DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. Continued From page 33 Findings: A 347

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1 A 347 (X1) PROVDER/SUPPLlER/LlA DENTFATON NUMBER: SUMMARY STATEMENT OF DEFflENES (EAH DEFENY MUST BE PREEDED BY FULL REGULATORY OR LS DENTFYNG NFORMATON) ontnued From page 33 Fndngs: A, Secton of the Medcal Staff Bylaws stated, "The purposes of the Medcal Staff are to serve as the prmary means for accountablty to the Board for the qualty and approprateness of the professonal performance of the Medcal Staff." Secton (a) stated, "The responsbltes of the Medcal Staff are to account to the Board for the patent ca~e processes and outcomes rendered by all Members... through a credentalng program, ncludng procedures for appontment and reappontment that matches verfed qualfcatons, performance, and competence wth the lncal Prvleges sought to. be exercsed or of specfed servces to be performed." On 02/27/08 at 10:00 a.m., the credentals fles of medcal staff members were revewed wth the medcal staff coordnator. The fle for Dr. 1 lacked specfc performance measurements or descrptons for the requested prvleges. The fle for Dr. 2 lacked current performance evaluatons at the tme of reappontment n (cross reference A 0340) n an ntervew wth EO on 02/27/08 at 3:30 p.m., EO stated that the radologsts who read xrays and MR flms for the hosptal's contracted vendors who perform these procedures on patents at the hosptal are not credentaled by the hosptal's medcal staff and do not have hosptal prvleges to perform these servces. (cross reference A 0340) B. Secton of the Medcal Staff Bylaws stated, "The purposes of the Medcal Staff are to provde for a unform qualty of patent care, treatment and servces, and report to and be =ORM MS-2567(02-99) Prevous Versons Obsolete (X2) MULTPLE ONSTRUTON A. BULDNG B. WNG STREET ADDRESS, TY, STATE, ZP ODE 8001 BRUEVLLE ROAD 10 A 347 PROVDER'S PLAN OF ORRETON (EAH ORRETVE ATON SHOULD BE ROSS-REFERENED TO THE APPROPRATE DEFENY) the nursng Polces and Procedures and to assure the current call system was defned for the Medcal staff as well. Approved n ME and BOT.. Serra Vsta Hosptal now ensures that nursng staff wll ntate and montor care and treatment for sgnfcant medcal condtons. 1. All Polces and Procedures under lncal Servces have been revewed and are currently beng revsed where needed. n addton to ths thorough revew and revson process, all Serra Vsta Hosptals Polces and Procedures. are annually revewed and revsed as needed. All revsed polces wll be mmedately revewed by all staff through a tranng schedule. 2. Polcy Nursng are of PhYScal Health Emergences and Polcy ntegrated Assessment have been updated to hghlght callng 911 pror to contactng the MD and clarty on the assessment and reassessment of patents. Nursng staff was traned on these polces. Tranng Began on the evenng shft on and was on-gong untl all staff was traned pror to begnnng ther shft. The focus of the tranng ncluded: dentfcaton of potental medcal rsks RN responsbltes for assessment and reassessment of the patent wth alteratons n medcal status rnnt~("t nfthp Prnted: 03/18/2008 OMB NO OMPLETON VWJJ11 f contnuaton sheet Page 34 of 86

2 Prnted: 03/18/2008 OMB NO STA TEMENT OF DEFENES (X 1) PROVDER/SUPPLER/LA DENTFATON NUMBER: (X2) MULTPLE ONSTRUTON A. BULDNG B. WNG STREET ADDRESS, TY, STATE, ZP ODE 8001 BRUEVLLE ROAD SUMMARY (EAH DEFENY MUST BE PREEDED BY FULL REGULATORY OR LS DENTFYNG NFORMATON) 10 PROVDER'S PLAN OF ORRETON (EAH ORRETVE ATON SHOULD BE ROSS-REFERENED TO THE APPROPRATE DEFENY) OMPLETON A 347 ontnued From page 34 accountable to the Governng Board." Medcal Staff Rules and Regulatons #8.2 stated, "n an emergency... when the attendng physcan or hs desgnee s unavalable, the Medcal Drector or hs desgnee must be, contacted and shall have the authorty to make provsons of care for the patent." n an ntervew wth the DS on 02/21/08 at 5:00 p.m., DS stated there was no wrtten nursng polcy or drectve that clearly descrbed the steps and sequence to follow for notfyng a physcan of a patent emergency or change n condton f a physcan was not on ste at the hosptal. The Medcal Staff had not provded gudance to staff to reflect the Medcal Staff Rule #8.2 (above). ntervews wth several nursng and MHT staff revealed nconsstences n knowledge for emergency response and notfyng a responsble physan, as well as dscrepances n where to locate emergency equpment. Staff dd not know where to locate a polcy to gude such response. (cross reference A 0063) n the case of Patent 1 who experenced a change n condton on 02/17/08 (found on floor, sweatng, short of breath, shakng), staff proceeded wth alcohol wthdrawal treatment and dd not successfully notfy any physcan of a change n condton or of hs pror complants of chest pan and need for a PAP devce. Patent 1 subsequently developed cardorespratory arrest and ded. n an ntervew wth Dr. 3 on 02/28/08 at 5:30 p.m. Dr. 3 explaned he was on call for the perod of Patent 1 's care on 02/16/08 and dd not receve calls from the staff carng for Patent 1. He stated that he consdered chest pan a very serous FORM MS-2567(02-99) Prevous Versons Obsolete A 347 physcan wth dentfed and escalatng medcal concerns D. Serra Vsta Hosptal medcal staff now ensures a tmely qualty assessment and response to patent adverse outcomes. 1. Polces Unantcpated Outcomes, Sentnel Event Revew and Reportng, and rtcal Event Revew and Reportng have been revew and affrmed and are now used to produce a systematc, tmely revew and analyss of adverse patent outcomes. 2. Nursng Servces are furnshed or supervsed by a Regstered Nurse to meet the patent care needs accordng to standards of practce and care. The followng polcy and procedures have been revsed: Nursng are of Physcal Health Emergences, ntegrated Assessment, Nursng Reassessment, Medcaton Now/Stat, Self Admnstraton of Medcaton, ode Blue, Durable Medcal Equpment and ontactng Physcans. The Nursng Staff have receved tranng on all polcy changes and focused tranng on the followng: The Assessment Process, Treatment Plannng Process, ode Blue. 3. Provson of ntensve educaton and tranng, and competency assessment for all RN's n the areas of assessment, treatment plannng, nterventon, supervson and montorng of nursng care 03/01/08 VWJJ11 f contnuaton sheet Page 35 of 86

