33589 Based on record review and interview, the facility failed to transfer necessary medical information along with the patient to the appropriate facility upon discharge for 1 of 10 patients, in that, Patient #9 was transferred upon discharge on 07/22/2015 and 07/30/2015 and the record did not document updated medical information being sent at discharge. Findings Included During record review on 12/22/2015 ending at 2:09 PM, Personnel #1 was unable to find documentation for Patient #9 for either discharge (07/22/2015 and 07/30/2015) of necessary medical information including medication reconciliation was sent at the time of transfer/discharge to the receiving facility. During a telephone interview on 12/22/2015 ending at 2:09 PM, Personnel #1 asked if there was documentation showing that necessary medical information including medication reconciliation was sent at the time of transfer/discharge to the receiving facility for either discharge. Personnel #1 stated, No.

25373 Based on record review and interview, the facility's written notice to 1 of 1 patient (Patient #1) who complained about several issues during confinement on 05/02/13 through 05/08/13, did not include the specific time frame for the evaluation, completion, and the resolution of the complaint. Findings included: Patient #1 voiced out several issues to an administrative assistant via telephone call on 08/23/2013. A response letter sent to Patient #1 dated 08/26/13 reflected that the issues would be evaluated. The letter did not indicate a specific date when the facility would follow-up with a written response. The facility's policy and procedure required 21 business days to complete evaluation of a patient complaint and/ or grievance. In an interview on 01/06/14 at 11:15 AM, Personnel #1, the Director of Risk and Patient Safety Officer was informed of the above findings and confirmed the findings. Policy: Patient Grievance and Complaint Management revised 04/2013 page 4 required .if the grievance may not be resolved .in seven business days, the complainant should be informed .that the facility will follow-up with a written response within 21 business days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 25373 Based on record review and interview, the Registered Nurse (RN) did not supervise and evaluate the nursing care for 1 of 1 patient (Patient #1) who was hospitalized from 05/02/13 through 05/08/13, in that there were no interventions for increased temperatures and/or reassessments after providing antipyretic medications. Findings included: Patient #1 was admitted on [DATE] for persistent fever. On the following dates, there were no nursing interventions and/or reassessments performed: 1. On 05/03/13 at 8:00 AM the patient's temperature (T) was 100.6F (Fahrenheit). 2. On 05/04/13 at 8:06 AM and 2:04 PM, the patient's T were 99.7F and 100.9F respectively. 3. On 05/06/13 at 7:30 AM, 8:12 AM, 9:00 AM, and 5:15 PM the patient's Ts were 102.8F, 100.9F, 100.8F, and 101.1F respectively. 4. On 05/06/13 at 8:00 PM the T was 101.1F. Tylenol was given as prescribed. No nursing reassessment was conducted. 5. On 05/07/13 at 3:30 AM, 7:44 AM, and 3:37 PM the patient's Ts were 102.0F, 99.2F, and 100.3F respectively. In an interview on 01/13/14 at 3:20 PM via phone call, Personnel #3 was informed of the above findings. Personnel #3 confirmed the findings. Personnel #3 was asked what the temperature parameters were to provide antipyretic medications. Personnel #3 replied the facility does not have written parameters for providing antipyretic medications. It was up to the physician to include the temperature so the nurse would know when to administer the fever medication. Personnel #3 stated the nursing competency skills were based from Lippincott nursing book. Lippincott Procedures - Temperature Assessment revised 04/05/13 Normal body temperature is commonly thought of as 98.6F (37C) .Mean temperature is lower in older adults .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 25373 Based on record review and interview, the facility's medical record entry was not accurately written in that, a CT scan of abdomen and pelvis result reflected that the examination was performed with and without contrast. The Physician's Order dated 05/02/13 indicated the examination was to be performed without contrast, citing 1 of 1 patient (Patient #1) who was hospitalized from 05/02/13 through 05/08/13. Findings included: Patient #1 was admitted on [DATE] for persistent fever. A physician's order for CT scan of abdomen and pelvis without contrast was written. Review of the CT scan abdomen and pelvis dated 05/02/13 reflected the heading to be: Exam: CT Abd Pelvis W/O Cont (contrast). The next line reflected Exam: CT Abdomen Pelvis with Contrast. The written result was unclear if the examination was performed with and/or without contrast. In an interview via electronic mail (email) on 01/14/14 at 6:20 PM, Personnel #3 (Administrative Director of Clinical Services) was informed of the above findings. Personnel #3 stated that this was an error. The radiologist dictated the exam as with contrast but the examination was performed without contrast. In an interview on 01/23/14 at 12:11 PM via phone, Personnel #4 (Director of Health Information Management) was informed of the above findings. Personnel #4 was asked if the facility had a policy and procedure in writing accurate clinical entries by health providers. Personnel #4 replied she could not find the requested policy.

