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Based on document review and interview, the facility failed to ensure that a registered nurse followed physician orders for 8 of 10 patients (patients #1-5 and 8-10), failed to complete pain assessments per policy for 3 of 10 patients (patient #1, 2 and 9), and failed to provide medications per order to 1 of 10 patients (patients #5).

Findings include:

1. Review of policy/procedure titled "PAIN MANAGEMNT" last reviewed/revised 11/30/14 indicated the following on page 5: "......3. Ongoing nursing assessment for the presence or absence of pain is completed by an RN (registered nurse) a minimum of every shift or more often as patient condition warrants."

2. The RN job description indicated the following under clinical judgement: "......Accurately communicates patient information and thoroughly documents nursing actions and plan of care...."

3. Review of patient #1's medical record for the first visit indicated the following:
(A) He/she was admitted to the facility on 10/6/15 at 0921 hours due to post operative bleeding from surgical site where a Baclofen pump had been placed on 10/5/15.
(B) Orders were written on 10/6/15 at 1321 hours to call M.D. (Medical Doctor) if heartrate was >120 or <50 or O2 sat < 90.
(C) Per clinical assessments flowsheet, the patient had two (2) episodes of heart rate >120. The documentation indicated he/she had a heart rate of 127 at 12:00 on 10/7/15 and a heart rate of 136 at 2000 hours on 10/7/15. The medical record lacked documentation that the physician was notified per order of the increased heartrate of 127 or 136. Review of the medical record indicated that the physician was notified of family member #1's concerns about discharge and increased heartrate, however this notification was at 1829 hours on 10/7/15 and prior to the episode of an increased heartrate of 136.
(D) Pain assessments were not completed per facility policy. There was no pain assessment completed for the 7:00 p.m. to 7:00 a.m. shift on 10/6/15 and 7:00 am. to 7:00 p.m. shift on 10/7/15. The section for the patient's pain score was left blank from 1700 hours on 10/6/15 through 2000 hours on 10/7/15.

4. Review of patient #1's medical record for visit #3 indicated the following:
(A) The patient presented to the ED (emergency department) at 0040 on 11/1/15 for pump malfunction and fever for several days.
(B) An order was written at 0355 on 11/1/15 to call M.D. if heart rate >120 or <50, O2 sat <90%, or systolic blood pressure >180 or <90. The patient had a heart rate of 124 at 0632 hours on 11/3/15 and 126 at 10:00 on 11/3/15. The medical record lacked documentation that the physician was notified per order.
(C) The medical record lacked documentation that pain assessments were completed per policy. There was no pain assessment documented for dayshift on 11/1/15 and 11/6/15.

5. Review of patient #2's medical record indicated the following:
(A) He/she was admitted on 10/4/15.
(B) An order was written at 1533 hours on 10/4/15 to call M.D. if systolic blood pressure <90 or >180, diastolic blood pressure >95, or heart rate <55 or >120.
(C) The medical record indicated the patient's blood pressure was 89/55 at 1600 hours on 10/5/15, 140/111 at 0500 hours on 10/7/15, and 178/100 at 2300 hours on 10/10/15. The medical record lacked documentation that the physician was notified per order of the vital signs.
(D) The medical record lacked documentation of a pain assessment on dayshift on 10/9/15.

6. Review of patient #3's medical record indicated the following:
(A) He/she was admitted to facility on 10/6/15.
(B) An order was written on 10/6/15 to call M.D. if systolic blood pressure >140 or <90 or heart rate >120 or <60.
(C) The medical record indicated the patient had a heart rate of 59 at 0200 hours on 10/7/15, 58 at 0400 hours on 10/7/15, 57 at 0800 hours on 10/7/15, 50 at 0200 hours on 10/8/15, 56 at 0400 hours on 10/8/15, 58 at 0600 hours on 10/8/15, 51 at 12:00 on 10/8/15, 50 at 0000 hours on 10/9/15, 49 at 0200 hours on 10/9/15, 50 at 0400 hours on 10/9/15, and 48 at 0600 hours on 10/9/15. His/her blood pressure was 150/66 at 0000 hours on 10/8/15, 147/66 at 0200 hours on 10/8/15, 147/118 at 2200 hours on 10/8/15, 146/65 at 0000 hours on 10/9/15, 154/68 at 0200 hours on 10/9/15, 155/67 at 0400 hours on 10/9/15, 168/69 at 0600 hours on 10/9/15. The medical record lacked documentation that the physician was notified of the vital signs per order.

