring the patient for necessary treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 17400 Based on reviews of medical records, policies and procedures, Medical Staff By-Laws and Rules, Emergency Services agreements, emergency room Physician schedules and staff and physician interviews, the facility failed to ensure that one (Patient #2) of 30 patients was provided a physical evaluation for surgical intervention at the request of the treating emergency physician. The findings include: Review of the medical record for Patient #2 shows the patient presented to the emergency room (ER) on 12/31/12 at 10:45 p.m. The patient had a gunshot wound to the abdomen and was determined to be a Priority 1 - in urgent need of care. A bedside ultrasound was done and fluid was seen in the right and left upper quadrant (upper areas) of the abdomen. The ER physician documented that he immediately called the on-call surgeon. The on-call surgeon refused to come to the hospital and treat the patient. When the ER physician explained this was a potentially unstable patient that needed to be taken to the operating room (OR) immediately, the on-call surgeon again refused to come in to the hospital and said the patient needed to be transferred to a trauma hospital. The ER physician called a hospital in [NAME] which had a trauma unit and he spoke to a physician there. The ER physician documented his conversation with the physician in [NAME] as Pt continued stable vital signs, no tachycardia, and no hypotension. Results discussed. Given that blood identified on bedside ultrasound, he did not feel that the patient was stable to fly. The ER physician placed another call to the on-call surgeon who continued to refuse to come to the ED and see the patient. After the patient had a CT scan, which showed bullet fragments in the rear left flank (side) of the abdomen, the ER physician called a trauma surgeon at a designated trauma unit in Fort [NAME], Florida. This trauma unit is approximately 30 miles from the hospital. After the ER physician spoke to the trauma surgeon in Fort [NAME], the patient was accepted for transfer. The patient was transferred, at 11:55 p.m., by ambulance and arrived at the Fort [NAME] trauma unit at 12:29 a.m. The patient was taken to the OR for emergency surgery and required multiple bowel repairs and a right colon resection. In an interview on 1/30/13 at approximately 4:10 p.m., the receiving trauma physician confirmed that the doctor from [NAME] Memorial called him and they accepted the patient for transfer. He said they had to do a damage control laparotomy (opening of the abdomen to explore); he said the patient had multiple holes inside the abdomen and in the colon. He did the repairs during the first surgery. Because the patient was losing blood, they needed to do a temporary closure at that time. The patient was placed in the Intensive Care Unit (ICU). When the patient was hemodynamically stabilized, they did a second look laparotomy and gave the patient a temporary right colostomy. Review of the facility transfer agreements shows [NAME] Memorial has agreements in place with the hospital in Fort [NAME], Florida and with a hospital in Sarasota, Florida. Review of the facility on-call schedule for the ER revealed the name of the on-call surgeon for 12/31/12. The name of this physician does not appear on the January, 2013 on-call schedule. Review of the facility's Medical Staff Policy & Procedures (MS Rules) revealed section 700 Department of Emergency Medicine #725, All on-call practitioners are required to respond when called from the Emergency Care Center at least by telephone within 30 minutes. Although the surgeon spoke with the ER physician twice he continued to refuse to come in and see the patient at the request of the ER physician. During an interview with the Chief Operating Officer and the Chief Medical Officer on 1/24/13 at 4:00 p.m., it was revealed that the facility has not concluded their investigation regarding the surgeon's refusal to provide services to Patient #2. The on-call surgeon refused to see Patient #2 at the request of the emergency room physician as required. He did not adhere to the facility's Medical Staff Rules and honor his obligation to report to the hospital and evaluate Patient #2 for emergency surgical intervention causing the patient to be transferred to another hospital, 30 miles away, for emergency surgery.

25618 Based on observation, record review, interview and review of Diprivan (Propofol) protocols, the nursing staff failed to ensure they administered the medication according to hospital standards for use and titration for 1 (Patient #28) of 2 patients reviewed for the use of the medication. The findings include: 1. Observation during the tour of the fourth floor ICU (Intensive Care Unit) on 7/30/12 at 9:45 a.m. revealed Patient #28 in bed and connected to a ventilator. The patient had bilateral wrist restraints, was receiving mechanical ventilation, and her eyes were closed. Clinical record review, on 7/30/12, revealed Patient #28 was admitted to the hospital for shortness of breath and respiratory failure. Review of the physician's orders for 7/27/12 revealed included printed orders for Use of Diprivan (Propofol) for Mechanically Ventilated Patients. 1. Patient monitoring parameters on the printed form included: a. Prior to initiation of Diprivan, record baseline data for HR (heart rate), heart rhythm, BP (blood pressure), respiratory rate, skin color, oxygen saturation, patient's mental status, level of consciousness. b. Assess and document above parameters every 5 minutes for 30 minutes after initiation infusion, then every 15 minutes x 2, then every 30 minutes thereafter, if hemodynamically stable throughout infusion. c. Assess and document above parameters every 5 minutes for 30 minutes with each increase in infusion rate. 3. Start Diprivan (Propofol 10 mg./ml) initially at 5 mcg/kg/minute for at least 5 minutes as an IV infusion . Increase by a rate of 5-10 mcg/kg/minute every 5-10 minutes until desired sedation level indicated below is achieved. The usual maintenance dose is 5-50mcg/kg/minute. Record review, in the presence of the ICU Clinical Director (CD), revealed a baseline assessment of the patient, dated 7/27/12 at 0200, as well as a neurological evaluation at 0208. Record review revealed the next nursing entry of the patient's condition was dated 7/27/12 at 0400, 2 hours later, and included, .Diprivan up to 50 mcg There was no assessment of the patient according to the Diprivan orders/protocol every 5 minutes for 30 minutes after initiation. In an interview on 7/28/12 at 9:00 a.m., the CD confirmed he could not locate any assessments according to the written protocol for Diprivan in the clinical record. He stated nursing was doing the checks every 15 minutes; but, not in accordance with Diprivan implementation protocol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 21187 Based on record review and staff interview, the facility failed to ensure telephone orders were dated, timed and authenticated promptly by the ordering practitioner in accordance with hospital policy for 10 (Patients #25, #53, #1, #11, #12, #19, #59, #60, #61, #62) of 67 sampled patients. The findings include: The Rules and Regulations of the Medical Staff state, 208. All clinical entries in the patient's medical record shall be accurately dated, timed and signed. The use of rubber stamps will not be permitted.; 303. B. Verbal and/or telephone orders must be signed by the prescribing physician within forty-eight (48) hours. The following have been deemed high risk orders: TPN, Restraints, and DNR. These high risk orders must be authenticated by the responsible physician within twenty-four (24) hours. The Hospital policy and procedure for Verbal/Telephone/Read-back Orders reads, IV (Roman numeral 4). Verbal/telephone orders will be signed by the prescribing physician at the time of his/her next visit or any time during hospitalization , but not later than 48 hours after order written. The following orders have been deemed high risk for patients and must be authenticated by the responsible physician within 24 hours: A. DNR; B. Restraint orders; C. TPN. 1. Clinical record review on 7/31/12 for Patient #25 revealed numerous sticky arrows attached to the sides of the physician's telephone and verbal orders. The flagged arrows revealed unsigned physicians' orders for: Four (4) dated 7/22/12; (2) for 7/23/12; (3) for 7/26/12, and (2) for 7/27/12. In an interview during the record review, the Clinical Director stated the unit secretary tries to help the physicians know where signatures are needed by placing arrows on the unsigned orders; however, despite this attempt, they remained unsigned. 2. A review of the closed medical record for Patient #53 reveals the patient was admitted on [DATE] with acute appendicitis. The patient underwent laproscopic appendectomy. The patient developed post-operative complications which required hospitalization through 6/19/12. A review of the physician's orders reveals telephone orders (TOs) were not authenticated properly. On 6/5/12, a phoned order, to Insert PICC, from Dr. P., was never authenticated. On 6/5/12, a phoned order, to ambulate the patient, from Dr. O.G., was never authenticated. On 6/5/12, a phoned medication order from Dr. P. was signed, but not timed and dated. On 6/7/12, a phoned medication order from Dr. K. was never authenticated. On 6/7/12, a phoned order, to Increase IPAP, from Dr. K., was authenticated on 6/24/12. On 6/10/12, Dr. G. phoned an order for Morphine; authenticated on 6/25/12. On 6/11/12, Dr. K. phoned a diet order; authenticated on 6/24/12. On 6/11/12, Dr. P. phoned a medication order; authenticated on 7/19/12. On 6/12/12, Dr. P. phoned a medication order; authenticated on 7/19/12. On 6/12/12, Dr G. phoned a medication order; authenticated on 6/25/12. On 6/12/12, an x-ray order and STAT Lab order , phoned by Dr. P., were never authenticated. On 6/14/12, Dr G. phoned a medication order; authenticated on 6/25/12. On 6/14/12, a medication order, phoned by Dr G., was never authenticated. On 6/16/12, Dr. B. phoned a TPN order; authenticated on 7/5/12. In an interview on 8/2/12 at 10:00 a.m., the medical records manager stated when handwritten records are scanned into the hospital HIS (health information system), they are available immediately for the physician to review. The physician reviews were done more that 48 hours after telephone orders were given. The chief nursing officer stated the physicians are to sign all telephone orders indicating date and time. She stated the staff on the floor are to assist in getting the physicians to sign telephone orders. 3. On 7/30/12 and 7/31/12 during review of open and closed clinical records with the third floor nursing and medical records staff, the following information was found: Sampled clinical records for Patients #1, #11, #12, #19, #59, #60, #61 and #62 contained telephone, verbal and written physician orders that were not dated, timed and signed by the ordering physicians.