HospitalInspections.org

Based on record review and interview, the facility failed to ensure it arranged appropriate post-hospital services for the patients. The facility failed to identify and document the patient's status on discharge related to skin impairment, edema, correct removal of intravenous access, and to notify the physician of non-availably of physician ordered home health therapy. This affected one (1) of 10 patient clinical records reviewed, Patient #3.

The findings included:

Review of the Policy & Procedure, titled Clinical Practice for Assessment / Reassessment, revealed: All assessments are documented in the patient's medical record. Information is exchanged in this manner, as well as through patient rounds, discharge planning, and team conferences on a need to know basis only and for patient care continuity. Patients in each clinical setting are reassessed at regular intervals to assure that the treatment plan remains appropriate. Patient reassessments are based on the anticipated length of stay, complexity, dynamics, response to specific treatment, or when a significant change occurs in the patient ' s condition or diagnosis.

Review of the provided 'Discharge Planning (D/C) - Hospital Compliance' Policy & Procedure included: The D/C planning screen is completed by the RN (registered nurse) for all patients ...The RN shares responsibility with the social worker, nurse case manager, physician, and in addition, other disciplines such as therapy, dietician,...for identifying patient needs and those that require post-hospital services. D/C planning is an interdisciplinary process that involves disciplines with specific expertise as dictated by the needs of the patient...The Case Management (CM) staff have been designated with the responsibility of assuring successful outcomes through coordination of community support systems that enable meeting the patient ' s healthcare and psychological needs after discharge. The CM and/or Social Worker (SW) is responsible to communicate with the physician and other members of the healthcare team to inform them of the discharge planning assessment and intervention, and to obtain their recommendations or orders...The discharge planning needs of the patient are reassessed, updated and revised during the episode of care to assure that continuity of care provided is based upon the patient ' s changes in condition or assessed needs at the time of discharge ... The discharge plan identifies the patient ' s continuing physical, emotional, symptom management, financial, transportation, social and other needs and arranges for the initial implementation of the services to meet those needs.

1. Review of the clinical record for Patient #3 revealed presentation to the emergency room on 12/24/15, was admitted on 12/25/15 at 01:45 AM, and was discharged on 01/08/16 at 5:02 PM. Review of the nursing admission assessment dated 12/25/15 at 01:45 AM revealed Patient #3 was alert, oriented with forgetfulness, had redness to sacrum and groin and a healing incision to abdomen (prior surgery) with steri-strips, had 2 intravenous (IV) access lines documented as Saline Locs (right antecubital and left hand), and no documented edema in extremities. The nurse also documented on this admission assessment that photos were taken on 12/24/15 at 6:15 PM of the superficial, stage I redness to sacrum & groin, with intact skin, measuring 08 X 17 X 18 (cm). Review of the clinical chart with the Risk Manager on 02/24/16 at 10:26 AM revealed no evidence the physician was notified of the excoriated areas.
The daily nursing documentation revealed the nurse documented redness and excoriation to sacral area / buttocks, vagina, folds, under stomach, and groin from 12/25/15 through 01/01/16 with barrier cream only being applied on 12/27/15 and 01/01/16.
Further review of provided evidence of excoriation revealed on 01/01/16, photos taken of the front groins and perineal areas that revealed extensive redness and excoriation of the areas. The redness noted on the photo had spread extensively over the perineal area, to the front groins and along the groins toward the back. The nurses documented redness to sacral area, groin, buttock and barrier cream applied, and patient repositioned. On 01/07/16, there was evidence of a specialty mattress provided for the patient.
Further review of the nursing shift assessment dated 01/08/2016 at 8:00 AM revealed: all extremities edematous,' 2+ - ½ inch' depression edema bilateral upper & lower extremities and limbs elevated on pillow; incontinent of bladder and bowel with care provided, redness to buttocks / sacral area and skin intact, barrier cream applied, no deep tissue injury / wounds, repositioned as needed, interventions documented, sinus tachycardia, no signs & symptoms of cardiac distress, weak right & left radial pulses, diminished right and left upper & lower breath sounds, pulse Ox 96%, no respiratory distress, has Saline Lock left hand, gauge #24 with dressing date of 01/07/16 and peripheral IV line left hand with gauge #22, IV fluids infusing and dressing dry & intact, responsive, Braden scale for pressure ulcer risk with score of 15 and is at low risk for pressure ulcer.

