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Based on medical record and policy review, as well as interview it was determined that the case management staff failed to assure that all relevant information was contained in the medical record as it pertains to post discharge communication with patients and/or families in one (1) of ten (10) medical records reviewed (Patient #1).

The findings include:

United Medical Center Policy CM - 504 entitled Case Management Department Documentation Guidelines, reviewed/revised August 2011 was reviewed. The Procedure section of the policy stipulates " ...Documentation notes must be clear and concise to depict the course of Social Work Intervention. Note: Some cases may remain open after discharge when continued efforts are made toward problem resolution. Notes are then sent to Medical Records for inclusion in the patient ' s record. A " Late Entry " notation and date must appear in the margin. "

Patient #1 was admitted on October 24, 2012 with diagnoses which included Hypotension, Hypernatremic Dehydration and Unspecified Renal Failure, as well as November 18, 2012 with diagnoses of Congestive Heart Failure and Urinary Tract Infection.

Review of the medical record revealed the patient was discharged to home with resumption of care services on November 14, 2012. At 10:00 AM on November 14, 2012, the social worker documented that a conversation was held with the patient ' s daughters regarding the impending discharge. At 5:40 PM the social worker documented notes detailing that the durable medical equipment (DME) was in place in the home, but required repair. The social worker documented that the vendor was contacted, and provisions were being made to assure repairs could be affected prior to the patient ' s arrival to the home. The medical record lacked documented evidence of case management communications with the patient ' s family and vendors regarding resolution of issues post-discharge.

According to the Nursing Notes, the patient was discharged at approximately 9:45 PM on November 14, 2012. The nurse noted that the daughter was contacted regarding being available to receive the patient at the house.

The patient ' s second discharge occurred December 3, 2012. The patient was discharged to home with hospice services. According to the social worker ' s notes of December 3, 2012 at 2:20 PM and 3:45 PM the case management staff had contacted vendors and suppliers to assure DME and feeding formula and supplies were in place prior to the patient ' s arrival to the home. The medical record lacked documented evidence of case management communications with the patient ' s family and vendors regarding resolution of issues post-discharge.

A face to face interview was conducted with members of the hospital ' s case management staff on February 14, 2013 at approximately 10:14 AM. The staff was queried regarding procedures to assure patients received durable medical equipment when discharged to home with services. The staff members stated they rely on patients and their families to assure and notify them that they have received everything required.

When queried regarding resolution of issues and concerns brought to attention post-discharge, the staff replied that a log and copies of interventions are kept regarding post discharge activities. The staff was asked where in the medical record would the information be found. The staff members responded that they were not aware that post discharge information had to be added to the medical record.

The case management staff failed to include logs of conversations and documentation of post- discharge activities as related to the patient ' s concerns regarding DME and supplies. The case management staff failed to assure the medical record content was complete.

Based on medical record and policy review, as well as interview, it was determined that the hospital staff failed to maintain a medical record which contained all information describing and/or monitoring the patient ' s progress and response to services as it pertains to wound care in one (1) of ten (10) medical records reviewed (Patient #1).

The findings include:

United Medical Center Medical Staff General Rules and Regulations approved September 30, 2010 Article 2 entitled Medical Records was reviewed. Item 2.4 regarding Progress Notes stipulates " ...Wherever possible, each of the patient ' s clinical problems should be clearly identified in the progress notes and correlated with specific orders, as well as results of tests and treatment ... " Item 2.6 regarding Consultations stipulates " ...The consultation report shall include evidence of a review of the patient ' s record by the consultant, pertinent findings on examination of the patient, the consultants opinion and recommendations ...A limited statement, such as " I concur " does not constitute an acceptable report of consultation ... "

United Medical Center Policy PCS 02 - 005 entitled Documentation: Patient Profiles (I-IV) - Graphic, Intake/Output, Activity, Patient Daily Assessment, reviewed October 2011 and revised November 2011 was reviewed. Within the Provisions section, under the category Profile III-Activity, it is stipulated " Activity section: Documentation is required minimally every shift or as patient ' s condition warrants ... Special Care Section: 1. Indicate with a check any care provided; 2. Document wound observations and care in multidisciplinary progress note ... "

