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Based on observation, interview and record review the facility failed to protect and promote Patient # 7's rights when she was not informed of the right to request a discharge evaluation and was not included in the discharge planning resulting in a worsening health status.

Refer to F0130 and F0806

Based on interview and record review the facility failed to include the patient in the development and implementation of his/her discharge plan when Patient #7's medical needs were not addressed upon discharge to home.

Findings include:

Review of Patient#7's History and Physical reflected a 64 year old female admitted on 12/27/16 with a chief complaint of MVC (motor vehicle collision)...restrained driver...rear ended...C5, T1 compression fracture along with right radial fracture and left calf laceration repaired with staples...."

An observation made on the morning of 2/27/17 in Patient #7's room revealed a morbidly obese female lying supine in bed. Patient #7 attempted to reach for her leg but was not able to reach past her abdomen. Patient #7 had dressings to her right and left lower extremities and an approximately 6 inch long dressing on the left forearm.

During an interview on the morning of 2/27/17 on the inpatient unit Room 390, Patient #7 stated,"...my arm and legs opened up while I was at home...they told me to treat the wounds, I was only given verbal instructions,...they told me to change the pad and rewrap it....I can't even reach my legs...I couldn't even see my wounds...Visiting Angels weren't allowed to touch my wounds ....The Social Worker just wanted to get me out...my son told her there was no one to take care of me at home .... Staff #9, (Primary Physician) assured me, 'we won't send you home without help'....No nurse came out to see me at home...." When asked if she had participated in a Care Plan meeting to discuss her home care needs Patient #7 stated, "No." When asked if she had practiced doing the wound care before she left the hospital, Patient #7 stated, "No...I couldn't use my right arm; it was fractured and hurt too much ..."

During an interview on the afternoon of 2/27/17, in the facility conference room, Staff #7, Director of Social Services stated, "...Visiting Angels provides minimal patient care, they are not nurses...we typically go by the provider orders...." When asked if the facility held a care conference with the patient, physical therapy, social services and the physician to discuss the impending discharge and the services the patient required, Staff #7 stated, "...Not where everyone was in the same room ...." When asked if the facility had a document that described the care Visiting Angels would be providing Staff#7 stated, "No."

Review of the facility provided document PATIENT RIGHTS AND RESPONSIBILITIES (undated) reflected "...be informed of your health status and participate in the development and implementation of your plan of care, including: to plan your care to meet your psychological, psychosocial, spiritual, cultural, and medical needs; to participate in your inpatient and outpatient treatment and care plan, discharge plan... receive information necessary to enable you to make informed treatment decisions that reflect your wishes...."

Based on observation, interview and record review the facility failed to conduct a discharge evaluation in order to identify specific areas that needed to be addressed in the discharge plan when Patient #7 was not evaluated on the ability to continue physical therapy's recommendations and wound care orders independently, resulting in Patient #7's worsening health condition.

Findings include:

Review of Patient#7's History and Physical reflected a 64 year old female admitted on 12/27/16 with a chief complaint of MVC (motor vehicle collision)...restrained driver...rear ended...C5, T1 compression fracture along with right radial fracture and left calf laceration repaired with staples...."

An observation made on the morning of 2/27/17 in Patient #7's room revealed a morbidly obese female lying supine in bed. Patient #7 attempted to reach for her leg but was not able to reach past her abdomen. Patient #7 had dressings to her right and left lower extremities and an approximately 6 inch long dressing on the left forearm.

During an interview on the morning of 2/27/17 on the inpatient unit Room 390, Patient #7 stated,"...my arm and legs opened up while I was at home...they told me to treat the wounds, I was only given verbal instructions,...they told me to change the pad and rewrap it....I can't even reach my legs...I couldn't even see my wounds...Visiting Angels weren't allowed to touch my wounds ....The Social Worker just wanted to get me out ...my son told her there was no one to take care of me at home....Staff #9, (Primary Physician) assured me, 'we won't send you home without help'....No nurse came out to see me at home...." When asked if she had participated in a Care Plan meeting to discuss her home care needs Patient #7 stated, "No." When asked if she had practiced doing the wound care before she left the hospital, Patient #7 stated, "No...I couldn't use my right arm; it was fractured and hurt too much...."