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 09348 18128 Based on observation, interview, and record review, the facility failed to document properly executed informed consent forms for 18 (Patients #1, #2, #3, #4, #9, #11, #17, #21,#23, #27, #43, #44, #46, #47, #60, #61, #62, and #63) of 67 patients sampled. The findings include: 1. On 7/30/12, review of medical records revealed Patient #9 was admitted [DATE] with swelling of the left leg. Review of the patient's medical record revealed four (4) improperly executed consent documents. - An Informed Consent Moderate Sedation form contained a patient signature, and a staff RN witness signature, but lacked the time and date of signatures, and a doctor's name. - An Informed Consent Moderate Sedation form, signed by the physician on 7/26/12, contained the patient representative and staff witness signatures, without time or date of the signatures. - A Consent & Disclosure for Medical/Surgical Procedures form for an internal jugular triple lumen catheter lacked notation for observation consent. This form had names on the signature line for the patient and patient representative with signatures and staff witness, dated 7/25/12. The physician signature was in place without time or date. The patient signature on this form did not match the patient signature on the other forms in the record. The patient representative signature did not match the signature of the patient's spouse found on other forms in the medical record. - A Consent & Disclosure for Medical/Surgical Procedures form for an internal jugular triple lumen catheter lacked the layman's term of the procedure, the doctor's name, the notation for consent for blood administration, and the physician's signature. The patient and staff witness signatures were dated 7/30/12. On 7/30/12 at 10:30 a.m., Patient #9 was observed with a triple lumen catheter in her right neck. The dressing over the catheter was dated 7/27/12. In an interview on 7/31/12 at 2:28 p.m., Patient #9's spouse verified his signature on Informed Consent Moderate Sedation. He said did not see his signature on the Consent & Disclosure for Medical/Surgical Procedures for an internal jugular triple lumen catheter. 2. On 7/30/12, medical records review revealed Patient #23 was admitted [DATE] with acute hypoxemia/respiratory distress. Review of the patient's medical record revealed the Conditions of Admission form with a signature of patient/authorized representative dated 7/29/12. Under it, If you are not the patient, please identify your relationship to the patient. There was no notation, suggesting the patient signed the consent. The form contained the signature of a staff witness. The form notes additional witness signature is required for patients unable to sign . This line is blank. On 7/30/12 at 10:50 a.m., Patient #23 was observed in bed with a ventilation mask on with family at bedside. The patient appeared non-responsive. In an interview on 7/31/12 at 10:42 a.m., the Director of Cardiac Services said the signature on the Conditions of Admission was not Patient #23's, rather it was the patient's sister. He admitted , We should have circled that (pointing to the word sibling). 3. Clinical record review on 8/1/12 revealed Patient #43 was admitted to the hospital for a cardiac catheterization. Review of the Consent for Blood Plasma and/or Blood Derivatives Transfusion form failed to include the name of the physician, or associate, who would inform the patient of blood transfusion therapy. 4. Clinical record review on 8/1/12 revealed Patient #44 was admitted to the hospital due to an abnormal stress test and was scheduled for a heart catheterization. Review of the Consent & Disclosure for Medical/Surgical Procedures form failed to reveal the date and time the physician explained the nature of the treatment to the patient. 5. Clinical record review on 8/1/12 revealed Patient #46 was admitted emergently to the hospital for a cardiac catheterization. While in the hospital, the record reflects the patient was scheduled for a thorancentesis and a gastrostomy tube placement. Review of the Consent & Disclosure for Medical/Surgical Procedures form for the thorancentesis revealed a nurse witnessing the telephone consent of the patient's son for the procedure; however, the consent failed to include the name of the doctor performing the test, whether the patient consented to blood administration or whether students or other observers could be in the room during the procedure. The physician also failed to sign this consent form. 6. Clinical record review on 8/1/12 revealed Patient #47 was admitted to the hospital with increasing altered mental status. Review of the Consent & Disclosure for Medical/Surgical Procedures form included the placement of a temporary pacer. The consent failed to reveal whether or not the patient consented to blood administration, or whether students or other observers, could be present during the procedure. 7. Clinical record review on 7/31/12 revealed Patient #27 was admitted to the hospital for right pupil dilatation. The record revealed the patient as alert and oriented and had not been deemed incapacitated to make her own health care decisions. Review of the Consent & Disclosure for Medical/Surgical Procedures form lists the patient's son as Power of Attorney for 7/24/12, and revealed telephone consent for the procedure was provided by the patient's son. The consent failed to reveal authorization for blood administration or whether observers could be in the room during the procedure. During an interview on 7/31/12 at 3:40 p.m., the clinical director stated nursing obtained consent from the patient's son because the patient had some confusion; however, could not define the severity of the confusion. The clinical director stated he called the patient's family, who brought in advanced directives. Review of the patient's Living Will and Designation of Healthcare Surrogate, dated 11/13/11, revealed her Living Will was to be honored - and and health care decisions made - by the patient's son only in the event Patient #27 was determined to be incapacitated by her attending/treating physician and another consulting physician. The hospital failed to honor the patient's advanced directives by ensuring a properly executed consent was obtained. 8. During review of open and closed clinical records with the 3rd floor nursing staff and medical records staff on 7/30/12 through 7/31/12, the following information was found: Sampled clinical records for Patients #1, #2, #3, #4, #11, #17, #21, #60, #61, #62, and #63 each lacked some of the required information on the facility's consent forms. Omissions included: layman's term of the procedure, authorization or refusal of blood administration, physician's signature, physician's name, name of family member signing for the patient, anesthesia service name, and consent or denial for observation of the procedure. 26933

26933 Based on observation and interview, the facility failed to ensure the facility's clean linen supply is stored in a safe and sanitary environment. The findings include: On 8/1/12 at 3:48 p.m. during an afternoon tour of the facility with the Environmental Services Director (EVSD), the clean linen storage room was inspected. In the clean linen room there was a red bicycle parked in front of a door with a sign marked Do Not Block Door. One of the electrical outlet covers was broken, with a piece missing, leaving some of the electrical connections visible. Thirteen (13) holes in wallboard near floor were identified. In an interview on 8/1/12 at 3:49 p.m., after viewing the broken electrical outlet and holes in the walls, the EVSD stated, I'll get a work order. For safety reasons, electrical connections should not be exposed. Holes in the walls could provide opportunity for insects and vermin to enter, which would contaminate the clean linen supply.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 18128 Based on observation, interview, and policy and document review, the facility failed to ensure the development and effective implementation of an infection control program in regards to sterile central venous catheter care, handwashing, and equipment disinfection involving 7 (Patients #13, #26, #27, #64, #65, #66, #67) of 67 patients sampled. The findings include: 1. Observation of the dialysis unit on 7/30/12 at 11:23 a.m. revealed Nurse K preparing to change the dressing to the right jugular Tesio catheter for Patient #26. A Tesio catheter is a central venous access device used for patients receiving hemodialysis. Observation revealed Nurse K donned a protective gown and placed a face mask on the patient and herself. She donned a pair of gloves and opened the catheter package in such a way as to create a sterile field on top of the patient's chest. She tossed her gloves on top of the foot of the patient's bed and put on another pair of sterile gloves. After this, she removed the dressing from the right jugular area and tossed it onto the sterile field. With the same gloved hands, she cleaned the area site and reapplied a clean dressing to the right jugular access site. Nurse K gathered the dirty supplies from the top of the patient, pulled her mask down under her chin and removed the patient's mask. Still wearing the same gloves, she laid the dirty supplies on top of the foot of the bed, removed wires from the patient's chest, removed a blood pressure cuff from the patient's arm, fastened the patient's gown and then gathered the dirty supplies and tossed them into the trash can. Still using the same gloved hands, she gathered linen and papers off of the patient's bed, pressed control buttons at the foot of the patient's bed and laid the linen back on top of the bed. She then removed her gown, gloves and mask and tossed them into the biohazard container. In an interview on 8/2/12 at 2:20 p.m., the Chief Nursing Officer (CNO) revealed the hospital follows the on-line Lippincott Nursing Policy and Procedures for Dressing Changes. She confirmed the nurse failed to use proper infection control techniques while conducting the dressing change. The 2012 Lippincott [NAME] & Wilkins Nursing Policy and Procedures for Central venous device dressing changes includes the following guidelines, -Preparation of Equipment: .Open a waterproof trash bag, and place it near the patient's bed. Position the bag to avoid reaching across the sterile field when disposing of soiled articles The nurse failed to ensure she had a trash bag properly positioned in which to place the soiled dressing. -Implementation: .Remove the old dressing by lifting the edge of the dressing at the catheter hub and gently pulling the dressing perpendicular to the skin, toward the insertion site, to prevent catheter dislodgement. Discard it in the waterproof trash bag. The nurse tossed the dirty dressing on top of the patient's chest near the clean supply area. .Remove and discard your gloves, perform hand hygiene, and put on sterile gloves. The nurse failed to remove the gloves she used to remove the soiled dressing. .Clean the catheter insertion site .allow the site to dry .Dispose of all used supplies, remove and discard your gloves, and perform hand hygiene . The nurse used the same gloved hands to change the soiled dressing, to reapply a sterile dressing and to handle patient supplies and equipment. Failure to change gloves after removing a contaminated dressing, and handling patient equipment and supplies increases the risk of cross contamination of potentially harmful micro-organisms. 