15855 Based on interview and record review the hospital failed to ensure the RN (Registered Nurse) evaluated and/or reassessed 1 of 10 ED (emergency department) patients (Patient #1's) vital signs and change of condition after receiving multiple doses of IV administered Morphine and Dilaudid. Findings included: The Fire Department Ambulance Record dated 05/02/13 timed at 19:00 PM reflected, (Patient #1) .medical emergency .stomach pain .B/P .146/87 patient was short of breath oxygen was successful in improving patient .abdomen .stomach was distended and tender due to possible constipation from hydrocodone . The PA (physician Assistant) (Personnel #6's) note dated 05/02/13 timed at 20:03 PM reflected, Abdominal pain .described as present and worsening .similar symptoms previously milder .respiratory distress with anxiety .abdomen moderate tenderness diffusely .bowel diminished . IV analgesia symptoms better .patient has had 16 mg of morphine .will stop giving and reassess . The physician's orders dated 05/02/13 timed at 20:24 PM reflected, Morphine IV (intravenous) 4 mg (milligrams) q (every) 15 min (minutes) for pain greater than or equal to 4/10 up to max (maximum) dose 20 mg with/doc (documentation) pain re-evaluation . The nursing notes dated 05/02/13 timed at 19:48 PM through 05/03/13 timed at 01:04 AM reflected, the following: At 19:48 PM, Pain level 10/10, B/P 115/86, HR (heart rate) 96, respiration 21, oxygen saturation, 100 room air, alert no distress . At 20:25 PM, Morphine 4 mg diluted with IV fluid slow IVP (intravenous piggy back) over 2 minutes .at 20:42 PM, Morphine 4 mg diluted with IV fluid slow IVP over 2 minutes .reports pain level as 9/10 .at 20:56 PM, Morphine 4 mg diluted with IV fluid slow IVP over 2 minutes .reports pain level as 7/10 .at 21:19 PM, Morphine 4 mg diluted with IV fluid slow IVP over 2 minutes .reports pain level as 8/10 .at 21:40 PM, Morphine 4 mg diluted with IV fluid slow IVP over 2 minutes .current pain level 7/10 . Vital signs were not documented after the administration of the above doses of IV Morphine. The physician orders dated 05/02/13 timed at 22:15 PM reflected, Morphine IV 4 mg now .Dilaudid IV 1 mg stat (now). The nursing note dated 05/02/13 timed at 22:05 PM reflected, Morphine 4 mg diluted with IV fluid slow IVP over 2 minutes .pain 7/10 .at 22:34 PM, Dilaudid 1 mg diluted with IV fluid slow IVP over 2 minutes . No documentation was found which indicated (Patient #1's) change in condition was monitored after receiving both Morphine and Dilaudid. The physician's orders dated 05/03/13 timed at 00:35 AM reflected, Narcan IV 0.4 mg every 2 minutes prn (as needed), for absence of respirations and patient unresponsiveness . The nursing note entry timed at 00:20 PM dated 05/03/13 reflected, Narcan 0.4 mg diluted with IV fluid rapid IVP . electronically signed at 00:41 AM .at 00:25 PM Narcan 0.4 mg rapid IVP .electronically signed at 00:41 AM .at 00:20 AM .patient transferred to trauma room .unresponsive before Narcan, became agitated after Narcan .electronically signed at 01:04 AM. No nursing documentation was found which described (Patient #1's) condition after he received the last dose of Morphine and Dilaudid and when the above medication Narcan was administered including what behavior and/or condition (Patient #1) was in. The nursing note entry timed at 01:00 AM reflected, Intubation performed by ED physician .proper airway placement confirmed by equal rise and fall of chest, CO2 detector .tube secured connected to ventilator and bagged .chest x-ray interpreted .at 01:05 AM .B/P 60/48, HR 105, Respirations 12, oxygen saturation 88% after intubation .at 01:35 AM .unable to obtain patient vital signs after multiple attempts on monitor, with manual B/P cuff, or portable pulse ox .unable to obtain vital signs other than heart rate . On 09/05/13 at 08:17 PM Personnel #3 was interviewed. Personnel #3 stated (Patient #1) kept complaining of pain and his pain was always at a ten. Personnel #3 stated (Patient #1) would take the monitor leads off, walked around and would not lay down. Personnel #3 was asked what kind of monitoring she did after administering multiple doses of Morphine and then Dilaudid. Personnel #3 acknowledged she did not take (Patient #1's) vital signs after she administered each dose of medication. Personnel #3 stated she guessed she did not document everything. On 09/11/13 at 09:30 AM Personnel #9 was interviewed. Personnel #9 stated the ED was busy during (Patient #1's) visit. Personnel #9 