3 (X 1) PROVDER/SUPPLER/LA DENTFATON NUMBER: SUMMARY (EAH DEFENY MUST BE PREEDED BY FULL REGULATORY OR LS DENTFYNG NFORMATON) (X2) MULTPLE ONSTRUTON A. BULDNG B. WNG STREET ADDRESS, TY, STATE, ZP ODE 8001 BRUEVLLE ROAD 10 PROVDER'S PLAN OF ORRETON (EAH ORRETVE ATON SHOULD BE ROSS-REFERENED TO THE APPROPRATE DEFENY) Prnted: 03/18/2008 OMPLETON A 347 ontnued From page 35 symptom and would expect to be nformed of any problems assocated wth chest pan as soon as possble. He dd not know Patent 1 had been admtted, dd not know about Patent's medcal problems or treatment plans. He sad that the medcal staff reled on hosptal staff to dentfy crtcal medcal problems and any change n condton when doctors were not present n the hosptal. He stated "absolutely" that any change n condton warrants a cau to the physcan. n an ntervew wth the Vce Presdent of the Medcal Staff (Dr. 7) on 02/28/08 at 11 :30 a.m., Dr. 7 stated the hosptal had a hgh rate of emergency room transfers, "probably hgher than 10%." Dr. 7 sad the medcal staff was reevaluatng the protocol for drug and alcohol detox. Dr. 7 beleved the alcohol detox "AWS" (alcohol wthdrawal scorng scale) relably. dentfed detox stuatons that became medcally complcated by a scorng system that would allow medcal nterventons to occur early, and could safely permt the physcan to be notfed and the patent transferred to an emergency room where hgher level of care could be provded. Dr. 7 stated he expected staff to notfy the physcan f a patent's detox course was medcally complcated or demonstratng unexpected sgns or symptoms. Dr. 7 stated that the medcal staff and admnstraton are jontly responsble for patent care and operaton of the hosptal systems. Revew of the Alcohol Wthdrawal Scale (AWS) Score, montorng gude for detox patents, ndcated a score of 25 would trgger callng the physan. ertan vtal sgn measurements. would also trgger a physcan notfcaton. Patent 1 had a maxmum score of 14 whch would not trgger a call to the physcan. n an ntervew wth the Medcal Drector on 02/29/08 at 4:30 p.m., the =ORM MS-2567(02-99) Prevous Versons Obsolete A The DON, Nursng Supervsors and Nurse Managers wll proctor and coach RN's on a daly bass. E. Serra Vsta Hosptal medcal staff now assures that ongong nursng care as a qualty performance ndcator n ts QAP program. 1. Through the nursng processes already tracked through closed chart audts, all charts wll be concurrently audted for nursng processes on a "Daly Medcal Record Nght Audt" sheet and defcences are mmedately addressed and corrected. Results of these audts are talled are reported through the Qualty ouncl Responsblty: Medcal Drector EO DON Drector P Montorng: All credentalng s presented n the redentals ommttee and through the ME monthly and BOT quarterly 1. The DON/DS ensured effectveness of tranng by montorng 100% of concurrent assessment-reassessment whch ncluded medcal problems for 30 days. After 30 days, montorng wll nclude concurrent revew of 100% of admssons whch nclude actve medcal problems and n... nnll"" fnr 100 o/ ~ f contnuaton sheet Page 36 of 86 VWJJ11

4 Prnted: 03/18/2008 (X 1) PROVDER/SUPPLER/LA DENTFATON NUMBER: (X2) MULTPLE ONSTRUTON A. BULDNG B. WNG STREET ADDRESS, TY, STATE, ZP ODE 8001 BRUEVLLE ROAD SUMMARY (EAH DEFENY MUST BE PREEDED BY FULL REGULATORY OR LS DENTFYNG NFORMATON) 10 PROVDER'S PLAN OF ORRETON (EAH ORRETVE ATON SHOULD BE ROSS-REFERENED TO THE APPROPRATE DEFENY) OMPLETON A 347 ontnued From page 36 Medcal Drector stated the threshold for notfyng the physcan on the AWS scale had been reduced to 15. Ths score stll would not have : dentfed Patent 1 as medcally complcated. Revew of the AWS for Patent 1 revealed an AWS score of zero on admsson despte Patent 1 's complant of chest pan and labored breathng wth sleep that requred a PAP machne. Patent 1 contnued to score zero that evenng untl he lad n bed and fell asleep. Vtal sgns were not measured through ths perod of 7 hours whle lyng n bed and sleepng wthout the PAP machne. Then Patent 1 was found on the floor and descrbed hs legs felt lke jello. The AWS, had no category for and dd not ncorporate n any exstng category falls, balance dsturbance, weakness, dzzness, or unexpected events. After Patent 1 was found on the floor, the AWS score was 14 n the "moderate" range and dd not trgger physcan notfcaton. Over the next hour, the scores dropped to 10 and 6 and 4 suggestng mprovement and medcal stablty. Approxmately one hour after ths, Patent 1 developed a cardorespratory arrest. n an ntervew wth Dr. 5 on 02/28/08 at 7:00 p.m., Dr. 5 stated, "of course expect the nurse to notfy me f a patent complans of chest pan, shortness of breath, or persstent pan," and "a nurse should know to always call the physcan for crtcal condtons that we consder red flags." He also stated that some detox cases need a hosptal settng. Detox treatment medcatons such as Vstarl can precptate a hypertensve crss, and the ncreased rsk mght warrant care n another settng. He agreed that longstandng alcoholsm carres rsks for cardomyopathy, lver falure and other organ damage that can make these patents more medcally complex. A 347 complance. 2. The montorng tool for communcaton effcency s the "Physcan ontact Log" whch montors the escalaton process from Physcan to Admnstrator on all (AO) and/or Medcal Drector. 3. n addton to the nursng processes already tracked through closed chart audts, all charts wll be concurrently audted for nursng processes on a "Daly Medcal Record Nght Audt" sheet and defcences medately addressed and corrected. 3. The faclty has undertaken a comprehensve revew and revson of the nursng department P plan and prortzed those processes that need to be captured, tracked, trended, and analyzed. Meanngful actons and ndcators have been developed and mplemented based upon hgh-rsk, hgh-volume and problem prone crtera. FORM MS-2567{02-99) Prevous Versons Obsolete VWJJ11 f contnuaton sheet Page 37 of 86