2. Observation on the dialysis unit, on 7/30/12 at 11:45 a.m., revealed Nurse N preparing to check the blood glucose level on a patient receiving dialysis. After obtaining blood from the tubing, the nurse inserted the test strip inside the glucometer. After results were obtained, Nurse N removed disinfecting wipes from a PDI Super Sani-Cloth container, wiped the outside of the glucometer and immediately placed the glucometer into the holding device. Review of the manufacturer's specifications for using the disinfecting wipes revealed: To Disinfect and Deodorize .Unfold a clean wipe and thoroughly wet surface. Treated surface must remain visibly wet for a full two (2) minutes. Use additional wipe(s) if needed to assure continuous two (2) minute wet contact time. Let air dry . The nurse failed to assure there was a 2-minute wet contact time of the disinfectant on the glucometer before placing it back into the holding device. An interview was conducted with the Infection Control Nurse (ICN) in the presence of the CNO, on 7/31/12 at 1:23 p.m. The ICN stated, You can't possibly expect them to keep rubbing the glucometer for 2 minutes to make sure it's wet . The ICN was informed of the manufacturer's specifications for properly disinfecting the glucometer. The CNO indicated she would look into the matter. 3. On 7/30/12 at 9:45 a.m., observation during the tour of the ICU (Intensive Care Unit), fourth floor, revealed signage posted in front of room [ROOM NUMBER] which stated the patient was on contact precautions. The nurse accompanying the tour indicated the patient was on contact precautions for respiratory MRSA (Methicillin Resistant Staph Aureus), and the use of gown and gloves was indicated while in the patient's room. During this observation, a physician removed his gown and gloves, discarded them into a trash receptacle inside the patient's room, and exited the room without washing his hands. The nurse accompanying this tour walked up this physician and encouraged him to wash his hands. The physician walked back into the patient's room, turned on the spigot, washed his hands, less than 10 seconds, turned the spigot off with his wet hands, dried his hands with a paper towel and exited the patient's room. Observation during the tour of the ICU on the third floor, on 7/30/12 at 10:32 a.m., revealed signage posted in front of room [ROOM NUMBER] indicating the patient was on contact precautions. A respiratory therapist was observed removing gown and gloves and placing them in a trash receptacle inside the patient's room. The therapist walked out of the patient's room, pulled back the sliding glass door and then sanitized her hands. Observation during the tour of the ICU on the third floor, on 7/30/12 at 10:35 a.m., revealed a CNA (Certified Nursing Assistant) wearing gloves. She walked out of room [ROOM NUMBER] and tossed dirty linens into the linen container and, while wearing the same gloves, walked across the hall and over to the supply area. Still wearing the same gloves, she transported oxygen back into the patient's room. Observation during the tour of the ICU on the 3rd floor, on 7/30/12 at 10:40 a.m., revealed a nurse exit room [ROOM NUMBER]. A sign revealing the patient was on contact precautions was posted on the outside of the room. The nurse exited the room and then quickly used hand sanitizer. After this, he walked across the corridor and over to a sink. After washing his hands, less than 10 seconds, the nurse turned off the spigot with his wet hands and then dried his hands with a paper towel. Review of the hospital policy and procedures for hand hygiene includes the following statement, Hand washing is the single most important method to reduce the spread of infectious agents from one person to another. It is the accepted concept, as noted by the American Hospital Association, that 'decontamination of the hands is absolutely essential for prevention and control of health care associated infections, there is no substitute for it.' The policy continued: II. Indications for hand washing: .before and after delivering direct patient contact .after contact with any blood, body fluids, secretions, excretions, mucous membranes, or non-intact skin to include wounds .BEFORE AND AFTER THE REMOVAL OF GLOVES .before and after patient contact. VI. Hand washing Procedure: .apply selected hand washing agent and distribute thoroughly over hands .vigorously rub hands together for 10-15 seconds creating friction on all surfaces of the hands and fingers. Paying particular attention to the thumb, backs of fingers, backs of the hands, and under fingernails .dry hands with paper towels, turning faucets without food pedals or with the paper towel to prevent recontamination of the hands . Facility staff failed repeatedly to wash their hands using proper hand hygiene techniques. The failure of the nursing staff to use proper hand washing techniques increases the risk of cross contamination of potentially harmful microorganisms to patients and/or visitors. 4. On 7/30/12, review medical records revealed Patient #9 was admitted [DATE] with swelling of the left leg. On 7/30/12 at 10:30 a.m., Patient #9 was observed with a triple lumen catheter in her right neck. The dressing over the catheter was dated 7/27/12. On 7/31/12 at 3:57 p.m., the surveyor observed Nurse A perform a sterile dressing change on the catheter in the right side of the patient's neck. The nurse sanitized her hands and donned clean gloves. She took off her left glove and untangled oxygen line, then reapplied the glove. She donned mask. The patient was not masked. The nurse set up sterile supplies on the bed beside the patient. The nurse then removed old dressing with some difficulty, as there was additional tape over the old dressing. She disposed of the old dressing. She sanitized her hands and donned sterile gloves. She then removed stat-lock (a clip holding the catheter in place). Without sanitizing her hands, the nurse re-gloved with new sterile gloves. She draped the patient with a sterile drape. She cleaned the site with chlorhexidine swabs and swabbed with skin prep while holding the catheter pig tails with her left hand. Using both hands, the nurse applied a new stat-lock and antimicrobial patch over the site. She applied an occlusive dressing, changed the caps on the pig tails, sanitized and flushed the lines. In interview on 7/31/12 at 4:26 p.m., Nurse A was unaware she had held the non-sterile lines then handled the sterile stat-lock and patch. She admitted she failed to sanitize her hands between the sterile glove changes. The surveyor explained that glove changes cannot substitute for hand sanitation. 5. On 7/31/12 at 4:27 p.m., the surveyor observed CNA S perform accucheck (a test for blood sugar level) on Patient #9. After the test, she gave glucometer to CNA C, who passed it to CNA M. CNA M placed glucometer into the charger in the clean utility room. The glucometer was not sanitized after use on Patient #9. In an interview on 7/31/12 at about 4:30 p.m., CNA M said they clean the glucometer after every patient. They wipe it with the purple-top (Super Sani-Cloth). It dries in a few seconds. CNA M was not aware of the 2-minute wet contact time requirement to disinfect the equipment. 6. At various times on 8/1/12, CNA J was observed performing accuchecks revealing: Patient #67 - 10:56 a.m. Wiped glucometer for about 1 minute with Super Sani-Cloth and returned it to the carrying case. Patient #66 - 11:00 a.m. Wiped glucometer with Super Sani-Cloth for 45 seconds and returned it to carrying case. Patient #64 -11:02 a.m. Wiped glucometer with Super Sani-Cloth for 25 seconds and returned to carrying case. Patient #13 - 11:07 a.m. Wiped glucometer with Super Sani-Cloth for 35 seconds. Patient #65 - 11:01 a.m. Wiped the glucometer with Super Sani-Cloth for 25 seconds. Patient #27 - 11:19 a.m. Wiped the glucometer with Super Sani-Cloth for 30 seconds. In an interview on 8/1/12 at 11:29 a.m., CNA J stated was not aware of the 2-minute wet contact time requirement to disinfect the equipment. 26933

30077 Based on record review and interview the facility failed to ensure the medical staff signed their physician orders within 48 hours, as required, for 3 (Patients #5, #6, and #7) out of 11 patients. The findings include: 1. A record review on 5/31/12, for Patient #5, revealed a verbal physician order dated 2/1/12 at 2000 and remains unsigned by the physician. 2. Patient #6's record revealed 3 verbal physician orders dated 4/5/12 at 1152 and 1805 and 4/9/12 at 2008 remaining unsigned by the physician. A physician order dated 3/30/12 at 1051 and 1447 was electronically signed by the physician on 4/26/12 at 1257, an order dated 4/6/12 at 0855 was electronically signed on 5/12/12 at 05:48 p.m. 3. Patient #7's record revealed a verbal physician order dated 2/28/12 at 2000, and three verbal physician orders dated 3/1/12 at 0930 and 2130, 3/6/12 at 1410 remaining unsigned by the physician. Verbal physician orders dated 2/21/12 were electronically signed 3/22/12, Three orders dated 2/27/12 were electronically signed on 4/14/12, Two orders dated 2/28/12 were electronically signed on 3/22/12, Order dated 2/28/12 was electronically signed on 4/11/12, Order dated 2/29/12 was electronically signed on 4/4/12, Order dated 3/2/12 was electronically signed on 3/27/12, Order dated 3/3/12 was electronically signed on 3/25/12, Order dated 3/6/12 was electronically signed on 4/11/12. The physicians have not hand signed nor electronically signed their physician orders within the 48 hour time frame as allowed by the governing body and policy and procedure. An interview with Employee #10 on 5/31/12, revealed she is in agreement the physician signatures are not within the 48 hour timeframe as set by hospital policy as evidenced by they have 48 hours to sign their orders and they aren't doing it. A Review of the By-Laws and Hospital Policies confirms the requirement of 48-hour signatures for all orders. Please refer to A-0457 for additional information and regulations.