7. Review of patient #4's medical record indicated the following:
(A) He/she was admitted on 10/8/15.
(B) An order was written at 0500 hours on 10/8/15 to call M.D. of systolic blood pressure >180 or <90, diastolic blood pressure >100 or <50, or heart rate <50 or > 120.
(C) The medical record indicated that the patient's blood pressure was 163/49 at 11:02 on 10/8/15 and 145/45 at 1406 hours on 10/8/15. The medical record lacked documentation that the physician was notified of the vital signs per order.

8. Review of patient #5's medical record indicated the following:
(A) He/she was admitted on 10/6/15.
(B) An order was written at 1500 hours on 10/6/15 to call M.D. of systolic blood pressure >180 or <90, diastolic blood pressure >100 or <50, or heart rate >120 or <50. The medical record indicated the patient's blood pressure was 200/109 at 2200 hours on 10/6/15. The physician was notified and orders received for Labetalol 20 mg IV push every 2 hours prn (as needed) and Hydralazine 20 mg IV push every 2 hours prn; both blood pressure medications. The record indicated his/her blood pressure was 214/107 at 0400 hours on 10/7/15, 173/108 at 0600 hours on 10/7/15, 202/103 at 0703 hours on 10/7/15, 161/102 at 1400 hours on 10/7/15, 186/98 at 0736 hours on 10/8/15, 150/126 at 0800 hours on 10/8/15, 141/106 at 0600 hours on 10/9/15, and 131/112 at 11:30 on 10/8/15 with a heart rate of 127 at 11:30 on 10/18/15. The medical record lacked documentation that the physician was notified of the vital signs per order. Additionally, the medical record lacked documentation that the prn medication was administered for the high blood pressure at 1400 hours on 10/7/15, 0800 hours on 10/8/15, and 0600 hours on 10/9/15.

9. Review of patient #8's medical record indicated the following:
(A) An order was written at 1642 hours on 12/14/15 to call with heart rate >130 or < 60. The order was changed at 2017 hours on 12/15/15 to call if heart rate >120. The medical record indicated the patient's heart rate was 123 at 1300 hours on 12/16/15, 127 at 1400 hours on 12/16/15, 135 at 1429 hours on 12/16/15, 132 at 1500 hours on 12/16/15, 127 at 2000 hours on 12/16/15, and 121 at 2200 hours on 12/16/15. The medical record lacked documentation that the physician was notified of the increased heart rate per order.

10. Review of patient #9's medical record indicated the following:
(A) An order was written at 0226 hours on 12/16/15 to call M.D. for heart rate > 120 or < 50. The medical record indicated the patient's heart rate was 138 at 0800 hours on 12/16/15, 134 at 1200 on 12/16/15, 137 at 1600 hours on 12/16/15, 141 at 2257 hours on 12/16/15, 140 at 2306 hours on 12/16/15, 144 at 0200 hours on 12/17/15, and 123 at 0400 hours on 12/17/15. The medical record lacked documentation that the physician was notified of the increased heart rate per order.
(B) The medical record lacked documentation of a pain assessment on dayshift on 12/16/15.

11. Review of patient #10's medical record indicated the following:
(A) The patient was admitted on 12/14/15.
(B) An order was written at 0549 hours on 12/14/15 to call M.D. if systolic blood pressure >160 or <90 and diastolic blood pressure >110 or <50. The medical record indicated the patient's blood pressure was 85/56 at 0700 hours on 12/14/15, 71/49 at 0800 hours on 12/14/15, 83/55 at 10:00 on 12/14/15, 167/75 at 2100 hours on 12/15/15, and 179/106 at 0400 hours on 12/16/15. The medical record lacked documentation that the physician was notified of the abnormal blood pressures per order.