5 (X 1) PROVDER/SUPPLER/LA DENTFATON NUMBER: (X2) MULTPLE ONSTRUTON A. BULDNG B. WNG STREET ADDRESS, TY, STATE, ZP ODE 8001 BRUEVLLE ROAD Prnted: 03/18/2008 (X4)D SUMMARY (EAH DEFENY MUST BE PREEDED BY FULL REGULATORY OR LS DENTFYNG NFORMATON) 10 PROVDER'S PLAN OF ORRETON (EAH ORRETVE ATON SHOULD BE ROSS-REFERENED TO THE APPROPRATE DEFENY) OMPLETON A 347 ontnued From page 37 A 347 n an ntervew wth Dr. 8 on 02/26/08 at 4:00 p.m., Dr. 8 stated, "the patents have a hgher acuty. thnk we take patents who are too sck. Maybe we shouldn't be dong that." n an ntervew wth the Medcal Drector on 02/29/08 at 4:30 p.m., the Medcal Drector agreed the medcal staff s accountable to the governng body and s responsble for all care to patents ncludng nursng care. The Medcal Drector stated the patents n general were scker today, the acuty at the hosptal was hgher, the medcal staff needed to develop approaches to respond effectvely and more quckly. She stated, "We need to be more serous and faster." The Medcal Drector also stated she expected nursng care plans to be developed for medcal condtons for whch "pm" orders were ssued, lke asthma. She expected ongong assessments to be done by nursng staff even f the condton s stable and not requrng actve treatment.. Revew of 9 patent records (patents 1, 2, 6, 9, 10, 12, 14, 17,30) on 02/27/08, 02/28/08, and 02/29,08 revealed nstances of serous and Sgnfcant medcal condtons dentfed but not addressed n specfc care plans, montorng orders, or ongong assessments. (cross reference A 0395, A 0396, A 0500) Medcal condtons such as palptatons, shortness of breath, asthma, dzzness, and chest pan were not lsted on the record Problem Lst. n some nstances when such medcal condtons were dentfed by nursng staff, there was no documentaton that the physcan staff had been notfed. n other nstances, the physcan had dentfed a medcal condton and ssued treatment orders but nursng staff dd not provde ongong assessments or a condton-specfc =ORM MS-2567(02-99) Prevous Versons Obsolete VWJJ11 f contnuaton sheet Page 38 of 86

6 (X1) PROVDER/SUPPLlER/LlA DENTFATON NUMBER: (X2) MULTPLE ONSTRUTON A. BULDNG B. WNG STREET ADDRESS, TY, STATE, ZP ODE 8001 BRUEVLLE ROAD Prnted: 03/18/2008 OMB NO SUMMARY (EAH DEFENY MUST BE PREEDED BY FULL REGULATORY OR LS DENTFYNG NFORMATON) 10 PROVDER'S PlAN OF ORRETON (EAH ORRETVE ATON SHOULD BE ROSS-REFERENED TO THE APPROPRATE DEFENY) OMPLETON A 347 ontnued From page 38 montorng plan, A 347 Secton (a) of the Medcal Staff Bylaws drected the medcal staff to "revew patent treatment plans to ensure that each s developed promptly, reapprased as approprate, and revewed, consdered, and followed by members of the approprate treatment team. n an ntervew wth the Medcal Drector on 02/29/08 at 4:30 p.m., the Medcal Drector agreed the medcal staff s accountable to the governng body and s responsble for all care to patents ncludng nursng care. The Medcal Drector stated the patents n general were scker today, the acuty at the hosptal was hgher, the medcal staff needed to develop approaches to respond effectvely and more quckly. She stated, "We need to be more serous and faster." The Medcal Drector also stated she expected nursng care plans to be developed for medcal condtons for whch "prn" orders were ssued, lke asthma. She expected ongong assessments to be done by nursng staff even f the condton s stable and not requrng actve treatment. D. Secton (e) of the Medcal Staff Bylaws drected the medcal staff to revew and assess ncdent reports and make recommendatons to prevent or reduce the potental for future ncdents. On 02/23/08 an mmedate jeopardy was called by the Department regardng the falure of the hosptal to respond tmely to patent care problems related to the death of Patent 1 on 02/17/08. [cross reference A 0395 (1)] n an ntervew wth DS on 02/22/08 he stated he had dentfed problems wth patent care FORM MS-2567(02-99) Prevous Versons Obsolete VWJJ11 f contnuaton sheet Page 39 of 86

7 ex 1) PROVDER/SUPPLlER/LlA DENTFATON NUMBER: (X2) MULTPLE ONSTRUTON A. BULDNG B. WNG STREET ADDRESS, TY, STATE, lp ODE 8001 BRUEVLLE ROAD Prnted: 03/18/2008 SUMMARY (EAH DEFENY MUST BE PREEDED BY FULL REGULATORY OR LS DENTFYNG NFORMATON) 10 PROVDER'S PLAN OF ORRETON (EAH ORRETVE ATON SHOULD BE ROSS-REFERENED TO THE APPROPRATE DEFENY) OMPLETON A 347 ontnued From page 39 related to Patent 1 but had not proceeded wth a response to correct them. A 347 n an ntervew wth Doctor 8 on 02/26/08 at 4:00 p.m., Dr. 8 stated he was a member of the Qualty ommttee. He was aware of the death of Patent 1. He had not been contacted to meet wth the Qualty ommttee to analyze the events surroundng Patent 1's death, to dentfy preventable aspects, and to develop a plan to correct dentfed problems. He stated, " thnk maybe we take patents who are too sck, the acuty s hgher, maybe we shouldn't be dong that. The Drector of Performance mprovement and Rsk Managment n an ntervew on 02/27/08 at 4:30 p.m. (ten days after Patent 1's death) stated that a problem related to the "hand-off' of communcaton between staff had been dentfed from revew of Patent 1's adverse event. He acknowledged the hosptal had a hgh rate of ER transfers. He suggested ER transfers may be necessary and the hgh number may be the baselne for the hgh acuty of ther patents. Other than lookng at the crtera for hosptal admsson, the hosptal had not dentfed nursng care qualty as a focus for correctng the problems related to Patent 1's medcal rsks. n an ntervew wth Doctor 8 on 02/26/08 at 4:00 p.m., Dr. 8 stated te was a member of the Qualty ommttee. He was aware of the death of Patent 1. He had not been contacted to meet wth the Qualty ommttee to analyze the events surroundng Patent 1's death, to dentfy preventable aspects, and to develop a plan to correct dentfed problems. He stated, " thnk maybe we take patents who are too sck, the acuty s hgher, maybe we shouldn't be dong! FORM MS-2567(02-99) Prevous Versons Obsolete VWJJ11 f contnuaton sheet Page 40 of 86

8 (X 1) PROVDER/SUPPLER/LA DENTFATON NUMBER: (X2) MULTPLE ONSTRUTON A. BULDNG B. WNG STREET ADDRESS, TY, STATE, ZP ODE 8001 BRUEVLLE ROAD Prnted: 03/18/2008 OMB NO SUMMARY (EAH DEFENY MUST BE PREEDED BY FULL REGULATORY OR LS DENTFYNG NFORMATON) 10 1 ' PROVDER'S PLAN OF ORRETON (EAH ORRETVE ATON SHOULD BE ROSS-REFERENED TO THE APPROPRATE DEFENY) OMPLETON A 347 ontnued From page 40 that. " A 3471 E. Secton 8.3(d) of the Board of Trustees Bylaws drected the medcal staff to establsh "a process desgned to assure that all ndvduals responsble for the assessment, treatment, or, care of patents are competent n... the ablty to : obtan nformaton and nterpret nformaton fn : terms of the patents needs.,' [and] an understandng of the range of treatment needed by the patents." n 9 of 32 patent records revewed durng the survey, falures to assess, montor and care plan as well as notfy the physcan of sgnfcant medcal condtons were dentfed. [cross reference A 0395 and A 0396] n a separate ntervew wth DS on 02/28/08 at 5:00 p.m., he stated there were no qualty ndcators that focused on nursng care, assessments, or treatment plans other than as mght be captured from revews of ncdent and adverse event reports.,n " an ntervew wth the DeS and Drector of Performance mprovement and Rsk Management on 02/29/08 at 4:00 p.m., they agreed that no qualty ndcators had been created to evaluate ongong nursng care that reflect assessment, care and treatment plannng, and notfyng the physcan, all problems relevant to Patent 1's hgh rsk profle and other patents dentfed n the survey. " A NURSNG SERVES The hosptal must have an organzed nursng servce that provdes 24-hour nursng servces. The nursng servces must be furnshed or supervsed by a regstered nurse. A 385 Serra Vsta Hosptal now ensures that all Nursng Servces are furnshed or supervsed by a Regstered Nurse to meet the patent care needs accordng to standards of practce and care /08 FORM MS-2567(02-99) Prevous Versons Obsolete ' VWJJ11 1/ contnuaton sheet Page 41 or 86