30077 This Condition of Participation is not met based on clinical record reviews, interviews, and reviews of policies and procedures, it was determined the hospital failed to protect and promote patient rights. The facility failed to provide incontinent care, the facility failed to assess/investigate what appeared to be blood on the back of Patient #7's head. This failure has the substantial probability to adversely affect all patients' physical health, safety, and well-being. Refer to A-0144 and A-0395 for additional information.

30077 Based on interview the facility has failed to maintain patient respect, dignity, and comfort as part of an emotionally safe environment. Facility failure to assess for wounds after observing probable blood on the back of her head for 1 (Patient #7) of 11 patients. The findings include: 1. On 3/4/12, Patient #7 was transferred from ICU to PCU for continued care. The patient was received on the PCU unit with dried, caked feces from her heels up her back. An interview on 5/31/12 at 6:00 p.m., with Employee #9, revealed she is the charge nurse and was informed by the Certified Nursing Assistant that Patient #7 was received on transfer from the Intensive Care Unit, to the PCU having dried, caked feces from her feet to her back. She stated, The aide was hysterical crying about it. She was so upset because the patient had dried feces and couldn't believe they left the patient like that. She came right away and told me. She actually cried while cleaning this woman because it was so bad. I reported it to my Director and they were going to talk to the Director of the ICU. It was really bad, the aide said it was from her feet to her back. 2. A record review on 5/31/12 of Patient #7's Electronic Medical Record (EMR) revealed a photograph, taken on 3/4/12 by Employee #8, of an area on the head of Patient#7, where there was what appeared to be blood. Further review of Patient #7's EMR as assisted by Employee #10 failed to revealed any Nursing Progress Note, Nursing Assessment or Neurological checks by Employee #8. The record failed to contain any notification to physician or family of the findings. A record review on 5/31/12 on the facility's Incident Log & Grievance Log does not contain an entry for Patient #7 on 3/4/12. Employee #10 confirmed the finding. An interview with Employee #10 on 5/31/12 confirmed Employee #8 did not conduct a nursing assessment as evidenced by lack of documentation of a Progress Note. She failed to notify the Physician and/or perform a Nursing Assessment as evidenced by stating, no I don't see it either. I can't find anything. We didn't when we looked. An interview on 5/31/12 with Employee #6 revealed when asked if Employee #8 had ever mentioned to her as her superior, of any head injury to a patient or noticed any bleeding from the scalp of Patient #7 and/or if she had been shown the picture Employee #8 took on 3/4/12, she replied no. (in response to all questions). An interview on 5/30/12 with Employee #4 revealed, I have seen this picture. I saw it about a week ago. Employee #8 is the nurse who took it. She didn't have much to say to me. I asked her if she can recall if anything happened with this lady, an injury, and a fall anything of that nature .she said no. She said as part of her assessment she took the picture. What she told me is that she saw a little blood on the pillow and then assessed her and then took the picture. She was asked where the assessment was and she replied I don't know. An interview on 5/31/12 with Employee #8 revealed the following: She was the author of the picture of the back of the head of Patient #7's whose name is on the photo. When asked what prompted you to take the picture and she replied, There was blood on the back of her head. I wasn't told that in report and I didn't see anything about it in her chart. When asked if she could recall what she did next she stated, no I don't. She was asked if she called the doctor she answered I do remember I saw bloody hair, but I couldn't find anything. She was asked if she could explain what I couldn't find anything means and she stated, I couldn't find a wound, so no, I didn't call anybody. She was asked if she knew where the blood was coming from she said I don't know off hand. When asked about writing a progress note, she said I'm not sure if I did. When asked is she alerted the charge nurse so she might be able to see where the bleeding was coming from she responded I don't remember if I did or not. She was asked if she remembers if she helped the patient get out of bed she replied no, I don't believe I did. When asked if she remembers an incidence of her falling she responded if she had fallen I would have filled out an incident sheet. Employee #8 was asked if she told anybody about what she found, another nurse maybe she responded I don't recall. She was then asked is it possible during turning her or positioning her she hit her head she stated, No, it happened early in the shift, there was blood on the pillow. When asked if the family was there she said, The family came in not long after. Did you tell the family, she responded I am not sure if I told them or if they noticed the blood in her hair.

30077 Based on clinical record reviews, interviews, and reviews of policies and procedures, it was determined the hospital does not have an effective organized nursing service that provides 24-hour services to maintain the health, safety and well-being of the patients it serves. The facility failed to ensure (1) nursing staff assess Patient #7 after discovering what appeared to be blood on the back of her head; (2) failed to notify physician and family of possible injury; (3) nursing services failed to deliver care for Patient #7 when she became incontinent and prior to transferring to another unit. This failure has the substantial probability to adversely affect all patients' physical health, safety, and well-being. Refer to A-0395 for additional information.