stated she made rounds in all the ED areas and none of the personnel requested any assistance and/or reported they needed help. Personnel #9 stated she remembered going to (Patient #1's) room and observed (Patient #1). Personnel #9 stated the patient was air hungry so she placed oxygen on (Patient #1). On 09/11/13 at 11:50 AM Personnel #4 was interviewed. Personnel #4 stated she did not speak with the nurse about (Patient #1) until Personnel #3 requested pain medication for (Patient #1). Personnel #4 stated Personnel #3 never said anything about any changes in (Patient #1's) condition. Drug information online at Drugs.com for Morphine Injection reflected, Adverse reactions .most serious is respiratory depression .high doses are excitatory .other side effects include .dizziness, euphoria .overdosage .is characterized by respiratory depression . Drug information online at Drugs.com for Dilaudid (hydromorphone) reflected, Side effects .agitation, changes in behavior, rapid breathing, shortness of breath tightness of chest . The policy entitled, Patient Care Standards Triage/Medical Screening Exam with a revision date of 11/2010 reflected, The intent is to ensure each patient's physical, psychological and social status is assessed and documented to assure continuity .documentation of ONLY vital signs may not be appropriate as evidence of reassessment unless accompanied by a nurses' note reflecting their relationship to the patient's presenting complaint . The policy entitled, Pain Management with a revision date of 11/2010 reflected, Pain assessment is an interdisciplinary process .pain should be reassessed and documented regularly as appropriate, before and after pain-producing or pain relieving interventions, and at interval appropriate for the patient's condition and response to treatment .document effectiveness or non-effectiveness of medication/alternative pain methods .prior to giving the medication and post/medication therapy .evidence of non-pharmacological pain control measures should be documented .assess the patient's activity or mobility and observe behaviors .when severe unrelieved pain persists, timely referral to an appropriate healthcare provider should be made .pain management should include management of side effects of pain treatment including .constipation and sedation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 21021 Based on review of documents and interview with staff, the facility did not ensure that the orders for physical restraint were in accordance with the required limits for 2 of 5 patients whose records were reviewed. Patient #1 and Patient #2, both adults, were physically restrained for combative behavior requiring an order renewal every 4 hours; these orders were not obtained. Findings were: The hospital's restraint policy, entitled PATIENT RESTRAINT/SECLUSION, last approved in February 2012, states under the section entitled PROCEDURE, the RN assessment of a patient who may need restraints includes whether the patient understands that he/she should not remove medical devices, and/or whether or not the patient understands the need to remain immobile. The RN assessment also includes determining if a patient is exhibiting aggressive, combative, or destructive behavior that places the patient or staff in immediate danger. Section 5A outlines the requirements for physician orders for restraint needed for non-violent behavior, such as the need to remain immobile or to leave medical devices undisturbed. In these cases, the physician orders are required at least every 24 hours. To continue restraint beyond the initial order duration, the physician or Licensed Independent Practitioner (LIP) must see the patient and perform a clinical assessment to determine if continuation of restraint is necessary at least each calendar day. Section 5B outlines the requirements for physician orders for restraint for violent or self-destructive behavior; the order must not exceed 4 hours for adults, aged [AGE] years and older. To continue restraint or seclusion beyond the initial order duration, the RN determines that the patient is not ready for release and calls the ordering physician to obtain a renewal order that does not exceed 4 hours for adults. Review of the medical record for Patient #1 revealed that the patient required the use of restraints for combative behavior from 5/13/2012 - 5/15/2012. Beginning at 2:40 pm on 5/13/12, nursing notes indicated that the patient was getting out of bed and wanting to leave. Patient #1 ripped all