9 (X 1) PROVDER/SUPPLER/LA DENTFATON NUMBER: SUMMARY (EAH DEFENY MUST BE PREEDED BY FULL REGULATORY OR LS DENTFYNG NFORMATON) (X2) MULTPLE ONSTRUTON A BULDNG B. WNG STREET ADDRESS. TY. STATE. ZP ODE 8001 BRUEVLLE ROAD 10 PROVDER'S PLAN OF ORRETON (EAH ORRETVE ATON SHOULD BE ROSS-REFERENED TO THE APPROPRATE DEFENY) Prnted: 03/18/2008 OMB NO OMPLETON A 385 ontnued From page 41 Ths ondton s not met as evdenced by: Based on observatons. staff ntervews. clncal record revews and hosptal document revews. the hosptal dd not meet the ondton of Partcpaton for Nursng Servces when the nursng staff faled to provde organzed nursng servces to meet the needs of patents as evdenced by: 1. The hosptal faled to ensure a RN supervsed 1 the nursng care for each patent on an ongong bases n accordance wth accepted standards of nursng practce for 7 of 32 sampled patents (1, 17,2,6, 10,30,9). On 02/16/08 at 5:20 p.m., the RN faled to assess Patent 1's complant of chest pan adequately. On 02/17/08 at 4:35 a.m. the RN faled to assess and montor Patent 1 to rule out cardac problems, after the patent was found on the floor wth a change of condton. The nght shft RN faled to notfy a physcan that Patent 1 had a change n condton. The RN faled to assess Patent 1 's need for medcal devces and faled to ensure patent breathng was assessed on ongong bases. The RN faled to notfy a physcan and faled to obtan: medcal equpment (PAP) after Patent 1. nformed the RN that he needed PAP at nght, for labored breathng problems. PAP, or ontnuous Postve Arway Pressure, s a devce wth a facemask attached to a tube and a :ORM MS-2567(02-99) Prevous Versens Obsolete A The faclty has ntated ongong tranng for all nursng staff that s focused on the provson of vglant watchful oversght of all patents, wth emphass on renforcement of polces and procedures related to assessment/re-assessment 0 f patents. 2. All RNs have receved aggressve reeducaton regardng expectatons and requrements of ther role n oversght, supervson and drecton of nursng care provded. 3. ntensve educaton and tranng, and competency assessment for all RN's n the area of patent assessment/reassessment, nterventon, supervson and montorng of nursng care has been provded. 4. Revew, revson, educaton and mplementaton of polces and procedures related to nursng care. 5. The Drector of Nursng, and House Supervsors now provde drect supervson, proctorng and coachng of RN's daly. 6. Each RN s now gven wrtten assgnment of specfc patents. Patent assgnments now nclude prompts for any pertnent patent nformaton n order to ensure clncal hand-off communcaton, heghtened awareness and vglance and mplementaton of other safety measures. 7. Defcences n the assessment /reassessment process are mmedately addressed by the DON and Nursng Supervsors wth trends ncorporated nto the departmental and hosptal-wde Performance mprovement Plan. 8. Through the nursng processes ; ) 03/01/08 VWJJ11 f contnuaton sheet Page 42 of 86

10 r (X1) PROVDER/SUPPLER/LA DENTFATON NUMBER: (X2) MULTPLE ONSTRUTON A. BULDNG B. WNG STREET ADDRESS. TY. STATE. ZP ODE 8001 BRUEVLLE ROAD Prnted: 03/18/2008 OMB NO / SUMMARY (EAH DEFENY MUST BE PREEDED BY FULL REGULATORY OR LS DENTFYNG NFORMATON) 10 PROVDER'S PLAN OF ORRETON (EAH ORRETVE ATON SHOULD BE ROSS REFERENED TO THE APPROPRATE DEFENY) OMPLETON ATE A 385 ontnued From page 41 A 385 Ths ondton s not met as evdenced by: Based on observatons, staff ntervews, clncal record revews and hosptal document revews, the hosptal dd not meet the ondton of Partcpaton for Nursng Servces when the nursng staff faled to provde org~nzed nursng servces to meet the needs of patents as evdenced by: 1. The hosptal faled to ensure a RN supervsed the nursng care for each patent on an ongong bases n accordance wth accepted standards of nursng practce for 7 of 32 sampled patents (1, 17,2,6, 10,30,9). On 02/16/08 at 5:20 p.m., the RN faled to assess Patent 1's complant of chest pan adequately. On 02/17/08 at 4: 35 a. m. the RN faled to assess and montor Patent 1 to rule out cardac problems, after the p~tent was found on the floor wth a change of condton. The nght shft RN faled to notfy a physcan that Patent 1 had a change n condton. The RN faled to assess Patent 1's need for medcal devces and faled to ensure patent breathng was assessed on ongong bases. The. RN faled to notfy a physcan and faled to obtan medcal equpment (PAP) after Patent 1 nformed the RN that he needed PAP at nght for labored breathng problems. PAP, or ontnuous Postve Arway Pressure, s a devce wth a face mask attached to a tube and a currently tracked through closed chart audts, all charts are concurrently audted for nursng processes on a "Daly Medcal Record Nght Audt" sheet and defcences are mmedately addressed and corrected. Results of these audts are talled and reported thought the Qualty ouncl. 9. All agency staff receves tranng on the hosptal's expectatons and requrements of ther role n the provson of nursng care provded pror to workng a shft on the unt. 10. The faclty wll ensure that unts are staffed wth ndvduals who are competent, capable and well-suted to meet the needs of the patents served.. The Drector of Nursng and House Supervsors now provde drect supervson, proctorng and coachng of RN's daly. 12. The followng polcy and procedures have been revsed: Nursng are of Physcal Health Emergences, ntegrated Assessment, Nursng Re-assessment, Medcaton Now/Stat, Self-Admnstraton of Medcaton, ode Blue, Durable Medcal Equpment and ontactng Physcans. The Nursng Staff have receved tranng on all polcy changes and focused tranng on the followng: The Assessment Process, Treatment Plannng Process, and ode Blue. 13. The Drector of Nursng and Nursng Supervsors evaluate all nursng medcaton errors to dentfy trends or ndvdual staff coachng requred. 02/22/08 =ORM MS-2567(02~99) Prevous Versons Obsolete. VWJJ11 f contnuaton sheet Page ftcf 86 q,za