30077 Based on record review and interview the facility failed to provide nursing care by not appropriately assessing patient care needs for 1 (Patient #7) out of 11 patients. The findings include: 1. On 3/4/12, Patient #7 was transferred from ICU to PCU for continued care. The patient was received on the PCU unit with dried, caked feces from her heels up her back. An interview on 5/31/12 at 6:00 p.m., with Employee #9, revealed she is the charge nurse and was informed by the Certified Nursing Assistant that Patient #7 was received on transfer from the Intensive Care Unit, to the PCU having dried, caked feces from her feet to her back. She stated, The aide was hysterical crying about it. She was so upset because the patient had dried feces and couldn't believe they left the patient like that. She came right away and told me. She actually cried while cleaning this woman because it was so bad. I reported it to my Director and they were going to talk to the Director of the ICU. It was really bad, the aide said it was from her feet to her back. 2. A record review on 5/31/12 of Patient #7's Electronic Medical Record (EMR) revealed a photograph taken on 3/4/12 by Employee #8 of an area on the head of Patient#7 where there was what appeared to be blood. Further review of Patient #7's EMR as assisted by Employee #10 failed to revealed any Nursing Progress Note, Nursing Assessment or Neurological checks by Employee #8. The record failed to contain any notification to physician or family of the findings. A record review on 5/31/12 on the facility's Incident Log & Grievance Log does not contain an entry for Patient #7 on 3/4/12. Employee #10 confirmed the finding. An interview with Employee #10 on 5/31/12 confirmed Employee #8 did not conduct a nursing assessment as evidenced by lack of documentation of a Progress Note. She failed to notify the Physician and/or perform a Nursing Assessment as evidenced by stating, no I don't see it either. I can't find anything. We didn't when we looked. An interview on 5/31/12 with Employee #6 revealed when asked if Employee #8 had ever mentioned to her as her superior, of any head injury to a patient or noticed any bleeding from the scalp of Patient #7 and/or if she had been shown the picture Employee #8 took on 3/4/12, she replied no. (in response to all questions). An interview on 5/30/12 with Employee #4 revealed, I have seen this picture. I saw it about a week ago. Employee #8 is the nurse who took it. She didn't have much to say to me. I asked her if she can recall if anything happened with this lady, an injury, and a fall anything of that nature .she said no. She said as part of her assessment she took the picture. What she told me is that she saw a little blood on the pillow and then assessed her and then took the picture. She was asked where the assessment was and she replied I don't know. An interview on 5/31/12 with Employee #8 revealed the following: She was the author of the picture of the back of the head of Patient #7's whose name is on the photo. When asked what prompted you to take the picture and she replied, There was blood on the back of her head. I wasn't told that in report and I didn't see anything about it in her chart. When asked if she could recall what she did next she stated, no I don't. She was asked if she called the doctor she answered I do remember I saw bloody hair, but I couldn't find anything. She was asked if she could explain what I couldn't find anythingmeans and she stated, I couldn't find a wound, so no, I didn't call anybody. She was asked if she knew where the blood was coming from she said I don't know off hand. When asked about writing a progress note, she said I'm not sure if I did. When asked is she alerted the charge nurse so she might be able to see where the bleeding was coming from she responded I don't remember if I did or not. She was asked if she remembers if she helped the patient get out of bed she replied no, I don't believe I did. When asked if she remembers an incidence of her falling she responded if she had fallen I would have filled out an incident sheet. Employee #8 was asked if she told anybody about what she found, another nurse maybe she responded I don't recall. She was then asked is it possible during turning her or positioning her she hit her head she stated, No, it happened early in the shift, there was blood on the pillow. When asked if the family was there she said, The family came in not long after. Did you tell the family, she responded I am not sure if I told them or if they noticed the blood in her hair.

30077 Based on record review and interview the facility failed to ensure the medical staff signed the physician verbal orders for 3 (Patients #5, #6 and #7) out of 11 patients. The findings include: 1. A record review on 5/31/12, for Patient #5, revealed a verbal physician order dated 2/1/12 at 2000 and remains unsigned by the physician. 2. Patient #6's record revealed 3 verbal physician orders dated 4/5/12 at 1152 and 1805 and 4/9/12 at 2008 reamining unsigned by the physician. A physician order dated 3/30/12 at 1051 and 1447 was electronically signed by the physician on 4/26/12 at 1257, an order dated 4/6/12 at 0855 was electronically signed on 5/12/12 at 05:48 p.m. 3. Patient #7's record revealed a verbal physician order dated 2/28/12 at 2000, and three verbal physician orders dated 3/1/12 at 0930 and 2130, 3/6/12 at 1410 reamining unsigned by the physician. Verbal physician orders dated 2/21/12 were electronically signed 3/22/12, Three orders dated 2/27/12 were electronically signed on 4/14/12, Two orders dated 2/28/12 were electronically signed on 3/22/12, Order dated 2/28/12 was electronically signed on 4/11/12, Order dated 2/29/12 was electronically signed on 4/4/12, Order dated 3/2/12 was electronically signed on 3/27/12, Order dated 3/3/12 was electronically signed on 3/25/12, Order dated 3/6/12 was electronically signed on 4/11/12. The physicians have not hand signed nor electronically signed their physician orders within the 48 hour time frame as allowed by the governing body and policy and procedure. An interview with Employee #10 on 5/31/12, revealed she is in agreement the physician signatures are not within the 48 hour timeframe as set by hospital policy as evidenced by they have 48 hours to sign their orders and they aren't doing it. A Review of the By-Laws and Hospital Policies confirms the requirement of 48-hour signatures for all orders.

19190 Based on review of the grievance process and administrative interview, the facility failed to specify an appropriate timeframe for the resolution of a grievance and the provision of a written response for 10 (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10) of 10 patient records reviewed. The findings include: Record reviews on 12/12/11 and 12/13/11 for ten (10) patients who had filed a grievance with the facility revealed the following: Patient #1 had filed a grievance on 10/26/11 with no written resolution letter documented as sent to date; Patient #2 had filed a grievance on 10/25/11 with no written resolution letter documented as sent to date; Patient #2 had filed a grievance on 10/25/11 with no written resolution letter documented as sent to date; Patient #3 had filed a grievance on 10/28/11 with no written resolution letter documented as sent to date; Patient #4 had filed a grievance on 11/7/11 with no written resolution letter documented as sent to date; Patient #5 had filed a grievance on 10/17/11 with no written resolution letter documented as sent to date; Patient #6 had filed a grievance on 10/5/11 with no written resolution letter documented as sent to date; Patient #7 had filed a grievance on 10/14/11 with no written resolution letter documented as sent to date; Patient #8 had filed a grievance on 9/8/11 with no written resolution letter documented as sent to date; and Patient #10 had filed a grievance on 11/28/11 with no written resolution letter documented as sent to date. During various interviews with the Chief Nursing Officer, Administrative Director of Quality & Outcomes Management, and Administrative Director of Risk Management confirmed no response letters had been sent to these ten (10) patients as required. The facility provided a copy of the Policy and Procedure entitled Grievance/Concerns Identified by Patient/Representative Policy No. P-10-003-R1 Revised 6/11 with the following notation: Definitions: Patient Grievance is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative regarding the patient care, abuse or neglect, issues related to the hospital compliance with the CMS Hospital Conditions of Participation (CoP) .Complaints received in any form become a grievance is not resolved by staff present. Procedures: II Grievance Process 3. If the employee who received the complaint/concern is unable to manage the resolution for the patient/family the employee should notify his/her immediate supervisor (e.g. Nurse Director, Administrative Director) of the complaint/concern c. Those Directors to whom the documentation of the concern has been sent are responsible for the investigation, resolution if possible, and complete follow up within 30 days. All completed documentation is to be done on the Patient Concern Log. Responsibilities: II. The Department Director is responsible to see that all complaints and concerns are resolved, if possible, and documented within 7 days. A written response, within 30 days is to be sent if the grievance cannot be immediately resolved or not resolved prior to discharge. Regulations specify that the hospital must review, investigate, and resolve each patient's grievance within a reasonable time frame. On average, a time frame of 7 days for the provision of the response would be considered appropriate. If the grievance will not be resolved, or if the investigation is not or will not be completed within 7 days, the hospital should inform the patient or the patient's representative that the hospital is still working to resolve the grievance and that the hospital will follow-up with a written response within a stated number of days in accordance with the hospital's grievance policy. The hospital must attempt to resolve all grievances as soon as possible. Review of the facility's Patient Concern Log for the 3rd and 4th Quarter on 12/13/11 contained a total of 87 entries with 28 additional entries (38 total) that revealed a column entitled Date Letter Sent with a notation of None. There was no documentation provided/submitted that demonstrated the facility had written and sent a resolution letter to each of the patients listed in a timely manner (within the appropriate timeframe of 7 days).