the EKG monitoring leads off and began to punch the sitter. Soft restraints were applied to arms and legs, and the physician was notified. Nursing notes for 5/14/12 state that the patient continuously moves self in bed even in restraints attempted to bite me while administering medication patient physically abusive. On 5/14/2012, an order for non-violent restraints was written by the physician at 8:15 am. The 2nd restraint order for non-violent behavior was obtained the next morning, 5/15/12. The facility considered Patient #1 as a non-violent patient who needed restraints for non-violent behavior every 24 hours; therefore, orders for violent behavioral restraints were not obtained per facility policy: There was no initial order at the time of initiation of restraints the afternoon of 5/13/12, nor were there renewal orders every 4 hours based on nursing assessments of the need to continue the restraints. Review of the medical record for Patient #2 revealed that the patient required restraints for combative behavior 4/28/2012 between the hours of 6:20 pm and 2:00 am, 4/29/12. Nursing notes indicate that at 6:20 pm on 4/28/2012, the patient was combative with physical aggression, and attempting to remove medical devices. At 7:20 pm, a code yellow was called because the patient was combative during nursing intervention and they required additional security staff. An initial physician order for non-violent restraint was obtained at the initiation of restraints for the duration of 24 hours, not the required 4 hours per combative behavioral restraint requirements. These findings were acknowledged by the facility [NAME] President of Human Affairs and the Director of ICU in a joint in-person interview conducted the afternoon of 7/2/2012.

21021 Based on review of documentation and interview with staff, the facility failed to ensure that staff monitored the physical and psychological well-being of 2 of 5 patients placed in restraints for combative behavior. Patient #1 and Patient #2 were placed in restraints and were not monitored every 20 minutes according to facility procedure. Findings were: The hospital's restraint policy, entitled PATIENT RESTRAINT/SECLUSION, last approved in February 2012, states that restraints used for non-violent behavior, such as a patient who pulls at tubes and devices, must be monitored at least every 2 hours. For those patients in restraints for violent behavior, the policy does not specify the timeframe required for monitoring. The staff training documents state that that patients should be monitored three times an hour (every 20 minutes) if in behavioral restraints, including documenting any changes in behavior, signs of injury, the alternatives attempted, and the patient's readiness for release from restraint. Review of the medical record for Patient #1 revealed that the patient required the use of restraints for combative behavior from 5/13/2012 - 5/15/2012. Beginning at 2:40 pm on 5/13/12, nursing notes indicated that the patient was getting out of bed and wanting to leave. Patient #1 ripped all the EKG monitoring leads off and began to punch the sitter. Soft restraints were applied to arms and legs, and the physician was notified. Nursing notes for 5/14/12 state that the patient continuously moves self in bed even in restraints attempted to bite me while administering medication patient physically abusive. Review of restraint documentation indicates that Patient #1's restraint status was monitored every 2 hours while the patient was restrained 5/13/12-5/15/12, not every 20 minutes as required by facility procedure for patients placed in restraints due to combative or violent behavior. Review of the medical record for Patient #2 revealed that the patient required restraints for combative behavior 4/28/2012 between the hours of 6:20 pm and 2:00 am, 4/29/12. Nursing notes indicate that at 6:20 pm on 4/28/2012, the patient was combative with physical aggression, and attempting to remove medical devices. At 7:20 pm, a code yellow was called because the patient was combative during nursing intervention and they required additional security staff. Review of restraint documentation indicates that Patient #2's restraint status was monitored every 2 hours while the patient was restrained for combative behavior, not every 20 minutes as required by facility procedure. These findings were acknowledged by the facility [NAME] President of Human Affairs and the Director of ICU in a joint in-person interview conducted the afternoon of 7/2/2012.