11 (X 1) PROVDER/SUPPLER/LA DENTFATON NUMBER: (X2) MULTPLE ONSTRUTON A. BULDNG B. WNG Prnted: 03/18/2008 OMB NO /2008 STREET ADDRESS. TY. STATE. ZP ODE 8001 BRUEVLLE ROAD SUMMARY (EAH DEFENY MUST BE PREEDED BY FULL REGULATORY OR LS DENTFYNG NFORMATON) 10 PROVDER'S PLAN OF ORRETON (EAH ORRETVE ATON SHOULD BE ROSS-REFERENED TO THE APPROPRATE DEFENY) OMPLETON A 385 ontnued From page 41 A385 Responsblty: Ths ondton s not met as evdenced by: Based on observatons, staff ntervews, clncal record revews and hosptal document revews, the hosptal dd not meet the ondton of Partcpaton for Nursng Servces when the nursng staff faled to provrde organzed nursng servces to meet the needs of patents as evdenced by: 1. The hosptal faled to ensure a RN supervsed the nursng care for each patent on an ongong bases n accordance wth accepted standards of nursng practce for 7 of 32 sampled patents (1, 17, 2, 6, 1 0, 30, 9). On 02/16/08 at 5:20 p.m., the RN faled to assess Patent 1's complant of chest pan adequately. On at 4:35 a.m. the RN faled to assess and montor Patent 1 to rule out cardac problems, after the patent was found on the floor wth a change of condton. The nght shft RN faled to notfy a physcan that Patent 1 had a change n condton. The RN faled to assess Patent 1 's need for medcal devces and faled to ensure patent breathng was assessed on ongong bases. The RN faled to notfy a physcan and faled to obtan medcal equpment (PAP) after Patent 1 nformed the RN that he needed PAP at nght for labored breathng problems. PAP, or ontnuous Postve Arway Pressure, s a devce wth a facemask attached to a tube and a DON EO Medcal Drector HRD Montorng. The DON ensures effectveness of tranng by montorng 100% of concurrent assessment-reassessment, treatment plans, medcaton management and approprate nterventons based on standards of nursng practce. Nursng competency n RN assessment/re-assessment wll be evaluated durng probatonary perod and annually thereafter. 2. The "Daly Medcal Record Nght Audt" sheets are montored daly on weekdays and quantfed at the close of the month by the DON. The results are reported to the Drector of P for trackng and trendng purposes and the results reported to the Qualty ouncl and ME on a monthly bass and the BOT quarterly. ;ORM MS Prevous Versons Obsolete VWJJ11 f contnuaton sheet Page p

12 (X 1) PROVDER/SUPPLlER/LlA DENTFATON NUMBER: SUMMARY! (EAH DEFENY MUST BE PREEDED BY FULL REGULATORY OR LS DENTFYNG NFORMATON) A 3851 ontnued From page 42 machne that blows pressurzed ar nto the mask 'and through the arway to keep t open, usually prescrbed by a physcan to treat sleep apnea, a condton characterzed by epsodes of stopped breathng durng sleep. (X2) MULTPLE ONSTRUTON A. BULDNG B, WNG STREET ADDRESS, TY, STATE, ZP ODE 8001 BRUEVLLE ROAD 10 1 A 3851 PROVDER'S PLAN OF ORRETON (EAH ORRETVE ATON SHOULD BE ROSS-REFERENED TO THE APPROPRATE DEFENY) Prnted: 03/18/2008 OMPLETON The defcent practces that resulted n Patent 1's nadequate assessments and n Patent 1 not recevng the necessary medcal equpment, presented an mmedate rsk to patents' safety. An mmedate Jeopardy (J) was called on 02/22/08 at 2:10 p.m. The faclty submtted an acceptable nterm Plan of orrecton (PO) on, 02/22/08 at 6:35 p.m. The J was lfted on 02/25/08 at 6:00 p.m., after fnal acceptable PO was mplemented by the faclty. (cross reference A 395) 12. The faclty faled to ensure they had adequate numbers of lcensed staff and other personnel to ; provde nursng care to patents accordng to the faclty's polcy and procedure on 02/16/08 (a.m.!, and evenng shft) and 02/17/08 (a.m. shft).(cross reference A 392) 3. The hosptal faled to ensure that the nursng staff developed and kept current, nursng care plans for 7 of 32 sampled patents (1, 2, 6, 14, 10 30, 9). (cross reference A 396) 4. The faclty faled to admnster drugs as! ordered by the physcan and n accordance wth accepted standards of practce for 5 of 32, sampled patents (5, 9, 12 17,26). (ross reference A 404) A 392: {b) STAFFNG AND DELVERY OF AR The nursng servce must have adequate numbers of lcensed regstered nurses, lcensee practcal (vocatonal) nurses, and other personn )RM MS-2567(02-99) Prevous Versons Obsolete The faclty now ensures that adequate numbers of lcensed staff and other personnel are avalable to provde nursng care to patents. 02/22/08 Ongong

13 (X1) PROVDER/SUPPLER/LA DENTFATON NUMBER: SUMMARY (EAH DEFENY MUST BE PREEDED BY FULL REGULATORY OR LS DENTFYNG NFORMATON) A 3921 ontnued From page 43 to provde nursng care to all patents as needed. There must be supervsory and staff personnel for each department or nursng unt to ensure, when needed, the mmedate avalablty of a regstered nurse for bedsde care of any patent. Ths Standard s not met as evdenced by:. Based on staff ntervew, record revew and P&P revew the faclty faled to ensure they had adequate numbers of lcensed staff and other personnel to provde nursng care to patents accordng to the faclty's P&P on 02/16/08 (a.m., and evenng shft) and 02/17/08 (a.m. shft). Fndngs: On 02/27/08 at 3:00 p.m. a revew of the faclty's P&P ttled "Patent A~uty and Staffng Factors" (# rev. 2-7) was conducted. The polcy ndcated n part that nursng servces utlze a 24 hour staffng pattern based on the acuty of the unt. A RN s assgned to each shft for each unt. There s a mnmum of two staff members assgned to each unt per shft, one of whch s to ~ be the assgned regstered nurse. All patents are assessed by the RN each shft for acuty. All patents have a standard of 1.50 hours of care per shft on the days and p.m. shft and 0.50 hours on the nght shft. On 02/27/08 a rev,ew of the staffng records from 02/14/08 through 02/21/08 on unts A, B,, and ORM MS-2567(02-99) Prevous Versons Obsolete (X2) MUL TlPLE ONSTRUTON A. BULDNG B, WNG STREET ADDRESS. TY. STATE. ZP ODE 8001 BRUEVLLE ROAD 10 A 392 j PROVDER'S PLAN OF ORRETON (EAH ORRETVE ATON SHOULD BE ROSS-REFERENED TO THE APPROPRATE DEFENY). The staffng pattern and acuty system have been revewed and revsed to ensure suffcent numbers and skll mx of staff on each unt based upon admsson and dscharge volumes, census, acuty, and the ndvdual needs of patents. 2. Nursng Supervsors receved educaton on the use of the acuty system and now approve all patent classfcatons before forwardng to the staffng coordnator. 3. Every patent s now assgned to an RN, each shft, wth prmary responsblty for patent care. 4. The faclty s aggressvely recrutng lcensed nursng staff usng all avalable resources and means. Responsble: BOT EO DON HRD Montorng:. A varance report and audtng tool has been developed and mplemented to dentfy and address any varances or gaps n staffng based on volumes and acuty. 2. The DON/DS now revews acuty daly and report complance wth acuty monthly to the Qualty ouncl. Prnted: 03/18/2008 " OMPLETON VWJJ11 f contnuaton sheet Page 44 of 86