19190 Based on review of the grievance process and administrative interview, the facility failed to provide, in its resolution of the patients grievance, a written notice of its decision that contained the name of the hospital contact person, steps taken in the investigation, the results, and date of completion for 10 (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10) of 10 patient records reviewed. The findings include: Record reviews on 12/12/11 and 12/13/11 for ten (10) patients who had filed a grievance with the facility revealed the following: Patient #1 had filed a grievance on 10/26/11 with no written resolution notice/letter documented as sent to date; Patient #2 had filed a grievance on 10/25/11 with no written resolution notice/letter documented as sent to date; Patient #2 had filed a grievance on 10/25/11 with no written resolution notice/letter documented as sent to date; Patient #3 had filed a grievance on 10/28/11 with no written notice/resolution letter documented as sent to date; Patient #4 had filed a grievance on 11/7/11 with no written notice/resolution letter documented as sent to date; Patient #5 had filed a grievance on 10/17/11 with no written notice/resolution letter documented as sent to date; Patient #6 had filed a grievance on 10/5/11 with no written notice/resolution letter documented as sent to date; Patient #7 had filed a grievance on 10/14/11 with no written notice/resolution letter documented as sent to date; Patient #8 had filed a grievance on 9/8/11 with no written notice/resolution letter documented as sent to date; and Patient #10 had filed a grievance on 11/28/11 with no written notice/resolution letter documented as sent to date. The facility provided a copy of the Policy and Procedure entitled Grievance/Concerns Identified by Patient/Representative Policy No. P-10-003-R1 Revised 6/11 with the following notations: Definitions: Patient Grievance is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative regarding the patient care, abuse or neglect, issues related to the hospital compliance with the CMS Hospital Conditions of Participation (CoP) .Complaints received in any form become a grievance if not resolved by staff present. * When the patient of patient's representative request their complaint be handled as formal complaint or grievance or when the patient requests a response from the hospital, then the complaint is a grievance and all the requirements apply. Review of the facility's Patient Concern Log for the 3rd and 4th Quarter on 12/13/11 contained a total of 87 entries with 28 additional entries (38 total) that revealed a column entitled Date Letter Sent with a notation of None. There was no documentation provided/submitted that demonstrated the facility had written/sent a resolution letter to each of the patients listed and had complied with the regulation. During various interviews with the Chief Nursing Officer, Administrative Director of Quality & Outcomes Management, and Administrative Director of Risk Management confirmed no response letters had been sent to these ten (10) patients as required. In other interviews with the Administrative staff, they reported that they verbally communicate with each complainant. Regulations specify that the hospital must provide the patient with a written notice of its decision that contained the name of the hospital contact person, steps taken in the investigation, the results, and date of completion. While the facility may use any additional tools they deem necessary to resolve a grievance, the facility, in all cases, must provide a written notice (response) to each patient's grievance (s). The written response must contain the elements listed in this requirement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 19190 Based on staff interview and medical record review, the facility failed to ensure the patient/family participated in the development, implementation and revision of the care plan process with regard to care needs due to health status changes for 3 (Patients #1, #6, and #8) of 10 patient records reviewed. The findings include: 1. Review on 12/12/11 for Patient #1 revealed the patient was admitted to the hospital on 10/21/11 with a diagnosis of Hydronephrosis (kidney disease) and discharged on [DATE]. Review of the clinical record revealed the patient was sent to a medical floor upon admission. Nursing documentation revealed at approximately 7:00 p.m. the patient's oxygen was set at 4L/nc (nasal cannula) and saturation level at 93%, the abdomen was slightly distended. The patient was complaining of abdominal discomfort from the CBI (continuous bladder irrigation) with notation the CBI was stopped at this time. Orders were received for bladder irrigation with patient reporting feeling much better. At 8:00 p.m. the nursing documentation indicated the patient was receiving the first unit of a blood transfusion with the abdominal condition noted as hypo bowel sounds, and oxygen set at 2L/nc with sats at 92-93% (no order noted for decrease in oxygen rate). Family was noted as being at the bedside at this time. At midnight, the nurse documented the second unit of blood completed, uneasy breathing with oxygen sats at 93% (no nasal cannula level documented). At 2:20 a.m., the next nursing documentation noted audible wheezing, patients sats very low at this time with the patient put on a non-rebreather, head in up position, appears very pale and distressed, Code H called with physician notified and orders received. The patient's condition began to change on 1022/11 at 8:00 p.m. until sent to the ICU (Intensive Care Unit) on 10/23/11 at 3:00 a.m. There was no evidence in the record the patient/family was given an opportunity to participate in the on-going development, implementation and revision of the care plan (from 10/22/11 to 10/23/11) to coordinate and maximize an effective treatment plan that included proactive involvement in the development and implementation of the patient's hospitalization and plan of care. 2. Review on 12/12/11 for Patient #6 revealed the patient was admitted to the hospital on 8/5/11 with a diagnosis of Gangrene of the Right Leg and End Stage Renal disease. Review of the clinical record revealed the patient was sent to a surgical floor upon admission. Nursing documentation revealed notes dated 8/16/11 at 5:44 p.m. reporting dressing changes completed by the surgeon's nurse. The next documentation in the record was written on 8/17/11 at 2:40 p.m. noting a Code Blue had been call by the surgeon's nurse. On arrival to scene _____(nurse's name) was holding pressure on pt's right groin. Pt was unresponsive. Pt was lying in blood soaked sheets. Pt regained consciousness and transferred to ICU. There was no nursing documentation in the record from 5:44 p.m. to 2:00 p.m. (+19 hours) to denote any changes in the patient's condition with reference to any health status changes (bleeding from the right groin site). There was no evidence the family was notified of the change in condition prior to the ICU transfer. There was also no evidence they were given an opportunity to participate in the on-going development, implementation and revision of the care plan to coordinate and maximize an effective treatment plan that included proactive involvement in the development and implementation of the patient's hospitalization and plan of care. 3. Review on 12/12/11 for Patient #8 revealed the patient was admitted to the hospital on 7/30/11 with a diagnosis of Right Hip Pain s/p Fall and discharged on [DATE]. Review of the clinical record revealed the patient was sent to a surgical floor upon admission with Buck's traction. Physician's Discharge Summary dated 8/17/11 revealed the patient had a repair of the right hip on 8/2/11. Post-op the patient was sent to the cardiac floor due to rapid atrial fibrillation (irregular heart beat) second to sinus tachycardia (fast heart rate). On 8/8/11, the patient had elevated liver function studies and underwent an Endoscopy procedure. On 8/11/11, the patient was found to have an incarcerated incisional hernia and was taken to the Operating Room for repair. Documentation in the nurses notes revealed on 8/11/11 at 5:00 p.m. the surgeon was informed of the patient's status with orders received. Post-op repair the patient went into respiratory failure and was intubated and sent to ICU at 6:00 p.m. for close monitoring. There was no evidence the family was aware of the patient's serious condition and notified of the patient's whereabouts prior to the ICU transfer. There was also no evidence in the record the patient/family was given an opportunity to participate in the on-going development, implementation and revision of the care plan (from 8/11/11 to 8/17/11) to coordinate and maximize an effective treatment plan that included proactive involvement in the development and implementation of the patient's hospitalization and plan of care.

19190 Based on clinical record review and administrative interview, the hospital failed to maintain an effective on-going hospital wide, data-driven Quality Assessment Program that monitors the effectiveness and safety of the service and quality of care the facility provides as it relates to the Grievance Process and Resolutions. This failure presents a substantial probability to adversely affect all patients' physical health, safety and well-being. Interviews with the hospital's Administrative Director of Quality throughout the survey process (12/12/11 through 12/13/11) failed to reveal the existence of a definitive program that addressed tracking and trending for Risk Management's written responses to patients' or the representatives' grievances/complaints filed during the 3rd and 4th quarter of 2011. Per the facility's Policy and Procedure Information entitled Grievance/Concerns Identified by Patient/Representative Policy No. P-10-003-R1 Revised 6/11 with the following notation: Responsibilities: IV. QM/RM (Quality Manager/Risk Manager) reviews the Patient Concern Log and Meditech Notifications of grievance and concerns and reports findings to the QCC (Quality Coordinating Council) quarterly. QM/RM is available to assist with the preparation of response letters by the Department Directors. There was no evidence provided of any review of the Patient Concern Log to demonstrate the QAPI (Quality Assurance Performance Improvement) program recognized the facility had a grievance process and resolution problem and thus, monitored the effectiveness and quality of care to the patients the hospital serves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 19190 Based on record review for 4 out of 10 sampled patients, administrative interview, and review of accepted standards of nursing practice and care, it was determined the facility failed to (1) ensure the registered nurse supervised and adequately evaluated the nursing care and care plan as it relates to assessments for the patient (Patient #1), (2) notify physician and patient's representative of care needs and health status changes (Patients #1 and #6), and (3) document the patient's skin/wound care interventions (Patients #3 and #4). This has the potential to affect the health, safety, and well-being of all the patients the hospital serves. Professional Standard of Care is defined in Chapter 766.102 as, the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers. Florida Statutes, Chapter 464 Part 1 (3)(a) reads: 'Practice of professional nursing' means the performance of those acts requiring specialized knowledge, judgment, and nursing skill based upon applied principles of biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, planning, intervention and evaluation, health teaching and counseling of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a licensed practitioner authorized by the laws of this state to prescribe medications and treatments. 