Review of the facility provided discharge documents for Patient #7's Physician's Order HOME CARE Instructions (dated 1/27/17) reflected "...
o Clean the wound daily with mild soap and water.
o Change any bandages (dressings) as told by your doctor.
o Put medicated cream and a bandage on the wound as told by your doctor.
o Change the bandage if it gets wet, dirty, or starts to smell....
Activity Precautions: Rt(right) Arm: Non Weight Bearing...Lifting Instructions: No lifting ...
Wound Care Instructions...right wrist...Change Dressing: Daily...Wound Location: LLE (left lower extremity) Care Instructions: as directed or demonstrated...11.RLE pain- orth following as well...recommend PT... Dispo-...hospital attempting...arrangements for 24 hour supervision in her home..."

Review of Patient#7's Physical Therapy (PT)note dated 1/26/17 at 10:58 a.m. reflected "PT Discharge Plan: Patient would benefit from further PT services following disc...Recommended Disposition: Home with home health PT."
During an interview on the afternoon of 2/27/17, in the facility conference room, Staff #6, PT (Physical Therapist) stated, "I took care of her...I remember her...we were told she would have wound care in the home...I don't believe she could do her own wound care...we recommended she go to Rehabilitation or a SNF (Skilled Nursing Facility)..."

During a telephone interview on the afternoon of 2/27/17, in the facility conference room, Staff #1, Nurse Practitioner (NP) stated, "Social Services worked on getting her placed...PT recommended a Skilled Nursing Facility...she was stuck going back home...there was no one to take care of her ...my understanding was that she was going to be receiving home health care with a nurse...I was aware she couldn't do the wound care herself...I wasn't aware Visiting Angels couldn't do the wound care...that would have been a different ball game...."

During an interview on the afternoon of 2/27/17, in the facility conference room, Staff #7, Director of Social Services stated, "...Visiting Angels provides minimal patient care, they are not nurses...we typically go by the provider orders...." When asked if the facility held a care conference with the patient, physical therapy, social services and the physician to discuss the impending discharge and the services the patient required, Staff #7 stated, "...Not where everyone was in the same room ...." When asked if the facility had a document that described the care Visiting Angels would be providing Staff#7 stated, "No."

Review Patient #7's readmission History & Physical dated 2/21/17 reflected "...63 years Sex: Female....Chief Complaint Non healing wounds both calves....Due to her morbid obesity she did not follow instructions and did not walk around and remained on bed at home. Now she came to clinic with non-healing necrotic wound on right calf as well. Previously it was on left calf only. She does not have any insurance that's why no wound care was established by her....Non-compliant patient...."

Review of Patient #7's Wound Evaluation dated 2/23/17 reflected a 25 cm. (centimeter) long x1 cm. wide x1 cm. deep wound to the left forearm with 40 % eschar (Dark patches of dead skin), a 7.2 cm. long x 13.5 cm. wide x .7 cm. deep wound to the left anterior calve with 10% slough (a mass of dead tissue in, or cast out from, living tissue) and a 5.0 cm. long x 10.3 cm. wide x unstageable depth wound to the right anterior calve with 100 % eschar ...."

During an interview on the morning of 2/27/17 on the inpatient unit, Staff#8, Case Manager, when asked about Patient#7's readmission to the facility, stated,"...she had wounds that she wasn't taking care of at home. She didn't move around at home...neglected herself at home...I believe she is waiting to have surgery, she is having skin grafts."

Review of the facility provided document Department of Case Management and Social Services (August 24,2015 ) "...The purpose of the Case Management and Social Services Department at University Medical Center (UMC) is to provide high quality patient care through appropriate resource allocation....Case Management Plan for care, treatment, and services:...
o Ensure that the level of care or service required by the patient can be provided by UMC and/or the facility in which UMC refers the patient to
o Assure that inpatient and outpatient hospital services provided are appropriate and medically necessary based on diagnosis, condition, and medical problems
o Assist the health care team in understanding the significance of social, economic, emotional, and family factors in relation to the patient's illness, treatment, and recovery...
VII. Social Service plan for care, treatment and services:
o Actively participate in planning aftercare for patients in need of continuing health care services to ensure maximum recovery, rehabilitation, and ongoing care...."

Review of the facility provided document Discharge, Plan (dated 4/11/2016) reflected "...B. The patient must demonstrate adequate understanding of the instructions by verbal acknowledgement and/or physical demonstration.