Review of the chart with the Quality Manager on 02/24/16 at 10:28 AM revealed there was no evidence or documentation the nurse notified the physician or the wound care nurse of the excoriation to the perineal area, groin, or chest area when it had occurred on admission or on 01/01/16 when photos taken, or through to discharge on 01/08/16.
Further review revealed no evidence the physician was notified on 01/08/16 at 8:00 AM of the edema in the patient ' s 4 extremities prior to discharge that same evening. Review of the physician orders with the Quality manager at this time revealed no evidence or documented physician orders for wound / excoriation treatment from admission to discharge.
The physician notes from 12/25/15 through 01/07/2016 were reviewed with the Quality Manager and there was no evidence the physician was aware of the excoriation, no documented treatment orders, and no documentation in the physician progress of any excoriation of the patient. Review of the attending physician notes dated 12/28/15, 12/29/15, 12/30/15, 12/31/15, 1/4/16, 1/6/16 revealed there was no evidence of edema in the extremities or skin impairment.
On 12/20/15, the general surgeon documented mild edema in extremities. On 01/02/16, the Gastroenterologist documented no edema. On 01/02/16, the attending physician documented no edema and there was no documentation of skin excoriation. On 01/04/16, the attending physician documented no wound breakdown. On 01/07/16, the attending physician documented maximum assist with Activities of Daily Living as the patient ' s baseline.

Review of the physician order on 01/08/16 at 2:17 PM for Patient #3 revealed: 'Discharge to Home with Home Health (HH), Resume previous diet and activity'. There was no specific type of HHA ordered such as nursing or therapy.
Review of the Case Management (CM) notes for 01/08/16 revealed the facility had notified a Home Health Agency of the post-hospital need for HH for physical therapy (PT) only. They had received a call from the HH Agency that PT was not provided by the patient ' s insurance. There was no evidence or documentation the physician was notified that HH would not be available.
Interview with the CM supervisor and the RN discharge planner on 02/23/16 at approximately 3:53 PM revealed: they were unaware the patient had severe excoriation to the groins, sacrum, and perineal areas; the physician had initially recommended the patient go to a nursing home and not back to the ALF; that Medicaid did not cover this patient's PT at the skilled nursing facility or ALF; and they confirmed again the unit-nurse & physician did not tell them the patient had excoriation of the perineal area so did not attempt to get HHA for care of the excoriation. The CM supervisor said the patient would be sent back to the hospital from the ALF if not appropriate or they (ALF) would call CM. They confirmed there was no written order to cancel the HHA. There was no evidence the physician was notified that HH would not be provided to the patient.
Interview with the Interim VP of Quality on 02/24/16 at approximately 10:30 AM confirmed all Case Managers have full access to all of the patient record documentation so could review the nursing notes for wounds or excoriation.

Review of nursing documentation dated 01/08/16 at 4:54 PM revealed IV (intravenous) removed but did not document whether one or two were removed, patient in stable condition, lungs clear, and discharge to an Assisted Living Facility (ALF). Review of the nursing 'Discharge Instruction' form included: Home with Home Health on 01/08/16 at 5:02 PM via ambulance; to resume previous activity and diet, no IV access, and educated on stroke risk factors and medications (no evidence of the patient with stroke or stroke symptoms in clinical record). There was no evidence of post-hospital care for the severe excoriation.

Interview with the VP of Quality on 02/24/16 at 10:21 AM revealed the director/unit manager of 2nd floor had called the nurse who had discharged Patient #3 on 01/08/16 and she confirmed she/the RN had gone to the ALF to remove the Saline-loc on the patient. He said the unit manager told him this was the first she heard of this as the RN did not tell her.
Interview with the unit manager (UM) on the 2nd floor on 02/24/16 at approximately 4:00 PM confirmed the UM had spoken with the registered nurse caring for Patient #3 and she had gone to the ALF to remove one of the two IV access lines, the Saline-Lock. The UM said she was not aware of this until this morning and there was no evidence of documentation of this in the clinical record.

Further interview with the Interim VP of Quality on 2/24/16 at 3:06 PM confirmed the nurse had not discontinued the saline-loc (IV access) on the patient prior to discharge and had gone to the ALF to remove it. He said it the expectation that all IV accesses be removed prior to discharge unless required for use after discharge. He also confirmed again that he looked through Patient #3 ' s chart and could not find documentation of the physician being notified of the excoriation to buttocks / sacral area on admission or during the stay of the patient. He also said he could not find nursing notes related to the excoriated areas following the 01/01/16 nursing assessment until discharge on 01/08/16. He confirmed there was no evidence the excoriation was addressed on discharge with the patient, representative or the facility to which the patient was being discharge to. He confirmed there was no evidence the physician was notified of edema the morning of discharge (8 AM).

Interview with 2 nurses on the 2nd floor on 02/24/16 at approximately 4:00 PM revealed if there is excoriation on admission, the wound care nurse or the physician should be notified. They said if there is a change in the patient's condition the physician should be notified.