25122 Based on interview and record review, the hospital did not follow their grievance process. The hospital did not address a known grievance from a representative for 1 of 1 patients (Patient # 1). The hospital further failed to inform them of the time frames for review of the grievance, and/or provide them with a response. Findings included: On 10/26/11 at 4:20 PM Personnel # 4 was interviewed. Personnel # 4 confirmed Patient # 1's representative (wife) had not filed a complaint or grievance with the hospital. She said the first time the hospital had heard of the complaint was from a follow-up call routinely made by a contracted company (Company # 1) ,who contacted patients approximately 3 months after being discharged from the Inpatient Rehabilitation Unit. Personnel # 4 stated Personnel # 5 had reported to her, she had received a Rapid Response Report, from Company # 1 on 07/20/10, with a complaint from Patient # 1's wife regarding her dissatisfaction with her husband's care while at the hospital. Personnel # 4 said she had advised Personnel # 5 the hospital did not need to follow-up on a complaint received from a satisfaction survey, and that she was following their hospital's Complaint & Grievance policy. On 10/26/11 at 3:10 PM Personnel # 5 was interviewed. Personnel # 5 said she had reported the complaint she had received from Company # 1, and reported it to Personnel # 4, who had advised her that no follow-up was needed for this complaint from a satisfaction survey. Personnel # 5 provided a copy of the following report from Company # 1 which noted the following: -Information source (wife) stated, My husband had 3 falls at (hospital). Two injured his head, and he ended up with a subdural hematoma. He was doing very well and ready to come home within two days when this happened. The nurses at (hospital) were negligent and I am going to sue for medical negligence. Personnel # 5 was asked if she had received any Rapid Response Reports in the past, and if so, what did she do to address them. Personnel #5 said she had received 3 prior reports from the company, and she had reported them to Risk Management, and she had also initiated the grievance process by calling the complainant. Personnel # 5 verified she had followed the advice from Risk Management, and had not initiated the grievance process for this serious complaint that met the definition of a grievance. In an interview at 4:20 PM on 10/26/11 with Personnel # 4, she agreed the complaint had been treated as a complaint, not as a grievance, and therefore, the hospital had not addressed the allegations made by the patient's representative (wife), according to the hospital's policy, including time frames for review and provision of a response to a grievance. The Patient Complaint & Grievance Resolution Process, #9.115, dated 12/10, noted the following: Complaints that Would be considered a Grievance: -Any request by a patient or a patient ' s representative to file a grievance. -Any verbal or written complaints (including e-mails and faxes) from an inpatient, an outpatient, a released/discharged patient, or a patient's representative regarding the patient care provided, abuse or neglect, or the hospital's compliance with CoPs (conditions of participation). -Telephone calls received from a patient or patient's representative describing patient care issues. Complaints that Would Not be considered a Grievance: -Post hospital verbal communications, which would have been handled by staff present if staff was aware of the complaint. This includes patient satisfaction survey information.