14 AND PLA.N OF ORRETON (X 1) PROVDER/SUPPLER/LA DENTFATON NUMBER: SUMMARY (EAH DEFENY MUST BE PREEDED BY FULL REGULATORY OR LS DENTFYNG NFORMATON) A 392 ontnued From page 43 to provde nursng care to all patents as needed. There must be supervsory and staff personnel for each department or nursng unt to ensure, when needed, the mmedate avalablty of a regstered nurse for bedsde care of any patent. (X2) MUL TPLE ONSTRUTON A. BULDNG B, WNG STREET ADDRESS, TY, STATE, ZP ODE 8001 BRUEVLLE ROAD 10 A 392 PROVDER'S PLAN OF ORRETON (EAH ORRETVE ATON SHOULD BE ROSS-REFERENED TO THE APPROPRATE DEFENY) 3. The Staffng Plan s revewed annually by the DON and HRD and presented to ME and BOT for approval and oversght. Prnted: 03/18/2008 OMB NO , (XS) OMPLETON Ths Standard s not met as evdenced by: Based on staff ntervew, record rev~w and P&P revew the faclty faled to ensure they had 1 adequate numbers of lcensed staff and other personnel to provde nursng care to patents accordng to the faclty's P&P on 02/16/08 (a.m., and evenng shft) and 02/17/08 (a.m. shft). ' Fndngs: On 02/27108 at 3:00 p.m. a revew of the faclty's P&P ttled "Patent Acuty and Staffng Factors" (# rev. 2-7) was conducted. The polcy ndcated n part that nursng servces utlze a 24 hour staffng pattern based on the acuty of the unt. A RN s assgned to each shft for each unt.. There s a mnmum of two staff members, assgned to each unt per shft, one of whch s to! be the assgned regstered nurse. All patents are assessed by the RN each shft for acuty. All patents have a standard of 1.50 hours of care per shft on the days and p.m. shft and 0.50 hours on the nght shft. On 02/27/08 a revew of the staffng records from 02/14/08 through 02/21/08 on unts A, B,, and )RM MS-2567(02-99) Prevous Versons Obsolete WJJJ11 f contnuaton sheet PageJA"~r 66,{'fa

15 (X 1) PROVDER/SUPPLER/LA DENTFATON NUMBER: (X2) MULTPLE ONSTRUTON A. BULDNG B. WNG STREET ADDRESS. TY. STATE. ZP ODE 8001 BRUEVLLE ROAD SA.RAMENTO, A Prnted: 03/18/2008 OMB NO SUMMARY (EAH DEFENY MUST BE PREEDED BY FULL REGULATORY OR LS DENTFYNG NFORMATON) 10 PROVDER'S PLAN OF ORRETON (EAH ORRETVE ATON SHOULD BE ROSS-REFERENED TO THE APPROPRATE DEFENY) OMPLETON A 392 ontnued From page 44 D were conducted wth the DS. Revew of Unt B's staffng records for 02/16/08 day shft, showed a patent census of 20 patents (ths number ncluded 1 patent that requred 1: 1 for ADL'S - actvtes of daly lvng). The DS sad that the nursng care hour requrement was not met on ths shft. The hours requred were 43 hours but actual care hours provded were 32. He sad the staff person that dd the acuty dd t ncorrectly. A 392 On the evenng shft of 02/16/08 the DS confrmed that the census was 20 patents, whch ncluded a patent that was montored for lne of sght. He confrmed that the requred hours were 34.5 hours and the staffng was short by 2.5 hours. Revew of the staffng record for 02/17/08 ndcated that day shft had a census of 21 patents. The DS confrmed that the requred amount of hours were 35.5 hours but the actual hours provded were 32.0 hours, 3.5 hours short of the requrement. A (b)(3) RN SUPERVSON OF NURSNG ARE A regstered nurse must supervse and evaluate the nursng care for each patent. A 395 The Hosptal now ensures that a regstered nurse supervses and evaluates nursng care for each patent. 02/22/08 Ongong Ths Standard s not met as evdenced by: Based on patent and staff ntervews and clncal : record revew, the hosptal faled to ensure a RN supervsed the nursng care for each patent on an ongong bases n accordance wth accepted standards of nursng practce for 7 of 32 sampled patents (1, 17, 2, 6, 10, 30, 9 ). :ORM MS-2567(02-99) Prevous Versons Obsolete 1. Provson of ntensve educaton and tranng, and competency assessment for all RN's n the areas of assessment, treatment plannng, nterventon, supervson and montorng of nursng care. 2. Durable medcal equpment- Polcy Medcal Durable Equpment was wrtten to assst Nursng Staff to understand and show how to access durable medcal equpment when VWJJ11 f contnuaton sheet Page 45 of 86!