3. The supervision and teaching of other personnel in the theory and performance of above acts The findings include: 1. Review on 12/12/11 for Patient #1 revealed the patient was admitted to the hospital on 10/21/11 with a diagnosis of Hydronephrosis (kidney disease) and discharged on [DATE]. Review of the clinical record revealed the patient was sent to a medical floor upon admission. Nursing documentation revealed at approximately 7:00 p.m. the patient's oxygen was set at 4L/nc (nasal cannula) and saturation level at 93%, the abdomen was slightly distended. The patient was complaining of abdominal discomfort from the CBI (continuous bladder irrigation) with notation the CBI was stopped at this time. Orders were received for bladder irrigation with patient reporting feeling much better. At 8:00 p.m. the nursing documentation indicated the patient was receiving the first unit of a blood transfusion with the abdominal condition noted as hypo bowel sounds, and oxygen set at 2L/nc with sats at 92-93% (no order noted for decrease in oxygen rate). Family was noted as being at the bedside at this time. At midnight, the nurse documented the second unit of blood completed, uneasy breathing with oxygen sats at 93% (no nasal cannula level documented). At 2:20 a.m., the next nursing documentation noted audible wheezing, patients sats very low at this time with the patient put on a non-rebreather, head in up position, appears very pale and distressed, Code H called with physician notified and orders received. The patient's condition began to change on 10/22/11 at 8:00 p.m. until sent to the ICU (Intensive Care Unit) on 10/23/11 at 3:00 a.m. There was no evidence in the record the registered nurse effectively evaluated the change in the patient's condition on an on-going basis from 8:00 p.m. (10/21/11) to 2:20 a.m. (10/22/11) and contacted the physician for further guidance and orders during that time. There was no evidence the family was notified of the change in condition prior to the ICU transfer. 2. Review on 12/12/11 for Patient #3 revealed the patient was admitted to the hospital on 10/26/11 with a diagnosis of Right Infected Knee d/t Total Knee Arthroplasty. Review of the clinical record revealed the patient was sent to a surgical floor upon admission. Nursing documentation revealed admission notes dated 10/26/11 at 5:46 p.m. reporting an abrasion on the right buttock with no dressing in place and left open to air. The next documentation in the record was written on 10/26/11 at 8:00 p.m. noting the skin was pale, warm, dry, and good turgor with no mention of any abrasion to the right buttocks. On 10/27/11 at 8:00 a.m. the nurse documented the skin as appropriate for patient, warm, dry, and good turgor without mention of the right buttock skin abrasion. On 10/28/11 at 8:30 p.m. the nurse documented there was an abrasion to the right buttock. Further review of the record revealed a physician's order dated 10/27/11 for the nurse to change the dressing and clean with betadine twice daily. Documentation in the nurses notes for 10/27/11 revealed the nurse provided wound care using an abdominal dressing pad with tape and failed to use betadine as ordered. There was no evidence in the record the registered nurse effectively evaluated the change in the patient's condition on an on-going basis and contacted the physician for further guidance and orders. 3. Review on 12/13/11 for Patient #4 revealed the patient was admitted to the hospital on 8/5/11 with a diagnosis of Gangrene of the Right Leg and End Stage Renal disease. Review of the clinical record revealed the patient was sent to a surgical floor upon admission. Nursing documentation revealed notes dated 8/16/11 at 5:44 p.m. reporting dressing changes completed by the surgeon's nurse. The next documentation in the record was written on 8/17/11 at 2:40 p.m. noting a Code Blue had been call by the surgeon's nurse. On arrival to scene _____(nurse's name) was holding pressure on pt's right groin. Pt was unresponsive. Pt was lying in blood soaked sheets. Pt regained consciousness and transferred to ICU. There was no nursing documentation in the record from 5:44 p.m. to 2:00 p.m. (+19 hours) to denote any changes in the patient's condition with reference to any health status changes (bleeding from the right groin site). There was no evidence the family was notified of the change in condition prior to the ICU transfer. 4. Review on 12/12/11 for Patient #6 revealed the patient was admitted to the hospital on 8/5/11 with a diagnosis of Gangrene of the Right Leg and End Stage Renal disease. Review of the clinical record revealed the patient was sent to a surgical floor upon admission. Nursing documentation revealed notes dated 8/16/11 at 5:44 p.m. reporting dressing changes completed by the surgeon's nurse. The next documentation in the record was written on 8/17/11 at 2:40 p.m. noting a Code Blue had been call by the surgeon's nurse. On arrival to scene _____(nurse's name) was holding pressure on pt's right groin. Pt was unresponsive. Pt was lying in blood soaked sheets. Pt regained consciousness and transferred to ICU. There was no nursing documentation in the record from 5:44 p.m. to 2:00 p.m. (+19 hours) to denote the registered nurse evaluated the patient for any changes in the condition with reference to bleeding from the right groin site. There was no documented evidence the physician and the family were notified of this change in condition prior to the Code Blue on 8/17/11 at 2:40 p.m.

17400 Based on clinical record review, family and staff interview, the hospital failed to ensure nursing staff performed an inclusive assessment for 1 (Patient #4) of 10 patients sampled. The findings include: Record review, on 10/18/11, for sampled Patient #4 document the patient was admitted to the hospital, on 7/29/11 and discharged home on 8/4/11. The patient had diagnoses that include, but are not limited to, a Urinary Tract Infection, Dehydration, Acute Renal Failure, and Chronic Lymphocytic Leukemia. The nursing progress notes, for 7/31/11, at 0337, document Patient #4 was found on floor. Nursing progress note shows no limitations in Range Of Motion (ROM); however, the 7/31/11 shift assessment done after 8:00 a.m. shows limited ROM in all four extremities. No further assessment documentation is recorded as performed by the nurse on 7/31/11 at 3:37 a.m. Documentation of a Physical Therapy evaluation, on 8/3/11, document a scab is noted on her left knee, but the nursing assessments do not document a scab. Interview with family reporting Patient #4 sustained two falls while hospitalized . A review of the patient's clinical record, on 10/18/11, only one fall is documented. Interview with the nurse manager, on 10/18/11, at 4:00 p.m., reveals she completed a facility report for the Patient #4 being found on the floor, at noon on 7/30/11. She stated the physician assistant was on the unit, was notified, and saw the patient approximately 45 minutes later. Review of the clinical record reveals the incident of the fall and a nursing assessment post fall is not documented. Per the nurse manager, an agency nurse was working that day and did not document the fall or an assessment in the record. Patient #4 was found on the floor twice during her hospitalization . Nursing staff failed to document that the patient was assessed completely for injuries post fall.

25370 Based on review of medical records, incident report, chest pain protocol, trespass warning notice, and Sheriff case reports and staff interviews the facility failed to ensure that appropriate medical screening examinations were provided within the capability of the Emergency Department for 2 of 23 sampled patients (# 3 and #23). See findings in Tag A-2406.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 18563 Based on review of medical records, incident report, chest pain protocol, trespass warning notice, and Sheriff case reports and staff interviews the facility failed to ensure that appropriate medical screening examinations were provided within the capability of the Emergency Department for 2 of23 sampled patients (# 3 and #23). Findings include A review of the clinical record for Patient #3, completed on 5/23/11, revealed the following: The patient has a previous history of pulmonary fibrosis ( this occurs when lung tissue becomes damaged and scarred.)and hypo plastic right lung (developmental abnormality of the lung . frequently associated with with malformations of the .musculoskeletal systems). He does not have a primary physician. On 5/12/11, Patient #3 presented to the emergency room at 10:41 a.m., with complaints of back pain. At 11:09 a.m., he was triaged as a 3 with a stated pain level at 10 of 10. He was taken to room [ROOM NUMBER] after the initial nursing assessment was completed. Patient Notes noted at: 11:20 a.m., states Pt Ambulating about in exam room without difficulty 11:25 a.m., states ARNP (Advanced Registered Nurse Practitioner) _____in to assess 11:35 a.m., states Pt ambulatory to ER (emergency room ) nurses desk with a brisk, steady, upright gait demanding to have information written down for him. ________ (ARNP) informs patient that he would not let her continue with the examination and became hostile with her using many profanities. Pt then turns and says how do I get out of here? and starts pacing with a steady, brisk, upright gait. Pt requests for the ER Director name and phone number, card provided with this information. Pt thankful and is let out of the ER, Pt leaves ER with steady, brisk upright gait. Pt left area at 11:40 a.m. Review of the ARNP assessment dictated 5/12/11 at 11:41 a.m., notes she was not allowed to finish a single question and he would not allow her to discuss with him his situation, was very argumentative. She also writes he is very frustrated because he does not understand what is going on related to his back pain. He refuses further evaluation and management in the emergency room . She then writes we had to call security to ensure that he leave the emergency room in a safe and calm manner. On 5/19/11 at 1:00 p.m., an interview with the Risk Management revealed her conversation with the hospital security found that security was not called or notified as noted in the ARNP assessment. They (Security)did not get involved with the situation until Patient #3 had left