25122 Based on interview and record review, the hospital failed to provide a safe setting for 1 of 1 patients (Patient # 1). A) The nursing staff did not follow their Post Falls Guidelines policy, and/or B) Exercise good nursing judgement, to ensure safety interventions were initiated (providing a sitter) for an identified High Fall Risk patient. Findings included: A) The Post Falls Guidelines policy dated 11/09, noted the following: -Minor Injury defined as .abrasion, bruise, minor laceration, skin tears and head trauma that is limited to soft tissue damage only. -For Minor Injury .#6. Consider placement of sitter with patient, if appropriate. -Major or High Risk Injury defined as .fractures, head trauma that includes the cranial bones and the brain .injuries which require medical or surgical intervention, increased hospital stay, or are disabling .to a degree that the patient will have any degree of permanent lessened function .patient on anticoagulants . -For Major or High Risk Injury (Suspected Head/Neck Injury or Use of anticoagulant) .#5 Place sitter with patient. B) Patient #1's medical record reflected Patient # 1 experienced 2 falls while hospitalized : Minor Injury Fall: The nursing note dated 03/27/10 timed at 6:45 AM reflected, patient's bed alarm was activated at 06:45 AM, RN went to patient's room and found patient lying on the floor with a cut above his right eye. Patient was assessed for further injuries and helped back to bed with assist X 2 (2-person assist). A rapid response was called and doctor (Personnel # 9) was paged . The nursing note dated 03/27/10 timed at the 8:00 AM, Nursing Day Shift assessment reflected, cut above right eye from fall 03/27/10 .injured during fall when trying to go to the bathroom .on bedrest .short term memory loss - out of bed by self. The Fall Risk Assessment score prior to this fall was 22, and re-assessment after the fall was 28. The day shift nursing Fall Risk Assessment, dated 03/27/10 timed at 8:00 AM reflected, after this fall, recorded fall history: + 11 (2) falls during this visit .cognition: patient not aware of physical limitations .total points: 28 .high risk measures implemented: yes .additional interventions may include: .24 hours supervision/sitter, as needed .High Fall risk comment: call light within reach, bed alarm on (comment did not include initiation of a sitter). Major or High Risk Injury Fall: Patient # 1's Medication Administration Record reflected Patient # 1 received an anticoagulant, Plavix 75 mg. (milligrams) by mouth daily. The nursing note dated 04/24/10 timed at 11:30 PM reflected, alarms went off, when entered room nurse saw patient at foot of bed, who then slipped and fell . Patient landed on back and hit back of head. Laceration to left elbow. Occipital hematoma. Patient complained of headache. Rapid Response Team called immediately and doctor (Personnel # 10) paged. Patient placed on backboard and C-collar, and transported to CT for CT of Head and C-spine. Doctor (Personnel # 10) was notified of CT results which were negative. The nursing note dated 04/24/10 timed at 11:30 PM, reflected under the Post Falls Summary, that before Patient # 1's fall - sitter present: none . The nursing note for 04/25/10 at 8:00 AM reflected, Received this AM but appears more confused for him, asking about moving something on the wall. Speech more garbled, non-coherent .BP (blood pressure 133/79, P (pulse/heart rate)-94 which is higher for him. TC (telephone call) placed to doctor (Personnel # 10) to notify of change in patient. New orders received for repeat CT of Head. 8:45 AM, Report of CT Scan called .to Personnel # 10 to notify him. Also notified supervisor of possible transfer. 9:42 AM, TC from Personnel # 10 who stated he spoke with accepting physician at another hospital, and that Patient # 1 will be transferred to them. 10:00 AM, Wife at bedside and ambulance arrived, discharged per stretcher with EMT's (emergency medical technicians) to receiving hospital. The Radiology CT of Head/Brain without contrast reported four (4) separate areas of hemorrhage in Patient # 1's brain. The physician's (Personnel # 10's) Discharge Summary, included Acute cranial bleed associated with a fall. On 10/26/11 at 9:05 AM Personnel # 1 was interviewed. Personnel # 1 stated, sitters can be requested by nursing staff through the Nursing Supervisor, and are used based on patient condition. Personnel # 1 confirmed a physician order is not required for a sitter, but is based on nursing judgment. Personnel # 1 verified the nursing staff had knowledge of Patient # 1's condition after a stroke, and his increased high fall risk after a reported minor injury fall during his first week in the hospital (PCU), but never requested a sitter for this patient with indications that an additional safety intervention was needed. Personnel # 1 confirmed nursing had not requested a sitter prior to Patient # 1's fall while he was on the Inpatient Rehabilitation unit, which resulted in a major head injury, while on an anticoagulant, and required his transfer to a higher level of care facility for a neurosurgeon.