12. Medical record information for patients #1-5 was verified by staff member #4 (Accreditation Specialist) beginning at 1:30 p.m. on 12/16/15.

13. Medical record information for patients #6-10 was verified by staff member #5 (Information Systems Clinical Manager) beginning at 11:00 a.m. on 12/17/15.

Based on document review and interview, the nursing staff failed to include surgical site and wound vacuum (VAC) in the patient care plan for 1 of 10 patients (patient #1).

Findings include:

1. Review of the registered nurse (RN) job description indicated the following under clinical judgement: "....develops, implements then evaluates the patient?s (known error) individualized plan of care; and modifies plan to meet mutually agreed-upon clinical outcomes..."

2. Review of patient #1's medical record for visit #3 indicated the following:
(A) The patient presented to the emergency department (ED) at 0040 on 11/1/15 for pump malfunction and fever for several days.
(B) The patient had surgery on 11/2/15 to replace the Baclofen pump from the right side to the left side. Per the operative note, a wound VAC was placed in the right surgical wound site after an incision and drainage.
(C) The patient's incision and wound VAC were not part of the patients care plan.

3. Medical record information for patient #1 was verified by staff member #4 (Accreditation Specialist) beginning at 1:30 p.m. on 12/16/15.

Based on document review and interview, the medical staff failed to write orders for wound vacuum (VAC) care and failed to include orders for wound VAC care upon discharge for 1 of 10 patients (patient #1), failed to complete a medication reconciliation per policy for 6 of 10 patients (patients #1, 5, 6, 8, 9 and 10) resulting in delay of seizure medication administration for 1 of 10 patients (patient #1).

Findings include:

1. Review of policy/procedure titled "CONTENT OF MEDICAL RECORDS" last reviewed/revised 2/28/15 indicated the following: Page 1: "The medical record shall contain sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and facilitate continuity of care among health care providers. The patient's medical record includes written, transcribed, and electronic information, and .........." Page 2 states under attending physician: "Documentation responsibilities of the attending physician include: 1. Progress notes, operative notes, and/or orders which reflect the management of the patient's care;......."

2. Review of policy/procedure titled "MEDICATION RECONCILIATION" last reviewed/revised 6/30/13 indicated the following: Page 3: "D. A good faith effort for the Medication History is best performed as early in the encounter as possible, no later that 24 hours after inpatient admission......F. Medication Reconciliation is a dynamic process and ultimately the responsibility of the prescriber. G. Medication Reconciliation will be done upon all transitions in care as defined above."

3. Review of patient #1's medical record, on 12/16/15, for the first visit, indicated the following:
(A) He/she was admitted to the facility on 10/6/15 at 0921 hours due to post operative bleeding from surgical site where a Baclofen pump had been placed on 10/5/15.
(B) The patient's home medications listed on the emergency department (ED) physician progress note included, but was not limited to, Depakene (for seizures) 400 milligrams (mg) three times a day (TID) and Phenobarbital 40 mg every a.m. and 60 mg every evening.
(C) The Physician Progress Note for the ED indicated the patient had seizure activity in the ED and was treated with Ativan.
(D) Per nurse notes, the patient had seizure activity and increased heartrate at 1334 hours on 10/7/15, which was reported, with orders to continue to monitor the patient. The medication reconciliation was not completed until 1528 hours on 10/7/15. Review of orders indicated the seizure medications were ordered on 10/7/15 at 1530 hours. There was no explanation in the medical record as to why the medication reconciliation was delayed or seizure medications not ordered upon admission.