16 (X 1) PROVDER/SUPPLlER/LlA DENTFATON NUMBER: SUMMARY (EAH DEFENY MUST BE PREEDED BY FULL REGULATORY OR LS DENTFYNG NFORMATON) A 395 ontnued From page The RNs faled to provde ongong assessments of patents wth medcal symptoms such as chest pan and breathng problems for Patent 1. a. On 02/16/08 at 5:20 p.m., the RN faled to assess Patent 1's complant of chest pan adequately. On 02/17/08 at 4:35 a.m. the RN faled to assess and montor Patent 1 to rule out v; cardac problems, after the patent was found on the floor wth a change of condton. The nght shft RN faled to notfy a physcan that Patent 1 had a change n condton. b. The RN faled to assess Patent 1 's need for medcal devces and faled to ensure patent breathng was assessed on ongong bases. The RN faled to notfy a physcan and faled to obtan medcal equpment (PAP) after Patent 1 nformed the RN that he needed PAP at nght for labored breathng problems. PAP, or ontnuous Postve Arway Pressure, s a devce wth a facemask attached to a tube and a machne that blows pressurzed ar nto the mask and through the arway to keep t open, usually prescrbed by a physcan to treat sleep apnea, a condton charactered by epsodes of stopped breathng durng sleep. The defcent practces that resulted n Patent 1's nadequate assessments and n Patent 1 not recevng the necessary medcal equpment, presented an mmedate rsk to patents' safety. An mmedate Jeopardy (J) was called on 02/22/08 at 2:10 p.m. The faclty submtted an acceptable nterm Plan of orrecton (Pa) on 02/22/08 at 6:35 p.m. The J was lfted on 02/25/08 at 6:00 p,m., after fnal acceptable pac was mplemented by the faclty. 'ORM MS-2567(02-99) Prevous Versons Obsolete (X2) MULTPLE ONSTRUTON A. BULDNG B. WNG STREET ADDRESS, TY, STATE, ZP ODE 8001 BRUEVLLE ROAD 10 A 395 PROVDER'S PLAN OF ORRETON (EAH ORRETVE ATON SHOULD BE ROSS-REFERENED TO THE APPROPRATE DEFENY) necessary for patents. Staff was traned on ths new polcy pror to begnnng ther shft on Ths process contnued untl all staff had been traned. 3. AssessmentJRe-assessment of the Patent - All Polces and Procedures under lacal Servces have been revewed and are currently beng revsed where needed, specfcally regardng Assessment and Reassessment of the Patent. All revsed polces wll be mmedately revewed by all staff through a tranng schedule. Polcy Nursng are of Physcal Health Emergenes and Polcy ntegrated Assessment have been revsed to hghlght callng 911 pror to contactng the MD and clarty on the assessment and reassessment of patents. Nursng staff was traned on these polces. Tranng Began on the evenng shft on pror to begnnng ther shft and was ongong untl all staff was traned and hghlghted: allng 911 pror to contactng the M D and ; larty on the assessment and re-assessment of patents; dentfcaton of potental medcal rsks; RN responsbltes for assessment and renf thp n~tpnt Prnted: 03/18/2008, 1 OMPLETON VWJJ11 f contnuaton sheet Page 46 of 86

17 (X 1) PROVDER/SUPPLlER/LlA DENTFATON NUMBER: (X2) MULTPLE ONSTRUTON A. BULDNG B. WNG STREET ADDRESS. TY, STATE. ZP ODE 8001 BRUEVLLE ROAD Prnted: 03/18/2008 SUMMARY (EAH DEF~ENY MUST BE PREEDED BY FULL REGULATORY OR LS DENTFYNG NFORMATON) 10 PROVDER'S PLAN OF ORRETON (EAH ORRETVE ATON SHOULD BE ROSS-REFERENED TO THE APPROPRATE DEFENY) OMPLETON A 395 ontnued From page The nursng staff faled to evaluate Patent 17's care when the patent complaned of multple medcal problems on admsson on 02/26/ The nursng staff faled to evaluate Patent 2's medcal problems. Patent 2 was not adequately assessed and medcated for pan. 4. The nursng staff faled to adequately assess Patent 6's pan The nursng staff faled to assess and evaluate Patent 10's medcal problems and complants of pan on admsson. The nursng staff faled to notfy the physcan. The nursng staff faled to note orders tmely. The nursng staff faled to assess and evaluate Patent 10's complants of pan, when pan medcaton was admnstered. 6. The nursng staff faled to noufy the physcan of Patent 30's medcal problems, and faled to adequately assess,evaluate and act upon Patent 30's complant of pan on admsson. The nursng staff faled to assess and reassess Patent 30's pan levels when Soma (skeletal muscle relaxant medcaton) was admnstered. 7. The faclty faled to notfy the physcan n a tmely manner when they wated 40 mnutes to report that Patent 9, contnued to complan of pan. The faclty faled to note physcan's orders n a tmely manner. The faclty faled to perform on-gong assessments when Patent 9 complaned of pan and faled to perform pan assessment pror to and after medcaton admnstraton of PRN medcaton (Mylanta). Fndngs: 1. The 02/21/08 clncal record revew showed an =ORM MS-2567(02-99) Prevous Versons Obsolete A 395 wth alteratons n medcal status; ontact of the physcan wth dent fed and escalatng medcal concerns. 4. ommuncaton of potental medcally compromsed patent to the physcan - Serra Vsta now ensures that Polcy ' Reassessment of the Patent was updated to nclude procedures for contactng the physcan when changes to a patent status. Addtonally, a memo was wrtten on to all Nursng Staff outlnng the physcan notfcaton protocols and was dstrbuted to all clncal unts. All nursng staff was traned on the polcy and memo pror to reportng to ther shft on Ths process contnued untl all staff was traned. Medcal Staff Polcy Physcan Notfcaton for Medcal/Psychatrc Emergences was developed to match the nursng polces and procedures and to assure the current call system was defned for the Medcal staff as well. Approved n Aprl 2008 ME and BOT.5. The DON, NS's and NM's wll proctor and coach RN' s on a daly bass. 6. Each RN wll be assgned a lst of specfc patents. The patent assgnment wll nclude prompts for the specal needs and VWJJ11 f contnuaton sheet Page 47 of 86

18 (X 1) PROVDER/SUPPLER/LA DENTFATON NUMBER: (X2) MULTPLE ONSTRUTON A. BULDNG B. WNG STREET ADDRESS. TY. STATE. ZP ODE 8001 BRUEVLLE ROAD Prnted: 03/18/2008 SUMMARY (EAH DEFENY MUST BE PREEDED BY FULL REGULATORY OR LS DENTFYNG NFORMATON) 10 PROVDER'S PLAN OF ORRETON (EAH ORRETVE ATON SHOULD BE ROSS-REFERENED TO THE APPROPRATE DEFENY) (XS) OMPLETON A 395 ontnued From page 47 ntake Form dated 02/16/08, 4:00 p.m., ndcatng Patent 1 was a "walk-n assessment" admtted to the hosptal, S unt, voluntarly, for severe ETOH (alcohol) abuse and depresson. The patent's wfe ndcated Patent 1 was drnkng a bottle of wne per nght as well as hard ETOH and that the patent was mxng the ETOH wth hs psychotropc medcatons. The 02/16/08,4:00 p.m., admsson physcan orders ndcated Patent 1 had an ETOH dependency. The orders contaned telephone Adult Sedatve/Hypnotc/Alcohol Detox Orders dated 02/16/08, 4:00 p.m., for Atvan 2 mg by mouth, to gve upon admsson and for Atvan per "Z" score and per Alcohol Wthdrawal Score (AWS) dosng as follows: 1). Mld-1 mg of Atvan by mouth or by ntramuscular njecton 2). Moderate-2 mg of Atvan by mouth or by ntramuscular njecton 3). Severe-3 mg of Atvan by mouth or by ntramuscular njecton Revew of the Medcaton Admnstraton Record (MAR) ndcated Atvan 2 mg was admnstered to Patent 1 by mouth on admsson on 02/16/08 at 5:00 p.m. Revew of the ntal ntegrated Nursng Screenng Part (face-to-face) assessment, completed by a RN (Regstered Nurse, RN A) on 02/16/08 at 5:20 p.m., ndcated that Patent 1 was a 55 years old male who walked nto the hosptal on 02/16/08 at 4: 15 p.m.., accompaned by hs wfe. Patent 1 was noted alert, orented tmes four, and cooperatve durng the nursng assessment. The vtal sgns were documented on the Part assessment as follows: blood pressure (SP) 81/54, pulse (P) 91, respratons (R) 24 and temperature 96.2 (F). The patent's heght and :ORM MS-2567(02-99) Prevous Versons Obsolete A395 ndvdualzed care of each patent. RN supervsors wll ensure the delvery of nursng care that meets the needs of the patents as assgned. 7. Defcences n nursng assessment, reassessment, care of the patent and/or documentaton w be mmedately addressed, wth trends ncorporated nto the departmental and hosptal-wde Performance mprovement Plan. Persons Responsble DON NSNM DPRM Drector Assessment & Referral (DAR) Montorng Mechansm:. A pre-admsson medcal screenng form s completed on all patents pror to admsson that now ncludes assessment of durable medcal equpment needs. 2. Montorng wll nclude a concurrent revew by nursng supervsor ensurng patents durable medcal equpment needs are met. 100% of patent's medcal equpment needs and complance wth polcy wll be reported monthly to the Q ommttee. 3. The DON ensures effectveness of tranng by montorng 100% of concurrent l nlam. VWJJ11 f contnuaton sheet Page 48 of 86