United Medical Center Policy PCS 02-012, last revised November 2011, entitled Skin and Wound Care was reviewed. The Provisions section stipulates the following: " The patient ' s nurse will: ...III. Perform a systematic skin inspection ... Document skin inspection findings in the patient record ... VII. Provide skin care after each episode of incontinence and apply a moisture barrier cream for skin protection ... XI. All alterations in skin integrity will be assessed and documented in the patient record. DOCUMENTATION by the patient ' s nurse will include: Location; Stage of pressure ulcer; Size (length, width, and depth); Condition ... XIV. The patient ' s nurse will assess wounds at each dressing change. Documentation of the wound will be done at least ONCE EACH SHIFT and will include: a. Wound location; b. Condition; c. Specific treatment provided ...XV. The patient ' s nurse will measure and stage all wounds AT LEAST ONCE WEEKLY and document ... XVI. The patient ' s nurse will notify the attending physician and the WOC Nurse of alterations in skin integrity that are not improving and document ... "

United Medical Center Policy CM - 504 entitled Case Management Department Documentation Guidelines, reviewed/revised August 2011 was reviewed. The Procedure section of the policy stipulates " ...Documentation notes must be clear and concise to depict the course of Social Work Intervention. Note: Some cases may remain open after discharge when continued efforts are made toward problem resolution. Notes are then sent to Medical Records for inclusion in the patient ' s record. A " Late Entry " notation and date must appear in the margin. "

Patient 1 was admitted on October 24, 2012 with diagnoses which included Hypotension, Hypernatremic Dehydration and Unspecified Renal Failure, as well as November 18, 2012 with diagnoses of Congestive Heart Failure and Urinary Tract Infection.

Review of the Nursing Database of October 24, 2012 at 6:55 AM revealed the patient was assessed with a present on admission (POA) Stage 2 Pressure Ulcer of the Left Buttock, and a Braden Score for Pressure Sore Risk of ten (10), indicative of high risk.

Review of the Nursing Notes for the admission period of October 24, through November 14, 2012 revealed the nursing staff documented " ...blister that ' s intact noted on the right under/inner part of the knee... " on November 4, 2012 at 7:45 PM and " [membrane dressing] applied to right inner knee and left leg. Pillows applied between the legs ...Blister on left leg intact, blister on right knee healing... " on November 6, 2012 at 10:00 PM.

Review of the Nursing Database of November 18, 2012 revealed the presence of three (3) POA wounds - Left Hip, Stage 1, Right Lateral Knee Stage 2 measuring 3.5 x 2 centimeters (cm) and Left Lateral Lower Extremity Partial Thickness Wound measuring 3.5 x 2 cm also.

Review of the Nursing Notes for the admission period of November 18, 2012 through December 3, 2012 revealed the nursing staff failed to document descriptions of all wounds to include location and conditions, and treatments.

The nursing staff failed to consistently document wound assessments to include condition of wound and/or peri-wound with all dressing changes or weekly wound staging and measurements.

The WOCN consultation notes were reviewed. Regarding the admission of October 24, 2012, the nursing staff documented that a WOCN consult was requested October 24, 2012. According to the notes, a WOCN consult was conducted on October 31, 2012. The WOCN documented " Patient seen for wound/skin assessment. Patient is bedbound with urinary and fecal incontinence. Partial thickness wound noted on admission but has closed. Skin protectant provided. "

The WOCN failed to follow the hospital ' s policies regarding timeliness of consultation and completeness of consult notes.

A subsequent consult was requested, and on November 8, 2012 at 12:50 PM the patient was again seen and examined by the WOCN who documented " ...new blisters on lower extremities. Patient with swelling upper and lower extremities. 4.2 x 2 cm [centimeters] open blister, Right Medial Knee - pink, moist, non-draining; no discharge. Blood blister Left Medial Knee 4.2 x 2 cm, intact without erythema. Suggestions provided for local wound care. " A corresponding telephone order was transcribed by the WOCN on November 8, 2012 at 12:45 PM for " 1. Transparent film dressing blister Left Lower Extremity - change weekly. 2. Clean open blister Right Knee with wound cleanser, pat dry - apply Exuderm. Change q [every] three days. "


The medical record reflects that the medical staff examined the patient daily and as needed for consultation purposes. The medical record lacked documented evidence of evaluation of and treatment and or care plans for the wounds by the Attending Physician and Consultants.

The WOCN and medical staff failed to follow the hospital ' s policies regarding documentation of complete progress notes.