4. Review of patient #1's medical record, on 12/16/15, for visit #3, indicated the following:
(A) The patient presented to the ED at 0040 on 11/1/15 for pump malfunction and fever for several days.
(B) The patient had surgery on 11/2/15 to replace the Baclofen pump from the right side to the left side. Per the operative note, a wound VAC was placed in the right surgical wound site after incision and drainage. The medical record lacked an order for care/maintenance of the wound VAC. Physician progress notes indicated the patient had the wound VAC, however there was no care to the wound itself documented.
(C) The patient was discharged back to facility #2 on 11/10/15. The discharge instructions lacked instructions/orders related to the wound VAC. The discharge instructions lacked documentation that the patient had a wound VAC.
(D) Review of case management progress note dated 11/3/15 at 1558 hours states "will follow up as .....to identify potential needs....." There were notes dated 11/4/15, 11/5/15, and 11/6/15 with basically the same information in each note and no potential needs identified. Case management note dated 11/10/15 at 1701 hours indicated the patient was to discharge to facility #2 via ambulance. The notes lacked evidence that arrangements had been made for a wound VAC at facility #2 for the patient.

5. Review of patient #5's medical record on 12/16/15 indicated the following:
(A) He/she was admitted on 10/6/15.
(B) The medical record lacked evidence that a medication reconciliation was completed.

6. Review of patient #6's medical record on 12/17/15 indicated the patient was admitted 12/4/15. The medication reconciliation was not completed by the practitioner until 12/7/15.

7. Review of patient #8's medical record on 12/17/15 indicated the patient was admitted 12/14/15. The medical record lacked evidence that the medication reconciliation was completed.

8. Review of patient #9 medical record on 12/17/15 indicated the patient was admitted 12/15/15. The medical record lacked evidence that the medication reconciliation was completed.

9. Review of patient #10's medical record on 12/17/15 indicated the following:
(A) The patient was admitted on 12/14/15.
(B) The medical record lacked evidence that a medication reconciliation was completed by the practitioner.

10. Staff member #18 (Director of Nursing at facility #2) indicated in phone interview beginning at 12:55 p.m. on 12/16/15 that patient #1 had wound VAC sponge frozen and stuck upon arrival to their facility and it took a couple days to get it out. He/she indicated there was no wound VAC sent with the patient.

11. Staff member #19 (Unit Manager at facility #2) indicated in phone interview beginning at 12:58 p.m. on 12/16/15 that patient #1 arrived with no orders for a wound VAC and there was a wound VAC sponge in a wound covered by a clear dressing. He/she indicated there was nothing in the paperwork about the wound VAC. He/she indicated there was "greenish pus" in the wound after the sponge was removed. The patient's pediatrician was notified and looked at the wound. The patient was sent to wound care.

12. Medical record information for patients #1-5 was verified by staff member #4 (Accreditation Specialist) beginning at 1:30 p.m. on 12/16/15.

13. Medical record information for patients #6-10 was verified by staff member #5 (Information Systems Clinical Manager) beginning at 11:00 a.m. on 12/17/15.

14. Staff member #20 (registered nurse [RN] wound therapy nurse) indicated in interview beginning at 12:30 p.m. on 12/17/15 that a wound VAC dressing change would typically be three (3) times a week on Monday, Wednesday, and Friday. He/she indicated that the wound therapy department is notified of the need for wound care through an order to change dressings or an order for wound VAC power plan which is entered by the physician. He/she verified that there was no wound care orders or wound VAC power plan entered by the physician for patient #1.

Based on document review and interview, the facility failed to transfer patients with appropriate information for follow-up care for 1 of 10 patients (patient #1).

Findings include:

1. Review of policy/procedure titled "CONTENT OF MEDICAL RECORDS" last reviewed/revised 2/28/15 indicated the following on page 1: "The medical record shall contain sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and facilitate continuity of care among health care providers........"

2. Review of policy/procedure titled "INTEGRATED CARE MANAGEMENT PROCESS" last reviewed/revised 9/14 indicated the following: V. Policy Statements: "A. Integrate Care Management (ICM) is a system-wide, interdisciplinary department that plans, organizes and provides health care services.....The purpose of ICM is to achieve the following 5. Develop safe discharge plan for transition through the health care continuum...."