19 , (X 1) PROVDER/SUPPLlER/LlA DENTFATON NUMBER: SUMMARY (EAH DEFENY MUST BE PREEDED BY FULL REGULATORY OR ls DENTFYNG NFORMATON) A 395 ontnued From page 48 weght were 5'11" and 234 pounds, respectvely. n the secton "revew of systems," RN A documented the followng treatment plan ssues for Patent 1: cardovascular problems for hypertenson, respratory problems for labored breathng evdenced by when sleepng-need PAP every nghtll and gastrontestnal problems for GERD evdenced by have acd reflux. take Nexum." The pan ntensty-scorng tool ndcated Patent 1 reported havng pan n the left chest at 6 out of 10 (on a scale 0-10) ndcatve of severe pan per chart on the form, The RN noted the patent took odene and Vcodn for the pan and alcohol worsen the pan. The RN ndcated on the form that the chest pan was not a treatment plan ssue, n the "sleep" secton, the nurse documented that Patent 1 had dffcultes gong to sleep and had "sleep apnea," notng t as a treatment plan ssue. The assessment comments secton dd not ndcate that a physcan was notfed about the chest pan or about the need for PAP at nght for Patent 1. Revew of physcan orders showed no orders for PAP for Patent 1. There was no ndcaton n the physcan orders, hstory and physcal, physcan progress notes, or nursng notes that the physcan was aware of Patent 1 complanng of chest pan and needng PAP. There was no documentaton n the record that Patent 1 was assessed to determne f the chest pan was cardac related. (X2) MULTPLE ONSTRUTON A. BULDNG B. WNG STREET ADDRESS, TY, STATE. ZP ODE 8001 BRUEVLLE ROAD 10 A 395 PROVDER'S PLAN OF ORRETON (EAH ORRETVE ATON SHOULD BE ROSS-REFERENED TO THE APPROPRATE DEFENY) Results of the montorng wll be reported monthly to the Q, ME and quarterly to the BOT. Nursng competency n RN assessment/re-assessment wll be evaluated durng probatonary perod and annually thereafter. 4. The "Daly Medcal Record Nght Audt" sheets are montored daly on weekdays and quantfed at the close of the month by the DON. The results are reported to the DP/RM for trackng and trendng purposes and the results reported to the Q and ME on a monthly bass and the BOT quarterly. 5. The montorng tool for communcaton effcency s the "Physcan ontact Log" whch montors the escalaton process from Physcan to Admnstrator on all (AO) and/or Medcal Drector. The "Physcan ontact Log" wll be montored a 100% of the tme by the NS or desgnee and reported quarterly toq. Prnted: 03/18/2008 OMPLETON On 02/21/08 at 3:30 p.m., RN A confrmed n an ntervew that she performed the ntal face-to-face assessment (part ) of Patent 1 completed on 02/16/08 at 5:20 p.m. The RN stated that as a part of her dutes she performed admsson assessments of patents upon arrval =ORM MS-2567(02-99) Prevous Versons Obsolete VWJJ11 f contnuaton sheet Page 49 of 86

20 !, ex 1) PROVDER/SUPPLER/LA DENTFATON NUMBER: ex2) MULTPLE ONSTRUTON A. BULDNG B, WNG STREET ADDRESS, TY, STATE, ZP ODE 8001 BRUEVLLE ROAD. Prnted: 03/18/2008 ex4) 10 SUMMARY (EAH DEFENY MUST BE PREEDED BY FULL ' REGULATORY OR LS DENTFYNG NFORMATON) 10 PROVDER'S PLAN OF ORRETON (EAH ORRETVE ATON SHOULD BE ROSS-REFERENED TO THE APPROPRATE DEFENY) OMPLETON A 395/ ontnued From page 49 1 to the unt. She "just followed the form" n the, admsson packet when assessng patents.! When patents answered yes to any questons, ; then she developed a plan of care for that : partcular problem. She recalled Patent 1's arrval to the S unt on 02116/08. The RN stated that Patent A was a walk-n patent, voluntary! admsson, from home, escorted by hs wfe. The patent looked obese. The patent's face was "flushed" when she talked wth hm. The patent told her he drank a bottle of wne every nght and now he could not work. The RN confrmed that Patent 1 complaned of pan n hs left chest (the nurse ponted to her left chest area) at 6 out of 10 (0-10 pan scale, 10 beng the worse pan). The. RN stated she dd not ask any more questons regardng the chest pan because Patent 1 dd not look sck and she dd not beleve the patent. She documented t because she "just followed the form." The RN checked the clncal record and confrmed that she dd not ntate the chest pan as a treatment plan ssue. She was not sure of the reason. The RN confrmed she dd not notfy the physcan of the chest pan because the patent dd not look sck to her. A 3951 RN A stated that Patent A told her that he needed PAP every nght for hs sleep apnea (condton wth perods of stopped breathng durng hours of sleep). The patent told the RN the PAP was at -home and he would tell hs wfe to brng t n the next day. When asked what the plan was for the upcomng nght, the RN stated that she developed a care plan ndcatng the patent needed the PAP but she dd not ensure Patent 1 had the PAP. She stated she dd not thnk the patent was gong to de. (The patent expred on 02/17108 after staff found the patent unresponsve n hs room on 02/17108 at approxmately 7:00 a.m.). The RN stated that ths :ORM MS-2567(02-99) Prevous Versons Obsolete VWJJ11 f conllnuatlon sheet Page 50 of 86