the facility when they were given the information needed to file a no trespassing with the sheriff's department against Patient #3. Review of an incident report written by the emergency room Director ([NAME]). Patient #3 was in the emergency room department on 5/12/11 related to back pain. The Nurse Practitioner (NP) tried to provide education to the patient when he became verbally threatening to her. The ARNP left the room as she felt uncomfortable from a safety aspect. The patient went to the nurses' station wanting his written report but the ARNP explained to him that she was unable to finish the medical screening because the patient became threatening. This conversation was witnessed by several of the emergency room personnel (names unknown). The patient then left and went to administration to talk with the writer (ER Director). The incident report goes on to say after the patient left her office she talked with the ARNP and since the ARNP felt unsafe, she notified security to issue a no trespassing warning that was served by the sheriff's department at the patient ' s home. Review of the trespassing warning dated 5/12/11 times 1325 (1:25 p.m.) it states ' Do not return or face arrest ' . The complaint was signed by hospital security. Review of the sheriff case report dated 5/12/11 at 1315 (1:15 p.m.) the officer arrived at the hospital when hospital security informed them they wanted a no trespassing against Patient #3 because he had threaten a nurse and they did not want him to return. The officer also wrote he was advised by Patient #3 that he was treated badly at the hospital and he had filed a complaint with the hospital about his treatment. On 5/19/11 at 2:30 p.m., after several interviews with the emergency room Director (ER Director) and after she was able to read her incident report dated 5/12/11 time stamped 1338 (1:38 p.m.) she stated her incident report is accurate as to how the event unfolded on 5/12/11. Her involvement in the incident with Patient #3 started when he walked into administration looking for her. She stated she talked with him in her office and he explained that he was in the emergency room (ER) and the Nurse Practitioner (NP) would not help him and did not give him his discharge papers and he wanted to file a complaint about the way she treated him in the emergency room . The NP stated that during the interview with Patient #3 she called the ER and they informed her the patient had gotten upset with the staff and was verbally abusive to the NP. She stated she told him since the NP could not finish the exam in the ER there were no discharge papers to give him at this time. She further stated he was upset but left the building and went home. She then went to the ER to gather further information about the incident, talked with administration and decided to issues a no trespassing order against Patient #3. When asked if she had any written document or statements from the ER staff involved with Patient #3 she said no. When asked if Patient #3 was verbally abusive to her or anyone in administration, she said no. She did say Patient #3 did use profanities when he was talking to her and his voice was high but he was not verbally abusive to her. She also stated security was not involved in the incident until she gave them the information needed to call the sheriff department to issue a no trespassing to Patient #3. On 5/19/11 at 3:00 p.m., an interview was held with the Administration Assistant (AA) and the Risk Manager. The AA stated she was not involved with Patient #3 on 5/12/11 but she did hear he had called a couple of times. She stated he had called at least 5 times and she had talked with him 3 of those times. He wanted to talk with the Chief Executive Officer of the hospital to explain his side of the story and file a complaint. She stated she had informed the administration and ER Director and was informed to tell Patient #3 he had to talk with the ER Director if he had concerns (which he had already done). Review of the Grievance Log revealed there were no complaints/grievances listed for Patient #3. On 5/ 19/11 the surveyor was not able to interviewed the ED charge nurse ___________ because she was out of the country. On 5/19/11 and 5/20/11 the surveyor was unable to interview the ARNP because she was not working on those days and was not able to do a phone interview until Monday 5/23/11. On 5/20/11 at 2:30 p.m., an interview was conducted with the security guard who was not on scene, at the time of the issues, and wrote the incident report dated 5/12/11. The report related to Patient #3 and information given to him from staff (ED Director). He was actually not on scene until 1325 (1:35 p.m.). His report stated about 12:15 p.m., Patient #3 swore and became verbal abusive with the NP while she was getting his medical history and he threatened her. She was afraid and left the room. The patient left the ER at 12:00 p.m. After his visit to the area, the security guard called the sheriff ' s department to issue a no trespassing warrant. He stated he was called by the emergency room charge nurse but was unable to explain why she had not charted that call in Patient ' s #3 medical records. He also stated the first time he heard about the incident was when the ER Director had given him the information needed for the no trespass warning. On 5/20/11 at 2:50 p.m., an interview with _____________RN an emergency room nurse working on 5/12/11 revealed she did not observe what happen in exam room [ROOM NUMBER] but she had seen the ARNP at the nursing station and Patient #3 had walked up to the nursing station and was using profanity. She stated there was several emergency room personnel around the station and we all stopped to observe the interaction. She also stated Patient #3 took a step inside the nursing station and the ARNP told him not to do that and he stopped. He appeared to calm down so the staff went about their tasks. She stated no one stepped in to talk with the patient but she thinks the charge nurse did talk to him afterwards. On 5/20/11 at 3:30 p.m., an interview was conducted with Doctor ________, the emergency room physician who was in charge on 5/12/11 during the incident. He stated he did not know what happen until later on that day when the ARNP told him of the incident. He stated no one had asked him to intervene in the situation or to finish the assessment for the ARNP because Patient #3 was using profanity. When asked if the patient had become violent and threatening, why they did not Baker Act him he stated he would only Baker Act a patient if they were a danger to themselves and he would call the police if they were a danger to the staff or other patients in the emergency room . On 5/23/11 at about 11:30 a.m., an interview was conducted with the ARNP related to this case. She was asked to recount the events of 5/12/11 and they were fairly close to what is documented above. She was asked what her examination of the patient revealed and she stated, I never touched the patient. All I did was reach over and tie his gown since they always fall off if not tied. She stated, he was threatening and I was afraid for myself so I left the room. She stated the room is small and the patient was sitting in a chair against the wall so when she arrived, she sat on the stretcher with very little room between herself and the patient. She stated the patient stood up and she asked him to sit back down. When he did not sit down, she felt threatened as he towered over her (Patient is 5 ' 9 weighing 150lbs) so she backed out of the room and went to the nursing station. She was asked if she went to get someone else to come back to the room with her she said no, the room was too small for three people. She was asked if she notified the physician she had not conducted a medical screening exam on this patient and she stated no. She continued by stating the patient was just anxious and scared. He really was a very nice man, he just wanted answers. When asked to explain further she stated, He came in with MRI films and he wanted me to look at them and tell him what they said. I explained we do not read films; he would have to wait until he saw his physician to get the results. He was insistent that he needed to know what the plan was for his pain. He started to become loud and his language was inappropriate, I was frightened. She stated she did not make any offers to examine him nor did she offer any remedies for the relief of his pain. She stated he was not here for pain, he wanted his films read. Patient #3 did not receive his medical screening exam. No treatment for the relief of pain was given/offered. The ARNP documentation is inaccurate. She stated she never touched the patient yet dictated a history and physical exam which are present in the clinical record. The ARNP did not advise the physician in charge of any issues until after the patient left the facility. She did not ask him (ED Physician) to complete the exam/screening. 2. Patient #23 did not receive a complete medical screening exam. Patient #23 arrived at the facility with complaints of chest pain on 5/21/11 at 1447 (2:47 p.m.). At 1455 (2:55 p.m.) an EKG was administered. At 1503 (3:03 p.m.) she was placed in an exam room. Original nursing assessment (at 3:30 p.m.) revealed a history of MI, Cardiomyopathy, and anxiety. Results from EKG: Normal sinus rhythm with sinus arrhythmia; ST & T wave abnormality, consider lateral ischemia; Prolonged QT; Abnormal ECG; When compared with ECG of 12/11/10; ST now depressed in inferior leads; inverted T waves have replaced nonspecific T wave abnormality in Anterolateral leads; QT has lengthened; Confirmed by Dr._________at 6:56 p.m. Patient left the facility at 1723 (6:23 p.m.) without any further intervention by staff. Interview with the ER Director on 5/24/11 at about 2:30 p.m., revealed she did not have any knowledge of this event. After her review of the clinical record, she stated, your right, we missed this. When asked what should have happened when a patient arrives with complaints of chest pain, she stated we have a chest pain protocol the staff is to follow. At about 2:45 p.m., on 5/24/11, the ER Director presented a copy of the chest pain protocol which is as follows: 1. Stat EKG - 12 leads 2. Stat CBC with 6 part differential 3. Stat Comprehensive metabolic panel 4. Stat Creatine phosphokinase 5. Stat Lactic Acid Dehydrogenase 6. Stat Lipid Profile 7. Stat Magnesium 8. Stat Phosphorus 9. Therapeutic Protime 10. Stat PTT 11. Stat POC Ed Cardiac Profile 12. Stat Lactic Acid 13. Stat Chest (X-ray) portable The only portion of the protocol followed was the Stat EKG which showed pronounced changes. There was no contact with a physician to do a medical screening exam. The patient left without being seen by a physician and not having the protocol for chest pain followed, after approximately 3 ? hours (from 2:47 p.m., until 6:23 p.m., when she left.). The facility failed to ensure that their chest pain protocol was followed to ensure that patient #23 received an appropriate medical screening examination on 5/21/2011.