3. Review of policy/procedure titled "DISCHARGE PLANNING" effective 7/31/14 indicated the following on page 2: "The discharge planning process will: A. Facilitate the transfer of the patient from one level of care to another while maintaining the continuity of care (hospital to post acute ).......... Oversight of this collaborative process assures that each patient and family will: ....B. Experience a smooth and safe transition between the various levels and/or areas of patient care..... D. Experience a timely development and implementation of a discharge evaluation and plan based upon the appropriate needs." Page 4 of 6 states "I. The discharge plan may include but is not limited to referrals for Durable Medical Equipment.....J. Necessary medical information will be provided for patients transferred to another inpatient facility or agency for post acute care needs at the time of transfer to the accepting facility/agency."

4. Review of policy/procedure titled "USE OF ALLSCRIPTS (ECIN) FOR DISCHARGE PLANNING last reviewed/revised 7/14 indicated the following on page 5: "H. Post Acute Facility Transition Packet contents (sent with referral) 1. Transition Document 2. PAS paperwork (sent with patient) 3. 5 day MAR 5. Consult notes 6. Rounds notes 7. Admission H/P or 1st progress note containing patient history 8. Chest x-ray (admit and most recent) 9. Most recent progress notes (each discipline) 10. Most recent therapy notes (all therapies) 11. Nursing notes with wound information 12. Copy of insurance card, if available. 13. Discharge instructions (sent with patient).

5. Review of patient #1's medical record for visit #3 indicated the following:
(A) The patient presented to the emergency department (ED) at 0040 on 11/1/15 for pump malfunction and fever for several days.
(B) The patient had surgery on 11/2/15 to replace the Baclofen pump from the right side to the left side. Per the operative note, a wound vacuum (VAC) was placed in the right surgical wound site after incision and drainage.
(C) The patient was discharged back to facility #2 on 11/10/15. The discharge instructions lacked instructions/orders related to the wound VAC. The discharge instructions lacked documentation that the patient had a wound VAC.
(D) Case management note dated 11/10/15 at 1701 hours indicated the patient was to discharge to facility #2 via ambulance. The notes lacked documentation that arrangements had been made for a wound VAC at facility #2 for the patient.

6. Staff member #19 (Unit Manager at facility #2) indicated in phone interview beginning at 12:58 p.m. on 12/16/15 that patient #1 arrived with no orders for a wound VAC and there was a wound VAC sponge in a wound covered by a clear dressing. He/she indicated there was nothing in the paperwork about the wound VAC.

7. Medical record information for patients #1-5 was verified by staff member #4 (Accreditation Specialist) beginning at 1:30 p.m. on 12/16/15.

8. Staff member #22, registered nurse (RN) charge nurse, indicated in interview beginning at 1:05 p.m. on 12/17/15 that nursing follows physician orders related to care of a patient with a wound VAC.

9. Staff member #8 (Case Manager for patient #1) indicated in interview beginning at 1:10 p.m. on 12/17/15 that the process for referral includes sending progress notes, clinical vital sign sheets, chart summary to Indiana University Care Alliance (IU CAS) and they send it to the facility. The physician is in charge of discharge instructions. He/she has no evidence that facility #2 was notified that patient #1 had a wound VAC or orders related to such.

10. Staff member #23 (M.D.) indicated in interview beginning at 1:25 p.m. on 12/17/15 that the physicians put in an order for wound team to consult and that the paperwork that goes with the patient at time of discharge would include wound VAC instructions and this is usually entered by the wound team.

11. Staff member #25 (RN Director of Integrated Care Management) indicated in interview beginning at 2:15 p.m. on 12/17/15 that information is sent to the receiving facility through Care Alliance and that tracking of the Care Alliance communications is not part of the medical record. He/she indicated that it is the responsibility of the Case Manager to coordinate any discharge equipment needs. He/she indicated the Case Manager should call the physician for an order if there is not an order in the charge for equipment. He/she verified there was nothing in the case management notes for patient #1 concerning a wound VAC.

12. Staff member #26 (Program Director for Care Alliance) indicated in interview beginning at 3:00 p.m. on 12/17/15 that all the documents sent to facility #2 for patient #1 were not all the documents required to be sent.